5

Where Do We Go from Here?¹

In the workshop’s final session, Wilma Alvarado-Little, the associate commissioner of the New York State Department of Health (NYS DOH) and the director of the Office of Minority Health and Health Disparities Prevention at NYS DOH, moderated a structured question-and-answer-based discussion with four panelists: Zarita Araújo-Lane, the president of Cross Cultural Communication Systems; Linda Cottler, the associate dean for research at the University of Florida College of Medicine and College of Public Health & Health Professions; Helen Osborne, the president of Health Literacy Consulting and the host of the podcast series Health Literacy Out Loud; and Michael Paasche-Orlow, a professor of medicine at the Boston University School of Medicine.

Health professional education in caring for and interacting with individuals with behavioral health conditions

Zarita Araújo-Lane commented that a patient’s trust of the medical system is crucial for getting better results and that trust is earned, which

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¹ This section is based on the discussion among moderator Wilma Alvarado-Little, the associate commissioner of the New York State Department of Health (NYS DOH) and the director of the Office of Minority Health and Health Disparities Prevention at NYS DOH, and panelists Zarita Araújo-Lane, the president of Cross Cultural Communication Systems; Linda Cottler, the associate dean for research at the University of Florida College of Medicine and College of Public Health & Health Professions; Helen Osborne, the president of Health Literacy Consulting and the host of the podcast series Health Literacy Out Loud; and Michael Paasche-Orlow, a professor of medicine at the Boston University School of Medicine, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

implies that handing patients a questionnaire on their first visit to a provider is not going to get the desired answers. Showing empathy, appreciating what the patients are going through, focusing on the human being in the room and finding commonalities, and working hard to overcome one’s own implicit biases can help trust develop. “I think that we as providers need to start looking at ourselves and how we interact with others and what are the things that we need to improve about ourselves,” Araújo-Lane said.

Helen Osborne said it is time to get the word out to the broader medical community—not just physicians—about the importance of health literacy and how to practice it. In the same vein, she said, it is imperative that the approaches that work get disseminated as widely as possible. Noting that she is not a policy maker or researcher but rather someone who was in clinical practice, she said that what she looks for are approaches that can improve the ability of everyone on the health care team, including those in the community, to provide information in a health-literate manner. These approaches have to be practical and doable, she said, because everyone has competing priorities and work demands. She asked if there was something like the “Ask Me 3” approach that would help staff focus on health literacy when interacting with a patient.

Linda Cottler focused her comments on the need to raise awareness. July, she noted, was National Minority Mental Health Awareness Month, which had not yet been mentioned during the day’s discussions even though members of minority groups have additional stigma associated with mental illness. She then said that the University of Florida College of Medicine requires clinical staff to receive hospitality training that helps them learn how to listen and interact with people when first meeting them. When this was first instituted, provider satisfaction ratings improved, she said. Cottler also recommended the Alan Alda Communications Program, which focuses on speaking and listening. Regarding the EHR, Cottler said that most information on the social determinants of health get deposited in what is commonly called the “junk drawer.” Instead, she said, that information needs to be more prominently displayed so that physicians, nurse practitioners, and physician’s assistants will see it. Cottler also suggested moving from the term “patient-centered” to “person-centered” and watching out for the word “normal.”

Paasche-Orlow began by saying that he agreed with all of the panel’s comments so far, and he then introduced the concept of dualism, which he said he believes is part of many of the problems the workshop had discussed. One type of dualism that is pervasive is Manichean dualism, he said, which divides everything into good and evil and underlies fear. One way this manifests itself in health care is when physicians fail to touch or engage physically with a patient who has schizophrenia because of an unconscious fear of “catching” schizophrenia, which sends a subtle message of stigma.

Another form of dualism, he said, is the Cartesian or Descartes dualism, which separates mind from body and has resulted in the separation of psychiatry and the rest of medicine. In his opinion, he said, this separation leads to all kinds of unwanted phenomena, including shaming. The counter to dualism, Paasche-Orlow said, is humanism, which translates into treating a person as a human being and not as a collection of disorders and is a fundamental part of patient-centered care rather than iatrocentric care, or care organized around the fiefdoms of medicine.

Necessary system changes for incorporating health literacy (and patientcenteredness) as a core principle of care

Araújo-Lane said that incorporating health literacy as a core principle of care has to start with who becomes part of the health care profession. “Are we accepting someone who has a heart, who has a mind, who has a gut and knows how to work with all these pieces?” she asked. “If they do not, what are we doing through our training, social work, mental health, clinicians, and health care?” Taking off from that point, Paasche-Orlow said that the diversity of the mental health workforce needs to be increased “massively” and that that workforce needs to be thoroughly integrated with the rest of the health care workforce. “Part of overcoming dualism is integration,” he said.

He pointed out that the field of psychiatry has evolved to the point that many psychiatrists are actually psychopharmacologists who are not trained in the practice of talk therapy or treatment through words. “I am a primary care doctor, and I actually take more time to talk with my patients than the psychiatrist does in terms of how the [patient] panels work,” Paasche-Orlow said. He added that many institutions are experimenting with or elaborating on integrated models of care, which will eventually break down the old model of care, but, he said, the transition to a more coordinated, person-centered care model will require support, structure, and a diverse workforce.

Cottler suggested that one approach to integrating different models would be through NIH’s Clinical and Translational Science Awards. Currently, she said, about 60 institutions around the country have these awards, which are designed to transform the culture at these institutions, particularly regarding community engagement. In her opinion, she said, health literacy training would fit into these programs, which could provide funding as well as infrastructure. Cottler also suggested working with emergency departments, participating in community town halls, and working with teachers, who are often the first to spot mental health issues but who are usually not as health literate as they want to be. “They would really benefit from training,” Cottler said.

Given the data showing that one-third of people who have Alzheimer’s disease do not know they do because their physician has not told them, Cottler said, physicians need to be on the list of those who get training on how to talk to their patients about mental and behavioral health issues. She said that she and her colleagues train community health workers to do early screening for cognitive impairment, but many physicians report they do not feel comfortable talking to patients and their families about this impairment.

Osborne said that a skill needed by everyone on the care team, including the recipients and their caregivers, is problem solving when the unplanned happens. “I would hope that our structures and supervisors who staff report to can somehow offer ‘wiggle room’ and the capacity to try the untried,” Osborne said. Doing so would require an organizational change, starting with system leadership, which she said that she would like to see happen.

Paasche-Orlow said that in some parts of the country the criminal justice system acts as an extension of the public mental health system. Boston Medical Center, for example, sends mental health workers to the home after a 9-1-1 call so that the first point of contact is with a mental health worker, not a uniformed officer, which alters the scenario significantly. He added that the evidence base showing that warm handoffs and coordinated care are effective is substantial, and he questioned why it is not the standard of care. “The question is not is there evidence,” Paasche-Orlow said. “The question is why have we not changed the system to use these models?”

Resources needed to move forward with successful models

Cottler suggested that grants from funding agencies, including NIH, the National Institute on Aging, the Centers for Disease Control and Prevention, and the National Science Foundation, as well as foundations, could serve as significant resources. Beyond that, she said, she believes that the word needs to get out about the prevalence of mental health issues, even among physicians, to start drawing more attention to the needs of those with mental and behavioral health challenges.

Osborne then challenged the workshop to talk not just about moving forward, but about where the system needs to be. “Where are we going?” she asked. “I want a sense of what this is going to look like. Moving [forward] is just passing through and getting some money and resources.” She would like the health care system to become more humane and less segmented, she said. In that regard, she said, health literacy is more than just communicating better; it is actually looking at what the other person will know, do, and feel as a result. “That is what we need to consider, but what that would look like in our contemporary, broken U.S. health care system, I do not know,” she said.

Araújo-Lane said her push would be to work with, rather than just use, medical interpreters and make them part of the clinical team. She also would like to see everyone who works in a health system be more aware of what is going on with those who are interacting with the health system. She said,

In her opinion, she said, the health system is afraid of having people who are from different cultures and backgrounds, but that will have to change because the demographics of the nation are changing.

Paasche-Orlow called for research on how best to form teams and do team medicine. He noted that in a medical home, many health care workers touch a patient, but the physician might never read the physical therapist’s or social worker’s notes. He also said the nation needs a robust AHRQ, as this is the agency that should be supporting and funding this kind of work.

Important research questions and resources to implement results in practice: What are the important research questions to pursue, and what resources will health care team members need to make use of the results of this research?

Cottler said that pragmatic trials and implementation science will be important in answering such questions as how outcomes change with different literacy strategies, whether workers with different training or skill sets are more effective than others in specific settings, and if different screening instruments are more appropriate and accurate than others for use with various minorities and underserved populations. She suggested answering these questions using a network of institutions in different settings around the country—“sentinel networks”—that all work on the same research question. This approach would enable important formative research and assessments. Cottler also suggested asking patients what she called the “magic wand” question: If you had a magic wand, what would you do to change your life?

Paasche-Orlow said he was of the opinion that because of limited funding opportunities, collaborative care and integrative behavioral and mental health has already moved into the quality improvement realm. As a result, health systems are experimenting actively in this area and will

develop approaches that are effective and that they can use with patients. Referring to Araújo-Lane’s comment about including interpreters as part of the care team, Paasche-Orlow said he agreed with that idea and said that research is needed on how to best use interpreters and make them part of a team. Osborne said she hoped that all research would include a practical component.

DISCUSSION

Terry Davis asked the panelists if the increasing number of medications that people take as they age might be driving some of the depression, anxiety, and other behavioral or mental health issues that older adults are experiencing. Paasche-Orlow replied that this would be good area for research. He noted that when a patient sees a clinician with a concern about a drug’s possible side effects, the general response is to have the patient continue to take the medication. “It takes a relatively assertive patient to say they are going to stop taking a medication,” he said. He added that the U.S. Food and Drug Administration has a list of dangerous medications, called the Risk Evaluation and Mitigation Strategies list, that the agency has decided clinicians should support with augmented education for their patients. Many physicians, however, do not know which medications are on that list, and most people sign away their rights to get more education when they go to the pharmacy and say without really thinking about it that they have no questions for the pharmacist.

Johanna Martinez commented that she would have liked to have heard how to create a system that places more emphasis on the social needs of patients as a way of addressing the social determinants of health. Laurie Myers then asked if law enforcement officers receive any training on how to deal with people who are experiencing a mental health or behavioral health crisis, and Osborne asked the same question regarding prison staff. Paasche-Orlow said that prison staff do, but the training is highly variable. He said that most states have now contracted health services in their prison systems to for-profit companies, many of which actually have severely restricted formularies and access to mental health.