Table of Contents Page
Number
Acknowledgements and Disclosures 5
Abstract 6
List of Abbreviations 7
Introduction 8
Background 10
Methods 14
Results 21
Conclusion 31
Future Directions 38
Footnotes page 49
References 51
Appendix A Figures and Tables 67
Figure 1 Quality Care Indicators 68
Figure 2 Healthy Living Indicators 69
Figure 3 Summary of ACA Provisions in Medicare and Medicaid
70
Figure 4 Definitions of NAALS Health Literacy
Terms 71
Figure 5 MFH Informant Interview Questionnaire
72
Figure 6 Summary of Pertinent Finding from the
Health Literacy Synthesis Report 73 Figure 7 Key Questions Used to Examine
Available Health Literacy Data and Evidence Assessment Key
72
Figure 8 Strength of Evidence Grades and Definitions
Figure 9 Single Interventions Demonstrating
Improvements in Health Literacy
75
Figure 10 PCMH Scoring Data Sheet 76
Figure 11 Assumptions Supporting the I GET IT model
78 Figure 12 Summary of AHRQ Synthesis Report
Recommendations for Future Study
79 Figure 13 IOM Potential Intervention Points 39 Figure 14 Dahlgren and Whitehead Socioeconomic
Model
40 Figure 15 PICOTS Methodology Used in the
AHRQ Synthesis Report
80 Figure 16 The Continuous Care Cycle for
Integrating Health Literacy
Interventions as a Driver of Positive Health Outcomes.
43
Figure 17 Family -centered Practice Model: Framework for Early Childhood Intervention and Support
45
Table 1 Database Comparison Using Health Literacy Search Terms
81 Table 2 Summary of Database Searches: Health
Literacy Testing
82 Table 3 Summary of Database Searches for
Evidence of Intervention Activities in Potential High Impact Health Literacy Clinical Application Settings
83
Table 4 Summary of Health Literacy-related Projects Supported by Robert Wood Johnson Foundation
84
Table 5 I GET IT 34
Appendix B Written Communication Archive 85
1. Permissions to Reproduce Figures
a. The State of HealthCare In Missouri (Figures 1-3) Thomas McAucliffe MFH
86 b. Patient Centered Medical Home Scoring
Data Sheet-NCHQ
86 c. Dahlgren and Whitehead Model
Institute for Future Studies
d. Framework for Practicing
Evidence-based Early Childhood Intervention and Family Support
86
2 Permission to Use Interview Data 87
a. Thomas Adams-MFH
b. Gwen Raterman-HLM
Acknowledgements
The author wishes to acknowledge the contributions of Garret Powell and Glenna Daniels with the Northeast Missouri Rural Health Network to the background and body of
knowledge of low health literacy and its significant impact on the effectiveness of clinical medicine outcomes which provided the author with the real-life clinical and quality improvement experience to draw conclusions and make what she hopes will be useful contributions to improve the quality of healthcare delivery, improve patient health outcomes and reduce the cost of health care.
The author also wishes to say a special thank you to Lori Evarts MPH PMP CPH,
University of North Carolina at Chapel Hill, faculty advisor, mentor, and challenge agent, Susan Kendig JD, MSN, WHNP-BC, FAANP who graciously agreed to be a second reader and lend a high level of expert evaluation for the author’s conclusions and thoughts, Arthur Culbert, Gwen and Marty Raterman and Sam Pettyjohn with Health Literacy Missouri for their insight, guidance, and suggestions which were key to guiding the direction of the authors work in this paper and over the last 10 years of discovery and passion-building, and Carol Brownson and Seth and Nancy Emont who have proven to be excellent, patient, mentors and good listeners as they help fuel my fire for evaluation and outcomes
management. This work would not have been completed without the last minute master work of Jean Blackwell, MLS, AHIP, Information Services at the University of North Carolina at Chapel Hill Health Sciences Library.
Disclosures:
Abstract
Background: The cost of healthcare in the United States is among the highest in the world yet our health outcomes are also among the poorest in the world (IOM 2003). The cost of healthcare and how to reduce it have been of intense focus in United States economic discussions for several years (National Research Council (NRC) 2010). With the recent changes in healthcare delivery stemming from the Affordable Care Act, both private and public health care insurers are looking for ways to reduce cost and increase patient outcomes (Centers for Medicare and Medicaid Service (CMS) 2010). Centers for Medicare and Medicaid Service (CMS) have targeted identifying the underlying causes of
unnecessary hospital readmissions as an area for more intense study to reduce the cost of care and improve outcomes (CMS 2012). The Agency for Healthcare Research and Quality (AHRQ) is focusing efforts to develop evidence-base for patient centered medical homes to improve care outcomes in outpatient settings and control costs while increasing incentives for providers to develop and implement practice standards based on the evidence-based models (2010).
Methods: A literature search was conducted using PubMed, Google Scholar, and Cochrane Library resources to assess for the depth and extent of research and
evidence-based guidelines for assessing health literacy in a population and interventions that improve health outcomes and provide health-care cost savings. Many of these sources are available in peer-reviewed journals and in project reports from community-based participatory research studies and independently supported projects by the Robert Wood-Johnson Foundation (RWJF) ( 2012) and the Missouri Foundation for Health (MFH)(2012). Additional sources of information will include past studies assessing health literacy in chronic disease outcomes and tool kits and resources developed by the Institute for Healthcare Improvement (IHI, 2012), Health Literacy Studies at the Harvard School of Medicine and the AHRQ (2010) (DeWalt et al., 2010).
Results: Low health literacy has been identified as a contributing factor in patient safety and negative health outcomes (Berkman 2011). Yet, very little research has been conducted to develop and test best-practice models, measure the impact of health literacy interventions on individual and population outcomes, or prove cost effectiveness of screening for low health literacy and integrating health literacy concepts into applied interventions (Berkman, et al., 2011; Rosenbaum et al., 2007; NIH, 2012; Rutherford et al., 2004; Parker, Ratzan, Lurie, 2003; Paasche-orlow, 2011). While clinical medicine and public health practitioners have acknowledged the need for culturally sensitive health education material written/spoken/presented in plain language, the evidence-base to support the efficacy of this premise is still emerging.
Conclusions: Despite the lack of best-practice models, several strategies have emerged which can be easily integrated into standard operating procedures to improve health literacy, improve patient satisfaction and safety, and contribute to improved outcomes at nominal cost. This paper will review key findings from the literature related to emerging strategies integrating health literacy training and applications to reduce readmissions, to improve patient outcomes in primary and acute care settings for people with chronic illness. It will also suggest strategies, implications, and suggestions for future study in the areas of public health and clinical medicine
List of Abbreviations
ACA Affordable Care Act
ACP American College of Physicians Foundation AHRQ Agency for Healthcare Research and Quality CHF congestive heart failure
CMS Centers for Medicare and Medicaid Service COPD chronic obstructive pulmonary disease DHSS Department of Health and Senior Services DM diabetes mellitus
ED Emergency Department HLM Health Literacy Missouri
IHI Institute for Healthcare Improvement IOM Institute of Medicine
KFF Kaiser Family Foundation MFH Missouri Foundation for Health
NAALS National Assessment of Adult Literacy Survey NCQA National Committee on Quality Assurance NRC National Research Council
PCMH Patient Centered Medical Home
c-PCMH Certified Patient Centered Medical Home
PICOTS Population, Intervention, Comparators, Outcomes, Timing, Setting RWJF Robert Wood-Johnson Foundation
REALM Rapid Assessment of Health Literacy in Medicine TOFHLA Test of Functional Health Literacy for Adults
s-TOFHLA Test of Functional Health Literacy for Adults-short form USDE United States Department of Education
Introduction:
Health Literacy is defined as “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (Ratzan and Parker, 2000; Seldon et. al., 2000).
This ability or skill as defined here has been identified by both clinical and economic experts in healthcare as one of the most important skills necessary to improve healthcare outcomes and reduce the cost and burden of disease on
individuals, populations, and the American healthcare system. These experts are the people. People who battle with the illness, the healing, the medical
professionals working to help their patients, the insurance establishments in business to provide for health, and the community resources available to support these efforts. No study or research is necessary to determine this. All that is
necessary is to listen to real people telling real horror stories about how their lack of understanding of the terminology used to prepare them for major health events lead to disaster or how it made them feel. The American College of Physicians
Foundation (ACP) prepared a video of real people telling their stories (ACP 2012). While most of them were not familiar with the term “health literacy”, they discuss how their lack of knowledge contributed to misunderstanding and medical errors (ACP, 2012). Some of them hold themselves accountable for not understanding and asking questions. Some do not. But in the end, health literacy, not a lack of
slows or prevents healing, and costs them money and quality of life (ACP. 2012; Niehlson-Bohlman, Panzer, Kindig, 2004). To view the video go to:
http://www.acpfoundation.org/materials-and-guides/video/videos-for-patients/health-literacy-video.html.
Because of these real people, health literacy has become a topic of significant discussion in the last 10 years, though current research is limited (Berkman, 2011). Charles Kindig, M.D. Ph.D., Chair of the Committee on Health Literacy, Institute of Medicine (IOM), refers to health literacy as the “ ‘ silent epidemic’ –the lack of understanding by most professionals and policy makers of its extent and effect, and the individual shame associated with it that keeps it even more silent and hidden.” (Nielson-Bohlman et al, 2002. Pp. xiii.).
The purpose of this paper is to suggest a strategy, based on a review of the current literature, recommendations by the Institute of Medicine, and clinical
observation, to improve health literacy, improve patient satisfaction and safety, and contribute to improved outcomes at nominal cost. Included is a review of key
Background
On March 21, 2012, Yahoo News published on its Blog, The Lookout, an article highlighting data from the Kaiser Family Foundation (KFF) discussing American opinion of the Patient Safety and Affordable Care Act (ACA) two years since the signing of the bill into law (Goodwin, 2012). Chronic disease and the cost of healthcare were constant themes throughout the article, which highlights the continued national focus on health and health education (Goodwin, 2012).
Several provisions in ACA to improve health outcomes and reduce costs have already been implemented (MMAP, 2008). Others are scheduled to begin to take effect in 2012, some of which will directly affect the bottom line of healthcare institutions in Missouri and throughout the United States who struggle to improve the quality of health care delivery and reduce costs (DHSS, 2011; National
Conference of State Legislators, 2012). In 2011, The Missouri Foundation for
Health (MFH), a philanthropic foundation dedicated to improving health and health care services in the state of Missouri with particular focus on the disparate
populations, published information comparing Missouri to United States rankings in several quality care indicators and indicators of healthy living (MFH, 2010). This data is reproduced in Figures 1 and 2 in Appendix A and further illustrates how the national issues will affect local institutions.
One intervention to improve quality and reduce cost adopted by CMS
provision will reduce payments on Medicare claims to those institutions scoring higher that the 80th percentile in congestive heart failure (CHF) readmissions
(within 30 days) (Mayo Clinic Institute, 2012). Acute care facilities with readmissions over this threshold for heart attack, CHF, community acquired
pneumonia, and/or heart attack will risk payment penalties (Mayo Clinic Institute, 2012). Figure 3 below is a reproduction of Table 4 reprinted with permission from the Missouri Foundation for Health highlighting the ACA Medicaid and Medicare provisional changes in primary care (MFH, 2010).
Lorig et al., 2001). One concern, however, is the nature of these models focuses on procedural changes within institutions or changes in each “bucket”…acute care, primary care, and public health institutions. Very little research has emerged that integrates these changes with changes being made in other “buckets” to maintain patient focus on continuity of care. Yet healthcare authorities such as IOM, the Agency for Healthcare Research and Quality, and the Institute for Health Improvement have identified the need for collaborative efforts to facilitate
successful shifts from an acute (crisis) care focus to patient (prevention care) focus (AHRQ, 2010; IOM, 2001; IOM, 2003; IHI, 2003).
Included in the items listed in the Yahoo News blog was a section quoted below:
“One of the most popular components of the health care law (according to a Kaiser Family Foundation tracking poll) is set to go into effect this fall, when health care plans will have to publish a uniform, easy-to-understand
description of their benefits so that customers can comparison-shop”(Goodwin, 2012, para. 12).
health (2004). The report points out that until work in health literacy research began, educators and health professionals worked on assumptions about how patients comprehended information (IOM, 2004). Data from the health literacy component of the 2003 National Assessment of Adult Literacy Survey (NAALS) demonstrated that 22% of Americans had only basic health literacy and 14% had below basic health literacy (see Figure 4 in Appendix A for definitions of these terms) (Kutner et al., 2006).
Prior to 2004, the Institute of Medicine had published other documents identifying the high cost of American healthcare and the lack of improvement in healthcare outcomes (IOM, 2001). Health literacy began to receive much attention as a potential underlying cause or contributory factor in the poor health outcomes. It has received international attention from the World Health Organization (WHO) including health literacy and health behavior workshops at the WHO 7th Global
Conference on Health Promotion (WHO, 2009) and an information paper on the Social Determinants of Health by the South Australian Council of Social Service (WHO, 2009; Cannon, 2008).
community settings which have evidence-base and have demonstrated positive outcomes are inconsistently available, often related to funding cuts (Rutherford & Greiner, 2004; Peikes et al., 2009; Norris et al., 2002; NCQA, 2011; Lorig et al., 2001). Very few programs which provide funding at a community level to test outcomes from evidence-based chronic disease self-management and environmental improvement programming which includes health literacy remain available. These are often the first programs dropped when budget reallocation occurs. (Norris et al., 2002; Lorig et al., 2001). While much research is emerging which demonstrates the effectiveness of integrating health literacy and health education techniques into healthcare delivery across settings, with potential to improve patient safety, the evidence-base is largely lacking to prove which interventions or combinations of interventions work to improve patient outcomes and reduce cost (Berkman et al., 2011). This paper will review the current literature and synthesis reports and suggest simple strategies that can be implemented now at minimal cost to improve patient health outcomes and satisfaction to meet the demands of the imminent policy changes and provide flexibility in application for health care delivery in acute, primary, and community care settings. Suggestions for future directions and opportunities for successful collaborations will also be discussed.
Methods:
The literature search included a review of three databases, PubMed, Google Scholar, and Cochrane Library for clinical research, opinions, reviews, and
identifying health literacy as a factor in clinical outcomes and the progression of how health literacy research and findings have found its way into public policy, patient education and health promotion, and clinical application research (DHHS, 2000). The quantitative data in the tables was extracted over a period of five days from March 6 to March 12, 20121. Each database was also searched for the number
of entries for “Health Education” as a comparative term.
PubMed was selected given the policy of the National Institutes of Health to support open access to peer-reviewed research submissions (Blixrud, 2011) and the extent of resources and use of this database in clinical and research practice
(Blixrud, 2011). Cochrane Library database was selected due to the nature of its use by clinicians despite the criticism about the adequacy of the number of reviews (Chalmers et al., 2003). Google Scholar was selected because of the nature of the flexibility of advanced searches which provides a macro-view of the volume of
literature available. Data from the database searches is displayed in a side-by-side comparison format in Tables 1, 2, and 3 in Appendix A. Table 1 is provided simply to illustrate a comparison and contrast the number of “hits” using the same key words when applied to the three databases.
The Cochrane Search was executed using the key words on the left of Table 2 to identify available bodies of work in Health Literacy, Health Literacy
Screening Cost, Health Literacy with an additional filters for Numeracy and
Testing using the Title, Abstract, or Key Words Search function and filtering for
no restrictions by record status. For Table 2, the Title, Abstract, or Key Words function was used with the search term Health Literacy Testing, searching all of Cochrane Library resources, with no restrictions by record status but filtered for years 2002-2012. The articles and abstracts were screened for content as listed. The Table 3 search data was conducted in a similar manner as table 1 and 2, but used the key terms Hospital Readmission Rates, Patient-centered Primary Care, and Health Promotion to quantify the volume of literature available for these terms. The first two terms were then filtered for Health Literacy, Congestive Heart Failure, Asthma, Diabetes, and Chronic Obstructive Pulmonary
Disease (COPD) using the same reference decade 2002-2012 using the terms Programming and Health Literacy.
The data from PubMed Search for Table 1 was collected using the search builder function using key words Health Literacy and filtered for Health Literacy Screening Cost, Numeracy, and Testing then set limits to search in
only Clinical Trials, Meta-analysis, Randomly Controlled Trials and
Reviews, written in English and referring to humans for a period of 10 years. Table 3 data was obtained in the same fashion with abstracts and articles reviewed using the criteria listed above. Data from Table 3 used key terms Hospital
Readmission Rates, Patient Centered Primary Care, and Health Promotion.
criteria but was searched using the search builder with the additional phrase
Health Literacy. Both key phrases “Hospital Readmission Rates” and “Patient
Centered Primary Care” then were attached to the terms Health Literacy,
alone, then Congestive Heart Failure, Asthma, Diabetes, and Chronic Obstructive Pulmonary Disease with a third filter Health Literacy. Data in
table 3 for CHF, Asthma, Diabetes, and COPD are reported without the third filter phrase “Health Literacy” since no data was returned with this level of filter.
The Google Scholar database search for Health Literacy, filtered as an exact phrase anywhere in the article, date entered was 2002-2012 with the search limited to four subject areas: Social Sciences, Arts, and Humanities; Biology, Life Science and Environmental Science; Medicine, Pharmacology, and
Veterinary Sciences; and Administration, Finance, and Economics;
Medicine, Pharmacology, and Veterinary Sciences for data in Table 1.
The remainder of the data in Table 1 used the same filters, but the primary search “exact phrase” filter was liberalized to anywhere in the article to allow for a
reasonable comparison. Table 2 data was drawn specifically using the 39 entries for “Health Literacy Testing”. All abstract entries were reviewed for content listed in the table. If the content was not found in the abstract, then the full article was reviewed. Table 3 data used four primary search terms, Hospital Readmission Rates, Patient Centered Primary Care, and Health Promotion. The number of
Arts, and Humanities; Biology, Life Science and Environmental Science;
Business, Administration, Finance, and Economics; Medicine,
Pharmacology, and Veterinary Sciences as with the first two tables. The
search used each clinical setting (hospital, primary care, public health promotion) filtering for the key phrases using “all of the words” in the title and anywhere in the document. Then the exact phrase “Health Literacy” was added as an additional filter. Then, each disease state (CHF, Asthma, Diabetes, COPD) was added as an additional filter term in the “all of the words”, with and without health literacy as a third filter. A fourth exclusionary filter for the word education was then added. Health literacy and health education are used similarly in the literature (Berkman, 2011). The purpose of this fourth filter was to see if some studies were testing for just health literacy interventions verses health education with a health literacy component (such as third-grade level patient education resources) to reduce readmissions and improve patient outcomes.
The Robert Wood Johnson Foundation website was also searched for health
literacy publications, reports, and projects (RWJF, 2012). The mission of the Robert Wood Johnson Foundation is to “improve the health and healthcare of all
identify areas of additional need in healthcare. Table 4 provides a summary of a search using a search tool on the RWJF site which yielded a number of projects related to health literacy. The documents were reviewed for content using key words Numeracy, Health Literacy, Plain Language, and Reading Level. Some of the content was coded in more than one category depending on the target population documented in the article. The categories where then stratified into Health Literacy (HL), Literacy (L), and Education (Ed). Health Literacy was only coded if the work contained one of the key words. The results were categorized by target audience: children, parents, substance abuse, assessment, adults, culture-specific or disparate population focus, with an additional category which was pertinent but not written for a target audience. The bodies of work were further stratified as a report or an article (published in a journal).
its effects Thomas Adams (personal communication, March 12, 2012). The
conversation was precluded by an introduction of the author, the purpose of the interview, and a request for information. The staff member was also asked for permission to include current programs and initiatives in this paper. Verbal permission was granted. The e-mail confirmation is included in the Appendix B. Interview questions are listed in the Appendix A Figure 5. The questions were written to identify key facts and open discussion to determine the extent to which the organization is working with health literacy issues through its grantees.
Personal interviews were conducted with two staff members with Health Literacy of Missouri (HLM) Gwen Raterman (personal communication, March 9, 2012), Sam Pettyjohn (personal communication, March 12, 2012). These interviews were key informant interviews and conducted to identify current projects
undertaken by this organization to address the health literacy issues discussed in this paper. After introductions were made and the purpose of the conversation discussed, both key informants were asked for permission to reference the work of Health Literacy Missouri in this paper. Verbal permission was granted. The e-mail confirmation is included in the Appendix B2b and c. The interviews were open-ended to encourage discussion and obtain and update on HLM initiatives. No questionnaire was used for these interviews.
The literature review also included a review of health education research available and yielded several key documents which were used extensively
and the extent to which health literacy and patient outcomes have been and are currently under study. These documents provide a considerable evidence-base for the conclusions and recommendations in this paper.
The citations noted in the bibliography were reviewed for outcomes and methods related to health literacy interventions in community, hospital, and primary care settings. The citations were also reviewed for other processes and methodologies that worked in terms of reduced readmissions, improved health outcomes, or increased patient satisfaction.
Results:
The three databases used for the literature search for the purposes of this paper included Cochrane Library because of its use by clinicians, PubMed because of its mission, to serve as a repository for the sharing of clinical research which allows for a review of work recently published in addition to archived work, and Google Scholar, because of its search abilities and wide use (Blixrud, 2011; Miller, 2007). PubMed also provides search refinements to filter for clinical information that is more likely to use accepted research methods, such as filtering for
Five resources provided significant synthesis information, summaries of
research quality, and data on current trends. These included (AHRQ Patient Centered Medical Home), IOM Report: “To Err is Human: Building a Safer Health System” (IOM 2000), the IOM report “Rx to End the Confusion” (IOM 2004), “Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in
patients with chronic heart failure: A Systematic Review” by Ditewig and associates (2010) and “Health Literacy Interventions and Outcomes: An Updated Systematic Review (Berkman, 2011). These citations summarize recommendations for
research, general intervention strategies, efforts in health literacy, and provide much of the evidence base for the conclusions and suggestions for future action.
The Health Literacy search yielded 16, 800 citations using Google Scholar, 438 using PubMed, and 6 using Cochrane Library. By contrast, the term “Health Education” yielded 418,000 citations in Google Scholar, 27,486 records in PubMed, and 7163 citations in the Cochrane Library with reviews on 167 (see table 1). Other terms often associated or used with Health Literacy include Numeracy, Health Literacy Testing, and Health Literacy Screening. Of these terms, Health
literacy Testing yielded to largest number of entries: 26 in Cochrane, 33 in
PubMed (of which 17 were duplicates or did not include any evidence about health literacy testing see Table 2), and 39 in Google Scholar. The term Health Literacy Screening yielded the fewest entries with only 4 in Cochrane, 8 in PubMed, and 6
In an effort to review the citations for quality of information, a search of the term Health Literacy Testing using all three databases was conducted. Table 2 summarizes the results. The citations were reviewed for information that discussed the development or testing of health literacy evaluation tools and any commentaries on the reliability or validity of these tools, and their applications to public health or clinical practice over the last ten years. Many of the tools used such as Test of Functional Health Literacy of Adults (TOFHLA and the short form- s-TOFHLA) and Rapid Assessment of Health Literacy in Medicine (REALM) have been assessed and are considered reliable and valid (USDE, 2006).
The purpose of checking the literature was 1) to examine the number of citations that discussed current applications and effectiveness; 2) to evaluate the number of articles discussing how the tools were administered and if testing helped subjects increase access to health education presented in plain language; 3) how many of the citations reviewed health interventions and outcomes that had a health literacy component where testing was only discussed; 4) the effectiveness of
Interestingly, two citations in the results from the Cochrane database were omitted from the final count because neither citation referenced health literacy in the article, though they were listed in the search results using the filters. Another article cited in Cochrane that discussed effectiveness of interventions to improve health literacy in people labeled as low health-literate did not discuss how these individuals were tested to assess the level of low health literacy (Johnson, Sandford, Tyndall, 2003). Some of the articles reviewed from PubMed were counted in more than one content category if the article addressed more than one of the criteria (see Table 2 notes). As is evident in the table, this review yielded very small numbers of studies cited in the literature. These results were consistent with data reviewed and discussed by Berkman and associates (2011).
A search for privately funded initiatives from the Robert Wood Johnson Foundation yielded 35 journal articles, two policy papers, and four reports/white papers related to the subject (2012). Table 4 summarizes of the number of studies and the target audience from RWJF initiatives. Many of the health literacy projects were published and have found their way into the literature (the search included the journal name and the additional information needed for citation). Some of the journal articles were noted in the PubMed and Scholar searches. Five of eight health literacy-related citations from the search were omitted from the results in Table 4; these were focused on health literacy from a health professional
bodies of work highlighted additional RWJF initiatives with health literacy
components.
The search of the Missouri Foundation for Health site with the references to Health Literacy Missouri was also included as references and background in the formation of the conclusions drawn in this paper. The Missouri Foundation for Health is a major funder of applied health research and health projects in the state of Missouri. Health Literacy Missouri began as a MFH funded project. It has since become its own entity and is working on pilot research to identify cost savings and improved outcomes in hospital and community-based settings, which are two of the three legs of the integration model suggested in this paper. The Missouri
Foundation for Health is also currently working in numerous primary care settings in similar projects to prove cost savings and improved patient outcomes (2012).
Berkman and associates recently published a second synthesis report (first was in 2004) reviewing current trends in health literacy research, the quality of data available, and methodology used to identify potentially reliable and valid studies (2011). Their findings indicate that more information is now available than in the original report, but data in many aspects of health literacy, patient outcomes, and cost savings is insufficient in most categories of health literacy intervention and warrants further study(Berkman, 2011).
available for application to practice (see sidebar Figure 7 and Figure 8 in Appendix A) (Berkman, 2011). The association of low health literacy to health outcomes and increased Emergency Department (ED) admissions, hospital use, and breast cancer and low immunization rates was moderate (Berkman, 2011).
Other health outcomes had low or insufficient evidence to determine a relationship (Berkman, 2011). Only moderate evidence demonstrated low literacy with taking of medication inappropriately, the inability to understand and use food labels and health messages, and problematic health status in older Americans (Berkman, 2011). Very little evidence (low) was available to show an association between the difference in health literacy level and the cost of healthcare, numeracy and health outcomes with relational studies only discussing health literacy and numeracy (Berkman, 2011). The review of single interventions to improve health literacy showed low to insufficient data to confirm the effectiveness (Berkman, 2011). Several interventions used alone showed enough improvement for the committee to acknowledge (Berkman, 2011). These single interventions are listed in Figure 9 below. Studies using interventions to increase health literacy with combinations of features (verses only one) showed moderate evidential strength only for intensive self-management and adherence to a reduction in ED use and
Excerpt from The Commonwealth Fund’s Safety Net Medical Home Initiative
“Patient-centered practices endeavor to increase their patients’ involvement in decision making, care, and self-management. They see effective health care as being respectful of a patient’s needs, preferences, and values, and work to ensure patients understand what is being communicated to them.”
(Wagner et al., 2012. Pp. vi.).
combination intervention and the efficacy on disparities, the combination health literacy interventions demonstrated mediation2 possibilities between racial
disparities and health outcomes(Berkman, 2011). The committee noted… “…effective interventions were high intensity, theory-based, had been pilot tested, and included skill-building exercises conducted by a health professional…” (Berkman, 2011. Pp. 219). Two interventions commonly used in public health practice designed to be used in public and clinical settings that meet these criteria include the Chronic Disease Self-management Training Program from Stanford and Diabetes Self-management Training Programs based on American Diabetes Association
guidelines (DHSS, 2010; Hanni, 2007; Lorig, 2001, Norris et al., 2002, Minet et al., 2010). Health Literacy
interventions that increase immediate knowledge4 (what high and low blood sugar feels like and what to do to treat
and prevent it using pictures and plain language), increase self-efficacy (receiving the praise and the satisfaction of successfully performing self-monitoring of blood glucose-demonstrate, coach, teach-back method), and increasing behavior change (verbalizes still
feeling full after decreasing amounts of potatoes and noodles and increasing vegetables daily after setting a goal to do so 4to 5 days per week-(patient goal setting and food journaling in plain language) were consistently found in the literature to be effective
During the health literacy literature review, many studies that used key words from the search discussed applications in hospital or acute settings as a part of transitions care to reduce readmission rates. The pivotal work in hospital
readmission reduction began with the IHI report Transforming Care at the Bedside
with funding from RWJF set up four over-arching guidelines: 1) Safe reliable care 2) Vitality and Teamwork 3) Patient Centered Care, and 4) Value-added care
processes (Rutherford, Lee, and Greiner, 2006). Minott (2007) provides a summary and some interpretation of the IHI report. Since then, many studies and
discussions have appeared in the literature. Ditewig and associates (2010) published a synthesis report of self-management interventions in CHF at the hospital level. The conclusions drawn were that several of the studies had
methodological concerns, which clouded the validity of the outcomes (Ditewig et al., 2010). Despite the conclusions, the results of 19 studies reviewed showed a
decrease in all-cause readmissions as well as CHF, lower death rate, and increased patient quality of life (Ditewig et al., 2010). Baker and colleagues (2002) found literacy as an independent risk factor for hospital readmission rates. This group tested for dementia and used the TOFHLA to verify literacy levels(Baker et al., 2002).
Excerpt from the American College of Physicians-What Is a
Patient-centered Medical Home.(2012. Pp. vi)
A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs
or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic
illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician,
works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and
safety
2008; CMS, 2012; Silow-Carroll, Edwards, Lashbrook, 2011). The concept behind this methodology involves a multidisciplinary team usually with an RN or
pharmacist coordinator who oversees the education, ensures the patient
understands “survival skills4”, and communicates to the primary care provider and/
or designee, as well as coordinating any other follow-up appointments the
individual may need post discharge. This also involves follow-up care usually via telephone and to primary care 24-72 hours post-discharge to assess progress, needs, and ensure the patient has safely “transitioned” to the next level of care. Minott (2007) and IHI both conclude more valid reliable research is needed before
standards of care can be established and identify important areas for future research
(Rutherford, Lee and Greiner, 2004). Health Literacy Missouri is currently
undertaking pilot projects in two hospital facilities to integrate health literacy training into operations (S. Pettyjohn, personal
Pettyjohn, personal communication, March 12, 2012). The next level of care where health literacy interventions could have positive impact is during follow-up at the primary care and specialty levels. In this realm of patient care, the literature revealed research is just emerging about the efficacy of using a patient centered medical home model to improve outcomes, reduce cost, and maintain continuity of care. The goal of the PCMH is to put the primary care physician on point to
with permission (see Appendix B1b), which includes several sections related to
“case-management” and “care coordination”. Several organizations are awarding demonstration project awards and supporting research to prove efficacy in this area (AHRQ, 2010; NCQA, 2011; ACP, 2012). In Missouri, the MFH is also working with several primary care clinics with the Missouri Medical Home Collaborative to assist them as they work through this conceptually new certification process (MFH, 2012).The literature search and review of the synthesis articles indicated a “gap in the research” which is also identified by Williams and colleagues in 2008. The websites for NCQH, (2011) AHRQ, (2010) and ACP (2012) each contained applications for demonstration projects/funding/awards in these areas.
Conclusions:
Single interventions designed to improve health literacy do not yet have adequate research to confirm a causal effect on health outcomes or the reduction of health costs (Berkman et al., 2011).
People 2010 objectives, specifically 11-2 which discusses health literacy as an
“…important component of health communication, medical product safety, and oral health…” (Niehlson-Bohlman, Panzer, and Kindig, 2004. Pp. 25) (HHS, 2000). They discuss the WHO view of the importance of health literacy principles and
interventions in health promotion and communication (Niehlson-Bohlman, Panzer, and Kindig, 2004). The authors also point out that adequate communication is key to dealing with chronic diseases that, left unattended, lead to acute illness
(Niehlson-Bohlman, Panzer, and Kindig, 2004). Niehlson-Bohlman and associates (2004) confirm that healthcare leadership in the United States and world-wide agree that improving health literacy is an absolute necessity to assure not only patient safety, but also public health safety related to the ability to understand what to do if attacked using bioterrorism and maintaining a safe home
environments. The Institute of Medicine later uses the term “patient-centered approach” which, according to Nielsen-Bohlman and associates, (2004) focuses on two cross-cutting interventions in communication”…”cultural and social sensitivity and improving health literacy” (pp. 11).
The Patient Safety Affordable Care Act (ACA) was written into law to pioneer a legislative effort to initiate true healthcare reforms. Health care costs are rising in America, and while our technology is far superior to many countries, healthcare outcomes and systems are often compared to non-industrialized countries
somewhat after the appeals and legal processes, many components of the ACA make an integrated approach to healthcare federal policy, in an effort to improve health outcomes while reducing cost (DHSS, 2012; DHSS, 2011; Office of Legal Counsel, 2010). It includes provisions for changes in health care delivery from acute care to a prevention and chronic control focus (Office of Legal Counsel, 2010). The ACA language specifies provision for not only changes in acute and ambulatory
(outpatient care) and in primary care settings, but also increased support for and utilization of community (public) health resources. These provisions are very consistent with the socio-economic model for the social determinants of health (Office of Legal Counsel, 2010).
By the fall of 2013, CMS will start reducing payments to hospitals and primary care clinics who demonstrate healthcare quality indicators outside of acceptable thresholds, such as readmission rates below 80 % within 30 days for CHF (Mayo Clinic Institute, 2012). In order to improve the quality of health care delivery, hospitals, institutions, and health care professionals must take action now to improve the quality of healthcare delivery or risk the loss of payment, which could lead to a reduction in the institutional capacity to provide healthcare services. Public health organizations have an opportunity to work with healthcare
institutions and policy makers to garner ongoing support for community
public health services as well (Prevention Institute, 2011). Until research can test and develop models which include strategies to improve health literacy, increase patient safety and health outcomes while controlling costs, there are some cost-
effective strategies fragmentally in use in various settings that can be implemented
Table 5. I GET IT
1. Include low health literacy as a universal precaution (Paasche-Orlow, 2011). 2. Grow collaborative communication between hospital, primary care and public health settings to provide patient education and services which include health literacy training (Nutbeam, 2000; Rudd, 2006; Rudd, 2007)
3. Educate patients across all settings about their illness, what to expect, how to treat and prevent complications, and how to communicate with their healthcare team when problems arise (Shohet& Renaud, 2006)
4. Train students and health professionals about speaking and writing in plain language that is sensitive to their patient’s cultural needs (Parker & Kendig, 2006; Berwick, 2011; Shohet & Renaud, 2006, Rudd, 2007; Gazmararian et al., 2003; Bryan, Kreuter, Brownson, 2009; Price-Haywood et al., 2010)
5. Identify health literacy issues using reliable and valid assessment tools in self-management settings and adjust self-self-management training accordingly (Niehlson-Bohlman, Panzer, and Kindig, 2004)
together, now, will likely improve health literacy, improve patient outcomes and control health costs (Berkman et al., 2011, Niehlson-Bohlman, Panzer, and Kindig, 2004). According to the literature, these strategies summarized in the I GET IT format in the following table, have been used at various levels of healthcare delivery and are applicable across healthcare settings.
Much of the literature reviewed, especially the search for health literacy testing, indicated that many people, especially those most vulnerable read below 6th
grade level (Paasche-Orlow, 2011; Rudd, 2006). Rather than testing and screening
all patient populations, “re-engineer” or
I
nclude patient instructions, notices,releases, and education material to be readable at a 6th grade level (or lower).
Ensure that institutional signage use pictures and plain language ( instead of radiology) (Rudd, 2011).
G
ather and develop collaborative organizations within communities that
E
ducating patients and the use of health communication strategies isfundamental to improving healthcare quality (Shohet & Renaud, 2006,
Gazmararian et al., 2003). Improving health literacy beats at the heart of quality health education. Patient safety has been the focus of much of the literature
reviewed in this paper and continues as such regarding ongoing research (Coleman et al., 2005; Cordasco, et al., 2009). Survival skills should be taught in plain
language with respect to the individual’s cultural background at all levels, from acute care to primary care, to community level services people use every day, such as the health department, Women, Infants, and Childrens (WIC) offices, grocery stores, pharmacies, and school programs. Knowing how and when to take medicine and what it is for; maintaining hydration and having access to healthy food choices; knowing the signs and symptoms of acute illness and what to do about it; and knowing when to call for help before the problem gets out of hand-all these things must be taught and repeated at all levels in plain language to improve outcomes (Nutbeam, 2000; Shohet & Renaud, 2006; Rudd, 2006; Rudd, 2007).
This will happen at all levels when health careers students, starting in primary and high school, are taught about health and healthcare, and then receive
T
raining in strategies for improving health literacy in college and post-graduatelevels (Parker & Kendig, 2006;Berwick, 2011; Shohet & Renaud, 2006, Rudd, 2007; Gazmararian et al., 2003; Bryan, Kreuter, Brownson, 2009; Price-Haywood et al., 2010). Acute, primary, and community healthcare institutions must make
mandatory during initial orientation and annually. This commitment must be
reflected in institutional policy, practiced, and enforced by healthcare leadership (Parker & Kindig, 2006; Rosenbaum, 2007; Shohet& Renaud, 2006).
Use health literacy screening and testing for interventions that
I
dentifycertain populations (such as a senior exercise class or a diabetes training designed for pregnant women with gestational diabetes) to tailor materials used at the intensive self-management level (Johnson, Sanford, & Tyndal, 2003; Berkman et al., Niehlson-Bohlman, Panzer, and Kindig, 2004). Ensure all levels of healthcare are encouraging attendance at self-management training programs and education using the collaborative to market and support institutional efforts in these areas.
Use primary care clinics that have become c-PCMH (certified Patient
Centered-medical Homes) to
T
rack outcomes data and identify areas in need ofquality improvement (IOM, 2001; IHI, 2012). As part of the collaboration and friendly hand-offs between institutions, ensure patient education and acute care data is shared across settings (Brownson et al., 2007). Maintain transparency through collaborative efforts to share outcomes and cost data (IOM, 2001).
The assumptions made by the author to support these strategies are
require, like many successful interventions, partnerships and collaboration to be successful (Brownson et al., 2007). The difficult part of any model or innovative idea is the How. How do we make it happen?
Future Directions
What we do know after studying the relationship of the social determinants of health and their influence on behavior, is that in order to empower people to take charge of their health and treat and prevent illness, education and
self-management training must be integrated into all aspects of an individual’s life (Bandura, 1998). Many innovative models for improving health and healthcare quality have included not only health education innovations but also environmental and social changes that promote healthy lifestyles (Anderson et al., 2003). Although evidence suggests that chronic disease self-management training empowers
patients to take charge of their health and supports behavior change, many people still struggle to understand much of the instruction they receive (Paasche-orlow et al., 2005; Norris et al., 2002; Rich et al., 1995; Safeer, Cooke, Keenan, 2006; Sanders
et al., 2009; Toman, Harrison, Logan, 2001). Health literacy has come to mean more than the ability to understand
Figure 13. IOM Potential Points for Health Literacy Integration
Figure 13. Nielson-Bohlman, L., Panzer, A.M., Kindig, D.A. (Ed). (2004). Health Literacy: A Prescription to End
Confusion. National Research Council. The National Academies Press. Washington DC.
evaluation of new health literacy measures, interventions in schools, initiation of health literacy competencies in professional education, healthcare system
intervention to reduce safety risks associated with low health literacy, and a call on accrediting bodies to include health literacy in their standards of care measures (Parker & Kindig, 2006). The authors of the AHRQ Health Literacy Synthesis Report5 highlighted key areas for future health literacy research which is
summarized in Figure12 in Appendix A
(Berkman et al., 2011). Both the IOM (2004) and AHRQ (2010) also emphasize that health literacy must be integrated into all aspects of health care. While institutional policy and practice share the bulk of the responsibility, other
stakeholders share in the
Figure 14. The Broad Determinants of
Health
Figure 14.Dahlgren G, Whitehead M. (1991). Policies and
Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies. Reproduced with permission from the Institute for Future Studies (Appendix B1c)
previous section, health literacy and culturally appropriate interventions and their impact on patient outcomes have become a global discussion and a topic of research as a publichealth problem in need of systems integration (WHO, 2009). The IOM diagram (Figure 13) demonstrates the points where health literacy should be integrated for maximum effectiveness. The Dahlgren and Whitehead
socio-economic model demonstrates where health interventions must be integrated in the components of an individual’s environment to influence health outcomes (Figure
14). Health interventions that work on
multiple levels as suggested this model have an evidence base to support the efficacy of designing multi-level interventions to improve health
outcomes (Anderson et al., 2003). These
two models have different focal points at first glance. Upon further examination, however, it is easy to see how closely the IOM “Potential Intervention Points” resemble the arrays that surround the individual.
I GET IT by healthcare institutions that serve people. Much of the literature discusses the importance of treating the whole person in order to achieve optimal health outcomes (Grumbach, 2003). Yet, a review of the studies cited in this paper demonstrates a focus on outcomes in only one “bucket” or another, for instance, hospital transitions care or primary care case management or integration into community-based program.
Few of the of research studies that address health literacy, improved health outcomes, and cost offer valid and reliable evidence at this point to enable the development of adaptable models useful for individualizing interventions in different settings (Berkman et al., 2011). Most projects to date have been demonstration projects or efforts to develop health literacy interventions as
suggested by IOM and other healthcare authorities (IHI, 2012, AHRQ, 2010; ACP, 2012; Prevention Institute, 2011; RWJF, 2012). Some make recommendations for future research into the best integration methods to coordinate efforts and reduce duplication between settings or “buckets” (IHI, 2012, AHRQ, 2010; ACP, 2012, Benbasset & Taragin, 2000; Bisognanao, & Boutwell, 2009; Coleman, 2005). At this point, while some integration methods show promise, few of the projects that work in one setting have been proven valid and reliable as yet. Most are very-setting-specific (such as hospital transitions care) which makes broad application in other settings ineffective. Models for successful integration of health literacy and the health education across settings are still necessary utilizing interventions
management, and cost control efforts (Berkman et al., 2011) While the I GET IT philosophy is easily institutionalized across settings and helpful toward achieving these goals, additional research is needed to help fine-tune and adapt interventions at various levels for the diverse needs of the population served.
Research does indicate that people have more difficulty understanding instruction when acutely ill and are less likely to remember survival skill education4 and safety training (Nettles, 2005). This has been established by
research for some years (Wenger et al., 1994; Bubela et al., 1990). The few days after an acute illness are critical to ensure patient safety (Nettles, 2005; Hanyu et al., 1999; Hammer, 2005; Greenwald & Jack, 2009; Geagan, 2011; Fonarow et al., 1997; Raymont et al., 2004). People who live with people and in tight-knit
communities with members who are sensitive to the fragility of those they care about immediately after discharge, often have better outcomes simply because someone is checking on them and is available to help to provide additional resources and support if needed (Brownstein et al., 2005; Bhattacharyya et al., 2010). Since American communities are diverse, not all communities have the resources
Hospital -based Transitions
Care including Health
Literacy Programming
Primary Care
Case Management
with Health Literacy
Components
Community
Case Management and
Health Literacy
Programming
function without vital public health services and resources after budget cuts, which eliminates a
patient safety net. If the community also lacks primary care options, strong public health
services maybe the only safety net between the person and additional illness and unnecessary
hospital ED admissions. Communication between available health services, (hospital-primary
care, and hospital-community resources, and primary care-community care) is essential.
Since the primary care provider is often working in the community, this is a step off point for people with a post-acute illness to resuming activities of daily and community living. The primary care provider may be the last opportunity for the
Figure 16 The Continuous Care Cycle
Figure 16.This Continuous Care Cycle model is intended to illustrate the collaborative, patient-centered relationships across care settings necessary for successful health literacy and health education
interventions to improve outcomes and reduce cost. Patient Decision
individual to link with community resources that ultimately will determine health outcomes (Bandura, 1998). Once the individual has resumed follow-up care with the primary care clinic, primary care staff and those working within public health entities in the community are often the primary providers of clinical, social,
emotional, and environmental resources (Boling, 2009; Brownson et al., 2007; Brownstein et al., 2005). Primary care availability and public health services will vary from community to community (Boling, 2009; Brownson et al., 2007;
Brownstein et al., 2005).
To facilitate smooth consistent communication between settings, current concepts that show promise in the research include transitions care in hospitals, primary care case management (as a function of the patient-centered medical home), and a community case manager or service coordination. Three-way
communication with not only the acute care institution, but also primary care and public health
resources to provide continuous care and support can lead to a soft hand-off while
Figure 17: Family -centered Practice Model: Framework for Early Childhood Intervention and Support
Figure 17. The components of early childhood intervention and family support used as the model for Missouri First Steps. Dunst, C.J. (2005). Framework for Practicing Evidence-based Early Childhood Intervention and Family Support. CASEinPoint. 1 (1). Pp 1-11. Reproduced with permission
case manager to take over and oversee the person’s individual needs including facilitating the utilization of community resources. Likewise, someone working
classes and exposure to education and health literacy interventions finds its way to the medical record. Maintaining education and self-management interventions (including health literacy) and training in the medical record would ensure each setting (hospital, primary care, and public health) would have access to the information about what education had been conducted and how well the
intervention was received in order to facilitate repetitive, consistent messaging and reduce duplication of services.
A similar model utilizing community case management is currently used in Missouri through the Department of Secondary Education called Missouri First
Steps. First Steps works in this manner with normal learning and development being the center focus of the community and family supports (first steps service coordinator, i.e. community case manager), parents, and learning opportunities (schools, daycare, etc.) (Figure 17).
This soft-hand off and multi-setting focus provides opportunities for
communication and three-way reinforcement of survivals skills and eliminates “the buckets”. The collaboration between community resource coordinator, the informed and health literate patient, and a primary care clinic case manager would yield the communication and self-management skills to reduce unnecessary hospital
admissions, improve continuity of care, and patient satisfaction.
2000; Clark, 2003; Coleman et al., 2004; DeWalt, Boone, Pignone, 2007; DiMatteo, Haskard, Williams, 2007; IOM 2003; IOM 2004; King, Eckman, Moulton, 2011). Providers who take the time to assess their patients’ health literacy level, health care needs and effectively tailor their communication to meet those needs will develop that high level of trust. That patient-centered focus; the realization that patients are more likely to trust a provider who communicates effectively with them and increases their health literacy will enable that patient to reach a higher level of self-management.
Care providers who take the time to communicate with their patients in plain language and either conduct intensive self-management training or refer to health professionals who specialize in community-level self-management training will help their patients achieve this higher self-management level. This higher level feeds self-efficacy and reinforces health behavior change. The research supports intensive self-management training as both a treatment and preventative intervention that improves health outcomes and is often the most effective means of delivery of skills to improve health literacy (DHSS, 2010; Hanni, 2007; Lorig, 2001; Norris et al., 2002; Minet et al., 2010; Brownson et al., 2007). As the provider operationalizes this kind of intervention, the primary care clinic now serves as not only a treatment center for illness, but also a center for prevention by helping the patient population access community health services and providing yet another soft hand-off for
Parker & Kindig, 2006; Sanders et al., 2009). It will take a collaborative effort
between all three entities (primary care, hospital/acute, and community care) supporting each other [sharing bucket contents, not just working in their own], and federal policy to achieve the level of population health outcomes needed to
demonstrate a reduction in healthcare cost and an improvement in population health for this country.
The new ACA legislation is a starting point for support. The research is under way and needs that support to meet the goals as directed by IOM. Developing evidence-based strategies and adaptable models to improve health literacy and health communication are key to improving health care in America in the 21st century and beyond (IOM, 2003; Berkman, 2011). Regardless of research
outcomes, we have a responsibility to work together (eliminate the buckets) to move our patients to the point where they can say “I GET IT” and have better health outcomes to show for the effort. The research is underway now. The
patient-centered models-transitions care and medical homes-may show improvements and cost control. The public health systems-approach already has evidence base and has demonstrated improvements in health and efficacy (chronic disease
self-management, etc.) and will require the same level of federal and local support as the emerging models in order to provide the three-legged approach to truly support patient care and population health. – It is not enough to do our best, we must know what to do, and THEN do our best W. Edwards Deming (Patterson et al.,
Footnotes:
1Levels of Health Literacy are defined in Appendix A, Figure 4
2 The author noted the number of studies available increased routinely since
spring of 2011 when study for this project began.
3As defined by Berkman and associates: Moderator- something that shows a
statistically significant effect from the exposure to the moderating effect.
Mediator- accounts for the relationship-how and why the effect happened (2011).
4 Survival skills are defined as the most basic information and training
needed by people with compromised learning or self-care abilities to ensure safety, medication and treatment compliance to advance healing, improve health outcomes, and provide the foundation on which to develop additional self-efficacy and additional self-management skills. This includes how and when to take medications, potential side-effects and treatment, consistent nutrition intake, resources for home self-monitoring and feedback, knowledge of the mode of onset of acute exacerbation, and who and when to call for help(Nettles, 2005). This broad definition is built on and adapted from work done in diabetes and chronic care management by the author.
5 Interventions listed here come directly from the synthesis report (Berkman
certified as a diabetes educator and has working knowledge of practical
application of these interventions.
6 Both St. Louis Missouri and Kansas City Missouri have health collaborative
which include acute, primary, and public health institutions as well as third-party payors that work together to monitor outcomes and develop initiatives to reduce costs. Go to http://stldiabetes.wordpress.com/programs-services/
or http://www.kcqic.org/
7 See Figure 15 for an explanation of PICOTS methodology. Permission
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