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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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EXHIBIT 1 Definitions

Topic Definition Author/Date
Health Literacy The degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions. Institute of Medicine (IOM). (2004). Health Literacy: A Prescription to End Confusion.
Language Access Is achieved when individuals with limited English proficiency can communicate effectively with the U.S. Department of Health and Human Services (HHS) employees and contractors and participate in HHS programs and activities. U.S. Department of Health and Human Services (HHS). (2013). Language Access Plan.
Cultural Competence A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. U.S. Department of Health and Human Services (HHS), Office of Minority Health. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care.
Communication and Language Assistance All communication needs and services; for example, sign language, braille, oral interpretation, and written translation. U.S. Department of Health and Human Services (HHS), Office on Minority Health. (2013).

National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice.

Patient-Centered Care Care that is respectful of and responsive to individual preferences, needs, and values and ensuring that patient values guide all clinical decisions. Institute of Medicine (IOM). (2001).

Crossing the Quality Chasm: A New Health System for the 21st Century.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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EXHIBIT 2 Integrated, Patient-Centered Framework

CLAS Standards Health Literacy Language Patient-Centered Care
Organization Culture and Values CLAS Standard 2: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.a Provide incentives to encourage employees to use good communication practices.b
Health care system needs to be more proactive and take responsibility to meet the needs of the people it serves by reducing the health literacy demands placed on individuals.c
The patient-centered medical home fosters an environment of trust and respect.d
Patient-centered care includes an interdisciplinary care team, which is led by a qualified provider of the patient’s choice who guides care in a continuous, accessible, comprehensive, and coordinated manner.d
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
CLAS Standards Health Literacy Language Patient-Centered Care
Accountability and Quality Improvement CLAS Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.a
CLAS Standard 11: Collect and maintain accurate and reliable demographic data. When linked with other data, health and health care organizations can make increased data-informed decisions and improve the quality of care, consistent with quality improvement activities.a
CLAS Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.a
Employ monitoring and accountability for health literacy policies and practices.e Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.f
Patients and families participate in quality improvement activities at the practice level.f
Routinely undertakes efforts to identify and eliminate any disparities in the quality of care received by its patients.d
Workforce CLAS Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce responsive to the population in the service area.a
CLAS Standard 4: Educate and train governance, leadership, and workforce in culturally and
Support changes to improve public health professionals’ health literacy skills.c
Professional continuing education programs in health and related fields should incorporate health literacy into their curricula and areas of competence.e
Training physicians to be more mindful, informative, and empathic transforms their role from one characterized by authority to one that has the goals of partnership, solidarity, empathy, and collaboration.g
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
CLAS Standards Health Literacy Language Patient-Centered Care
linguistically appropriate policies and practices on an ongoing basis.a
Assessment
Individual CLAS Standard 11: Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.a Health literacy assessment should be a part of health care information systems and quality data collection.e
Evaluate the effectiveness of communications.c
Ensure that health information is relevant to the intended users’ social and cultural contexts.h
Assess the language assistance needs of current and potential customers to inform policy and processes necessary to implement language assistance services that increase access to programs and services for all populations.i Collects data on race, ethnicity, sex, primary language, and language services for each patient and records that information in a manner that can be reported and used to plan and respond to the health and language needs of patients in the practice.d
Community CLAS Standard 12: Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.a Consider the current literacy level of the intended audience and design messages based on that level.c Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.c
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
CLAS Standards Health Literacy Language Patient-Centered Care
Community Engagement CLAS Standard 13: Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.a Involve representatives from target audiences in planning, implementing, disseminating, and evaluating health information and services.c
Develop key partnerships to help facilitate change, influence behavior, and generate interest in health literacy.c
Develop partnerships with local programs and institutions that improve quality and access to services, strengthen systems, and formulate effective policies. This includes fostering broad, interdisciplinary approaches to health literacy.e
Relevant stakeholders, patients, families, clinicians, and health systems should be involved in developing a family of measures to capture important aspects of patient-centered care. Doing so will also provide an opportunity to align stakeholders’ perspectives on what counts as patient-centered care and how it should be accomplished.g
Collaborate with patient and family advisors in quality improvement and practice redesign.d
Communication
Materials CLAS Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.a Present health information in varied forms/mediums or written in clear, everyday terms so that people can take needed action.e
Use plain language, including key elements.c,h
Supplement instructions with pictures.h,j
Make written communication look easy to read.h,j
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Improve the usability of information on the Internet.h,j
Consider the communication capacities of the intended users, including those with communication disorders/challenges. Tailor communication strategies to their needs and abilities.h
Consider the current literacy level of the intended audience and design messages based on that level.c
Be sure the materials and messages reflect the age, social and cultural diversity, language, and literacy skills of the intended users. Consider economic contexts, access to services, and life experiences.h,j
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
CLAS Standards Health Literacy Language Patient-Centered Care
Oral CLAS Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.a
CLAS Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs at no cost to them to facilitate timely access to all health care and services.a
Health practitioners communicate clearly during all interactions with their patients using everyday vocabulary.e
Avoid jargon and explain technical or medical terms.h
Ask open-ended questions instead of those that can be answered with “yes” or “no.”j
Use the teach-back method to ensure the message is understood and remembered.j
Ensure health information and services are appropriate, actionable, and easy to understand and use.c
Information and education to facilitate autonomy, self-care, and health promotion.i
A more active invitation for involvement.g
Tailored communication to patients’ needs to permit meaningful deliberation and shared mind.g
CLAS Standard 1: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.a Patients should receive care whenever they need it and in many forms, not just face-to-face visits.e
Provide health information in a manner appropriate to the audience.e
Allow ample time for discussions between patients and health care providers.e
Patients feel free and comfortable to ask questions as part of the healing relationship.e
Acknowledge patients as persons in context of their own social worlds who are listened to, informed, respected, involved in their care, and whose wishes are honored (but not mindlessly enacted).g
Provide emotional support and alleviation of fear and anxiety.i
Caregivers’ patient-centered care considers both the art of
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
generalizations and the science of particulars.g
The patient-centered medical home “knows” its patients and provides care that is whole-person oriented and consistent with patients’ unique needs and preferences.d
Patients and clinicians are partners in making treatment decisions.d

a U.S. Department of Health and Human Services, Office of Minority Health. (2013, April). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Retrieved from https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf (accessed February 21, 2018).

b U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Retrieved from https://health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf (accessed February 21, 2018).

c Centers for Disease Control and Prevention. (n.d.). Welcome to Heath Literacy for Public Health Professionals. Retrieved from at https://www.cdc.gov/healthliteracy/training/index.html (accessed February 21, 2018).

d National Partnership for Women and Families, Principles for Patient- and Family-Centered Care: The Medical Home from the Consumer Perspective (2009) as quoted in Scholle, S. H., Torda, P., Peikes, D., Han. E., and Genevro, J. (2010, June). Engaging Patients and Families in the Medical Home. Retrieved from https://pcmh.ahrq.gov/sites/default/files/attachments/Engaging%20Patients%20and%20Families%20in%20the%20Medical%20Home.pdf (accessed February 21, 2018).

e Institute of Medicine. (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press.

f American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. (2007, March). Joint Principles of the Patient-Centered Medical Home. Retrieved from http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf (accessed February 21, 2018).

g Epstein, R., and Street, R. L. J. (2011). The values and value of patient-centered care. Annals of Family Medicine, 9(2), 100–103. doi: 10.1370/afm.1239.

h U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Health Literacy Basics. Retrieved from https://health.gov/communication/literacy/quickguide/factsbasic.htm (accessed February 21, 2018).

i U.S. Department of Health and Human Services. (2013). Language Access Plan. Retrieved from https://www.hhs.gov/sites/default/files/2013-hhs-language-access-plan.pdf?language=en (accessed February 21, 2018).

j U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Improve the Usability of Health Information. Retrieved from https://health.gov/communication/literacy/quickguide/healthinfo.htm (accessed February 21, 2018).

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

EXHIBIT 3 Structure Measures

Structure Measures Domains of Integrated Patient-Centered Framework
Organization Culture/Values Accountability/QI Workforce
Staff and Patient Surveys
Communication Climate Assessment Toolkit (C-CAT)a Leadership commitment Performance evaluations Workforce development
Organization Survey
Cultural Competency Implementation Measure (RAND)b Leadership Integration into management systems and operations Data collection, public accountability, and quality improvement Workforce diversity and training
Accreditation
Hospital Accreditation (Joint Commission)c Use data and information in decision making.

Set priorities for performance improvement and patient health outcomes.

Use the results of data analysis to identify improvement opportunities.

Collect data on the patient perception of the safety and quality of care, treatment, or services.

Governing bodies conduct orientation regarding safety and quality for the population served.

Staff is oriented to cultural diversity based on their individual responsibilities.

Staff receives education and training regarding the population served.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

Community Engagement Assessment Communication Patient Engagement

Community engagement Information collection Cross-cultural communication Language services Health literacy Individual engagement

Community engagement Data collection, public accountability and quality improvement Patient–provider communication Care delivery and supporting mechanisms

Leaders involve staff and patients in the design of new or modified services of processes The needs of the population served guide decisions about which services will be provided.

Identify the patient’s oral and written communication needs.

Provide language interpreting and translation services.

Provide information to the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs.

Perform a needs assessment for each patient, including the patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.

Provide information in a manner tailored to the patient’s age, language, and ability to understand.

Evaluate the patient’s understanding of the education and training provided.
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Structure Measures Domains of Integrated Patient-Centered Framework
Organization Culture/Values Accountability/QI Workforce
Health Plan Accreditation (NCQA)d QI program description specifies objectives for serving a culturally and linguistically diverse population. Report selected HEDIS measures.

Demonstrate quality improvement.

Quality improvement programs include objectives for linguistically diverse and special needs populations.

Member satisfaction is assessed.

Adjust the providers in its network to meet the cultural and linguistic member needs
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

Community Engagement Assessment Communication Patient Engagement
Assess characteristics and needs of the population, including race/ethnicity, cultural health beliefs and practices, preferred languages, health literacy, vision and hearing limitations, and other communication needs.

Assess the availability of community resources.

Provides notice of member rights, appeals process in culturally and linguistically appropriate manner.

Provides communication and language assistance services at no cost for member services, complaints, and appeals.

Materials (provider directories, QI program information, decisions about grievances and appeals) in easy-to-understand plain language.

Organization tests directory, and health appraisal, patient self-management tools for ease of use and readability.

Health assessment and patient self-management tools provided in multiple formats: digital, printed, telephone.

Organization provides resources to communicate with those with special visual/hearing needs.

LTSS care plans include assessment of member goals and preferences, including preferred method of communication, and self-management plan.

Patient self-management tools are used.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Structure Measures Domains of Integrated Patient-Centered Framework
Organization Culture/Values Accountability/QI Workforce
Multicultural health care distinction (NCQA)e Program description includes objectives for serving a culturally diverse membership Lists measurable goals for improving CLAS and reducing disparities Assesses the use of and experience with language services.

Evaluates the effectiveness of interventions to improve CLAS and reduce disparities.

Reports HEDIS Diversity of Membership measures.

Analyzes the capacity of the network to meet the cultural and language needs of the membership.

Uses competent interpreter or bilingual services.

Supports practitioners in providing competent language services.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

Community Engagement Assessment Communication Patient Engagement
Has a process to involve the diverse community in QI Collects data on race/ethnicity and language needs of individuals and of community Translates vital documents into threshold languages.

Provides timely and competent interpreter or bilingual services.

Collects and publishes information about practitioner languages and language services.

Supports practitioners in providing language services.

Provides notice of the availability of language services in appropriate languages.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Structure Measures Domains of Integrated Patient-Centered Framework
Organization Culture/Values Accountability/QI Workforce
Primary Care Practices (NCQA Patient-Centered Medical Home [PCMH] 2017)d Clinician and leadership support the PCMH model.

Communicates and engages patients on the medical home.

Identifies disparities in care; implements actions to reduce the disparity.

Stratifies performance data by race and ethnicity or by other indicators (for example, age, gender, language needs, education, income, type of insurance, disability, health status).

Identifies a vulnerable group in the patient population where there is evidence of disparities.

Sets goals and acts to improve performance.

Builds a health-literate organization (for example, applies universal precautions, provides health literacy training for staff, system redesign to serve patients at different health literacy levels).

Acts to establish processes that address health literacy to improve patient outcomes.

Educates staff on how to interact effectively with people of different cultures.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

Community Engagement Assessment Communication Patient Engagement
Involves patients and families in governance and QI.

Uses information on the population served by the practice to prioritize needed community resources.

The practice maintains a community resource list by selecting five topics or community service areas of importance to the patient population.

Assesses the usefulness of resources by requesting and reviewing feedback from patients/families/caregivers about community referrals.

Engages with schools or intervention agencies in the community.

Collects information on how patients identify, for example, race, ethnicity, and other aspects of diversity, such as gender identity, sexual orientation, religion, occupation, and geographic residence.

Documents language needs in its records.

Provides comprehensive health assessment.

Demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources, or other tools to serve the ongoing needs of its population.

Demonstrates an understanding of the patients’ communication needs.

Uses patient-centered methods, such as open-ended questions (for example, Teach-Back or collaborative method).

Develops patient care plans for the patients identified for care management.

Works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan.

Addresses barriers.

Works with patients/families/caregivers to develop self-management instructions.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Structure Measures Domains of Integrated Patient-Centered Framework
Organization Culture/Values Accountability/QI Workforce
Program Requirements
Medicare Merit-Based Incentive Payment System (MIPS)f Improvement Activities Leveraging a QCDR for use of standard questionnaire (for reducing disparities) Implementation of formal quality improvement methods, practice changes, or other practice improvement processes.

Participation in CAHPS or other supplemental questionnaire (like cultural competence)

a University of Colorado, Center for Bioethics and Humanities (n.d.). About C-CAT. Retrieved from http://www.ucdenver.edu/academics/colleges/medicalschool/centers/BioethicsHumanities/C-CAT/Pages/About-C-CAT.aspx (accessed February 21, 2018).

b National Quality Forum. (2012, August 10). NQF Endorses Healthcare Disparities and Cultural Competency Measures. Retrieved from http://www.qualityforum.org/News_And_Resources/Press_Releases/2012/NQF_Endorses_Healthcare_Disparities_and_Cultural_Competency_Measures.aspx (accessed February 21, 2018).

c The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Retrieved from http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf (accessed February 21, 2018).

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

Community Engagement Assessment Communication Patient Engagement

Engagement of community for health status improvement.

Practice improvements that engage community resources to support patient health goals.

Regular review practices in place on targeted patient population needs.

Use of toolsets or other resources to close health care disparities across communities.

Leveraging and QCDR to standardize processes for screening (for social determinants) Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities. Engagement of new Medicaid patients and follow-up.

Improved practices that disseminate appropriate self-management materials (address literacy, language).

Leveraging a QCDR to promote use of patient-reported outcome tools.

Engagement of patients, family, and caregivers in developing a plan of care.

Evidence-based techniques to promote self-management into usual care.

d National Committee for Quality Assurance. (2017). Patient-Centered Medical Home (PCMH) Recognition. Retrieved from http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx (accessed February 21, 2018).

e National Committee for Quality Assurance. (2010). Multicultural Health Care Distinction. Retrieved at http://www.ncqa.org/programs/other-programs/multicultural-health-caredistinction (accessed April 24, 2017).

f Centers for Medicare & Medicaid Services. (n.d.) Quality Payment Program: Learn About the Program. Retrieved from https://qpp.cms.gov/learn/qpp (accessed February 21, 2018).

NOTE: CAHPS = Consumer Assessment of Healthcare Providers and Systems; CLAS = Culturally and Linguistically Appropriate Services; HEDIS = Healthcare Effectiveness Data and Information Set; LTSS = long-term services and support; NCQA = National Committee for Quality Assurance; QCDR = Qualified Clinical Data Registry; QI = quality improvement.

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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EXHIBIT 4 Process Measures

Target Entity Measures Source
Health plan/prescription drug plan Percent of time that teletypewriter services and foreign language interpretation were available when needed by prospective members who called the plan’s prospective enrollee customer service phone number. Centers for Medicare & Medicaid Services Star Ratingsa
Hospital The percentage of limited English proficient patients receiving both initial assessment and discharge instructions supported by interpreters who are assessed and trained or from bilingual providers and bilingual workers/employees assessed for language proficiency. The George Washington University School of Public Health and Health Servicesb
Hospital The percentage of patient visits and admissions where preferred spoken language for health care is screened and recorded. The George Washington University School of Public Health and Health Servicesc
Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×
Target Entity Measures Source
Medical group Stable coronary artery disease: percentage of patients with stable coronary artery disease who have demonstrated an understanding of how to respond in an acute cardiac event by “teaching back” as to how they would respond in the case of acute cardiac event. Institute for Clinical Systems Improvementd

a Centers for Medicare & Medicaid Services. (n.d.). Star Ratings. Retrieved from https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx (accessed February 21, 2018).

b Agency for Healthcare Research and Quality. (n.d.). Language Services: The Percent of Limited English-Proficient (LEP) Patients Receiving Both Initial Assessment and Discharge Instructions Supported by Assessed and Trained Interpreters or from Bilingual Providers and Bilingual Workers/Employees Assessed for Language Proficiency. National Quality Measures Clearinghouse). Retrieved from https://www.qualitymeasures.ahrq.gov/summaries/summary/27296/language-services-the-percent-of-limited-englishproficient-lep-patients-receiving-both-initialassessment-and-discharge-instructions-supported-by-assessed-and-trained-interpreters-or-from-bilingual-providers-and-bilingual-workersemployees-assessed-for-language (accessed February 21, 2018).

c Agency for Healthcare Research and Quality. (n.d.). Language Services: The Percent of Patient Visits and Admissions Where Preferred Spoken Language for Health Care Is Screened and Recorded. National Quality Measures Clearinghouse. Retrieved from https://www.qualitymeasures.ahrq.gov/summaries/summary/27294/language-services-the-percent-ofpatient-visits-and-admissions-where-preferred-spoken-language-for-health-care-is-screened-and-recorded (accessed February 21, 2018).

d Agency for Healthcare Research and Quality. (n.d.). Stable Coronary Artery Disease: Percentage of Patients with Stable Coronary Artery Disease Who Have Demonstrated an Understanding of How to Respond in an Acute Cardiac Event by “Teaching Back” as to How They Would Respond in the Case of Acute Cardiac Event. National Quality Measures Clearinghouse (NQMC). Retrieved from https://www.qualitymeasures.ahrq.gov/summaries/summary/46814/Stable-coronary-artery-disease-percentage-of-patients-with-stable-coronary-artery-disease-who-have-demonstrated-an-understanding-of-how-to-respond-in-an-acute-cardiac-event-by-teaching-back-as-to-how-they-would-respond-in-the-case-of-acute-cardiac-event (accessed February 21, 2018).

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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EXHIBIT 5 Patient Experience Measuresa

Topic Cultural Competence Health Literacy Patient-Centered Medical Home
Communication X X X
Medications X X
Tests X X
Forms X
Interpreters X
Complementary and alternative medicine X
Experiences of discrimination X
Trust X
Self-management support X X
Shared decision making X
Mental health X
Provider knowledge of specialist care X
Access X

a Agency for Healthcare Research and Quality. (n.d.). Supplemental Items for the CAHPS Clinician & Group Survey. Retrieved from https://www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/index.html (accessed February 21, 2018).

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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EXHIBIT 6 Examples of Survey Items Related to Experience of Health Literacy and Cultural Competencea

Content Examples
Common to Health Literacy and Cultural Competence HL2/CU2. How often did this provider use medical words you did not understand?

HL3/CU3. How often did this provider talk too fast when talking with you?

HL17/CU8. How often did this provider use a condescending, sarcastic, or rude tone or manner with you?

Health Literacy HL4. How often did this provider use pictures, drawings, models, or videos to explain things to you?

HL14. How often did this provider ask you to describe how you were going to follow these instructions?

HL30. In the last 12 months, how often were you offered help to fill out a form at this provider’s office?

Cultural Competence CU17. In the last 12 months, did you feel you could trust this provider with your medical care?

CU20. In the last 12 months, did you feel this provider really cared about you as a person?

CU14. In the last 12 months, how often have you been treated unfairly at this provider’s office because of your race or ethnicity?

CU24. In the last 12 months, how often were you treated unfairly at this provider’s office because you did not speak English very well?

CU11. In the last 12 months, has this provider ever asked you if you have used an acupuncturist or an herbalist to help with an illness or to stay healthy?

CU26. In the last 12 months, did anyone in this provider’s office let you know that an interpreter was available free of charge?

CU32. Did any of your appointments start late because you had to wait for an interpreter?

a Agency for Healthcare Research and Quality. (n.d.). Supplemental Items for the CAHPS Clinician & Group Survey. Retrieved from https://www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/index.html (accessed February 21, 2018).

Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
×

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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Suggested Citation:"Appendix D: Accompanying Exhibits to the Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2018. A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24918.
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Health literacy, cultural competence, and language access services are distinct but inextricably linked concepts for delivering equitable care to all members of the increasingly diverse population of the United States. These concepts are linked, but they developed via different paths, and each has its own unique focus with regard to enabling every individual to obtain the ability to process and understand basic health information and services needed to make appropriate health care decisions. Fragmentation of these disciplines has impeded implementation of relevant measures for quality improvement and accountability.

To foster an integrated approach to health literacy, cultural competency, and language access services, the Roundtable on Health Literacy initiated a project with three components: a commissioned paper to propose a framework for integrating measurements of health literacy, cultural competency, and language access; a workshop to review and discuss the framework; and a second commissioned paper that will provide a roadmap for integrating health literacy, cultural competency, and language access services as well as a revised measurement framework. Held on May 4, 2017, the workshop explored the quality performance measures for integration of health literacy, cultural competence, and language access services. This publication summarizes the presentations and discussions from the workshop.

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