Increased Access to Comprehensive Health Care Services Recommended Community Strategies

December 7, 2011

Voices. Choices. Health Care Access Task Force United Way of Greater Greensboro in partnership with Cone Health Foundation Greensboro, NC Jean B. Pudlo, Facilitator

EXECUTIVE SUMMARY

From January to September, 2011, a Health Care Access Task Force was formed by the United Way of Greater Greensboro and the Cone Health Foundation to explore dimensions of health care access a key concern in the Voices. Choices. Community Assessment and to recommend community wide strategies to improve Access to Comprehensive Health Services. The Task Force used this definition of the aspects of health care accessibility: The Availability of health care providers in a community is critical to access for residents. Accessibility includes those factors that make it physically and financially possible for someone to get to a health care provider. This would include transportation and insurance or other means of payment for services. Acceptability of care refers to factors that influence the effectiveness of the health care interaction such that a patients needs are understood and a patient can understand and carry out their providers direction for appropriate self-care. The Task Force adopted the term Effectiveness to describe this aspect of care. While acceptability denotes that care is culturally comfortable and understandable to a consumer/patient, effectiveness of the interaction includes the dimension that people are able to make positive health choices based on the information they received from their provider. The recommended strategies address the Accessibility of health care in particular helping people find the way to appropriate care for themselves and their families, and Effectiveness of care interactions so that patients are more assured of being able to use the information they received about their health and act on it. The six strategies are: 1. 2. 3. 4. 5. 6. Information and Referral: Improved Database Access to Health Resources Helping People Find Their Way: Lay Patient Navigators (Community Health Workers) Helping People Find Their Way: Professional Patient Navigators Public Awareness Campaign Health Literacy Strategies Consumer/Patient Health Literacy Strategies Health Care Provider

The Task Force recommends that United Way and Cone Health Foundation consider incorporating a focus on Accessibility to Health Care and Effectiveness of Health Care interactions into their respective funding priorities, and to continue the collaboration begun in this process. They believe that all of these strategies can be undertaken by existing health care or social service agencies in collaboration or independently. To begin this work, the Task Force recommends a pilot project using Lay Health Navigators (Community Health Workers) in one or more neighborhoods with high rates of chronic disease using organizations already working in these neighborhoods and in health outreach; professional education to increase the understanding of aspects of health care access and how to start the recommended strategies; improvement of database access to health care resources; and incorporation of health literacy strategies into activities in a variety of settings.

BACKGROUND
In 2009-10, the United Way of Greater Greensboro (UWGG) conducted a community needs assessment called Voices. Choices. Access to Comprehensive Health Care Services was noted as a top community concern in the Executive Summary of that report: Access to healthcare and lack of coordination between and among service providers was the most frequent comment made by participants in focus groups and community forums. A strong level of frustration was noted from minority and ethnic groups who felt there was a lack of cultural competence and understanding from providers who provide services to ethnic minorities. Significant health disparities exist in Guilford County among racial and ethnic groups, with whites having significantly better health outcomes than other ethnic and racial minorities. Despite advances in health care, racial and ethnic minorities continue to have higher rates of disease and premature death related to breast cancer, prostate cancer, diabetes, and high blood pressure, communicable diseases including tuberculosis, HIV, syphilis, and gonorrhea, higher rates of infant mortality, low birth weight, and teen pregnancy exist for non-minorities. These disparities arise from many complex factors, but two major contributing factors are inadequate access to care and substandard quality of care for these groups. With the changing economic times, families have been impacted by the inability to afford primary and preventive care and by deep cuts in some health programs, such as community support for people with mental illness and substance abuse issues. In addition, personal care services that help people with disabilities or severe medical conditions to remain in their homes and out of institutional settings have been reduced, placing greater stress on family caregivers. The states Medicaid population has grown by nearly 200,000 residents since January 2008. Budget shortfalls will continue as steep declines in local and state revenue persist; revenue will be insufficient to maintain public services at current levels, much less restore service to the level prior to the recession. The growing percentage of our population experiencing poor health and mental health outcomes and gaps in services makes it more urgent that we address health and mental health disparities. Poorer health outcomes impact businesses and the economy through absenteeism, productivity, performance and business outcomes. The health of children and youth impacts their educational attainment and job readiness. Untreated mental health and substance abuse disorders contribute to poor educational attainment, disruption of normal daily and workplace activities, impaired family relationships and homelessness and can result in high costs in community crisis are services. Helping all populations to achieve access to high quality health care services will promote wellness, better health care outcomes, and a higher quality of life for our community. Upon completion of the Community Assessment, the Community Investment Council of UWGG sought to provide leadership in addressing the four priorities that were selected in the process. Input from these planning processes will be used to determine funding priorities for the next few years. This process fits into an increasing strategic emphasis on community level change on the part of United Way. For the health goal Access to Comprehensive Health Care Services Cone Health Foundation expressed interest in partnering in a process to develop strategies to address the community health needs. This fit well with the Cone Health Foundations mission, To invest in the development and support of activities, programs and organizations that measurably improve the health of people in the greater Greensboro area.

In late 2010, leadership of the UWGG and Cone Foundation identified leaders of organizations that work in health care or with populations that face challenges in accessing care. This provided a group of approximately 20 social service and health care agencies who formed the Health Care Access Task Force for this planning process. Jean Pudlo, an independent consultant, was hired to facilitate the exploration of health care services and development of strategies that would lead to increased access to health care by the greater Greensboro community. The Task Force was given the following charge: This Task Force is being asked to recommend strategies and action plans that could be taken on by various facets of the community, including the United Way, its network of agencies and other community stakeholders. Access is one of four issue areas chosen to be most reflective of the critical needs affecting health and human care in Greensboro at this time, with three goals identified in the area: Goal: People have access to primary care services including medical care, mental health services, substance abuse treatment and dental care Goal: Increase the percentage of people who have insurance or health care coverage Goal: Promote and advocate for the elimination of health disparities among all racial and ethnic minorities and other underserved populations. Anticipated outcomes will include strategies and action plans in one or more of the goal areas listed. All three areas will be explored, but it is up to the Task Force to determine which areas are of greatest need or offer the greatest potential for progress. An Agenda for Change will be developed to address these questions for each strategy: What are we trying to do? Why are we doing it? What are we trying to change? What does success look like? The process is to focus on long term change in selected indicators. Planning will take place in the context of factors that cut across all issues in Voices. Choices.: cultural competency and understanding, the challenging economic climate, and racial and ethnic disparities in health outcomes.

PARTICIPANTS
Adult Center for Enrichment AHEC Cone Health Foundation Cone Health, Family Practice Clinic Congregational Nurses Family Life Council Family Services of the Piedmont Greensboro Health Disparities Collaborative Guilford Center Guilford Child Development Guilford County Department of Public Health Hospice and Palliative Care of Greensboro Partnership for Health Management Piedmont Health Services Reading Connections Senior Resources Triad Adult and Pediatric Medicine UNCG Center for Youth, Family and Community Partnerships UNCG Center for New North Carolinians United Way of Greater Greensboro YMCA YWCA Greensboro 5 Nancy Gore Charles Hansen Susan Shumaker, Antonia Reaves Denya Hawkins Lelia Moore, Sandra Blaha Teri Wellendorf Theresa Johnson Nettie Coad, Jennifer Schaal, MD, Nora Jones Anne Kimball Joyce Fairley Ward Robinson, Laura Mrosla Risa Hanau Claudette Johnson Lloyd Mickens Jenny Gore Ellen Whitlock, Renee Griffin Brian Ellerby, Lisa Duck Jen Kimbrough, Kelly Graves Addy Jeffrey Keith Barsuhn, Jennifer Ruppe Kim McKone Lindy Garnette

PROCESS
The process was developed to enable the group to explore the three identified goals and the various aspects of health care access in order to develop strategies that could make measurable changes in our community. A significant side benefit was the development of relationships and understanding between health care focused agencies and social service agencies that worked with specific populations with unique health care access challenges. Thus, the meetings provided opportunities for networking and sharing of information in addition to the work of understanding the issue and developing strategies. Beginning in January, 2011, the Task Force usually met twice a month for two hours. Twelve meetings of the full task force were held through September, 2011. Several committees had separate meetings as well. The discussions included these areas:

Review of area programs that increased access to health care by addressing one of the three identified goals. Identification of populations of community members that need increased access to care. Exploration of what access looks like for Low Literacy, Limited English Speaking and Senior community members, as examples of populations with specific needs. Exploring the definition of health care access by Dr. Giselle Corbie-Smith based on the National Institutes of Health definition. Identification of gaps between current and desired status by looking at each aspect of access to care from both the provider and the consumer/patient perspective. Choosing gap areas to focus further research by small groups: Health Literacy, Patient Navigators, Public Awareness, Cultural Competency. The areas of Dental Care and Transportation also rose to the top as key gaps, but are being addressed by the Guilford Community Care Network and the Cone Health Foundation. Divided into four committees to explore these issues. After reports from each of the four areas, the Task Force chose Patient Navigators as a key focus. During the summer months, the Task Force envisioned what that strategy would look like and realized a need for a variety of strategies because of a continuum of varied health care education needs. Developed overall concept Bridging Communities to Care with an emphasis on Accessibility to care, particularly in helping people connect to the appropriate health care resources, and Effectiveness of care, with strategies to strengthen understanding by the consumer/patient and thereby increase compliance with health care recommendations. Developed six strategies which included patient navigation, but also health literacy, a database of resources, and a public awareness campaign.

EXPLORATION OF ACCESS TO COMPREHENSIVE HEALTHCARE SERVICES

These next few pages summarize the explorations of various aspects of access to health care that led the Task Force to the recommendations made in this report. First was an effort to understand what efforts are ongoing in the community and a better understanding and framework for access to care, so that we could move the discussion forward to practical strategies for the community.

CURRENT EFFORTS IN HEALTH CARE ACCESS

Many entities working in the community have health care access as a significant part of their missions, either by providing health care services or helping to support people who need care. A listing of these is included in the notes from the meeting of January 14, 2011, where the agencies that impact each of the three health access goals are listed by goal. (Attachment 1) It was the general assumption of the Task Force that any strategic solutions that are suggested by the process could be housed at one of the existing agencies or a collaboration of two or more of the agencies, and would not require a new entity for implementation. The existence of community collaborations (such as Guilford Community Cares Network) demonstrates the community has a willingness to work together to make use of existing resources for health care challenges.

SCOPE AND DEFINITION OF ACCESS TO CARE

The broadness of the scope of access to health care seemed overwhelming at first as there are so many different aspects to a person receiving the care they need. It was helpful to learn about a definition of access from the National Institutes of Health as described by Dr. Giselle Corbie-Smith and provided a framework for the Task Forces discussion. In a presentation to Cone Health Foundation Dr. Corbie-Smith (UNC-Chapel Hill) described three areas that constitute health care access, based on a definition by the National Institutes of Health. The Availability of health care providers in a community is critical to access for residents. Accessibility includes those factors that make it physically and financially possible for someone to get to a health care provider. This would include transportation and insurance or other means of payment for services. Acceptability of care refers to factors that influence the effectiveness of the health care interaction such that a patients needs are understood and a patient can understand and carry out their providers direction for appropriate self-care. The Task Force adopted the term Effectiveness to describe this aspect of care. While acceptability denotes that care is culturally comfortable and understandable to a consumer/patient, effectiveness of the interaction includes the dimension that people are able to make positive health choices based on the information they received from their provider. Under this framework, Accessibility includes includes physical accessibility such as transportation, financing whether through insurance or other means, time- how long to wait for an appointment or how long to wait in the office, and other aspects/potential barriers that affect the ease of obtaining care. We have also defined

Accessibility as being able to determine where to get the care needed that the information is available to an individual to determine the health care service needed and where to find it. Effectiveness, in our framework, addresses the extent to which services meet the values and needs of the users. Factors include language and culture, varying attitudes toward care, education and understanding of beneficial health care practices. If health care services are effective, then patients are able to adhere to instructions for selfcare and follow up.

DISCUSSION THEMES
Following is a summary of some key themes in the Task Forces conversations as they explored the complexity of health care access. These are briefly summarized below, in no particular order of relative importance.

HELPING PEOPLE FIND THEIR WAY TO APPROPRIATE CARE

In the Voices. Choices. Community Assessment, a common theme heard was helping people connect to the resources they need. Again and again we heard stories in health care of individuals not knowing or understanding what kind of care they needed or where to find it, and the challenges that even professionals in the field face when making referrals or assisting people in getting past the barriers to care that they faced. This includes what type of care, where to find it, who are appropriate care providers, and how to find care in ones home. There is a continuum of need from people who may not understand the value of having a medical home with a primary care medical provider and well checkups, to those with critical illness needing a variety of services or those with chronic illness and specialized needs. Finding the way also takes on a very practical aspect in the presence of easy to understand signage on streets and buildings to find medical offices.

ACCURATE TIMELY INFORMATION

Task Force members expressed frustration with being able to find easily accessible, up to date information to find appropriate resources for people with various needs including changing contact information, resource and referral websites that are not updated or are difficult to use. During this same time period, a Leadership Greensboro team was conducting an evaluation for United Way of Greater Greensboro of the 2-1-1 referral services which affirmed the potential benefit to make this resource more responsive and easy to use. The nature of changing programs and services, targeted programs for specific populations that make it a challenge to determine who qualifies for which services, changing contact information, and even agency name changes all demonstrate the need for a responsive information source. An effective source could support agency and health provider staff who are aiding people in getting appropriate care, as well as the general public seeking their own information directly.

MULTIPLE ACCESS POINTS AND PEOPLE HELPING PEOPLE

One model addresses the frustration that people feel in trying to find the right service, but calling on the wrong organization. A no wrong door approach includes all participating agencies conducting a similar intake process for someone who contacts them, and then referring them to the appropriate agency who does not need to repeat the intake process. An example is in place in our community with agencies serving seniors the Piedmont Triad Community Resource Connection. 8

This is one example of a way to ease the need for people to find their way through a system of care.

WELCOMING EXPERIENCE/ATTENTION TO HEALTH LITERACY

It is critical for effective care that people find a welcoming setting that respects and understands their own cultural and personal attitudes about heath care, where they are treated in a way that is non-judgmental, and so feel comfortable. This is important for people of any race, culture, and income or education level. Part of the welcoming experience is clear communication, recognizing that over a third of patients have limited health literacy. Health literacy is the ability to obtain, process, and understand basic health information and services needed to make appropriate decisions. Limited health literacy is associated with poor management of chronic diseases, poor ability to understand and adhere to medication regimes, increased hospitalizations and poor health outcomes. According to the National Assessment of Adult Literacy, African American, Hispanic/Latino, and American Indian adults were significantly more likely to have below basic health literacy when compared to their White and Asian counterparts. In 2006, adults with less than a high school degree were 50% less likely to have visited a doctor in 1 the past 12 months compared to those with at least a bachelors degree.

RACIAL DISPARITIES IN HEALTH OUTCOMES

As discussed in the Voices. Choices. Community Assessment report, there is a wide discrepancy in health outcomes based only on race that is not explained by income, education level or other criteria. There are higher rates of chronic disease including cancer, heart disease, stroke, lower respiratory disease, and higher rates of communicable diseases. Besides experiencing less health care, people in groups often have less access to the conditions that promote better health such as education, understanding of healthy habits, access to healthy foods, safe neighborhoods, freedom from racism and other discrimination, and health insurance. The Task Force reinforced the message of the Assessment that care is not well coordinated or easy to understand. Many anecdotes were also shared about the differential treatment of non-white patients and inattention to different cultural norms about health care. The importance of culturally competent or better yet culturally proficient care was underscored in many conversations. It was recognized that training alone was not sufficient to make changes in provider office as staff and providers both need reinforcement to develop and routinely use the communication skills that would enable the most effective delivery of health care. It is key in our community that the long term focus of strategies include overcoming disparities in access to care in order to overcome disparities in health outcomes.

Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.

EVALUATION CHALLENGES IN MEASURING ACCESS TO CARE

Each time the Task Force met, there was a discussion about choosing measures of health care access that would ultimately show the progress of any implemented strategies in improving greater Greensboros health care. The only clear conclusion is that there are not one or two measures that can easily and reliably relay that information. If, for instance, the community looked at appropriate use of emergency department visits, one could easily envision significant changes that bear no relationships to possible success of strategies. For instance, imagine a large economic shift which could reduce (or increase) the number of insured families and dramatically change the number of people using emergency departments because of a lack of no cost alternatives which could overwhelm the impact of community strategies on the outcome. As part of the overall funding process review for United Way of Greater Greensboro, the UNCG Center for Youth, Family and Community Partnerships will provide input on appropriate ways to measure the aspects of health care access. In addition, Cone Health Foundation is commissioning a white paper on Health Care Access in the coming year which will likely address the evaluation challenges. This Task Force recommends some possible measures related to each of the suggested strategies, but supports the need for further exploration of appropriate outcome measures. As strategies are chosen for addressing health care access in greater Greensboro, great care needs to be taken in determining outcome measures that are true indicators. It must be recognized that community level indicators are influenced by many factors beyond strategies that are implemented.

PATIENT RESPONSIBILITY
Some provider agencies in the Task Force expressed frustration with high no-show rates for appointments and low compliance with medical advice of their patients. If people were better about keeping appointments, we could make better use of the providers that we have. Others cautioned to be careful not to immediately blame the patients, but to look for reasons and address those including their possible lack of understanding of common health care practices. For instance, they may not understand the need for regular checkups or return visits, or even to call if they are not able to make an appointment. However, if patients are satisfied with their appointments, have understood their instructions and feel respected, they are more likely to return as appropriate for further care and follow up. It was felt that patient responsibility and follow up could increase with increased knowledge by patients of the importance of medical visits, the etiquette that surrounds them, and by effective communication within the appointment. Health navigators and health literacy strategies can both address these needs.

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ACCESSIBILITY AND EFFECTIVENESS OF HEALTH CARE INTERACTIONS GOAL: INCREASE ACCESS TO COMPREHENSIVE HEALTH CARE BY LINKING PEOPLE TO SERVICES THAT ARE AVAILABLE, ACCESSIBLE AND EFFECTIVE.

BRIDGING COMMUNITIES TO CARE

The Voices. Choices. Health Care Task Force began to think about how to present our understanding of health care access and the recommended strategic approach graphically, and created this image below. Access to care was seen as multilayered first, providers need to be present in the community, then people need to be able to find, pay and get to the care; finally the care needs to be understandable and appropriate to the patients values to effectively help the persons health. The strategies recommended are ones that connect community members to an effective health care interaction.

Effectiveness of Health Care Interaction Accessibility of Health Care Availability of Health Care

Community

STRATEGIC APPROACH
The recommended strategies being presented represent the understanding that there is no quick, easy way to address the complexity of community health care needs. There is no low hanging fruit, because even the strategies the quickest impact require careful planning and capacity building to conduct effectively and so will take time to implement. Health Care Access, as previously discussed, contains areas of Availability of Health Care- enough health care providers are in the community, Accessibility people can access the health care physically and financially, and Effectiveness people have a satisfactory interaction that provides them the information they need to make appropriate health care decisions and to follow instructions for their self-care. The focus of this Task Force has been in helping people to access appropriate care by helping them find where they need to go, overcoming barriers to getting there, and in increasing the effectiveness of the interaction. Availability of health care providers is not addressed in this set of strategies, nor are some community wide strategies to address broad issues in Accessibility of care. This is because there are existing efforts to address these areas of care. In the greater Greensboro area, the hospital system, health department, individual medical 11

practices and other organizations such as Triad Adult and Pediatric Medicine, focus on increasing the availability of health care providers in the community. In particular, it was recognized that there is a shortage of dental services especially for low-income people. The Task Force identified dental care as in particular need for more providers, but this community need is already being explored and addressed by Guilford Community Cares Network (GCCN). While the need is not yet solved, GCCN is providing leadership in addressing the need. Transportation is an Accessibility issue that crosses many social service needs and is also being addressed by GCCN. Several other factors contributed to the approaches suggested: As the Greensboro and Guilford County communities grow in diversity of culture and ethnicity, strategies addressing cultural differences become critical to making a difference in racial disparities of health care outcomes. The recommended strategies interact with and can be components of each other. Patient Navigation strategies that help people find the appropriate general and specialized care that they need can incorporate Health Literacy strategies that help them have a more effective interaction with a provider with improved communication and understanding. There is no one strategy that can alone solve a communitys access to care challenges. Strategies that were consumer focused were deemed by the Task Force to have the quickest impact for the people being served, but strategies that helped create systemic change in how people are welcomed and treated in the health care system were considered to have the broadest long term impact. Approaches from both directions are necessary.

STRATEGIC RECOMMENDATIONS
The strategies are summarized below. Attachment 2 provides a two page summary of key elements of each of these strategies,including why and how they should be implemented.

INCREASE ACCESSIBILITY: CONNECT PEOPLE TO CARE 1. INFORMATION AND REFERRAL: IMPROVED DATABASE ACCESS TO HEALTH RESOURCES
The Task Force recommends investment in an effective and responsive database that is accessible for people who are helping others find the care they need, and for individuals themselves. The database should be easy to use (including for low literacy individuals) and comprehensive. The increased complexity and changes in health care services require significant knowledge and up-to-date information to navigate. Creating or improving an existing database can raise public awareness of health care options and provide easier-to-understand information to the general public. As a result, more people will be able to access appropriate health care. As mentioned earlier, United Way of Greater Greensboro has already embarked on a review of the 2-1-1 Information and Referral Services, and has been aware of the needs expressed by the Task Force. If this or another

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existing database can be enhanced to provide superior responsiveness, it could be a viable option in meeting this need.

HELPING PEOPLE FIND THEIR WAY: PATIENT NAVIGATION STRATEGIES

In our community and others, there is emerging success with patient navigation programs. Particularly in dealing with breast cancer, there is a body of experience in improving health outcomes by helping patients connect to health care that they need and overcoming individuals barriers to care. Professional patient navigators may go by that title, or may be social workers, nurses, or other professionals who focus their efforts on helping their clients access appropriate care and addressing hurdles to care. The Task Force recommends two approaches. One uses Lay Patient Navigators in neighborhood settings to reach out to peers and help them connect to care. Another is increasing the capacity within the community to use professional health or social service staff as Professional Patient Navigators. A selected biography of literature on how to run patient navigator programs is Attachment 3.

2. LAY PATIENT NAVIGATORS (COMMUNITY HEALTH WORKERS)

Lay Patient Navigators are trained to help peers or others by sharing health care information and connecting people to a health care home or to other professional help, and to provide support to individuals as they seek care. They could be volunteers, paid volunteers (such as AmeriCorps members), or paid staff in an organization. They could also be called Community Health Workers. Neighborhood Pilot Program: A suggested approach would be to identify 1-3 neighborhoods with a high rate of chronic disease (as determined by public health records), and work together with established neighborhood groups to recruit, train, and support volunteers in the communities. It would be critical to plan carefully for appropriate training, placing, oversight and support of these navigators. An existing health care or social service agency (or a collaboration of agencies) would organize the effort and provide volunteer and program management support. Through such an effort, more people would connect to a medical home; basic health, wellness and safety knowledge would be increased; and there would be an increase in adherence to medical guidance as the navigator helps individuals better understand instructions and the importance of following them.

3. PROFESSIONAL PATIENT NAVIGATORS

Also recommended is the use of Professional Patient Navigators in a two prong approach providing agencies (health care and social service agencies) with training to build the capacity of their staff to provide patient navigation, and to support the hiring of more navigators in the greater Greensboro community. Professional Patient Navigators would work within existing health care and social service agencies, helping people who require significant one-on-one assistance and education due to the complexity of their health care needs or their life situation. This would help ensure the use of appropriate care and increased adherence to medical guidance that can lead to improved health outcomes, avoiding unnecessary emergency department visits. Examples of this approach have already proven effective in Greensboro, particularly in breast cancer treatment and through the Partnership for Health Management which works with Medicaid recipients. Extending these services here and in other agencies will address the frustrations voiced in the Voices. Choices. Assessment that people do not know how to connect with care. It is critical that training of patient navigators, both lay and professional, includes significant attention to working with patients with differing cultural and ethnic backgrounds and expectations, as well as health literacy strategies. 13

The next steps for these strategies are to more carefully review models of best practice and to identify comprehensive training resources to initiate and expand patient navigation programs.

INCREASE EFFECTIVENESS: BUILD MORE EFFECTIVE HEALTH CARE INTERACTIONS 4. PUBLIC AWARENESS STRATEGIES
The Task Force is very aware that there is a continuum of health needs and understanding of health, wellness and safety care and prevention. To that end, the implementation of a broad public awareness campaign could support other strategies by reinforcing positive health messages and helping prepare people to better prevent illness or obtain care sooner rather than later. Possibilities include the benefits of having a medical home, how to talk to your doctor, when is the time to take a child to the doctor, and how to find appropriate health care resources. The purpose would be to increase individuals knowledge of how to care for their own and their familys health, encourage them to have a primary care provider/medical home, and empower individuals to help make their health care interaction effective. Efforts in this area should tie into existing efforts in the community and also support other strategies (such as the Ask Me 3 health literacy strategy discussed below).

HEALTH LITERACY STRATEGIES 5. HEALTH LITERACY STRATEGIES CONSUMER/PATIENT FOCUSED

The Health Access Task Force recommends implementing health literacy strategies that are focused on individuals seeking care (also referred to as patients or consumers) to provide them the skills to better care for their own health, and to get and understand the information that they need from their health care provider. To that end, the Task Force recommends implementing the Ask Me 3 campaign from the National Patient Safety Foundation. Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to understand the answers to three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? The campaign includes reaching out to groups and individuals and general public awareness through the media, as well as training for health care providers to be prepared and help create a positive environment for communication. Second, increase efforts to distribute plain language materials in health provider and community settings such as restaurants, recreation centers, and faith communities. Many materials are available but need to be distributed and restocked on a regular basis. Plain language materials are written at a lower reading level than most health information, as well as make use of graphics and simpler words to reach audienceS with diverse reading levels and levels of English understanding. In addition, train agencies and program managers to incorporate health information in community-based settings. Many current United Way agencies could incorporate health learning activities into their programs with youth,

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families or individuals whom they serve in a variety of ways. Finally, promote the use of adult education to improve health literacy skills to address individual and family wellness and safely goals. These strategies help to build a bridge to health information and health services. They encourage adults to take responsibility for their health and that of their families through increased knowledge, support and readily accessible, readable information. Many of the tools and materials for consumer focused health literacy strategies exist, and there is experience within the community using various health literacy strategies. Increasing these efforts into a variety of program and community settings will reach a broader group of individuals. The resulting increase in health care knowledge should result in long term better health outcomes. To the degree that efforts are targeted on specific populations, these strategies can reduce health disparities.

6. HEALTH LITERACY STRATEGIES HEALTH CARE PROVIDER FOCUSED

Every health care interaction has two sides, and the Task Force recommends strategies that increase the tools used by health care providers to create a welcoming setting that optimizes the opportunity for their patients to get the information they need to best care for their health. In a community with increasing diversity, cultural proficiency is necessary so that all people feel respected and are able to communicate with and understand their health care professionals. To ensure best success of the Ask Me 3 campaign, the Task Force recommends that the provider component of this program also be implemented. Second, promote the use and development of plain language or universally readable materials. Increase the frequency of workshops to help health care offices adjust their written materials, and promote those that already exist that could meet the providers needs. Follow up to determine if materials are being integrated into health care services. Third, develop and promote attendance at training to build cultural proficiency the skills and strategies needed to work with people with an increasing variety of values, cultural norms and expectations. Together with this, determine what organizational changes may be needed to incorporate culturally proficient behaviors on a daily basis. Providers may need incentives to tailor their care to diverse patients. With increased use of simpler language and attentiveness to cultural differences, the Task Force would expect improvement in patient satisfaction, increased attendance at follow up appointments and increased adherence to medical advice given.

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RECOMMENDATIONS FOR NEXT STEPS

Structural
1. Incorporate the strategic directions of Connecting People to Care and Creating Effective Healthcare Interactions into the funding strategies at Cone Health Foundation and United Way of Greater Greensboro. Continue dialog to determine which organization can be most effective in supporting individual strategies, and where collaboration between funders is critical. Guidelines to include: a. Programs to increase health care literacy for any at risk population, such as those served by many United Way and other partner agencies. b. Strengthen the capacity of the community to integrate health literacy strategies and understanding health care enough for individuals to get appropriate health care. c. Staff development in health care and social service agencies in cultural competency, health literacy strategies and patient navigation methods. d. Six part strategy focus as outlined in this report. Whenever possible, use existing organizations to carry out the strategies. In many instances, collaboration is appropriate to bring both the expertise needed and access to target populations of either health care providers/office staff or groups of consumers/patients. Use the UWGGs Health Impact Council to monitor progress toward strategic ends. Maintain one or more representatives of Cone Health Foundation on this council. Upon completion of Cone Health Foundations commissioned white paper on Health Care Access in the spring of 2012, consider other ways to collaborate in addressing access to comprehensive health care services.

2.

3. 4.

Strategy Specific
5. Increase efforts to create an effective and accessible database of health care resources for use by those helping connect people to appropriate care, or individuals themselves seeking resources. Explore the improvement and/or redevelopment of existing websites such as 2-1-1 before choosing to start anew. 6. Present a community conference to increase awareness of racial health disparities and the aspects of access to care explored in this effort and How-To information on strategies in patient navigation, health literacy and cultural proficiency. This can raise awareness of the strategies and give organizations some insights into how to get started or to enhance current efforts. Include health care providers, agencies who might implement health literacy and patient navigation strategies and potential partner organizations. 7. Increase the health literacy strategies that health care providers use in their day to day operations. Connect organizations with the expertise in health literacy with those that reach health care providers and their office staffs for training. In addition to training, begin to address structural issues of health care providers (time, funding et al), so that cultural competency and health literacy strategies are incorporated and maintained. 8. Develop a pilot project that uses lay health navigators in 1-3 neighborhoods. Build appropriate volunteer management capacity including training, job description development, placement and support. Partner with agencies capable of expanding into this work with increased capacity and resources. 9. Support current and new efforts in consumer focused health literacy strategies. Consider a variety of approaches and working through organizations that have access to target populations. 10. Be responsive to initiatives that incorporate the strategies the Task Force has identified by seeking and providing resources for such efforts. Encourage agencies to collaborate to suggest approaches within these multiple strategies.

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Attachment 1 January 14, 2011 Convening Meeting Notes Resources in the Community by VC Goal Goal 1: People have access to primary care services including medical care, mental health services, substance abuse treatment and dental care Medical Internal Medicine training program/MCHS Family Practics Health Serve/TAPM Community Clinic of HP Evan-Blount Clinic/GCDPH/PHS GCDPH Direct Care services Mental Health Hospice and Palliative Care (grief) Guilford Center Crisis/Emergency --medical management Healthserve MCBH UNC-G Psychology Clinic Guilford center call center 1.800 Substance Abuse ADS OP FSOP-OP Daymark (Wendover) IP/RES Guilford County Schools screening for students Dental Chandler (GCDPH) pediatric Overarching Congregational RN program Partnership for Health Management Multiple committees and systems across the community (Cone system, juvenile justice, NC Tracs, CRI trauma network, interpreter services, one stop shop, HIV coordinator (CHN), Guilford Co. Collaboration of care, Congregational nurse/SW, school based clinics) Guilford Community Care Network Organizations that are grant-based and are free or sliding scale (Family Services, Childrens Home Society, med. Case management 0-21 years) Partnership for Heath Management Launching in about 36 months

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Goal: Increase the percentage of people who have insurance or health care coverage Health Care Reform If you dont have a pre-existing Young adults getting back on parents insurance Small business insure employees Education on what resources are in our community?? The new population The Community Care Network 211 SHIIP Senior Health Insurance Information Program CHIIP Childrens Health Insurance Information Program Blue Cross Blue Shield offer some programs Liaisons in the ERS, Community Care Network 1. 2. 3. 4. 5. GCCN all in wheel Any agency with case management services Gov. legislation (insurance) School nursing and leadership PACE access for older adults

Congregational Nurse Program education CRC Community Resource Connection DSS, Shahbaz, etc. Goal: Promote and advocate for the elimination of health disparities among all racial and ethnic minorities and other underserved populations Center for New North Carolinians Interpreter Access, Americorps GSO Health Dis. Collaborative Access ENLACE Project Shine Reading Connections Health Literacy, English as a second language FLC-CHS GCDPH Planned Parenthood Triad UNCG YWCA Womens Resource Center Piedmont Health Services CNNC-IHAP College Bound Sisters A&T Dr. Bird work on Health Disparities

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Health Care Access Community Agenda: Detailed Community Agenda: Accessibility Finding the Appropriate Care Needed

Strategy: 1. Improved Database Access to Health Resources

Who will be the focus? General Public Health Navigators (including volunteer, I&R, case manager, and professional navigators) What are we trying to do? Provide easily accessible information for individuals and health care/social service workers to find appropriate health care for specific needs make use of 2-1-1 resources, consider return to local control Look at NC CRC systems, Call center, Care Link, Substance Abuse website to make use of what is already in place Why are we doing it? Increase public awareness of health care options through a comprehensive database. Provide easier to understand information for general public. Need for easy to use, comprehensive database Complexity and changes of health care system require significant knowledge and up-to-date information to navigate What are we trying to change? Develop an easy to use, comprehensive database for better access to information so that people can access appropriate health care services Increase public awareness of health care options Provide easier to understand and find information for general public What does success look like? What are possible indicators of success? People receive appropriate health care Database is well used Use a set of questions for test callers to test accuracy of information accessed, repeat at set intervals Obtain last six months usage records then compare after improvement efforts

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What do we know about how to do this effectively? Review existing databases (211, Partners Ending Homelessness, etc.) Partner with existing health information agencies to increase public awareness on how to use Keep information up to date and verify accuracy Look to health literacy principals for web page design and use Quick navigation less text more buttons Translation to multiple languages Ease of use for providers to update their own information Quick points, large print Phone referral forward a phone call to appropriate agency in addition to giving contact information so that one call can get caller to correct person.

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Community Agenda: Accessibility Finding the Appropriate Care Needed

Strategy 2 : Volunteer, Neighborhood Based Patient Navigators

Identify agencies using navigators o Volunteer, congregational nurses Provide basic health, wellness and safety information Use Bottom Up approach o Identify neighborhoods and train/support community leaders o Provide coaching to lay help in community o Together with Building Stronger Neighborhoods/Congregational Nurse Program o Chose 5 neighborhoods with BSN presence o Use CNP model beyond churches (add navigation to CNP activities), e.g. Willow Oaks Need to have structure in place for volunteer management o Need support, materials, ability to focus on issues that arise from neighborhood/congregation o Training needs to include cultural proficiency and an understating of institutional racism Increase capacity of nurses to help in patient navigation and to support community navigators. Strategy seeks to leverage system already in place with CNP Tie in with Health People 2020 AmeriCorps health literacy additional resource. Reading Connections has for this year, possible 3 year renewal/expansion Who will be the focus? People who need assistance to get a medical home Initially a few neighborhoods Look to health department for target neighborhoods with need for change in long term health outcomes What are we trying to do? Connect people to health care knowledge and empower them to direct their medical care through outreach and education from people they trust. To reach people who dont access health care at all; To reach people who do not navigate the health care system well to get to what they need; To reach people who need more support and help understanding to make health care choices Why are we doing it? Developing a bridge to health care knowledge and services What are we trying to change? Use community leaders to provide basic health, wellness and safety information and connect
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people to health care resources that they need using an asset based approach. Increase basic health, wellness and safety knowledge Increase adherence to medical guidance Increase access to resources for health care and medical home Increase perceived support and trust in medical providers Patients empowered to direct their own care Build bridge to connect to understanding health care needs and resources What does success look like? What are possible indicators of success? Baseline criteria assess o Knowledge of resources o Health improvement o Having medical home o Confidence in ability to access care o Assess/measure uninsured o Cost implications (of measurement?) Increased knowledge of how to care for health and resources available to them. Increased number of people stating they have a medical home Reduction in rate of chronic illnesses Long term reduced racial disparities in health outcomes What do we know about how to do this effectively? Support for excellent training o Sponsoring agency to provide o mentoring options use a mentoring model System to organize and recruit, engage and maintain relationships with these volunteers Community ownership balanced with structure to maintain Pilot program in ready community Partners with Building Stronger Neighborhoods, use public health data to find areas of need Training o Cultural sensitivity o Training must include community members o Training to be a two way process Personal connection to encourage utilization of appropriate resources Possibly actual assistance with forms, phone calls, etc. What are next steps? Develop consistent message Job description (includes boundary issues) Understanding of community resources Identify community/neighborhood and its leaders o Determine incentives to encourage participation Develop a training/support network for lay patient navigators o Identify lead agency to oversee these volunteer efforts/provide training Develop an evaluation strategy

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Community Agenda: Accessibility Finding the Appropriate Care Needed

Strategy 3: Professional Patient Navigators

Help people connect to appropriate healthcare through the use of professional patient navigators Provide training to case managers, nurses, others on how to help people navigate Increase number of patient navigators, especially through social service agencies Who will be the focus? People served by participating healthcare and social service agencies who require significant one on one assistance and education due to complexity of health care needs or life situation. What are we trying to do? Increase the use of appropriate care in complex situations for best chance at improved health outcomes. Provide the knowledge of care and resources so that individuals can make informed treatment decisions. Why are we doing it? To build a bridge to effective health care by addressing physical, cultural and financial barriers that prevent access to our fragmented and changing health care system. What are we trying to change? Build the capacity of organizations that interact with people who would benefit from patient navigation services. Build capacity of our community to connect people to health care services they need. What does success look like? What are possible indicators of success? More follow up appointments are kept. Patient satisfaction with health care provider improves. did they get to services rather than better health outcomes Monthly navigator survey/outcome report ER visits avoided, link to health care home, meds obtained and medication compliance What do we know about how to do this effectively? Provide training for Level 2 Patient Navigation (per definition of Colorado) to people in organizations whose job brings them into contact with people who need to connect to appropriate health care.
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Training to include health care navigation, cultural proficiency and an understanding of history of racism. Clear sense of activities Clarity of target audience Training protocol and schedule/knowledge sharing mechanism Look at creating a hub (P4HM, Congregational Nurse Program) Build community relationships/provider relationships Start with exiting people, but look at expanding person power Monthly navigator template (what does this mean?) Paradigm shift/different way of doing business/connecting our services

What are next steps? 1. Review models of best practice 2. Identify whats out there new/what level of training needed 3. Identify tasks/duties/goals of patient navigators

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Community Agenda: Effectiveness Preparing Individuals and Providers for Effective Health Care Interactions

Strategy: 4. Public Relations/Media Campaign with health, wellness and safety messages.
Possibilities include how to talk to your doctor, benefits of having a medical home, how to find appropriate health care resources. Who will be the focus? General public What are we trying to do? Increase knowledge of how to care for ones health Increase knowledge of need for medical home for appropriate primary care and how to connect to one Empower individuals to help make their health care interaction effective Why are we doing it? Encourage population to get appropriate primary care Reduce non-emergent uses of the emergency care facilities Improve continuity of care for improved health outcomes

What are we trying to change? Health, wellness and safety messages Short, succinct messages, explain the reasons behind Draw on national/regional campaigns that have been developed

What does success look like? What are possible indicators of success? Increase number of people with a medical home Increased satisfaction with medical providers Long term improved health outcomes for the targeted community and reduction of racial health disparities Reduced non-emergency visits to the ER Increased no. of patients with a health care home @ 200% poverty Measure how and where people learned about new knowledge.

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What do we know about how to do this effectively? a. Multilevel strategies including social media b. Mainstream media and funding sources c. Communicate needs to public officials d. Community kiosk sites? Flyers? e. Faith communities f. Public gathering places a. Store, community centers, services, salons, agencies, parks, libraries, schools b. Neighborhood groups and neighborhood congress

What are next steps? Engage media and marketing expertise Gather professionals (its cost effective) Include the people you are trying to reach to determine how to access needs regarding PR

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Community Agenda: Effectiveness Preparing Individuals and Providers for Effective Health Care Interactions

Strategy 5: Consumer focused Health Literacy Strategy

Potential strategies include the following activities: Implement Ask Me 3 program Distribute universally readable materials (e.g. in provider settings, library, restaurants, rec centers) Train others to incorporate health information in community-based settings Promote use of adult education to improve health literacy skills to address individual and family wellness and safety goals

Who will be the focus? Individuals with limited English, or limited reading and writing skills Individuals with limited knowledge of the U.S. health care system Individuals with limited knowledge of basic health and wellness practices

What are we trying to do? Provide knowledge and resources for adults to take responsibility for their health and that of their families through increased knowledge, support, and readily accessible, readable information.

Why are we doing it? To promote community-wide positive health outcomes To build a bridge to consumers who do not readily access health care services To increase the ability of the community at large to read, understand and act on health information

What are we trying to change? Consumer understanding of their familys health care needs and how to meet them. Consumer interaction with health care providers Consumer perception of health care provider communication

What does success look like? Easily understood health and wellness written materials are available on a regular basis in
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targeted places in the community. Increased satisfaction of healthcare interactions as indicated by patient satisfaction surveys and consumer sampling Long term better healthcare outcomes in overall populations (reduced health disparities, link to Healthy People 2020 goals) An increase in healthcare knowledge as measured by pre/post survey for targeted population served. Improved participation in one own health care management, better understanding of whats going on medically for self

What do we know about how to do this effectively? Consumer strategy needs to be linked to provider strategy Communicate/motivate consumer re: importance of and long term impact of taking care of health Focus on life-long learning Develop and communicate importance of healthcare Materials exist the Challenge is to get them to patients o Patient centered handouts thru the Dept. of Public Health, Web, SAMSHA, website, etc., JAMA o http://www.plainlanguage.gov/populartopics/health_literacy/index.cfm o Educate patients to know the health care literature is available o Call to obtain literature let patient know what the number is through the health and wellness messages are going promoted PR strategy o Database of information through the health dept., AHEC, Library o Up to date materials are free and accurate, non-biased and evidence based o Important to make sure information accurate and timely o Strategies to educate provider to provide the info to consumer o PSA; it becomes the norm to go to the source to get health care information o Continuing education about where to go to access information (Seminars, Churches bulletins, HC provider, training he universities provide What are next steps? Determine how to expand/continue grassroots efforts o Connect with Reading Connections

Include consumers in focus groups and training development Develop training for consumers

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Community Agenda: Effectiveness Preparing Individuals and Providers for Effective Health Care Interactions

Strategy 6 : Provider focused Health Literacy Strategy

Potential strategies include the following activities: Implement Ask Me 3 program. Promote use and development of universally readable materials Develop and promote attendance at trainings to build cultural proficiency

Who will be the focus? Health care providers and staff, social service agencies

What are we trying to do? Assist health care providers in creating and maintaining effective partnerships with consumers with varying cultural norms and health literacy skills

Why are we doing it? To facilitate more effective interaction between health care provider and patient To diminish lack of felt respect and understanding to promote consumer access To improve consumer adherence to provider directions which would lead to improved health outcomes

What are we trying to change? Help providers and office staff understand the benefit of o Simpler written communications o Clearer communication and understanding o Awareness of different needs of different groups of people What does success look like? Written materials in provider offices are simpler Increased patient satisfaction with their interaction with provider Improved follow up appointment rate

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What do we know about how to do this effectively? How do we make the provider improve communication with a variety of patients? Involve patient in the process of gaining knowledge Purposefully seek to understand the patient population that is being served Start where the client is. Provider use the Database and web to learn more about the population they serve Health equity training o Develop training that addresses the consumers needs

Work with consumer to understand what their needs are

What are next steps? Medical educators include in training (e.g. nursing schools, ECPI, residency training, SW training, med techs, GTCC, and tech) Consumer satisfaction (re all staff with providers) o Feedback program like hows my driving?, with feedback to those involved

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Attachment 3 Process of Patient Navigation Implementation Courtney Albertson, MSW Intern Adult Center for Enrichment Phase One: Hire personnel Training: o Comparable to learning the institutions registry system, cultural diversity and linguistic capacities appropriate to the population served (Paskett et al., 2011, p.239) Example: three-day training and certification program (Thrall, 2009) Make personnel knowledgeable of their purpose, which is to overcome both relationship and instrumental barriers to care. Instrumental interventions are task-oriented or logistic in nature (example: helping patient find transportation to appointments or information about their diagnosis). Relationship interventions are those that build and strengthen the interpersonal relationship between patient and provider (Paskett et al., 2011, p.245) Learn four components: 1) case identification-systematic approach to the identification of individuals in need of follow-up care 2) identifying individual barriers to receiving care by contacting patients and eliciting information about the barriers to completion of recommended care 3) developing an individualized plan to address the barriers that are identified 4) tracking, which is a systematic method of following each case through resolution of the problem (Freund et al., 2008, p.3)

Phase Two: Locate physicians who make a high number of referrals and meet with the physicians offices to inform them about the PN program (Schwaderer & Itano, 2007, p. 633) Have PNs contact the managing physicians for approval to approach patients about the program (Schwaderer & Itano, 2007, p. 635) Create community resource directory to identify participating institutions(Schwaderer & Itano, 2007, p. 635) Create computerized database to house patients demographic and diagnostic information, as well as physician contact information (also include barriers to care, number of times contacted, time PN spends with patient dealing with access issues) (Schwaderer & Itano, 2007, p. 636) Create physician and patient satisfaction surveys (Schwaderer & Itano, 2007, p. 636) Phase Three: Patient Navigators begin their work by: o o o Putting the four components from phase one into action facilitate timely access to quality care that meets cultural needs and standards of care for all patients, arranging various forms of financial support (Freund, 2008, p.3) arranging for transportation to and childcare during scheduled appointments, identifying and scheduling appointments with culturally sensitive caregivers, coordinating care among providers, arranging for interpreter services, ensuring coordination of services among medical personnel (Freund, 2008, p.3)

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o o

ensuring that medical records are available at each scheduled appointment, address health literacy, train patients to advocate for themselves (Freund, 2008, p.3) If the patient is uninsured: help find state health care programs or help fill out paperwork to get aid from pharmaceutical companies (Service Lines: Full Steam Ahead Finally for Patient Navigators?) Address emotional and practical concerns, address patient and family concerns, help build and strengthen the interpersonal relationship between patient and provider (Paskett et al., 2011, p.242) Address literacy issues, misinterpretations that may contribute to fears of diagnosis and treatment (Schwaderer & Itano, 2007, p. 633) Consider the perspectives held by the patients by providing emotional support, information and problem-solving assistance, and logistical assistance (Paskett et al., 2011, p.247)

o o

Phase Four: If all goes as planned, these outcomes should be witnessed o Better quality of life as measured by an Impact of Events Scale (IES) which addresses the distress, intrusive thoughts, and misgivings precipitated by the troublesome event of an abnormal screening result or diagnosis which should be collected at both the initial contact with the patient and the post-diagnosis treatment time period of patients experiences (Freund, 2008, p.5) Better patient satisfaction (possibly regarding timeliness, relationships, comfort, and treatment?)-this was unclear and needs further research Improvements in adherence to follow-up visits or appointments that were encouraged to be kept by both the physician and PN (Paskett et al., 2011, p.238) Improvements in timeliness of resolving an abnormality or illness for patients (Paskett et al., 2011, p.238) Increase in patient self-efficacy in dealing with diagnosis and related health services as measured by the Communication and Attitudinal Self-Efficacy Scale (CASE) which assess self-efficacy in dealing with health care in ways that are relevant to follow-up after initial contact (Freund, 2008, p.6) References Freund, K., Battaglia, T., Calhoun, E., Dudley, D., Fiscella, K., Paskett, E.,Roetzheim, R. (2008). The NCI patient navigation research program methods, protocol and measures. Cancer. 113, 2-17 Paskett, E., Harrop, P. & Wells, K. (2011). Patient navigation: An update on the state of the science. Ca: A Cancer Journal for Clinicians. 61, 237-249 Schwaderer, K. & Itano, J. (2007) Bridging the healthcare divide with patient navigation: Development of a research program to address disparities. Clinical Journal of Oncology Nursing. 11, 633-639 Thrall, T. (2009). Full steam ahead finally for patient navigators? Hospitals & health Networks.

o o o o

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