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7 Concluding Remarks Thomas Boat, M.D. George Isham, M.D., M.S. Nicole Lurie, M.D., M.S.P.H. The chairs of the Forum on the Science of Health Care Quality Improvement and Implementation, the Roundtable on Health Dis- parities, and the Roundtable on Health Literacy ended the workshop by providing comments on the presentations made during the day. Collaboration and creativity Collaboration, mentioned frequently throughout the workshop, is needed to facilitate change, said Boat, Isham, and Lurie. More fre- quent collaboration across the silos of disparities reduction, health literacy, and quality improvement is needed. Collaboration was also discussed in terms of working with com- munities. Sharing responsibility with communities requires that the context in which care is delivered be clearly characterized, Isham said. Characterizing populations to generate common agendas between care delivery organizations and local public health agencies builds a bridge between these two important players as they work to improve the health of individuals and the population. Practice tools are needed to drive meaningful collaboration from these two fragmented systems. Lastly, collaboration between health care systems and other industries can influence quality, Lurie said. Many problems with the delivery of health care could more effectively be solved by col- laborating with others. Ways in which others have worked through 71
72 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS communication problems are abundant, such as using pictures but not words to clearly communicate instructions for operating con- struction tools and airplane exit doors. Drawing from Wolfâs and Pignoneâs discussions (see Chapters 3 and 4), innovative methods for communication have been developed by others and should be creatively used in health care. Education is an important field for collaboration, Lurie said. The bridge connecting health literacy and basic education needs more attention, as increased graduation and GED rates are funda- mental for health and health literacy. Leaders in both communities must engage in cross-cutting conversations. Those in the health field must pay attention to how general education, performance measures, and accountability influence patientsâ health care. Bridges must be built with other fields that have components that overlap with health. Learnings from these bridges should be leveraged and shared, Isham said. Communication Communication is at the heart of quality care and needs to be improved, Boat said. A growing body of literature describes effec- tive ways to communicate. For example, motivational interviewing, which uses open-ended questions and reflective interchanges of words, is being adopted in various health care settings. Physicians lack knowledge about how to communicate effectively, including how to listen to patients and provide them with opportunities to share information necessary for developing the best possible action plan, Boat said. Changes in health professions training are needed to improve clinician communication. Data, measures, and standardization As discussed throughout the workshop, data are necessary but not sufficient to drive action, requiring the development of new methods and incentives, Lurie said. While the moral imperative is enough for some providers, others require financial incentives, resulting in the development of pay-for-performance programs. Such programs must be implemented carefully, however, as they may disadvantage some populations. Other types of individual incentives, such as cash transfers, should also be explored, Lurie said. Such programs are being tested in Mexico and New York City to get people into care. Institutional incentives should also be put
CONCLUDING REMARKS 73 in place to obtain more resources for those serving disadvantaged populations. The push to standardize care but also to customize care pres- ents a dichotomy, Isham said. Arriving at the right balance between standardization and customization for every patient, every time, is an incredibly difficult challenge, especially in the largely fragmented health care industry. This balance must be kept at the forefront of efforts to develop more standards and to provide individually tai- lored care. Developing literacy throughout the life span Literacy, in general, is achieved in the first 10 years of life, but the implications for health literacy are unclear, Boat said. It may be necessary to lay the foundation for peopleâs understanding of health in the first years of life, such as teaching the importance of diet, exercise, and sleep. We need to think creatively about universal approaches to literacy, potentially involving preschools, schools, and primary care. Lurie agreed, stating that the health care system should also be designed to teach health literacy over the course of a patientâs life, beginning with early development and adapting through old age. At-risk populations Different populations require different delivery models to pro- vide the best care; for example, at-risk populations and immigrants may require special attention. The successful execution of each model is critical to developing appropriate interventions, Boat said. The capacity for health literacy in these populations, as well as their ability to participate in programs to improve their own care, must be assessed. Community interventions may be an important strat- egy to assess health literacy, especially for children. One-third of children in underserved areas receive home visitations, which pro- vide assessment and care of mixed quality; this is an opportunity to assess what parents know, identify what children are being exposed to, and develop appropriate interventions. Another group that may require special attention is immigrants, Lurie said. Immigrant populations encounter the health care system as families, because children often accompany family members to help translate and navigate the system. The system must change to accommodate the looming demographic transitions facing the coun- try and avoid the perfect storm, described in Chapter 2.
74 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS Models of care The medical home is not yet well defined and means different things to different people, Isham said. One version of the medical home focuses on cultural and health literacy problems and faces the challenge of evaluating patient complexity at the point of care while also tailoring care to the patient. The use of payment models to catalyze development of this model should be explored. Revisiting Somersâs point, Isham noted that infrastructure that facilitates integration of disparities reduction and health literacy improvement must be built for physicians in solo practices, given the many individuals who receive such care. Furthermore, clinician training, among other infrastructure needs of these delivery models, is needed. Self-management Health literacy is the process of obtaining, processing, and under- standing information important to healthâinformation on which people must be empowered to act, Boat said. Self-management is an important concept of care organization. To facilitate self-care, patients should be educated to participate in care processes. Fur- thermore, it is the responsibility of clinicians to assess their patientsâ level of confidence and to encourage patients to become involved in developing action plans for their own care. Additionally, mecha- nisms are needed to evaluate the ongoing success of these efforts. Conclusion Each chair suggested that continued collaboration among those in health literacy, disparities reduction, and quality improvement could lead to new and exciting opportunities to positively affect health care and improve health outcomes. Specific steps for progress include â¢ using data to drive action; â¢ teaching health literacy over the life course; â¢ focusing interventions on target populations; â¢ finding a balance between standardization and customization of health care; and â¢ enhancing organizational capability to address disparities, literacy, and quality.