1. Assessing Cultural Competence and Health Literacy from the Patient’s Perspective AHRQ 2011 Annual Conference September 18-21, 2011 Beverly Weidmer RAND Corporation Santa Monica, CA

2. CAHPS Item Set for Addressing Health Literacy Collaborators: Cindy Brach, AHRQ Ron D. Hays, UCLA Beverly Weidmer, RAND 2

3. CAHPS Cultural Competence Item Set Collaborators: Rob Weech-Maldonado, University of Alabama at Birmingham Adam Carle, University of Cincinnati School of Medicine Beverly Weidmer, RAND Margarita Hurtado, AIR Quyen Ngo-Metzger, HRSA Ron D. Hays, UCLA 3

4. Motivation for Development Increased focus on reducing health disparities by providing more culturally competent care and improving patients’ health literacy Interest from users and stakeholders in measures related to health literacy anc cultural competence Health literacy and cultural competence not included in any of the CAHPS surveys up to that point 4

5. 5 Measuring Improvement Need tools/survey items that can: Identify areas for quality improvement at the clinician and group level Evaluate QI activities designed to improve communication with patients and provide more culturally competent care Report quality data back to physicians and other health providers Provide information to consumers

6. 6 CAHPS Item Set to Address Health Literacy Designed to measure patients’ perspective on how often healthcare professionals provided easy-to- understand information and assistance with health literacy tasks Designed as a supplemental item set for the CAHPS Clinician and Group Survey Developed by CAHPS grantees under the leadership of RAND

7. 7 Development and Testing Used CAHPS approach to developing survey items: Conducted environmental scan Obtained input from stakeholders Conducted cognitive interviews in English and Spanish Field tested via mail with phone follow-up Analyzed field test data to assess validity and reliability, relation to CAHPS core composites, and relation to overall ratings

8. 8 Content Twenty-nine items that users can choose from on six main topic areas: Communication with doctors and nurses Communication about health problems/concerns Communication about medicines Communication about tests Communication about forms Disease self-management 8

9. 9 Composite on Communication About Medicines How often… did this doctor give you easy to understand instructions about how to take your medicines? did this doctor explain the possible side effects of your medicines? did this doctor explain the possible side effects of your medicines in a way that was easy to understand? did this doctor give you written information or write down information about how to take your medicines? was the written information you were given easy to understand? did this doctor suggest ways to help you remember to take your medicines? 9

10. 10 How to Use the Item Set Users can pick and choose items or domains depending on interest or QI focus Domains allow users to “drill down” to obtain more actionable information on a particular topic, at the clinician level (e.g. communication with providers) Users can use “short-version” of the item set 10

11. 11 Short version of the health literacy item set Five items found to be closely associated with global rating of doctor and provide feedback on various health literacy practices: HL9: Doctor give you all the information you wanted about your health? HL10: Doctor encourage you to talk about all your health problems or concerns? HL13: Doctor ask you to describe how you were going to follow instructions? HL19: Doctor give you easy to understand instructions about how to take our medicines? HL25: How often were results of blood test, x-ray or other test easy to understand? 11

12. 12 Health Literacy Quality Improvement Crosswalk ItemQuestion: In the last 12 months…..AMA recommendation HL1.how often were the explanations this doctor gave you hard to understand because of an accent or the way the doctor spoke English? Slow down. Use plain language and short statements. Ask for teach-back to ensure patient understanding of what the doctor has said. HL2.how often did this doctor use medical words you did not understand? Use plain, non medical language. HL3.how often did this doctor talk too fast when talking with you? Slow down. Break information down. HL4.how often did this doctor use pictures, drawings, or models to explain things to you? Use visual aids to help understand medical information. Images should be age- and culturally appropriate. HL5.how often did this doctor ignore what you told him or her?Listen rather than speak. Elicit understanding, identify information gaps, and assist patient management of care.

13. 13 Health Literacy Quality Improvement Crosswalk ItemQuestion: In the last 12 months…..AMA recommendation HL6.how often did this doctor interrupt you when you were talking? Listen rather than speak. HL7.how often did this doctor show interest in your questions and concerns? Encourage patients to ask questions. Create a patient-centered visit in which the clinician focuses on addressing the patient’s concerns. Wear a button that states, “Ask me. I Can Help.” HL8.how often did this doctor answer all your questions to your satisfaction? Schedule time for patient education. Ask patients if all their questions were answered before they leave. Enlist the aid of others (patient’s family or friends) to promote understanding. HL9.how often did this doctor give you all the information you wanted about your health? Schedule time for patient education. Plan for health literacy help.

14. 14 Health Literacy Quality Improvement Crosswalk ItemQuestion: In the last 12 months…..AMA recommendation HL10.how often did this doctor encourage you to talk about all your health problems or concerns? Ask if patients have any concerns that have not been addressed. HL12.how often did this doctor give you easy to understand instructions about what to do to take care of this illness or health condition? Limit the amount of information given at each visit—and repeat it. Organize information into two or three concepts. HL13.how often did this doctor ask you to describe how you were going to follow these instructions? Teach-back to confirm patient understanding. HL14.how often did this doctor ask you whether you would have any problems doing what you need to do to take care of this illness or health condition? Use plain, nonmedical language. Elicit understanding, identify information gaps, and assist patient management of care. HL15. how often did this doctor explain what to do if this illness or health condition got worse or came back? Schedule time for patient education and questions.

15. 15 Health Literacy Quality Improvement Crosswalk ItemQuestion: In the last 12 months…..AMA recommendation HL16.how often did this doctor use a condescending, sarcastic, or rude tone or manner with you? Design a safer, shame-free environment. Create a patient-centered visit focusing on patient’s concerns. Exhibit a general attitude of helpfulness. HL17.how often did you feel this doctor really cared about you as a person? Create a patient-centered visit in which the clinician focuses on addressing the patient’s concerns. Exhibit a general attitude of helpfulness. HL19.how often did this doctor give you easy to understand instructions about how to take your medicines? Organize information into two or three concepts. Ensure medication review and/or reconciliation for all patients at all encounters. HL20.did this doctor explain the possible side effects of your medicines? Identify information gaps, and assist patient management of care. Ensure medication review and/or medication reconciliation for all patients at all encounters.

16. 16 Health Literacy Quality Improvement Crosswalk ItemQuestion: In the last 12 months…..AMA recommendation HL21.how often did this doctor explain the possible side effects of your medicines in a way that was easy to understand? Explain things to patients like you would explain them to your grandmother. HL23.how often was the written information you were given easy to understand? Provide handouts in an easy-to- read format. HL24.how often did this doctor suggest ways to help you remember to take your medicines? Read aloud and highlight, underline, circle, or number key points for the patient to remember. Draw supplemental pictures and write out steps and directions. HL25.how often were the results of your blood test, x-ray or other test easy to understand? Aim for fifth- to sixth-grade reading level on all written information. HL27. how often did someone explain the purpose of a form before you signed it? Offer to read aloud and explain.

17. 17 Health Literacy Quality Improvement Crosswalk 17Question: In the last 12 months…..AMA recommendation HL28.how often were you offered help in filling out a form at this doctor’s office? Routinely offer all patients assistance in completing forms. HL29.how often were the forms that you got at this doctor’s office easy to fill out? Simplify paperwork demands. Only collect information that is essential. HL30.(Spanish version only) how often were the forms that you had to fill out available in Spanish? Provide forms in patients’ languages.

18. 18 Version for the CAHPS Hospital Survey CAHPS developed health literacy supplemental item set for HCAHPS Domains include: –Patient-provider communication –Discharge planning –Communication about medications –Communication about test results –Communication about forms

19. 19 Version for the CAHPS Health Plan Survey Currently developing health literacy supplemental item set for CAHPS Health Plan Survey Will be completed by late Summer 2012 Domains include: –Health plan information on the Web –Communication with Customer Service –Information about Coverage and Benefits –Grievances and Appeals –Claims Processing –Interpreter Services

20. CAHPS Cultural Competence Item Set Designed to measure patients’ perspective on the cultural competence of health care providers Designed as a supplemental item set for the CAHPS Clinician and Group Survey Developed by CAHPS Cultural Comparability Team Field-tested with funding from the Commonwealth Fund under the leadership of Rob Weech Maldonado, University of Alabama at Birmingham 20

21. Development and Testing Used CAHPS approach to developing survey items: Developed conceptual framework Identified domains to include through environmental scan Translated item set into Spanish Conducted cognitive interviews (English/Spanish) Field tested via mail with phone follow-up Analyzed field test data to assess validity and reliability and relation to CAHPS overall doctor rating 21

22. Data Analysis Psychometric analysis Regression analysis –Overall doctor rating (0-10)= f (CAHPS Cultural Competence domains, gender, age, education, and perceived health status) 22

23. Results Factor analysis provided support for eight factors/domains All Cultural Competence domains were positively and significantly associated with overall doctor rating 23

24. Content 3 reporting composites –Doctors are polite and considerate –Doctors give advice on staying healthy –Doctors are caring and inspire trust Other topics –Doctor communication- alternative medicine –Equitable treatment –Shared decision making –Language access –Overall ratings (trust, interpreter services) 24

25. Reporting Composites Doctors are polite and considerate (3 items) Doctor interrupted you when you were talking Doctor talked too fast Doctor used condescending, sarcastic or rude tone or manner Doctors give advice on staying healthy (4 items) Doctor talked with you about healthy diet and eating habits Doctor talked with you about exercise or physical activity Doctor talked with you about things that worry you or cause stress Doctor asked the patient about feelings of depression 25

26. Reporting Composites--continued Doctors are caring and inspire trust (5 items) You could tell doctor anything You could trust doctor with your medical care Doctor always told you the truth, even if bad news Doctor cared as much as you do about your health Doctor cared about you as a person 26

27. Other Topics Doctor communication- alternative medicine (2 items) –Whether the doctor asked the patient about his/her use of an acupuncturist or herbalist or natural herbs Equitable treatment (3 items) Perceived unfair treatment based on race/ethnicity, insurance type, language (not speaking English very well) Shared decision making Respect patients’ preferences and promote their active participation in clinical decision-making to the extent that patients’ are willing to take part Refer to Patient-Centered Medical Home Survey 27

28. Other Topics--continued Language access (17 items) –Need for interpreter services Asks patients about their preferred language and their doctor’s proficiency in that language –Access to interpreter services Telling patients about their right to interpreter services Receiving interpreter services in a timely manner Courtesy and respect by interpreter Use of family and friends as interpreter 28

29. Overall Ratings Overall rating of trust in doctor (0-10) Overall rating of interpreter provided by doctor’s office and used most often (0-10) 29

30. Identifying Cultural Competence Priorities Cultural competence is a multi-dimensional concept Findings from the field test show that 3 cultural competence domains are most highly correlated with doctor’s overall ratings Doctors are polite and considerate Doctors are caring and inspire trust Equitable treatment 30

31. Using Results in Quality Improvement Assess baseline performance –By topic area and for individual items –Identify strengths and weaknesses –Analyze racial/ethnic and language differences Gather additional data that provides insight on survey findings (optional step) Identify action plan to address gaps Implement action plan Evaluate effectiveness of action plan Strive for continuous improvement 31

32. 32 Reporting Results Results can be reported for… Individual clinicians Aggregated at the group level (medical practice or clinic) level

33. Using Results for Provider Feedback Use composite reports for benchmarking and reporting at the group level. For example, a health system may use composite reports to compare performance across member provider groups Provide item-level feedback to individual providers. This can help identify behaviors that can hinder effective communication 33

34. Conclusions The CAHPS Item Sets to Address Health Literacy and Cultural Competence: –Assess how well health providers are doing in meeting patients’ health literacy needs –Asssess culturally competent care from the patient’s perspective –Demonstrate adequate measurement properties –Address aspects of care that are important to patients’ ratings of care –Relate to other efforts and requirements for improving care and reducing disparities in health outcomes 34

35. 35 Acknowledgments Funding for the development of the Health Literacy and Cultural Competence Item Sets was provided by the Agency for Healthcare Research and Quality Our thanks go to all the stakeholders that provided input on the content of the item sets

36. Acknowledgments--continued AHRQ –Chuck Darby –Cindy Brach –Anna Caponiti Commonwealth Fund –Melinda K. Abrams –Anne Beal (currently at Aetna Foundation) CAHPS Consortium –Cultural Comparability Team –Instrument Team –Reports Team University of Wisconsin- Madison –Elizabeth Jacobs University of California, San Francisco –Alicia Fernandez –Hilary Seligman Field Test Partners –Affinity Health Plan –Care1st –University of Mississippi –St. Luke’s Hospital 36