SUMMER 2011

Impact

MOHEC puts the pieces & partners together

Missouri’s Health Disparity Data Puzzle:

Center for Health Policy University of Missouri

News Briefs 4 | Data & Health Disparities 8 | Summit 2011 14 | CHP Presentations 16 | Collaborator Spotlight: Diane L. Smith, PhD 18

From the Director

Recently, I’ve found myself drawing connections between what I’ve been seeing in the patients that I treat in clinic, and with the challenges that I’ve been witnessing in our policy discussions across the state and nation. Doctors and politicians actually have a lot in common. Health care providers and elected officials are regularly looking at both short term and long term problems and recommending treatments.

In the past few months, we have seen how acute and chronic challenges are demanding more time and resources from our state and local services. Acute disasters, like the devastating tornado in Joplin and the flooding in Northwest and Southeast Missouri, have required rapid emergency response from many care teams, from the Federal Emergency Management Agency (FEMA) to our own MU Extension.

Just as damaging are chronic disasters. These have included our long road to economic recovery; our friends’ and families’ struggles with chronic illnesses like heart disease, obesity, diabetes and COPD; and our collective traumas like economic hardship,

substance abuse and mental illness. Chronic disasters also demand a coordinated response on the parts of many organizations and individuals. These acute and chronic challenges reflect our society’s changing needs, and how health care practice and health care policy will need to adapt and be ready to respond.

Our stories in this issue of Impact highlight this tension between acute and chronic. We know that many patients in Missouri struggle with levels of low health literacy. It’s estimated that low health literacy costs Missouri more than $3 billion each year. While there are many factors at work in perpetuating low health literacy, we know that the health care community can do better at improving its communication with patients. The Center is proud to say it’s developed an acute response, through an innovative Clinical Simulation program created with funding from the Missouri Foundation for Health and Health Literacy Missouri. You can read more about that program that trains health care providers on page 3. And perhaps one of the most challenging chronic issues that thought leaders in medicine, policy, public

health and administration are working to address is how to understand and close health disparity gaps experienced by many underserved people in our state (see page 8). Through the Missouri Health Equity Collaborative (MOHEC) project, we believe that working with communities, collecting reliable, uniform data, and forging stronger partnerships can help us get there.

As I reflect on these acute and chronic issues, I know they hold lessons for all of us in Missouri. And if any of these ideas or stories has sparked a connection for you, I encourage you to let us know at chp@missouri.edu.

In good health,

Karen Edison, MDCenter for Health Policy Director

Dear Colleagues and Friends,

2 Impact | Summer 2011

ImpactVol. 7, Issue 2

Published by the MU Center for Health Policy

Karen Edison, MDDirector

LaRita Emanuel, MBAAdministrative Associate Fiscal/Human Resources

Suzanne Hansford-Bowles, MA GPCGrant Writer

Stan Hudson, MAAssociate Director

Amy Lake, MSProject Director

Nancie McAnaugh, MSWProject Director

Dave ZellmerProject Development Specialist

Ioana Staiculescu, MPHResearch Specialist

Amy Dunaway, MPH, MAJon Stemmle, MAEditors

Caress DeanGraduate Research Assistant

Contributors:Pavan Vangiparum

Photography from the Center for Health Policy, istockphoto.com, Microsoft, Morguefile.com.

Impact is published twice a year by the University of Missouri Center for Health Policy.

The University is an affirmative action, equal opportunity employer.

News Briefs

Missouri Health Equity Collaborative

New GraNt SUPPortS CHP’S CoNtINUING HealtH eqUIty work

The CHP received continued support of the Missouri Health Equity Collaborative (MOHEC) from the Health Care Foundation of Greater Kansas City this spring. Combined with support from the Missouri Foundation for Health, the Center’s staff and MOHEC partners will continue to mobilize key stakeholders across the state in order to create the partnerships that will help eliminate health disparities in the areas of policy, research needs, and education.

Building on MOHEC’s work in the past year, the project will more closely examine how health disparities are impacting Missouri communities and explore potential solutions to achieve health equity. This information will be shared in regional meetings across Missouri later this fall and will be highlighted in a statewide health equity conference currently being planned for the spring or summer of 2012.

Said Project Director Nancie McAnaugh, “Last year, as we

looked at the health disparities populations were experiencing in Missouri, it became very clear that these disparities do not have a one-size fits all solution. The best practices and policies that can begin to address these health disparities will vary depending on how an issue is experienced in a local community. We are excited to be able to continue this important work.”

tHe ClINICal SIMUlatIoN workSHoP HItS tHe roadIt’s widely believed that health literacy is a strong predictor of a person’s health outcomes, and that doctors and health care providers can be effective mediators in improving a person’s health literacy and understanding of their health and treatment options. But communication is not a required course in the average medical or allied health school curriculum. To fill this gap, CHP developed an innovative health literacy training program.

Known as a “clinical simulation,” doctors and care providers are trained in health literacy tools and techniques. Then they are given a chance to practice those

In Brief

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Center for Health Policy | 3

News Briefs

communication techniques with actors playing the role of patients. Doctors and care providers are introduced to and allowed to practice health literacy techniques to improve understanding, such as “teach back method.” This is a simple practice to determine whether a patient understands the medical information being shared, and comprehends the next steps they need to take. This practice can go a long way to ensuring the patient understanding that is necessary for them to take an active role in their health care.

“This is a very exciting program,” said CHP Associate Director Stan Hudson. “We have been able to raise awareness and get health professionals to engage in meaningful reflection about how they talk to and interact daily with patients, and now we can provide a learning experience that provides

them with the tools necessary to change the way they practice.”

This spring, Ioana Staiculescu, research specialist at CHP, presented findings from the clinical simulation trainings to the Central Group on Educational Affairs’ (CGEA) Spring Conference, Omaha, Neb. CGEA is part of the Association of American Medical Colleges (AAMC) and is a regional organization of 37 medical schools. A copy of the presentation is available on the CHP website at: http://healthpolicy.missouri.edu/

docs/presentations/CGEA_2011_CHP_Poster-March-2011.pdf.

“There was a lot of interest in our program,” shared Staiculescu. “Since CGEA is part of the AAMC, there were many providers there who shared that experience of knowing their patients were confused leaving the office. We are hopeful to be able to expand this model and train more doctors.”

Hudson, Staiculescu and graduate assistant Danielle Barille also took the training program to the Missouri Association of Osteopathic Physicians and Surgeons’ annual conference in Osage Beach, Mo. Over two days, the CHP staff trained the front office staff of osteopathic providers through its hands-on health literacy simulation program.

“We had over 25 participants in the simulation training and it was exciting because it was the first time I have seen office staff included in an annual conference,” said Staiculescu. “To be able to help train these key front line workers in health literacy was critical. One participant shared how much she learned and what steps she would take in her office next time to help all patients get more out their doctor’s visits.”

Participants identified plans to share the information learned in the workshop with coworkers and office managers in order to raise awareness about health literacy and techniques that can increase the quality of patient communication and adherence. Providers also shared their own ideas for making health literacy an action step in their offices. Among the ideas shared was establishing an insurance billing code for a “Brown Bag” or medication review. In this example, patients could see their health care provider and bring in all of their medications in a brown bag. The provider could review all of the medications and discuss how the patient is taking them to make sure that the patient isn’t taking too much or too little.

“That was an interesting idea,” said Staiculescu. “Time will tell whether insurance companies will pick that idea up, although the Affordable

Research Specialist Ioana Staiculescu in Omaha.

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News Briefs

Care Act does outline ways to integrate health literacy principles into the realm of health coverage.”

MoHIt toUrS tHe State IN PerSoN aNd oNlINe

In March, the Missouri Health Information Technology (MoHIT) Assistance Center took its message on the road for the “EHR Road Show.” Assistance Center staff and experts visited Rolla, Poplar Bluff, West Plains, Lebanon, and five sites in the St. Louis and Kansas City areas. During each stop, the MoHIT group answered questions and explained what options were available for different health care settings.

Doctors and other health care providers were able to find out more about the Medicare and Medicaid incentive programs, the ways of reaching meaningful use, and the technical assistance options available to providers who are making the switch to electronic records. MoHIT representatives also explained how eligible health care professionals can tap into

the Assistance Center’s subsidized support to adopt and become meaningful users of certified EHR (electronic health record) technology.

“This series of EHR roadshows,” said MoHIT Project Director Nancie McAnaugh, “was designed to raise awareness about the options providers have in moving to EHRs, and also to make it easier for people to ask questions and get the direct one-on-one responses that they need.”

Along with the road show, the MoHIT Assistance Center also spread the news digitally, through a new video as well as a free webinar.

Dr. Burton D. Cox, DO, a family practice physician in Poplar Bluff, explained how EHR’s benefitted his practice in a short, four-minute video.

“I can do anything I want to, just like that,” says Dr. Cox. “Within a month, I felt very comfortable with [the EHR].”

From reducing the time it takes to pull paper files, to ensuring certain medicines aren’t contraindicated, Dr. Cox explains how his EHR system has made it easier to care for patients. He also explains a real advantage to patients: While it can take days or weeks to obtain paper copies of records, with his new EHR system, Dr. Cox is able to give

patients a copy of their tests or lab reports at the office visit.

“To me that’s service. And medicine is a service,” says Dr. Cox. “If you give [EHRs] a fair chance, I don’t think you’ll ever go back to paper again.”

The video featuring Dr. Cox is available by visiting http://ehrhelp.missouri.edu.

Webinars were held this spring for providers interested in learning more about EHRs and available federal incentives. The first web/audio conference, “Getting Your Share of the EHR Pie,” was held in February. Participants learned about eligibility for EHR incentive programs and support options, including the Assistance Center’s services to providers and health care systems.

Dr. Burton Cox, DO explains his decision to move to EHRs in a short web-video.

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tHe ValUe of eHrS IN dISaSter reSPoNSe

CHP’s MoHIT Team recently released a moving new video from their visit to Joplin, Mo. On May 22nd the nation’s deadliest tornado in 60 years ripped through the town, killing 156 people. Residents, neighborhoods, businesses, and the city’s hospitals and health care providers all suffered unfathomable losses.

But less than a month after the EF-5 tornado, MoHIT’s Becky Woelfel and Samir Prasad uncovered rays of hope in residents’ stories and the health care choice that one provider made.

Dr. Tracy Godfrey, a family practitioner with the Family Health Center of Joplin, describes that

terrible day in the six-minute video. Godfrey explains how her decision to move to EHRs enabled her to rapidly respond to the disaster. In less than 72 hours, she was able to access her patients’ vital medical records, reopen her practice in a temporary location, and help the patients who most needed her.

Watch the video at http://ehrhelp.missouri.edu.

HealtH reVIew of MISSoUrI leGISlatUreCHP Project Development Specialist Dave Zellmer, who serves on the Missouri Council for Activity and Nutrition (MoCAN), shared a wrap up on the key health and well-being legislation introduced in the state legislature.

Says Zellmer, ”This was an interesting legislative session for those working in or advocating for health care. Among the legislation that MoCAN worked on were HCR 23 – Complete Streets and HB 344 – Farm-to-Table. Both are strong indicators of the level of commitment the General Assembly

has for the health and well-being of Missourians. They are good first steps to more binding legislation in the future.”

What were the outcomes for key legislation?• HCR 23 declares support for Complete Streets policies regarding the shared use of our roads and highways by motorists, bicyclists and walkers. Passed.• HB 223 establishes the Nursing Education Incentive Program and authorizes a nonrenewable advanced placement grant to certain recipients of financial aid under the A+ Schools or Access Missouri programs. Passed.• HB 344 is a Farm-to-Table bill that creates an advisory board to increase awareness of local agriculture and promotes the use of locally grown products in school meals and snacks. Passed.• HB 423 establishes the Health Care Compact. Under the compact, member states have to pledge to improve health care policies within their state. Passed.• HB 262 would have enabled Missouri residents to buy health insurance in other states. Failed.• HR 39 and SR 27 were both challenges to the Affordable Care Act’s constitutionality. Failed.• HB 528 would have mandated timeliness to delivering medical records. Failed.

Health Equity SurveyAre you or your organization working to make good health an opportunity for all? The Missouri Health Equity Colla-borative (MOHEC) wants to hear about your work! Take our survey online at

MOHEC.org

News Briefs

6 Impact | Summer 2011

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News Briefs

Follow the latest CHP health policy news on Twitter: @CHPMissouri

• HB 609 which would have created the Show-Me Health Insurance Exchange Act. Failed. (The bill passed the House but was not voted on in the Senate.)

For more information on the Missouri General Assembly, visit http://www.moga.mo.gov/.

HealtH lIteraCy traINING for MedICal ProVIderS Now aVaIlaBleIn collaboration with the American Board of Internal Medicine (ABIM), the Center is pleased to launch its Health Literacy Maintenance of Certification program. This program was designed to assist physicians in integrating health literacy principles and techniques into their own practice to improve communication with patients and increase patients’ understanding of their health and care.

“The program consists of a one-day interactive session in which physicians are introduced to best practices in provider/patient communications through simulation training, including health literacy coaching on how to incorporate evidence-based techniques and resources,” says CHP Assistant Director Stan Hudson. “These include the Health Literacy Universal Precautions Toolkit, which was developed and evaluated by the Agency for Health care Research & Quality (AHRQ). The toolkit is specifically designed to translate health literacy knowledge into clinical practice.”

Participating physicians design a health literacy action plan for their own practice, including monitoring how well their patients perceive and understand the communication that goes on in clinical visits. Program staff provide participating physicians with a tailored brief patient survey designed with items from the Item Set for Addressing Health Literacy from the Consumer Assessment of Health care Providers and Systems (CAHPS) Clinician & Group Survey.

After baseline data is established, physicians implement the action plan they developed for their clinic, and survey patients again at 6 and 12 months. All survey data are collected and analyzed by program staff who provide confidential results and feedback, including recommendations for continued

improvement. Ongoing technical assistance is provided throughout the duration of the physicians’ participation.

This program was developed with funding from Missouri Foundation for Health and Health Literacy Missouri and has been accepted as an ABIM Approved Quality Improvement (AQI) Pathway for 20 Maintenance of Certification (MOC) points. Members of other boards or specialties can contact the Center about additional MOC points. The Center is currently going through the certification process with other boards.

Learn more or register at: http://healthpolicy.missouri.edu/projects/hlmoc.shtml.

CoMINGS aNd GoINGSThe Center said goodbye to Danielle Barille, a graduate research assistant, who finished her master of public health (MPH) degree in May, and to Shawn Willingham who served as the Office Support Staff III. We wish them both the very best!

In June, the Center welcomed Caress Dean as a graduate research assistant. She is earning her MPH degree with a concentration on health policy and administration. In July, Suzanne Hansford-Bowles, MA, GPC joined the Center as our part-time grant writer. We are delighted to have them both join our team!�

Center for Health Policy | 7

It’s a Monday morning in late spring and CHP Project Director Nancie McAnaugh is focused on her computer screen. From her perch on the fifth floor of the Clinical Support & Education Building at the MU School of Medicine, McAnaugh is studying graphs and Excel sheets doggedly searching for an example of the social determinants of health.

“Here,” she says, triumphantly pointing to a document from the Missouri Department of Health and Senior Services (DHSS). “In Missouri, if you have asthma, you are almost five times more likely to have to go to an emergency room if you are black than if you are white. If you keep looking, you’ll also see that blacks suffering with diabetes are also more likely to be hospitalized than their white counterparts. That’s over 200% higher.”

What McAnaugh is trying to explain is how a person’s life span,

in many parts of Missouri and across the nation, can actually be predicted based upon a person’s race and zip code. The World Health Organization (WHO) defines the social determinants of health as “the conditions in which people are born, grow, live, work and age, including the health system.”

“Where you live makes a big difference in how healthy you and your family are and stay,” shares McAnaugh. She explains that access to transportation, health care services, grocery stories and even walking trails can often help or hinder a family’s overall health and well-being.

For example, 2009 data from the U.S. Department of Agriculture’s Food Environment Atlas shows that between 18.1% and 36.8% of low-income preschoolers are obese in Osage County. Move west one county to Cole County and you’ll find that

low-income preschoolers have a lower obesity rate (10.1-14%).

Health care advocates from all political persuasions point to examples like these and agree that location obviously matters to health outcomes, but not always for the expected reasons. Degrees of personal responsibility and access to health care do not always lead to healthier people. In fact, there are far deeper forces that mediate and intervene in a person’s overall health. “So many things affect health,” says McAnaugh. “There are biological factors like whether someone has inherited genes for neurological diseases or blood disorders. There are personal behavioral factors such as smoking or not exercising. There are policy factors, environmental factors, and social factors. All of these factors influence health and well-being. But the key to remember is that the

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When patients, policy and data collide: Data measures to improve health opportunities for all

8 Impact | Summer 2011

MOHEC

choices we make are influenced by the choices that we have. If we are going to reduce cost and improve care, we have to start looking at these issues and develop a common plan of action.”

McAnaugh is currently leading the Center’s work with the Missouri Health Equity Collaborative (MOHEC). MOHEC began in 2002 as part of a grant from the Missouri Foundation for Health (MFH) and the Health care Foundation of Greater Kansas City in order to understand Missouri’s own needs and

to help reduce health disparities in the state.

“MOHEC is designed for collaboration,” said CHP Director Karen Edison, MD. “From community advocates to academic researchers to private companies working in health care, we

have been reaching out to all groups to better understand what gaps exist and what their challenges are. We know that what’s happening in Springfield is very different than what is happening in mid-Missouri or Kansas City. By being informed about what has been happening on the ground, we can start the conversation around how we can

collectively better the outcomes and opportunities for all Missourians.”

MoHeC findings from 2010Along with MOHEC’s work on collaboration, the group has also

conducted community-led assessments of the health opportunities found where we live, learn, work and play. Based on research conducted last year, the MOHEC team reviewed existing data sets and led its own original research, comprised of focus groups and surveys with ethnic groups across the state. Through the data analysis, MOHEC

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showed a number of disparities that Missourians were experiencing.

Among the findings, MOHEC reported that minority groups suffering with asthma, diabetes and high blood pressure are more likely to get treatment for these conditions in the emergency room (ER) than whites. And disturbingly, blacks in Missouri have a rate more than twice that of whites for all of these conditions.

“What these numbers mean is that our current health care system isn’t working well for everyone,” says CHP Research Specialist Ioana Staiculescu. “With this knowledge, we know that we have to start to look at some of the challenges people face when they try to get good health care.”

McAnaugh agrees. “The MOHEC 2010 data are important to have,” she attests. “Those data help us understand what is actually happening in Missouri. Yet we know it’s not a complete picture. Part of the picture rests on having consistent, common data across systems.”

She cites that finding change over time can be quite hard, especially when the data is not tracked consistently among groups and departments. “This is especially true for emergency rooms where underserved populations go more often,” McAnaugh said. “Plus, much of the data gathered to date has been limited to Medicare, Medicaid and Veterans Administration patients. This is helpful data but not everyone is included here. Likewise, most of

these data just compares whites to blacks. Few studies look at other ethnic groups, such Hispanics, the needs of newcomer populations emigrating from other countries, or other identity issues, such as gender expression and sexual orientation.”

While recent émigrés from Bosnia, Somali, Iraq and Mexico are important to consider in looking at health data, so too is the data collected by local drug stores and pharmacies.

“There’s a whole gap in our understanding,” points out Staiculescu, “because we don’t have sufficient pharmacy data on the prescribing practices of doctors. It’s hard to know if patients are actually doing what their doctor tells them to do when they have to take a certain medication for treatment. Are they refilling their heart or cholesterol medicines? Are they getting the medicines that they need? We just don’t know. Additional research is needed in Missouri to fill in these gaps.”

where are we now?Based on the analysis from the 2010 study results, MOHEC is building on that data to fill in some of the understanding gaps. Several new studies focusing on newcomer populations and mental health care are currently underway in Kansas City and St. Louis to answer some of these questions.

“People often think that when we say social determinants we’re only talking about one type of problem or about one group of people,” said

Top photo: Participants of the first MOHEC EHR data meeting in the May. Bottom photo: CHP collaborator Steve Jeanetta with CHP’s Ioana Staiculescu.

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MOHEC

10 Impact | Summer 2011

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Edison. “But we know in Missouri, there are many gaps. For instance, there’s a gap in health care between rural and urban residents. There’s a gap in mental health care. MOHEC is working to close those gaps. As a team, though, we are also fully aware that there are limitations and pitfalls to the data, too. Simple things, like increased screenings, can affect data. We know that within all of these data collection, we need to balance that rush for information with

a degree of caution on how we look at and interpret the data. Due diligence will help to inform us and our partners about the most appropriate strategies we can take to resolve the issues.”

New strategies for integrated data collectionIn May 2011, MOHEC assembled more than 25 advocates from around the state to discuss how to

begin to address health disparities in Missouri through data collection and reporting.

“We gave an overview of some of the gaps our collaborators have brought to the table, as well as those we found in the 2010 MOHEC study, and we emphasized that data collection was a

MakING SeNSe of tHe terMS

The discussion around health care and health opportunities for all can be quite confusing. Terms like SDOH, health disparity, health equity and more. What do they all mean? Here’s a quick rundown of some of the more common terms you might encounter:

Health equity Everyone has the opportunity to reach his or her full health potential.

Health disparity These are differences in health status that occur among population groups, usually defined by specific characteristics. For example, gender defines a health disparity between men and women, as more women suffer from breast cancer than men.

Public health A combination of science, practical skills and values, public health is designed for the maintenance and improvement of the health of all people. Many public health departments are divided into key areas such as population health, surveillance, disease prevention, and health promotion.

Determinant of health These are the personal, social, economic and environmental factors that determine the health status of people or populations. The determinants of health can be grouped into seven broad categories: socio-economic environment; physical environments; early childhood development; personal health practices; individual capacity and coping skills; biology and genetic endowment; and health services.

Source: Public health agency of Canada and the WHO Commission on Social Determinants of Health.

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MOHEC

Center for Health Policy | 11

large piece to making progress for all residents,” said McAnaugh.

Along with highlighting the revised standards from the Joint Commission and the guidelines from the Affordable Care Act, MOHEC team leaders also reviewed the two national strategies released in April from the U.S. Department of Health and Human Service’s Office of Minority Health (HHS OMH) and the National Partnership for Action to End Health Disparities (NPA). HHS OMH’s “Action Plan to Reduce Racial and Ethnic Disparities” and the NPA’s “National Stakeholder Strategy for Achieving Health Equity” were both released to help communities and organizations integrate best practices across programs and policies.

“These are two separate but related strategies,” said McAnaugh. “One is for what the government is going to do on its end to close the gaps, and then NPA is designed to help communities and organizations with what they can do to complement those efforts.”

After reviewing the new strategies and standards MOHEC team leaders opened the discussion to participants. Among the questions posed was how to be sensitive in data collection so that questions are posed appropriately and people both do not feel shameful in asking the question and reporting the answer. Other participants asked how data could be better collected and how to create

more effective office visits by being prepared before patients walked through the office door.

Staiculescu explains that if you are seeing a regular patient, and you know that a patient coming in is Somali and will need an interpreter, having medical interpreter services lined up beforehand can help improve experiences and outcomes. “An electronic health record (EHR) could help to document that need someone has for interpretive services. The front office staff could arrange to have the interpreter there before the patient gets there. Then the doctor can do his or her job and the patient can get the care that he or she needs.”

McAnaugh continued, “We know there are requirements and standards already in place, such as the Joint Commission and National Standards on Culturally and Linguistically Appropriate Services (CLAS) that

can help to get us started. But the meeting also raised interesting discussions. For some of our participants, it also raised the issue that spirituality may need to be considered. Culture and ethnicity only go so far. We may need to ask, ‘What are your spiritual needs.’”

Likewise, participants voiced their concerns with data collection. Along with the potential pitfalls in interpretation, they also cited the fatigue patients feel when they have to share the same information time and time again, often within the same health care system.

“It’s true,” says Edison, CHP Director and herself a medical doctor. “How many times are you collecting this data so that you’re not asking the same patient to report this information multiple times? We know we need to be more efficient with how we share information in an EHR and how that ‘electronic handshake’

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MOHEC

12 Impact | Summer 2011

Join the collaboration online at Mohec.org. There you can find the latest news about the project, new research related to health equity, and much more, including:

• Monthly blog posts • White papers and downloads• Links to the MOHEC health equity list serv• Surveys, polls, and more about what’s happening around health equity in Missouri

plays out between departments and care providers.”

Getting more voices at the tableUltimately, says McAnaugh, “We know that data is just one part of the solution. The other parts include the patients and the policies we create. Solutions require a lot of voices at the table, not just ours at the Center, or MOHEC’s, but all of ours. I’m talking about the people working in the field at the nonprofit health clinic; all the way to the local community members who see some of the problems their neighbors are facing, and just don’t know what to do about it.”

McAnaugh encourages these advocates and other organizations to get involved by joining MOHEC. “There are no fees,” she laughs. “We want people at the table because that’s the only way we’re going to get at the solutions. We can’t begin to address these complex and often intertwined issues apart from the community and our partners.”

Joining MOHEC is simple and only requires a quick email or phone call to McAnaugh or the Center. The project also has a web site at MOHEC.org and a new blog that highlights trends and issues as well as Missouri leaders who are working on these issues across the state. There is also a health equity list serv where MOHEC members can add to he conversation.

“We will send out announcements through our partners and on the MOHEC web site about the community meetings,” says Staiculescu. “So people can stay tuned and also speak up through these communication tools.”

Until then, McAnaugh and the rest of the MOHEC team will be collecting and analyzing data and working with communities in hopes of improving health outcomes for all Missourians “The opportunity for health starts before you need care,” she says. “It shouldn’t matter whether you live in Osage or Ozark County.”

Learn more about MOHEC at MOHEC.org. �

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Get Connected to MoHeC!

MOHEC

www.mohec.org

Center for Health Policy | 13

The call to strengthen our health care workforce and how to pay for quality care will be the focus of the MU Center for Health Policy’s its Ninth Annual Missouri Health Policy Summit in late October

2011. The summit’s theme “Health Workforce and Mental Health in a Reform Environment,” unites renowned thought leaders, including columnist David Brooks; mental health expert Ron Honberg, JD; and health care policy and payment reform expert Harold D. Miller.

The keynote speakers will discuss the intersection of individual decision making and health, the growing but underserved needs of mental health care, and how to deliver better services without breaking the bank. These keynotes, and panels exploring

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NatIoNal tHoUGHt leaderS HeadlINe 9tH aNNUal HealtH PolICy SUMMIt

Strengthening health care workforce

& paying for effective care

14 Impact | Summer 2011

Summit 2011

the issues of workforce and mental health further, will be the highlights of the Oct. 28 event at the Hilton Garden Inn in Columbia, Mo. The summit will begin at 7:15 a.m. with breakfast and registration and conclude with discussion and final remarks at 3:30 p.m.

Miller, the morning’s featured speaker, will deliver the health workforce keynote address. As Executive Director of the Center for Health care Quality and Payment Reform and President and CEO for the Network for Regional Health care Improvement, Miller has been spearheading initiatives to improve the quality of health care services through payment reform on the national and regional levels. He has written a number of papers related to reform on payment and delivery, including: “From Volume to Value: Better Ways to Pay for Health care,” which appeared in the September 2009 issue of Health Affairs.

Luncheon keynote speaker David Brooks is a frequent contributor to The New York Times, “The NewsHour with Jim Lehrer” and National Public Radio. Brooks recently published his latest book, The Social Animal: The Hidden Sources of Love, Character and Achievement, which examines

the science behind cognitive psychology and how these findings play out in our emotions, character development, and decision making. Brooks will be featured live from Washington, DC via telecast.

With one-in-four families affected by mental illness, Ron Honberg, JD is featured as the Summit’s mental health keynote speaker. Honberg, the National Alliance on Mental Illness Policy and Legal Affairs Director, will address our nation’s growing mental health care needs and how the health care system can better support individuals and families. Honberg has been a lead author on NAMI’s Grading the States reports. He has appeared on NBC’s “The Today Show,” ABC’s “Nightline” and “The CBS Evening News.”

The Missouri Health Policy Summit was created to bring together prominent researchers, policy makers and the public to examine urgent Missouri health care matters. This year, attendees will discuss the relationship mental health has in health care, including its effects on specific populations such as returning military servicemen and women, the homeless, and the incarcerated. The morning’s workforce keynote and panel will discuss crisis standards of care, the

value telehealth services can bring to health care, and how the state can increase diversity in health care now and in the future.

The conference is open to registered participants. The registration fee is $150 per person before October 1. After October 1, the registration fee is $175 per person. Fees include all conference materials and food.

To register for the Ninth Annual Missouri Health Policy Summit, or for more information about the event, visit the MU Office of Continuing Medical Education Web site at http://som.missouri.edu/CME/ or contact Lindsey Beckmann at (573) 882-3458 or beckmannli@health.missouri.edu.

This event is sponsored by the MU Center for Health Policy, the Office of Continuing Medical Education, University of Missouri Health Care, Missouri Foundation for Health, MU School of Medicine, MU Sinclair School of Nursing, MU School of Journalism Smith/Patterson Lecture Series, MU School of Social Work, MU Master of Public Health Program, Mizzou Advantage Health Reform Network, Missouri State Medical Association, and Primaris. �

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Featured 2011 Health Policy Summit speakers (l to r): David Brooks, Ron Honberg and Harold

Miller. Registration details are available at healthpolicy.missouri.edu/events

Center for Health Policy | 15

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Jan 3 Missouri Health Care for All, Presentation, MHCFA Strategic Cross-Coalition Meeting - First Baptist Church-Jefferson City, MO, Karen Edison

Jan 12 Health Literacy in the U.S., Presentation, Department of Health & Senior Services - Jefferson City, MO, Stan Hudson

Jan 12 Missouri Health Care for All, Presentation, William Jewell College - Liberty, MO, Karen Edison

Jan 26 Putting the Meaning in Meaningful Use, Presentation, Metro Medical Group Management Association - YMCA South Facility, Joplin, MO, Nancie McAnaugh

Feb 2 Making Better Health Decisions; Plain Language Training, MU School of Medicine, Columbia, MO, Dave Zellmer

Feb 3 Getting Your Slice of the EHR Pie, Presentation, Missouri EHR Webinar, Nancie McAnaugh

Feb 7 The State of Missouri’s Health, Presentation, Association of Health care Journalists - Jefferson City, MO, Nancie McAnaugh

Feb 8 The Missouri Health Information Technology Assistance Center, Presentation, Regional LPHA Meeting in Macon, MO - The Comfort Inn, Nancie McAnaugh

Feb 17 Health Literacy in the U.S., Presentation, Health Literacy Lecture, MU School of Medicine, Columbia, MO, Stan Hudson

Feb 21 Montgomery is My Home: A community-produced video about health care and the rural economy, Presentation, Montgomery County Extension Annual Dinner & Meeting at The Firehouse Building in Big Spring, MO, Amy Lake

Feb 23 Making Better Health Decisions; Plain Language Training, Presentation, Health Literacy Missouri, St. Louis, MO, Dave Zellmer

Feb 23 Health care Policy for Missourians, Presentation, KFRU with radio host David Lile, Karen Edison

Mar 3 The Missouri Health Information Technology Assistance Center, Presentation, Regional LPHA Meeting in Springfield, MO at the Clarion Hotel, 3333 South Glenstone, Nancie McAnaugh

Mar 8 Improving Client Understanding Through Health Literacy, Presentation, Greater KC Association of Health Underwriters, 9th Annual Winter Health care Symposium “Health care-Changes and Challenges”, Overland Park Convention Center, Overland Park, KS, Stan Hudson

Mar 8 Health care Policy for Missourians, Presentation, Osher Life Long Learning Class, Stephen’s Lake Activity Center, Columbia, MO, Karen Edison

Mar 9 MO HIT Assistance Center, Presentation, Jefferson City, MO, Karen Edison

Mar 10 Straight Talk Training-Pilot, Presentation, Regional Arts Commission, St. Louis, MO, Stan Hudson and Ioana Staiculescu

Mar 10 Straight Talk Workshop, Presentation, Catholic Family Services, St. Louis, MO, Stan Hudson, Dave Zellmer and Ioana Staiculescu

Mar 11 The Missouri Health Information Technology Assistance Center, Presentation, Regional LPHA Meeting in Jefferson City, MO, Nancie McAnaugh

Mar 14 The Missouri HIT Assistance Center Presentation, Presentation, Rolla, MO, Nancie McAnaugh

Mar 15 The Missouri HIT Assistance Center Presentation, Presentation, Poplar Bluff Chamber of Commerce, Poplar Bluff, MO, Nancie McAnaugh

2011 Presentations

16 Impact | Summer 2011

Presentations

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Mar 15 Health care Policy for Missourians, Presentation, Osher Life Long Learning Class, Stephen’s Lake Activity Center, Columbia, MO, Karen Edison

Mar 16 The Missouri HIT Assistance Center Presentation, Presentation, Lebanon, MO, Nancie McAnaugh

Mar 22 The Missouri Health Information Technology Assistance Center, Presentation, Regional LPHA Meeting in Southeastern District Office - Poplar Bluff, MO, Nancie McAnaugh

Mar 23 The Missouri Health Information Technology Assistance Center, Presentation, Regional LPHA Meeting in South County Health Center-St. Louis, Dr. Nouhan Auditorium, St. Louis, MO, Nancie McAnaugh

Mar 25 Using Simulated Patients to Enhance Health Literacy Communication and Patient Understanding, Poster, Central Group of Educational Affairs (CGEA) Annual Meeting, University of Nebraska Medical Center, Omaha, Nebraska. Authors: Stan Hudson, Karen Edison, James Campbell, David Fleming, Kimberly Hoffman, Diane Smith, Dena Higbee, Ioana Staiculescu

Mar 28 The Missouri Health Information Technology Assistance Center, Presentation, Central Jackson County Fire Protection District Education Center - Blue Springs, MO, Nancie McAnaugh

Mar 30 The Missouri Health Information Technology Assistance Center, Presentation, St. Louis-Meramec, St. Louis, MO, Nancie McAnaugh

Mar 31 The Missouri Health Information Technology Assistance Center, Presentation, PRIMARIS, Columbia, MO, Nancie McAnaugh

April 15 Health Literacy Workshop-Front Desk Staff Presentation, MOAPS Annual Conference, Tan-Tar-A Resort, Osage Beach, MO, Stan Hudson, Ioana Staiculescu

April 16 Health Literacy Workshop-Doctor, Presentation, MOAPS Annual Conference, Tan-Tar-A Resort, Osage Beach, MO, Stan Hudson, Karen Edison, David Fleming, Ioana Staiculescu

Apr 27 One Health One Medicine One Community Network, Poster, Mizzou Advantage Poster Session, AUTHORS: Karen Edison, Amy Lake, Stan Hudson, Molly Vetter-Smith, Sharon Grass, Joseph LeMaster, Melissa Maras

Apr 27 The Simulated Patient, The Simulated Physician: Two Workshops Designed to Enhance Health Literacy Communication Skills, Presentation, Society of Teachers in Family Medicine Annual Meeting in New Orleans, LA, James Campbell

May 5 Straight Talk For Your Doc-Workshop Implementation Training, Presentation, Institute for Health care Advancement 10th Annual Literacy Conference, Irvine, CA, Stan Hudson

May 10 The Impact of the 2009 Institute of Medicine’s Crisis Standards of Care Letter Report, Presentation, Institute of Medicine’s Phase 2 Standards of Care Committee Meeting, Washington DC, Nancie McAnaugh

May 13 The Missouri HIT Assistance Center Presentation, Presentation, Missouri Bar Association’s Health Law Committee Meeting, Jefferson City, MO, Nancie McAnaugh

May 21 Health Literacy for Child Health, Presentation, 33rd Annual Common Childhood Problems Conference, M615 MU School of Medicine, Columbia, MO, Karen Edison

Jun 3 Improving Patient Understanding and Adherence Through Health Literacy, Presentation, Missouri Academy of Family Physicians 63rd Annual Scientific Assembly, Camden on the Lake, Lake Ozark, MO, Stan Hudson 

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Affiliate Spotlight:

diane l. Smith, Phd

Anyone who has ever gotten lost in a hospital, not understood their doctor’s directions, or

felt “talked-down to” in a hospital can appreciate Dr. Diane Smith’s research. Smith, the chair of the Department of Occupational Therapy at MU and health literacy researcher who works with the MU Center for Health Policy (CHP), has made it her goal to improve provider-patient relations and make sure patients leave the hospital understanding what they must do to get better.

“Health literacy is an issue of environment and access,” Smith said, “That’s how occupational therapy and health literacy go together. In this case, with health literacy, it has to do with the inability of a typical person to access the health care system physically and cognitively.”

Issues arising from the intersection between occupational therapy and health literacy include the

complexity of hospital signage and forms, and the quality of patient-provider interactions. Smith said that too often patients are unable to understand signs in hospitals and written instructions from their doctors, leading to frustration and confusion. Many doctors simply place forms in front of their patients to read and sign, which Smith said can lead to problems with informed consent.

“Everything printed is supposed to be at a 5th to 8th grade reading level, but often I see health care facilities use big words without a definition,” Smith said, “In some of the projects I’ve done, we’ve seen things written at the 14th or 16th grade level. That implies some level of college education.”

Research backs Smith’s statements. According to National Adult Literacy Survey (NALS) data, 90 million adults don’t understand complex text. Additionally, the Central Intelligence Agency (CIA) World

Factbook states that nearly 20 percent of Americans have difficulty speaking and understanding English. Based on the research, Smith said that providers shouldn’t assume even highly-educated patients understand the doctor’s instructions.

“Sometimes you have doctors talking so fast that patients don’t understand what they’re saying,” Smith said, “Many people don’t ask questions because they don’t want to appear as though they’re not smart.”

To help facilities and health professionals provide a better patient experience, Smith, as part of a grant project with Health Literacy Missouri and the CHP, conducts assessments of health care facilities to see how effectively they communicate with their patients.Some common problems Smith found in her assessments were confusing signs, printed materials

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18 Impact | Summer 2011

Collaborator Spotlight

written at a high grade level, and deficiencies in cultural communication. A common problem she saw was different signs for the same place.

For example, there were signs saying “x-ray” and “radiology” directing patients to the same department.

“This is where health literacy and cultural competency come together,” Smith explained, “Doctors have to be sure that all of their patients, not just the English-speaking Americans, understand their instructions.”

To help doctors communicate better with patients, Smith recommends they follow three techniques – “flip it”, “show me” and “teach back”. “Flip it” encourages providers to be mindful of the order in which they

present information to patients. Studies show that patients are less likely to remember directions (e.g. medication schedule) when they come at the end of an explanation of the diagnosis. Providers are encouraged to “flip” the order of the information they present. Instead of giving directions after explaining the diagnosis in detail, they are more successful when they give the directions up front and then explain the diagnosis in more detail.

“Show me” encourages doctors to have their patients show them how they would perform their at-home procedures, such as injecting insulin or taking pills in a particular order. “Teach-back” encourages doctors to tell patients, “If you were to go home and talk to your roommate,

girlfriend or parent, what would you tell them about your situation?”Using clinical simulation centers, such as the MU School of Medicine’s Russell D. and Mary B. Shelden Clinical Simulation Center, Smith and CHP staff and faculty are able to teach doctors these techniques in a controlled setting. For more information about the Center’s work on clinical simulations, please click here. In the future, Smith plans to continue her health care facility assessments and spreading the message of improved signage, paperwork and provider-patient interactions.

“Don’t be afraid to ask questions,” Smith said she tells all patients. “Don’t be afraid to call back for clarification. Repeat the message back and be assertive.”�

Have you heard of MoCaN?

The Missouri Council for Activity and Nutrition (MoCAN) is a coalition comprised of representatives from statewide and local agencies, institutions, organizations, other coalitions or individuals who work together to support healthy eating and active living through policy and environmental changes to measurably improve the health and quality of life of Missouri residents.

Find out more at www.MoCan.org.

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Center for Health Policy | 19

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