7

Reflections on Lessons Learned

George Isham, the roundtable chair, asked the members of the roundtable to reflect on what they heard and learned from the commissoned paper and the presentations delivered during the workshop.

Paul Schyve said that most of his reflections centered on the subject of implementation. The first issue was the need for interaction among intrinsic motivation, extrinsic requirements, and extrinsic incentives, as discussed earlier. The second concerns what can be done directly with the consumer to increase health literacy in the population. The third is how to enable those providing care to do so in a health literate way.

Winston Wong said it is ironic that in some areas there is no thought of discussing return on investment (ROI), such as with the simple safety precaution of washing hands before seeing a patient. When does health literacy cease to be a question of ROI and instead become basic to providing good care? To move forward requires three things. One is to make the case for system-level reform. Health literacy is not just a personal attribute; it is an issue of system-level change. Second, how can meaningful measures for outcomes of health literacy interventions be developed, both in clinical areas and for population health? Third, instead of talking about incentives, what are the financial models that align with supporting the development of health literacy proficiency?

Patrick McGarry said that the workshop and, in particular, Horton’s presentation brought home why health literacy is important—because of people and because their beliefs and the context in which they live affect health. Health literacy interventions take these determinants into account.



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7 Reflections on Lessons Learned George Isham, the roundtable chair, asked the members of the round- table to reflect on what they heard and learned from the commissoned paper and the presentations delivered during the workshop. Paul Schyve said that most of his reflections centered on the subject of implementation. The first issue was the need for interaction among intrinsic motivation, extrinsic requirements, and extrinsic incentives, as discussed earlier. The second concerns what can be done directly with the consumer to increase health literacy in the population. The third is how to enable those providing care to do so in a health literate way. Winston Wong said it is ironic that in some areas there is no thought of discussing return on investment (ROI), such as with the simple safety precaution of washing hands before seeing a patient. When does health literacy cease to be a question of ROI and instead become basic to provid - ing good care? To move forward requires three things. One is to make the case for system-level reform. Health literacy is not just a personal attri- bute; it is an issue of system-level change. Second, how can meaningful measures for outcomes of health literacy interventions be developed, both in clinical areas and for population health? Third, instead of talking about incentives, what are the financial models that align with supporting the development of health literacy proficiency? Patrick McGarry said that the workshop and, in particular, Horton’s presentation brought home why health literacy is important—because of people and because their beliefs and the context in which they live affect health. Health literacy interventions take these determinants into account. 63

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64 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS Margaret Loveland said that the commissioned paper makes clear the enormous task involved in instilling concepts and practices of health literacy into providers and payors. It is encouraging to hear from the pan- elists that progress is being made and that some organizations and indi- viduals are beginning to act on health literacy. Another important point that emerged from the paper and the discussion is the idea that health literacy is closely related to patient safety, which may motivate providers to incorporate health literacy into their practices. Finally, although none of the panelists represented the pharmaceutical industry, that sector has been involved in health literacy activities for quite some time because of its recognition that health literacy and medication safety are closely related. Partnerships with that industry may be one way to advance the implementation of health literate practices, she said. Benard Dreyer expressed great admiration for the commissioned paper and the presentations. He suggested that the 18 attributes described should be reorganized and prioritized in a way that connects them more directly to accountable care organizations or patient-centered medical homes or patient safety. It might also be useful to place them in a Venn diagram with health disparities, he said. Second, something that is specific to children needs to be added. Third, the discussion about the diversity of cultures and language, which is included in the paper, should be elevated to a more prominent discussion. Finally, there is the issue of how to move the discussion into action. One of the points made is that there must be defined measures for assessing whether an organization is health literate. There are a number of current measures, including the new HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), that can be used as a start. Identification and discussion of measures may be a worthy topic for the roundtable to follow up on. Will Ross said that the paper and presentations effectively married health literacy to dimensions of quality. As a consequence, this has ele - vated health literacy as a recognized part of the pathway to quality care. The roundtable should begin discussions about and an examination of the relationship between health literacy and quality. Ruth Parker quoted Oliver Wendell Holmes, Jr., who said, “I would not give a fig for the simplicity on this side of complexity, but I would give my life for the simplicity on the other side of complexity.”1 The paper and the discussion have shown that health literacy is complicated. The next step is to discover how to make the concepts and discussion understand - able, clear, actionable, and useful. Sharon Barrett said that the paper and discussion has helped move the focus from emphasis on the patient’s responsibility to be health literate to 1 Many attribute this quote to Oliver Holmes, Sr.

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65 REFLECTIONS ON LESSONS LEARNED a focus on the responsibility of the provider and the system to encourage health literate practice. It is important to understand what the return on investment of health literate practice is. Another important concept that emerged is the need to trace what happens to patients across a continuum that includes not only the health care setting but also the patient’s cultural and home environments because those environments play key roles in determining whether patients follow treatment regimens. Clarence Pearson said that the workshop has shown the importance of getting four sectors—government, business, nonprofits, and academia— to work together to foster health literate practices. Susan Pisano said that the commissioned paper was fabulous and encouraging. The presentations were also encouraging because they showed the commitment of many different kinds of providers and orga- nizations to the concepts of health literacy. It will be important to help organizations translate the paper into action. Leadership will be crucial, but it is important to note that leadership does not have to start at the top of an organization. There have been tremendous grassroots efforts that have culminated with an organization’s chief executive officer embracing ideas that began at the bottom of the organization. Scott Ratzan said the ideas presented in the presentations and the paper were inspiring. Of particular interest, he said, were the things that the American Dental Association has undertaken to improve oral health literacy. Oral health literacy is an area that the roundtable may wish to continue to pursue, in addition to its upcoming workshop on that topic. The paper itself might benefit from an executive summary or a frame - work for action, he suggested. Is there some way to fit important points on one page so that they will be more accessible to a broader audience? Another issue to explore is a framework for what organizations might do to become health literate. Perhaps one could develop checklists or scorecards that could be used to assess the status toward achieving each of the attributes. Yolanda Partida noted that the discussion has focused on health care, but when one talks about overall return on investment, one must focus on health, on preservation, and on disease prevention. Cindy Brach said the commissioned paper was fantastic. The majority of the paper emphasizes the system or the organization. The presenta - tions were also inspiring, but discussion frequently shifted to a focus on increasing the health literacy of patients. It is important not to lose the idea that the system can be health literate. Martha Gragg said she agreed with one of the speakers that the 18 attributes presented in the paper need to be bundled. Hoverman made the point that she was hearing about some of the tools for health literate prac- tice for the first time. Perhaps the revised paper could include a resource

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66 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS guide. Another point is the need to think about measures—what particu - lar measures are needed and useful and how can these be developed. An audience member said that there is absolutely a need for showing return on investment for health literacy interventions. Even with organi- zational champions and leadership, if one cannot show a return on invest- ment, then that investment will not continue. Moving from the elevated discussion down to practicalities, the audience member asked, What are the actionable things that can be done? How can we institutionalize health literacy into our organizations, associations, and agencies? Cynthia Baur, another audience member, said that the commissioned paper is well aligned with the National Action Plan to Improve Health Lit- eracy (ODPHP, 2010). Those developing the plan recognized that it is a challenge to connect strategies or attributes with what one actually does. There is a Centers for Disease Control and Prevention website2 that has a number of tools and resources for organizations to use. Another point, Baur said, is that from her perspective health literacy encompasses both communication and education. These approaches may require slightly different infrastructures and supports. An example involving tobacco may help clarify this difference. One can deliver a message about the need to stop smoking, and that is a communication activity. It is another level of activity and support to think about supporting someone in the act of quitting smoking. In going forward with the paper, one might think about that idea. How does an organization communicate or deliver messages as well as educate or support behavior change? Audience member Steven Rush said that UnitedHealth created a sur- vey, based on the national action plan, to audit itself on health literacy. It is an interesting tool and ties in very nicely with the attributes discussed at the workshop. Leonard Epstein said the commissioned paper has the potential for two major conceptual shifts. The first is, as the title says, to focus on “the other side of the coin,” that is, on health literacy at the system level. The other shift is to integrate the concepts of health literacy with cultural language and plain language as essential ingredients for effective com- munication. The presentations foster support for broadening the concept of health literacy in these ways. Deborah Fritz suggested a communication strategy. It would be easy, she said, to reframe the paper in terms of what is desirable versus what is affordable. But if framed that way, it is easily dismissed. Rather, as this paper is disseminated, it should be defended as a vision of a health liter- ate organization. Engle’s proposed model that biological, psychological, 2 See http://www.cdc.gov/healthliteracy/.

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67 REFLECTIONS ON LESSONS LEARNED and social factors all play a significant role in disease or illness 3 was seen as utopian when it was published, but it led to a revolution in thinking about health and medicine. This paper also has the potential to change the way that people think. George Isham said that the group discussed the need to track a patient across a continuum. There is also a need for integration across a con - tinuum, including the need to integrate dental, medical care, and mental health care. This applies to health literacy as well. The commissioned paper has taken the conversation a long way in terms of practical steps for becoming health literate and the rationale behind those steps. Judging by the number and tenor of the comments during the day, everyone is eager to begin to use the input provided to revise and strengthen the paper. The first panel identified the major challenge to implementing health literate practices as financing. Isham agreed with Fritz that framing imple- mentation as an issue of resources is a disservice to the importance of health literacy. Health literacy is essential to good patient care. There is an opportunity to think about these attributes in terms of organizational effectiveness, using the concepts that come out of business schools about effective use of resources. Another way to think about these attributes is to think about the concepts in the report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). REFERENCES IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. ODPHP (Office of Disease Prevention and Health Promotion). 2010. National Action Plan to Improve Health Literacy. Washington, DC: U.S. Department of Health and Human Services. 3 George L. Engel at the University of Rochester proposed the biopsychosocial model in 1977 in an issue of Science.

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