influenced by government websites, television, advertising of one type or another, or by friends and neighbors, and will the information they obtain be accurate or appropriate? We need to better understand the ecology of health decision making and how to achieve the greatest impact at the population level. Toolkits, websites, and projects are good starts, Isham said, but they are only the very firsts step in a chain of implementations.

Another question is how to measure the success of the ACA. Metrics could relate to process, financial gain or loss, or health outcomes. A related question is how to dissect out the impact of health literacy initiatives.

Throughout the workshop there was discussion about the relationship between quality improvement and health literacy. Researchers may want to study the impacts of quality and literacy in isolation. A practical implementer, however, will need to address these factors together, and in concert with other elements to achieve the desired impact.

Prioritizing will be important. There is much to be done, and areas of focus will need to be identified. We must start by understanding what people need to be well, and what they need to get better when they are ill. Isham supported the idea of segmenting by market, in other words, identifying the needs of seniors, children, and other vulnerable or underserved populations. Once we understand what they need, the next questions are what, objectively, is the status of current efforts on those issues, and what should be the short- and long-term goals going forward? The next questions that would follow are, what measures exist to be able to assess implementation for quality improvement and accountability, and what resources are available to be able to take action? It will then be important to continually cycle back to look at customer needs.

Isham identified Medicaid expansion as the primary opportunity to impact health literacy. Two targets in the implementation are the exchanges and choice. Health literacy will be a factor for underserved populations in these areas.

There are concerns about changes to the delivery system, and we need to think in terms of how health literacy is embedded in health system transformation. With accountable care organizations, for example, how will shared savings be spent? Will they be returned to the accountable care organizations since they created them? Will they be returned to consumers in the form of lower premiums? Will they be reinvested to address other issues? Another charge for accountable care organizations is to know their populations and be able to measure the health literacy of those they serve.

Isham also highlighted the workshop discussions regarding the importance of making the business case for health literacy. Success will involve cultural change, management change, leadership, and innovation.



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