A Proposed Framework for Integration of Quality Performance Measures for Health Literacy, Cultural Competence, and Language Access Services Proceedings of a Workshop (2018) / Chapter Skim
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Appendix C: Commissioned Paper on a Proposed Framework for Integration of Health Care Quality Measures Related to Health Literacy, Language Access, and Cultural Competence
Appendix C: Commissioned Paper on a Proposed Framework for Integration of Health Care Quality Measures Related to Health Literacy, Language Access, and Cultural Competence
Pages 87-120
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From page 87... ...
955-3500 Fax: (202) 955-3599 Project Director: Sarah Hudson Scholle National Committee for Quality Assurance Staff: Jessica Briefer French Judy Ng Madhyatu Taylor Commissioned by the Roundtable on Health Literacy of the National A cademies of Sciences, Engineering, and Medicine 87
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Building on evidence about the common elements of effective interventions to improve patient understanding and engagement in health care and the essential components of a care system for addressing health literacy, language access, and cultural competence, we propose an integrated, patientcentered framework for measurement. Our review of existing measures finds many structure, process, and patient experience measures relevant to this framework that can be readily implemented through a patient-centered care lens, yet challenges remain.
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This will require a multistakeholder process -- including patients, representatives of different types of health care organizations, and payers -- to fully vet and develop these ideas. 1.0 INTRODUCTION Health literacy, language access, and cultural competence are commonly suggested concepts that address the provision of quality care to diverse and at-risk populations, including those facing persistent health care disparities based on individual characteristics, such as race, ethnicity, or culture, as well as communication, literacy, and language needs.1,2 Although health literacy, language access, and cultural competence are linked concepts and share commonalities -- including overlapping populations, similar implications for care providers or organizations, and the primary goal of improving quality of care -- all of these concepts have grown out of distinct histories that emphasize different aspects of care, subgoals, and patient subgroups that do not always overlap (e.g., health literacy efforts tend toward improving quality for a broad array of patients; language access and cultural competence efforts tend toward improving quality by focusing on racial/ethnic minorities or other at-risk populations)
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ties payment directly to clinician performance in four areas: quality, resource use, clinical practice improvement activities, and advancing care information (meaningful use of electronic health records) .7 In the wake of this shift to VBP, there is growing recognition that social risk factors -- such as race/ethnicity, income, education, environmental fac tors, and available resources -- should play a role in quality measurement.8,9 Because it may take more resources to care for patients with these social risk factors -- and because it may be more difficult to achieve higher performance on quality of care measures -- there are concerns that VBPs may have unintended consequences for providers who care for such at-risk populations.8,9,10 Strategies for addressing these issues include measuring health equity, setting high standards for all populations, and considering incentives for organizations that achieve or improve performance for at-risk populations.10 These may include strategies to address the unique needs of these populations as they relate to health literacy, language access, and 4 Institute of Medicine.
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While we have been referring to three general terms -- health literacy, language access, and cultural competence -- the remainder of this paper further defines other relevant concepts (e.g., communication and language assistance as an expansion of language access) , explores opportunities for alignment between multiple linked concepts, provides examples of known effective interventions addressing these concepts, details opportunities for quality measurement, and offers recommendations for using an integrated, patient-centered framework to guide broader implementation and evaluation of these critical aspects of care.
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. Retrieved from https://www.ahrq.gov/professionals/qualitypatient-safety/quality-resources/tools/literacy/index.html (accessed February 21, 2018)
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2013 Language Access Plan defines language access as being achieved "when indi viduals with LEP [limited English proficiency] can communicate effectively with HHS employees and contractors and participate in HHS programs and activities."1,18 To facilitate language access, care providers, organizations, and other entities may provide "language assistance," which is defined as "all oral and written language services needed to assist individuals with LEP to communicate effectively with HHS staff and contractors and gain meaningful access and equal opportunity to participate in the services, activities programs or other benefits administered by the HHS."17 Viewed alternatively, and as framed by the National Academies of Sciences, Engineering, and Medicine (the National Academies)
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Standards defining cultural competence as "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."22 Cultural competence may be viewed as a strategy that health care providers, organizations, and other entities use to improve quality of care and reduce health care disparities, primarily by providing services that are respectful of and responsive to diverse populations, including populations that vary by race, ethnicity, culture, or language proficiency.1,23 Cultural competence may also be viewed as the ability of -- not just a strategy used by -- providers and entities to provide such services.1 The term "cultural competence" began emerging more consistently in relation to health care in the 1990s.3 An important driver behind this was the increasing diversity of the United States population, with clinicians seeing patients with more varying perspectives regarding health, as influenced by their social or cultural background.1,22 Another important driver was the growing evidence of persistent racial/ethnic disparities in health care and the importance of providing culturally competent, patient-centered care to address these disparities and improve care quality.1,3,22 Two key IOM reports shone a national spotlight on these issues: in 2001, Crossing the Quality Chasm, and in 2002, Unequal Treatment.3,22,24,25 Outside the health policy and research world, an acclaimed 1997 book and winner of the National Book Critics Circle Award, The Spirit Catches You and You Fall Down by Anne Fadiman, brought the discussion of "ways in which American medicine is practiced across cultures" further into medical and 22 U.S. Department of Health and Human Services, Office of Public Health and Science, Office of Minority Health.
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There is evidence that the lack of cultural competence presents care barriers for many populations, including barriers related to cancer screenings and care, mental health diagnosis and treatment, maternal health outcomes, and sexually transmitted disease.2 The delivery of culturally competent care will be especially salient in addressing the disparities that affect diverse populations. 2.2 Expanded Concepts Based on National CLAS Standards and Patient-Centered Care More recent efforts to expand and align the focus of health literacy, language access, and cultural competence have pointed out the interrelatedness of these concepts and suggested new terminology.
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The enhanced standards define communication and language assistance as encompassing "all communication needs and services, including sign language, braille, oral interpretation, and written translation."28 This update is more specific in acknowledging the needs of those with certain disabilities and impairments -- such as visual, hearing, speech, and cognitive impairments.28 As mentioned previously, under the definition of "language access," "language assistance" may also be viewed as the means or process by which communication needs are met.1 Understandable Care and Services Under the enhanced standards, understandable care and services rely on a clear exchange of information between those providing care and services and those receiving them. Individuals should be able to fully com prehend how to access care and services, what their treatment options are, and what they need to get and stay well.
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communication and language assistance; and (4) engagement, continuous improvement, and accountability.28 The standards also provide an additional framework for integrating concepts that may address health literacy, language access, and cultural competence, with the enhanced standards acknowledging the broader definitions and interrelated constructs that may be entailed within the three concepts.
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. Although the original charge for this paper was to suggest an integrated framework for the measurement of health literacy, cultural competence, and language access, we applied the broader terms or meanings as described in the enhanced National CLAS Standards, including communication and language assistance, and we included patient-centered care as a complementary and expansive approach to addressing similar or related concerns.
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3.1 Evidence for Effective Interventions to Address Health Literacy, Communication and Language Assistance, and Cultural Competence There is a growing body of evidence demonstrating effective interventions for addressing health literacy, communication and language access, and cultural competence, as well as patient-centered care. The evidence shows several common themes across these concepts.
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improves patients' understanding of their disease and results in improved self-management and better outcomes.35 Communication and Language Assistance A key component to achieving health literacy and reducing health disparities is to ensure that patients can communicate with medical personnel and obtain information about their conditions in their preferred language. Research shows that providing information in writing is associated with improved care, and that, like the health literacy intervention, visual aids were associated with better patient adherence among people with LEP.36 Studies show improved adherence among non-English-speaking patients when information was provided in the patient's preferred language.
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Chin and colleagues described promising interventions to improve cultural competence and reduce disparities.40 The authors recommend culturally tailored, multi-disciplinary, team-based interventions that address patients at multiple points in their interaction with the health care system. They further recommend interactive patient education approaches and family and community engagement in patient navigation efforts.
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Retrieved from https://www.pcpcc.org/sites/default/files/resources/The%20Patient-Centered%20Medical%20 Home%27s%20Impact%20on%20Cost%20and%20Quality%2C%20Annual%20Review%20 of%20Evidence%2C%202014-2015.pdf (accessed February 21, 2018)
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3.2 Integrated, Patient-Centered Framework Based on Common Domains To develop an integrated framework for measurement, we considered the evidence, as well as standards or other authoritative guidelines for providing care designed to address the concepts of health literacy, communication and language access, and cultural competence, and we added the concept of patient-centered care. This framework illustrates how these concepts share common domains.
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training materials on health literacy,49 and the Joint Principles of the Patient-Centered Medical Home44 all highlight the importance of quality measurement, quality improvement, and accountability in implementing and continually improving the effectiveness of health literacy, cultural competence, communication and language assistance, and patient-centered care. National CLAS Standard #10 is Conduct Organizational Assess 47 Scholle, S
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Workforce Skills Preparedness of the workforce through recruitment and training has been highlighted as an important domain across all these concepts. Subdomains include • Diverse workforce • Training and workforce skills Diverse workforce The National CLAS Standards, echoed by the HHS Office of Inspector General, specify that recruitment of a diverse workforce at all levels of the organization is valuable for providing culturally and linguistically sensitive care and services.28,50 The National CLAS Standards present the rationale for a diverse workforce that includes creating a welcoming environment for culturally diverse individuals (staff and patients)
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Numerous authorities identify assessment as a critical component of providing services that are understandable and tailored to the needs, culture, and language of the patient.11,13,28,49 Assessments can inform service and resource planning at the organizational level, as well as for tailoring individual care plans. The National CLAS Standards also recommend conducting organizational assessments; however, because this activity is linked to quality improvement, we have addressed that requirement in the Accountability and Quality Improvement domain.
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likewise recommends engaging the community in the development and provision of culturally and linguistically appropriate health education and information services.48 Epstein and Street suggest that patient-centered care practices engage patients, families, and other stakeholders in developing measures to evaluate patient-centered care to ensure such measures reflect what matters to the community.30 Communication The Institute for Healthcare Communication presents evidence of the impact of communication in the health care setting.52 It describes studies that tie communication effectiveness to diagnostic accuracy, patient adherence to treatment, patient safety, and patient and team satisfaction. Patient-centered care principles and shared decision making depend on effective and supportive communication.44 The National CLAS Standards identify communication as key to avoiding malpractice, and the provision of CLAS is key to effective communication and reduction of disparities.28 Subdomains include • materials, and • oral communication.
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These include providing time for discussions between patients and providers and helping patients to feel comfortable asking questions within a therapeutic relationship.13 National CLAS Standard #1, while overarching, also points to engaging patients, and Standards #5 and #7 address the provision of language services and ensuring the competency of language service providers as a vehicle to promote and enhance patient engagement.28 The Joint Commission recommends that health care organizations "accommodate patient cultural, religious, or spiritual beliefs and practices."54 The Maryland Department of Health and Mental Hygiene's Office of Minority Health and Health Disparities recommends using collaborative care and shared decision making.51 Epstein and Street recommend that physicians display specific behaviors to ensure patients are engaged in their care,30 and the Joint Principles of the Patient-Centered Medical Home also identifies 53 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.
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Second, we suggest streamlined and innovative approaches to take advantage of existing measures and push for future efforts to fill in the gaps. 4.1 Existing Measures Address Health Literacy, Communication and Language Assistance, and Cultural Competence Health care quality measures can assess structures, processes, and outcomes.55 "Structure" refers to the infrastructure and capability of health care organizations (such as workforce and health information technology)
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A previous review of accreditation standards found that accreditation programs often have opportunities for organizations to demonstrate attention to health literacy, communication and language assistance, and cultural competence.56 However, organizations can often achieve accreditation without meeting specific program elements related to our framework, such as the collection of race/ethnicity data. Hospitals. The Joint Commission's accreditation program for hospitals addresses several elements of the framework, primarily around data collection and addressing communication needs.
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This program has not been revised since OMH's publication of the revised national CLAS standards in 2013. Uptake of this specialized program is quite limited; of the more than 1,200 health plans that currently have NCQA's Health Plan Accreditation, only 27 have NCQA's additional Distinction in Multicultural Health Care.61 Primary care practices. NCQA's PCMH recognition program for primary care practices includes expectations related to addressing health literacy, communication and language assistance, and cultural competence, and the standards address all domains of the integrated framework.
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. Several activities are related to topics extraneous to this framework but could be used as models or adapted to address health literacy, communication and language assistance, and cultural competence.
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. 4.2 Recommendations and Next Steps Despite the existence of relevant measures addressing the concepts of health literacy, communication and language assistance, and cultural competence, the uptake of these measures in existing programs and accountability efforts has been limited.
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While this tool is primarily intended for internal quality improvement efforts, it could be a useful method for assessing the implementation of the framework. NCQA's 2017 PCMH program illustrates how the integrated, patient-centered framework could be implemented in standards -- in some cases, the concepts of health literacy, communication and language assistance, and cultural competence are called out as separate elements (e.g., training and staff preparation, data collection)
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As discussed, PCMHs are highly aligned with the concepts of health literacy, communication and language assistance, and cultural competence. While there is limited appetite among providers and health care systems to implement new measures or to adopt measures that address a relatively narrow segment of the population served, there is growing interest, spurred by federal, state, and private payer incentives, in patient-centered care models.
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Stratify Existing Quality Measures to Target Improvement and Equity The ultimate goal of an integrated, patient-centered framework is to achieve equity in health care and outcomes across populations with diverse needs. We recommend stratifying existing clinical process and outcome measures by various social risk factors to assess the presence and magnitude of disparities and to monitor changes over time.
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Similar efforts to publish data on health care equity are under way in California.68,69 During the past year, CMS released three reports on disparities in Medicare Advantage health plans using data on quality and patient experiences.70 Although several helpful and detailed toolkits exist for the collection of race, ethnicity, and language data, and although collection of these data has been encouraged for many years, the data are substantially incomplete.71,72 Incomplete information on social risks limits opportunities for stratified reporting. Ng and colleagues recently showed that most health plans -- commercial, Medicaid, and Medicare -- lacked complete data on race, ethnicity, and language needs of their members.73 For the Medicare Advantage reports, CMS used statistical methods to attribute race and ethnicity where data were incomplete using other Medicare and U.S.
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Implementing structure measures may be the most immediately available opportunity, due to the high interest in patient-centered care and the alignment of payer incentives promoting PCMH adoption. This broader approach holds appeal for providers and health care organizations because it is relevant to the entire population, and it offers the added benefit of providing an integrated framework for the concepts of health literacy, communication and language assistance, and cultural competence.
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Our paper presents a first look at opportunities for the integration of health literacy, communication and language assistance, and cultural competence. The examples of measures provided are not intended to be exhaustive, but rather to be illustrative.
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CONCLUSION Although the concepts of health literacy, communication and language assistance, and cultural competence grew out of different movements and historical contexts, they have many common components and address common concerns. The enhanced National CLAS Standards have done much to integrate these concepts by broadening the way we think about language and communication and culture.
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