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7 Industry Contributions to Providing Health Literate Primary and Secondary Prevention Conrad Person Director of Corporate Contributions Johnson & Johnson Johnson & Johnson has maintained an 18-year relationship with Head Start, focused primarily on management improvement in collaboration with the Anderson School of Management at the University of California, Los Angeles. In 1999 the decision was made to expand the focus to look at children. Head Start directors were surveyed and asked to identify issues that impede access to quality health care for children. Directors identified parents as the major issue, not because of lack of concern on their part, but because of the difficulties that parents face in navigating the healthcare system. Many Head Start parents are immigrants or migrants. They often face language barriers and are more likely to use emergency services as opposed to preventive services. They are also likely to have low health literacy. Head Start is a family-oriented federal program that is uniquely trusted by the parents it serves. It was created as part of President Lyndon B. Johnson’s War on Poverty and, since 1965, has served over 25 million low-income families and children aged up to five years of age. Currently, Head Start serves 1 million children and families with a $7 billion operating budget. In 2001 Johnson & Johnson and the Anderson School of Manage- ment created the Health Care Institute (HCI) which in partnership with 47
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48 PROMOTING HEALTH LITERACY the Institute for Healthcare Advancement sought to provide Head Start parents with the skills and knowledge to • enable them to become better caregivers by improving health care knowledge and skills, • empower them in decision making, • enhance their self esteem and confidence, and • contribute to reducing escalating health care costs. The program provides training and information for implementing health care literacy programs. During the research phase, the institute conducted a survey of Head Start families. The survey revealed that only 20 percent of families had any health care reference material at home. Less than 5 percent said that they would first refer to a book for information if a child was sick. Almost 70 percent of families said that they would first go to their doctor if a child was sick; 4.5 percent said they would visit the emergency room. Once training was provided, there was a tenfold increase (from 4.7 percent to 47.55 percent) in the families who first referred to a book for information when a child was ill. Since the program began, HCI has engaged in training with 55 Head Start programs in 38 states, resulting in 14,000 families of ten different ethnicities receiving training in seven languages. Training sessions took place in the evening after work for three hours. In the training sessions, parents learned when it is necessary to keep a child home due to illness and how to use their interactions with doctors effectively. An important observation made was that training cannot consist simply of giving a book to the parents. It takes personal interaction with a person who can notice if a parent cannot read, who can help the parent use a book effectively, and who can help personalize the book and make it the parent’s own. It takes someone whom the parents trust, who can sit down next to a parent and help him or her go through the materials. That, Person said, is what is spe- cial about Head Start and certain other community-based organizations. Following the training there was a 42 percent drop in the number of doctor visits and a 58 percent drop in the number of emergency room vis- its. The institute was able to convince parents that doctors are resources, not only for medical care, but also for information and consultation. There was also a 29 percent drop in the average number of school days missed and a 42 percent drop in the average number of work days missed. While the goal of training was not to save money, by decreasing doc- tor and emergency room visits, the savings per family trained was $554 per year. Given that there were approximately 9,000 Head Start families
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49 INDUSTRY CONTRIBUTIONS trained, this amounted to a net savings of $5 million. The cost of training was only $60 per family. Following training there was increased parental awareness of health warning signs, a faster response to early signs of illness, use of the health reference book, a better understanding of common childhood illnesses, and fewer school absences, and the parents felt a good deal more empow- ered. They talked extensively in focus groups about the fact that they had anxiety about their children’s health and that they felt less anxious once they had the knowledge the training provided. Since the initial training, the federal government has awarded a $1.2 million grant for the program to be implemented in Missouri. The way the program is structured, Person said, allows any organization to work with the Head Start programs within its own area. Juli Hermanson, M.P.H., R.D. Senior Nutrition Scientist Bell Institute of Health and Nutrition General Mills General Mills is the world’s sixth largest food company. Its products are marketed in more than 100 countries and the company employs 30,000 people worldwide. General Mills’ mission is to nourish lives through its products. Nutrition means nothing unless it’s consumed, so making prod- ucts that are convenient and fit into a busy lifestyle is important. General Mills is constantly working for product improvement in terms of nutrition profile, and in 2005, the Big G Cereal Division announced that all of its cereals would be made with whole grains. Since then, each serving of a Big G Cereal has had at least 8 grams of whole grain. The Bell Institute of Health and Nutrition was created 10 years ago to serve as the source of nutrition expertise for General Mills products. Nutrition scientists, registered dietitians and food scientists work together to improve the nutrition profile of products. The Institute is involved in both nutrition research and nutrition communication. Consumer research has shown that, in terms of consumer engagement with health and wellness, the population can be thought of as divided into thirds. A significant portion of the population—approximately 30 percent—is not engaged in health and wellness. They offer a variety of reasons for this, including not feeling that there is enough time in the day and feeling that it will not make a difference to their health no matter what they do. To engage these individuals, Bell Institute develops materi- als and education programs that span different levels of health literacy, from very simple package icons and communication at roughly a fifth-
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50 PROMOTING HEALTH LITERACY grade reading level all the way up to very technical white papers, and continuing medical education programs for health professionals. Effective communication for General Mills starts on the front-of-pack labeling on its products. For example, many of their cereal packages feature Nutrition Highlights, which call out six nutrients in the product on the front of the package. The six nutrients are calories, saturated fats, sodium, sugars, and then two discretionary nutrients which vary depend- ing upon the product. These highlights allow consumers to quickly see key nutritional information. Another example is the Smart Choices pro - gram, a voluntary program for manufacturers and food retailers in which a highly visible and universal checkmark is displayed on packaging to indicate that this product meets certain nutrition criteria. General Mills also supplies the Women, Infants, and Children (WIC) program and other supplemental food programs with thousands of pieces of nutrition education per year. One example is the website eatbetterearly.com. This website is designed to provide basic nutrition tips and easy recipes with simple steps. The site is available in Spanish and English. While some may argue that the Internet is not the most effective choice of media to reach this audience, almost 50 percent of WIC partici - pants do have access to the Internet. Mente Sano en Cuerpo Sano (Healthy Mind, Healthy Body) is an interactive program that provides health information and “better-for- you” recipes, Hermanson said. This program was started in 2008 by Gen- eral Mills with support from other sponsors. It is aimed at young Latina mothers and it is active in 14 U.S. communities. Ten classes are taught and the key is use of the promotores model of education. The program identifies a well-respected community leader who is given the tools and education to lead the interactive activities. The program has reached more than 100,000 individuals and the plans are to expand the program to other communities. Another program that focuses on Hispanic outreach is Destination Heart-Healthy Eating. This is an educational resource that health profes- sionals provide to their patients. Existing materials were deemed inad- equate for Hispanic patients, so focus groups of Hispanics were convened to find what was useful or not, what made sense, what was meaningful. Then a specialist in nutrition communications who is a registered dieti - tian, helped devise the new copy and the content. An illustrator who focuses on Hispanic-relevant images developed the illustrations. The con- tent is available at www.bellinstitute.com. Children are also important consumers of products and health infor- mation. For the “Go With the Whole Grain for Kids” program, cartoon characters (Grain Boy and Grain Girl) dressed like heroes on a hunt for whole grains were created. These two heroes take kids on a hunt for whole
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51 INDUSTRY CONTRIBUTIONS grain through a slide program that is downloadable from the General Mills website. The materials provided as part of the program include nutrition messages and fitness activities that can be used by health professionals, teachers and nurses. General Mills also has a foundation that provides Champion Grants for Healthy Kids in collaboration with the American Dietetic Association and the President’s Council for Physical Fitness. For each of the past six years, the program has provided 50 grants of $10,000 each to grassroots, nonprofit agencies to develop programs relevant to their populations. Over 2 million children have been served by this program. These are a few of the many reasons, Hermanson said, that as a reg- istered dietitian and a public health nutritionist, she feels very fortunate to work at a company like General Mills, a place where people are com- mitted to something beyond the bottom line, to the benefit of nourishing lives. Jeffrey Greene President and CEO MedEncentive MedEncentive is a Web-based incentive system designed to improve health care and health, and to control health care costs. This is accomplished by rewarding consumers and doctors for using evidence-based treatment practices and for advancing patient education and empowerment. Greene said that patient behavior and provider performance are the main drivers of cost in the health care system. While doctors have a unique relationship with patients that allows them to inspire behavior change and improvement, such existing solutions as wellness and preven- tion, information technology, and care management lack provider and consumer engagement. MedEncentive decided to align the interests of the insurer or employer, the physician, and the patient or consumer. An Internet appli - cation designed to encourage doctor–patient accountability allows insur- ers to reward doctors and patients who demonstrate to one another that they adhere to a number of performance standards. The first performance standard chosen was information therapy. According to a study published in Archives of Internal Medicine, patients with lower health literacy had significantly higher mortality rates than those who were health literate (Baker et al., 2007). Furthermore, Greene said, those with poor health literacy were more likely to consume greater quantities of health care resources, which can be very costly. Poor doctor-patient communication also interferes with clinical and economic outcomes. The issues to be addressed were
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52 PROMOTING HEALTH LITERACY 1. how to create a solution that would help doctors treat health illit- eracy and poor doctor-patient communications, and 2. how to create an environment in which patients would be moti- vated to become health literate, informed, and empowered. Health illiteracy and poor doctor-patient communication should be diagnosed and treated by physicians, they should be compensated for this work, and patients should be financially rewarded if they could demon- strate health literacy, Green said. A participating physician logs in once a day to enter each patient’s diagnosis. When the information is entered, a decision tree pops up that leads the doctor through relevant literature and practice guidelines. The Web site asks if the doctor is following this guideline to treat the patient, to which he or she may respond yes or no. The second question asks “What information therapy would you like to prescribe to your patient?” For each office visit, a participating doctor earns an extra $15. Physicians do not like to be told how to practice medicine, so the system allows the physician to still receive the $15 even if the physician says he or she is not following the guideline if the physician explains why the guideline does not fit a particular patient. This is done by ask - ing the physician to check one of 12 possible reasons for deviating from the guideline. The physician then communicates this information to the patient and allows the patient to acknowledge the fact that the guideline is not being followed in this instance. Claims data are obtained from the customer’s insurance administra- tor and a determination is made about whether the doctor has prescribed information therapy. Based on the doctor’s recommendation or on claims data, an information therapy prescription letter is generated and sent to the patient asking him or her to go to a particular Web site to receive the recommended therapy. The letter suggests alternative Web access options if the patient does not have Internet at home and also provides log-on instructions with the URL. A user ID and password help ensure privacy. The patient is instructed to complete various tasks online and is told how much money he or she will earn by participating. Once the patient logs on, he or she answers questions about his or her health behavior, reads information about his or her specific condition, and is given a health literacy test about the condition. Incorrect answers cause the patient to be asked to reread information. The patient is also asked to rate the phy- sician’s performance against recommended care. Timely completion of “information therapy” results in immediate financial reward to patients for compliance. The system was first introduced in Duncan, Oklahoma. After four years $181,227 had been invested but over $1.6 million was saved, Greene
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53 INDUSTRY CONTRIBUTIONS said. Since the original trial in Duncan, the system has expanded. To measure the efficacy of the information therapy delivered through the program, all patients are required to answer the following question, “On a scale of 1 to 5, how helpful has this information been to you in self- managing your health (5 being most helpful)?” The aggregate score of the 13,673 responses was 4.07. In addition, patients are asked to voluntarily comment on the program. Greene said that MedEncentive is successful because the process is based upon behavioral science. That is, studies show that patients do not want their doctors to think they are medically illiterate and non- compliant. Conversely, doctors do not want patients to think they practice sub-standard care. The appropach taps into the doctor-patient relation- ship to generate “mutual accountability” which leads to better health and lower costs, Greene said. As of 2009, MedEncentive and Medical Justice entered into a partner- ship. Medical Justice is a malpractice carrier that has agreed to offer lower pricing to physicians who participate in the MedEncentive program and to grant physicians who participate in MedEncentive’s demonstrations free coverage during a three-year evaluation. Green said that to solve the health care cost and quality problems requires interventions that include the payer, the physician, and the consumer. Furthermore, using interactive incentives to achieve doctor- patient mutual accountability is the most efficient and effective way to control costs through better health and health care, Greene said. One also needs precision-guided interactive financial incentives to invoke a state of doctor-patient mutual accountability. Finally, one must improve health literacy through the use of information therapy. DISCUSSION Winston Wong of the Roundtable asked Person if there had been any partnerships established between the Health Care Institute’s Head Start program and state children’s health insurance programs. Person said there had not. He also said that Missouri will be making its actual cost data available after the program’s completion, and that other corporations have partnered with Head Start programs in several states. Roundtable member Benard Dreyer asked Hermanson how the efforts of the Bell Institute coincide with General Mill’s advertising and market - ing efforts. Hermanson responded that, speaking for General Mills and also as a registered dietitian, a variety of foods can fit into a diet, if taken in moderation. The cereals currently being produced by General Mills and other companies are not as high in sugar or as low in nutrients as they were 20 or even 5 years ago. By advertising the nutritional information,
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54 PROMOTING HEALTH LITERACY General Mills not only informs consumers but also challenges the indus - try to make better products for Americans. Roundtable member Amy Wilson-Stronks asked Greene how MedEncentive is able to reach those who struggle with illiteracy, who speak English as a second language, or who have other barriers to using a Web application. Greene said that during the first year in Duncan, the city put a kiosk at the city hall and there was a steady flow of individu - als, many of whom were not computer-literate or did not know how to use computers. That year the participation rate was about 43 percent. MedEncentive urges insurance providers to encourage employees within plans and their beneficiaries who do not speak English or who have dif - ficulties with computers, to reach out to friends and family members who can help. He also said that for the right financial incentive, he believes people will find a way to participate. As time goes on, Greene said, infor- mation therapy is being delivered through video and audio messages which, it is hoped, will circumvent some of these literacy issues. Cynthia Baur of the Centers for Disease Control and Prevention said that because of strict regulations public health agencies find it very dif- ficult to conduct the kinds of consumer research that private companies do. She asked if there was a way to build partnerships between con- sumer product companies and public health agencies to do research that helps everyone better understand people’s needs and wants. Hermanson responded that it is probably true that consumer product companies have extensive data that help the companies craft messages to be relevant for consumers, in order to reach the populations the companies want to tar- get. General Mills would, she said, be open to continuing the dialogue begun at this workshop. Another participant asked Greene if physician offices need to have electronic medical records in place to participate in MedEncentive. Greene replied that the system is designed to be flexible so that it can be used in either low-tech or high-tech environments. For example, doctors can handwrite their responses for nurses to enter, as long as the nurse is enrolled in the program under the supervision of the physician. On the other end of the spectrum, some doctors have integrated the program with their tablets so that when a beneficiary arrives at the practice, a MedEncentive icon pops up to alert the physician to the presence of a relevant guideline. Isham said that he was impressed by the ingenuity of the three approaches discussed by this panel. On the one hand, there is the Head Start program that reaches out and educates a vulnerable segment of the population. Then there is the program from MedEncentive which attempts to triangulate incentives for three major stakeholders—the physician, the
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55 INDUSTRY CONTRIBUTIONS consumer, and the insurer. Finally, there is a large consumer product corporation that is teaching how to segment, label, and help people to make choices. That kind of combination of talent and approaches are needed, as is good science, Isham said, in order to make progress on health literacy.
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