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Impact Center for Health Policy

University of Missouri

Better Health 10 Years On

Summit 2012 Asks How Fast? How Soon?

Health Policy Summit 2012 6 CHP’s Program for Improving Communication 14 Collaborator Spotlight: Molly Vetter-Smith 20 WINTER 2013


From the Director

Dear Colleagues and Friends,

When I co-founded the Center for Health Policy in 2002, I had no idea how newsworthy health policy and health care reform would become. As I look back on the past six months, we have seen some impressive changes, both in shifts in attitudes, and in program delivery models across America and in Missouri. Some of these shifts are highlighted in this edition of Impact. As the Tenth Anniversary Health Policy Summit kicked off, we were mindful that change only goes so far. It takes the committed work of many people and organizations to achieve better health outcomes with fewer discretionary dollars. Our panelists from MO HealthNet, the Missouri Health Advocacy Alliance, UnitedHealthcare and Mercy, to name but a few, highlighted some of the best solutions that Missouri has to offer its citizens. I encourage you to not only read about the presentations from these thought-leaders, but to also watch the video clips online at healthpolicy.missouri. edu. Their ideas and convictions about the road ahead for the state and the nation are not to be missed. Since many provisions of the Affordable Care Act (ACA) have gone or are going into effect, I am frequently reminded that one of 2 | Impact | Winter 2013

the most important ways of improving care is communicating effectively with patients. The Center’s Health Literacy Quality Improvement Program, the first of its kind in the nation and approved by the American Boards of Family Medicine, Internal Medicine and Pediatrics, has now been implemented by practitioners in Colorado, Illinois, Missouri, North Carolina and Texas. The program not only lets providers earn their necessary credits for maintaining their certifications, but the hands-on training gives them concrete ways to improve their patients’ health and their own patient satisfaction scores. To learn more about the program, see page 14 or contact us at chp@missouri.edu. As we look forward to the days and months ahead in 2013, all of us at the Center wish you, your colleagues and families’ good health and opportunity. As always, please reach out to us via email, phone or social media. In good health,

Karen Edison, MD Center for Health Policy Director


Impact Vol. 9, Issue 1 Published by the Center for Health Policy Karen Edison, MD Director Stan Hudson, MA Associate Director Nick Butler Project Director Shannon Canfield, MPH Project Director LaRita Emanuel, MBA Administrative Associate Fiscal/Human Resources Candy Fincher Office Support III Specialist Suzanne Hansford-Bowles, MA Grant Writer Jill Lucht, MS Project Director Ioana Staiculescu, MPH Research Specialist Dave Zellmer Project Development Specialist Amy Dunaway, MPH, MA Jon Stemmle, MA Editors Stanford Griffith Designer Photography from the Center for Health Policy, Flickr, and Depositphotos.

Impact is published twice a year by the University of Missouri Center for Health Policy. The University is an affirmative action, equal opportunity employer.

In Brief MISSOURI HIT NEWS The Digital Prescription for Getting Started

(CMS) and the Office of the National Coordinator for Health Information Technology (ONC) to help health n 2013, the Missouri Health care providers switch to electronic Information Technology (Missouri health records (EHRs) in a timely HIT) Assistance Center will continue and effective way. Providers who to host its jumpstart webinar series meet the milestones of Meaningful for those interested in moving to Use are eligible to receive the electronic health records (EHRs) financial incentives that can help and those who have already started defray the costs of switching to but still have EHRs. The announcement on Stage questions in 2 Meaningful Use covers actual the advanced implementation and use of EHRs, practice webinar including making patient data series. Cosponsored by Primaris, available online. The final rule also webinar slides and handouts from pushed the Stage 2 implementation earlier presentations are available deadline out from 2013 to 2014. from http://ehrhelp.missouri.edu/ Read more. ?q=node/44. The Missouri HIT Assistance Center MOHEC NEWS has continued to help doctors and Regional Meetings and health care systems switch to EHRs New Data Forthcoming ast fall, the Center’s Missouri and maximize their opportunities Health Equity Collaborative for federal incentive payments. For (MOHEC) hosted four regional more information, visit http://ehrhelp. health equity missouri.edu. meetings New Meaningful Use a c r o s s Definition Set the state to discuss preliminary n 2012, U.S. DHHS announced the findings from new health equity final rule on Stage 2 Meaningful research. These findings included the Use for electronic health records. barriers and perceived challenges Meaningful Use refers to the rules faced by newcomer and immigrant established by the Centers for populations, as well as those suffering Medicare and Medicaid Services with mental illness across the state.

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News Briefs

Initial data show that newcomer and immigrant populations place great value on someone who can help them through a complicated health care system, whether that person is a health care worker, a case manager or a medical interpreter. Transportation services and affordable payment options were also factors that contributed to positive health care experiences. However, problems cited included a lack of medical interpretation services, problems with transportation, materials that were in English only, and no connection to someone who could help guide the patient through the system. Topline findings from these studies were shared during MOHEC’s fall regional meetings along with promising practices from each community that were meeting some of these challenges. The meetings were held in Columbia, St. Louis, Springfield and Sikeston featuring presentations from PedNet, the Sedalia/Pettis County Blue Ribbon Task Force, Mental Health America of Eastern Missouri, and the Oasis Institute, to name but a few. Presentations from the events are posted at http://mohec.org.

Health Among LGBT Populations: A New MOHEC Blog Post

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dult Missourians who are lesbian, gay, bisexual or transgender (LGBT) are 1.5 times more likely to be uninsured than their nonLGBT peers. They are also two times more likely to go

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Health Equity Series:

Responding to LGBT Health Disparities August 2012

Written by C. Winter Edited by R. Barker and T. McAuliffe

without critical health care services than non-LGBT adults in Missouri. The MOHEC blog series recently highlighted health equity from a lesbian, gay, bisexual and transgender (LGBT) perspective. Written by Meghan Garvey of SAGE Metro St. Louis, the blog post highlights significant findings from the Missouri Foundation for Health (MFH) report, Responding to LGBT Health Disparities. Read the complete post at MOHEC.org. Are you interested in blogging for MOHEC? Let us know! Contact us at chp@missouri.edu.

FUNDING CHP Awarded Two Mizzou Advantage Grants

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n December, Center Director Karen Edison, MD, announced the receipt of two new grants totaling $50,000 to improve the health and wellness of Missourians, as well as the capacity of state decision-makers. The Healthy Community Initiative (HCI) program, the first of the two grants funded through Mizzou Advantage, further expands the Center’s work with the Department of Family and Community Medicine in Sedalia/Pettis County. The HCI project links researchers and academic partners with local leaders in Sedalia and Pettis County to assist in bridging the gaps among health service delivery, public health outreach, and community development. The Informatics for Integrating Biology and the Bedside (i2b2) project is the second Center-led effort funded by Mizzou Advantage. Working with the Missouri Department of Social Services, MO HealthNet Division, and the Office of Social Economic Data Analysis (OSEDA), the Center aims to simplify access to Missouri Medicaid data by developing a user-friendly, web-based search engine run by i2b2


News Briefs

open source software. i2b2 is currently the industry standard for health informatics and is in use by more than 50 health systems and academic health centers. Learn more about each project at http://healthpolicy. missouri.edu.

HTRC NEWS Edison Expands National and Regional Discourse on Telehealth for HTRC

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n October, Center Director Karen Edison, MD, gave the luncheon keynote address at the Oklahoma Telemedicine Conference in Oklahoma City, Okla. Edison spoke to over 150 attendees on behalf of the Heartland Telehealth Resource Center (HTRC) and explained the role telehealth will play in health care reform implementation. Her presentation is available online at http://heartlandtrc.org/resources/ oklahoma-telemedicine-conference-presentations. Also in October, Dr. Edison presented for the Institute of Medicine’s (IOM) webinar on federal telehealth reimbursement. The webinar was part of a series the IOM offered on Geographic Adjustment in Medicare Payment and underscores the growing national attention on how states can make telehealth a priority for meeting federal priorities under the new health care law. Details.

RESOURCES Health Equity Presentations on YouTube

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id you miss the Missouri Health Equity Conference last April? Now you can catch most of the highlights online. Presentations from the conference, “Healthy Lives, Healthy Communities,” are available on YouTube. Don’t miss the AAMC’s Darryl Kirch, MD, Johns Hopkins’ Thomas LaVeist, PhD, and many more thought leaders

from Missouri and around the country. http://www. youtube.com/healthpolicymu.

New Guide for Future Health Care Workforce

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ast fall, the American Association of Medical Colleges (AAMC) and the Association of Schools of Public Health (ASPH) released a new guide, Cultural Competence in Education for Students in Medicine and Public Health, which clearly gives health care educators a framework for aligning medical and public health curricula for the changing needs of America’s health. While medicine and public health are separate disciplines, they share many of the same interests in health promotion, disease prevention and improved health outcomes. The new guide combines the recommendations from both disciplines and outlines ways educators can use these shared competencies in their curricula. Read more.

Health Policy Videos from Summit 2012

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atch selected health policy discussions from Mercy’s Tom Hale, MD, PhD, health care futurist Joe Flower and other featured speakers from the 2012 Missouri Health Policy Summit. Videos are available online on the Center’s YouTube and Vimeo channels.

CENTER NEWS Comings & Goings

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HP recently welcomed Shannon Canfield, MPH, as a new project director. Canfield directs the MOHEC and Healthy Community Initiative. Jill Lucht, MS, from the College of Agriculture, Food and Natural Resources, joins the MO HealthNet Data Project and related initiatives.

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SUMMIT 2012

years of health care Health care is hot. After 10 years of health Disease Control and Prevention; and Joe care policy debates and presentations,

Flower, health care futurist and health

the Tenth Annual Missouri Health Policy

care management speaker, joined over

Summit proved no less thought provoking

100 health care administrators, providers,

and controversial than the first Summit

and thought leaders on October 26th for

did in 2002. Keynote speakers Jay Angoff,

“Critical Crossroads: Keeping Missourians

U.S. Department of Health and Human

Healthy Without Breaking the Bank,� at

Services; Glen Nowak, PhD, Centers for

the Stoney Creek Inn in Columbia, Mo.

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Angoff

Maxfield

Morning Keynote Jay Angoff

insurance will be able to go online and compare plans, options, and costs. The law has already forged some cooperative partnerships, including the provision for allowing children to stay on their parents’ plans until the age of 26. “The insurance industry has been very cooperative,” Angoff said. While other popular provisions include not discriminating on gender, there has been a compromise on age-related premium hikes. However, Angoff was quick to point out that the ACA has limits on what insurers can charge based on age.

A lawyer and Acting Director of U.S. Health and Human Services (HHS) Region 7, Angoff has held a variety of roles at the juncture of health policy and implementation. He served as the first director of the Office of Consumer Information and Insurance Oversight at HHS and had a bird’s eye view of how states were rolling out key provisions of the Affordable Care Act (ACA). Just 11 days before the national election, Angoff discussed many aspects of the ACA, including health insurance exchanges. Given the deadlines by which states had to declare whether they would run their own exchanges, or have a federal or hybrid model, Angoff said he believed Missouri would end up, at least initially, with the federal government running an exchange for Missouri. “The ACA doesn’t specify all rules that an exchange must follow,” he pointed out. “A lot of discretion is given to whoever is running the exchange.” By 2014, Angoff said, people looking to purchase health

Routh

Watch the panel online.

Christy Maxfield The Mission Center

Get ready for a new health insurance carrier in Missouri. Fastpaced was the theme of Christy Maxfield’s presentation on her organization’s work to provide a CO-OP health insurance option to Missouri’s citizens. While the CO-OP option is lesser known in health care reform, this option is an important player. A CO-OP Health Reform Panel Following Angoff’s presentation, stands for Consumer Operated the health reform panel featured and Oriented Plan and is a plan panelists Christy Maxfield, CFRE, run by customers that is intenfrom The Mission Center; Andrea ded to be consumer-friendly and Routh, JD, from the Missouri affordable for individuals and Health Advocacy Alliance; and small businesses. The Mission Tony Sun, MD, MBA, FACP, from Center, L3C leverages educaUnitedHealthcare. Each panelist tional programs, consultation discussed the impact the and outsourced professional Affordable Care Act has on the accounting, human resources and information technology services Show-Me state.

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10 Years of Health Care

The Fiscal Cliff and the CO-OP Option In early January 2013, Congress passed legislation to avoid the fiscal cliff. Cuts were made in a variety of areas, including health care implementation. One of the most notable was the cut in funding that would help CO-OP plans get off the ground. Before the legislation passed, 24 other states had received funding to establish their CO-OPs. Missouri was one of the remaining 26 that had yet to be funded or had an application for funding pending. To date, it is unknown whether a legislative fix could restore this funding. As the Center learns more in the weeks ahead, news will be posted to healthpolicy. missouri.edu.

Attendees enjoyed a catered lunch buffet with healthy options.

to help nonprofits create sustainable organizations that support and enhance their core missions. The Missouri CO-OP plan, said Maxfield, “has the potential to really change things from the way they are today.” Each of the states can form a CO-OP by January 2014. The Mission Center worked with the Missouri Foundation for Health to develop the program. While this insurance option is not yet operational for Missourians, it will be available on the exchange. “It will be a 501c29 and run by and for the community. It is charged by law to enroll two-thirds [of] individuals and small employers, employers employing less than 50,” said Maxfield. But as Angoff mentioned many of the details are left up to the states, Maxfield, too, acknowledged that how the CO-OP would work in all instances is yet to be established. “There is a lot of unknowns,” she

said. “There’s an exciting potential to use this opportunity to bring people into the system who have traditionally been underserved.” She stated that the Missouri Community Health Care CO–OP, would begin to give coverage by January 1, 2014. “We have our eye on what we need to do today to make health care more affordable for the nonprofits in our community, the employees that they serve, and we have an eye on how do we support efforts like the Missouri Community Health Care CO-OP in being available for what health care looks like in 2014, 2015, etc.” said Maxfield.

Andrea Routh, JD Missouri Health Advocacy Alliance Andrea Routh, JD, from the Missouri Health Advocacy Alliance explained that her organization represents consumer advocacy groups and safety net health care providers that serve children and the disabled.


Summit 2012

Sun

start abiding by these timeframes,” Routh said. “By October of 2013, we all, citizens of Missouri, are going to have to go through an open enrollment process…So there’s no more time. We’re behind the eight ball already.”

Nowak

Helping to explain many of the details of the ACA, Routh said that the ACA brings every state’s Medicaid expansion program up to 133 percent of the poverty level. For an individual, she stated, that’s up to $14,856 a year in annual income. For a family of four, 133 percent of poverty is approximately $30,656 in annual income. “We’re talking about a lot of working, low-income people in our state,” she said. Routh also brought up an important implementation point. Disproportionate share payments are reimbursements that hospitals receive to cover the poor. Routh explained that hospitals agreed to reduce these payments because they knew that Medicaid expansion would happen with the ACA. But, Routh pointed out, “As the Supreme Court decided in June that Medicaid was a state option,

we’re leaving some of our critical care hospitals and rural hospitals at risk. If Missouri doesn’t take the Medicaid expansion, they’re going to get a double hit. Critical care hospitals would be at risk because [of] losing their disproportionate share payments. It’s possible we could lose rural hospitals in our state. It’s going to have an impact on everybody in that area who relies on that rural hospital.” The Medicaid expansion in Missouri is projected to cover an estimated additional 300,000 people. With “[e]veryone in the system, it creates a new paradigm. We will now be managing risk and helping people be healthy, trying to prevent illness rather than insurance companies selecting or avoiding risk,” said Routh. She pointed out that the time for politicking was over. “We have to

Tony Sun, MD UnitedHealthcare Accelerated might be the best adjective to summarize Dr. Tony Sun’s presentation. The Market Medical Director from UnitedHealthcare said that a lot has already been happening around insurance reform. “The most exciting part,” said Sun, “is this innovation on how we really begin to tackle health care reform. We’re just now really trying to cover everybody. And how are we really going to be affordable, we’re barely touching the tip of that.” Citing how important health care is to local economies, Dr. Sun reminded the audience that, “reform has already begun. The train’s left the station awhile back. It’s a bullet train and it took off. We can’t keep looking back. We’re not

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10 Years of Health Care Luncheon Speaker Glen Nowak

Flower

going to go back and say we’re not going to cover those 26-yearold kids if they’re still under their parents’ insurance plans, or you know what, let’s bring back those lifetime limits. Those are things we just don’t do anymore. We need to move forward.” Sun discussed how in this health care reform moment, many organizations are dealing with dramatic change in culture. He described it as the tension between, “The old culture of dealing with volume and the new culture of how to deal with value. That’s where a lot of the money’s at. That struggle, especially in the provider community,” he said. “We don’t have a system but we have various sectors and they don’t behave under the same rules.” Sun advised, “It’s critical to rethink on how we deal with

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health care and health care outcomes.” Citing the need to focus on readmissions, he aptly described them as “defects. Let’s call it what it is,” he stated. “If we don’t want to pay for defects, we need to critically go back and work on it. For a long time, to the CFOs, readmissions still means revenues.” Yet he pointed out that large hospital CFOs have a vested interest in reducing admissions. “They want to save money for their own employees,” he reminded participants. “A large hospital system has five-, six-thousand employees and they want to save money themselves. Boeing has it’s own patient-centered medical home initiative. We’ll see that kind of action from Wal-Mart, Lowe’s…this [health care change] is happening in the private sector, moving from volume to value.”

Making policy is one thing, but making people comply with policy is quite another. A seasoned health communicator, Glen Nowak, PhD, senior advisor to the director, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), provided the luncheon keynote and addressed this challenge. Reminding attendees that policy only goes far, Nowak highlighted how policies, laws and regulations often need skilled health communicators to make individuals and groups comply with these changes in order to achieve any intended outcome. Citing advertising campaigns that have failed to connect with audiences, Nowak stated how good packaging could go a long way in making a product or policy userfriendly and persuasive for behavior change. Nowak stated that often, people needed a good messenger, and, as in the case of the CDC, sometimes the best messenger was an everyday American. Highlighting the social media and e-tools developed by the CDC, Nowak stated how individual Americans could easily encourage the people they loved to quit smoking by using some of the e-cards and social media tools on the CDC’s websites. Working to increase vaccination rates, Nowak told the audience


Summit 2012

Boyce

Kasal

to changing regulations, changing consumer habits, and changing management strategies. “The for-profits are buying up lots of nonprofit hospitals and health systems,” Flower explained. “The big chains are getting bigger. [They’re] doing it with different strategies. Afternoon Keynote Joe Flower Dignity expanded in occupational “Where are we going? We don’t health across 20 states.” “The big concern,” Flower really know,” said afternoon keynote speaker Joe Flower. Flower, a health continued, “is being cut out of the care futurist and popular health market. Everyone is at risk of not management speaker, quickly existing anymore…but no one grabbed the attention of the knows what the whole thing costs. How can an industry survive when it afternoon audience. Citing the challenges that the doesn’t know how much it costs to diagnosis-related groups (DRGs) produce its effects? We need better created for the American health care cost analysis…we need to turn system, Flower pointed out how into deep learning organizations. capping unit costs didn’t cap the cost How much did it cost to replace Mr. of the health care system. Instead, he Herndon’s hip? Hospitals have a lot pointed out, “Over the last 30 years, of rotation so people don’t work we have not only done increasing together in teams all the time.” Pointing out the need to change volume, but we have upcoded and found increasing complex things to how we look at data, look at the customer and look at disease, Flower do for the same problem.” Recognizing that increasing summed up his point for health care efficiency is needed to reduce costs, organizations and providers: “If you Flower reiterated that health care stay in the old business model, that in America would need to adjust is [a] slow death.” how shifting a message from an individual focus of ‘you should get vaccinated or you’ll get sick’ to ‘get your shot to protect your family,’ has gone a long way in increasing flu vaccinations, among others.

Hale, Edison

Innovation in Care Delivery Panel Health care delivery and payment panelists Joe Boyce, MD, Heartland Health; Mary Kasal, Missouri Health Connection; Tom Hale, MD, PhD, Mercy Center for Innovative Care; and Samar Muzaffar, MD, MPH, MO HealthNet medical director, discussed the innovative solutions health systems are already putting in place to meet both the needs of patients’ and the boundaries of state and local budgets.

Joe Boyce, MD Heartland Health Dr. Boyce gave highlights on the work unfolding at Heartland Health System and opened his presentation with the importance of incentives. “If we get the incentives aligned,” he said, “I think the rest of the stuff will come around. The incentives are key.” Heartland is a 300-bed hospital in St. Joseph, Mo., with several accountable care organizations (ACOs) operating there, including a Medicare ACO, the Heartland ACO, and commercial ACOs with health

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Summit Spotlight

Muzaffar

Watch the panel online.

insurance carrier Aetna. Boyce stated he’s seen more change in the last six months with those ACOs than any other time in his 20year career. For organizations looking to improve care delivery and control costs, Boyce advised those in the audience to focus first on care for the beginning and end of life. He said, “Start looking at chemotherapy in the last two weeks of life. One of the dangers of the ACO is if you’re making money off of not doing things, you need clear criteria on why you’re not doing them. The first thing [critics] will say is ‘death panels’.” Boyce advised that ACOs need explicit criteria already published on why things are and are not done. Boyce raised the issue of meaningful use but quickly noted that this was “stuff we should have been doing anyway.” Where ACOs and organizations could also look is around changing expensive health behaviors, such as smoking and methamphetamine use. With an ACO’s shared savings, Boyce stated that, “All you’re doing

is measuring by fee-for-service, but sharing by outcomes.” Citing a flaw in the Medicare ACO structure, Boyce outlined how a Medicare patient could see his or her primary care doctor for back pain, but be dissatisfied with the service. If that patient gets another MRI for his or her back, that test will cost the ACO money. “It’s a big flaw,” he said. But the potential for savings under the ACO model is worthwhile, as Boyle pointed out with the fact that his group saw 20 percent reductions in the first year of their ACO. In addition to the ACO model, Boyce said that understanding the population and the data were critical, and the big data analysis required technology. “We are ahead in technology in terms of the talent to deploy the tools,”

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he said. Showcasing the Lewis and Clark Information Exchange (LACIE) dashboard tool Heartland developed to report health care measures and outcomes, Boyce outlined how organizations needed to start determining the returns on investment and using measures to incentivize doctors on how well they are doing and how well they stack up against other doctors. In closing his presentation, Boyce said that many ACOs will see a 2- to 3-year drop in revenue, but that drop would be necessary in order to survive with the cuts coming from health care reform. Boyce reiterated how some hospitals might close due to the changing nature of hospital reimbursement, and that the total number could affect as many as a third of the state’s hospitals. In terms of innovative payment and care delivery models such as ACOs, Boyce warned, “If you don’t do this you’re going to have a hard time.”

Mary Kasal MO Health Connection For Mary Kasal, CEO of the Missouri Health Connection, the use of

An attendee asks a question to morning keynote speaker Jay Angoff.


Summit 2012 For more information or to watch selected video clips from the Summit, see http://www.youtube.com/user/ HealthPolicyMU

technology and how limited dollars are allocated in health care reform are the keys to success. While technology has been new and exciting, she said the fact that so many education dollars had to be allotted to train people should be less of a concern. Technology, she explained, was becoming more intuitive as the workforce ages and changes. “The education budgets that we had to use in the past to implement technology use really should diminish,” she said. But investment would still be needed in team development. Explaining how teamwork continues to be a core value in her work, Kasal said that this might be Missouri’s most important fundamental. Likewise, she said, “In my early days in health care IT, the IT budget used to be under 2 percent. Over the last 10 years, we ‘ve seen hospital organizations shifting that budget to a large investment in systems for their organizations.” She continued, “We have to look at more fundamental things around teamwork, around the fact that things are more intuitive now, and become more aware of the cost to implement a system within an organization if we hope to have

any money left to do things across positive outcomes for sepsis due to states and across our country.” the e-ICU program. “We were able Overall, Kasal advised, that to save 100 lives over nine months health care administrators and of the program in one hospital,” he policy makers should start with explained. “The length of stay went simple things first instead of more down from eight days to three days. complex ones. This is a significant impact.” Moreover, technology could also be used for less dramatic, but Tom Hale, MD, PhD Mercy no less significant, health care “Everything starts with good change. Hale described how Mercy leadership,” opened Tom Hale, MD, has been able to use telemedicine PhD, medical director for Mercy’s to increase services for limitedCenter for Innovative Care. “If we English proficient populations. build another hospital again, we will have failed. Our long term strategy Samar Muzaffar, MD, MPH MO HealthNet Program is growing the village.” Leading Mercy’s new Center Samar Muzaffar, MD, MPH, medical for Innovative Care, Hale described director for MO HealthNet, provided ways that his organization is an overview of the state’s primary improving care and reducing care and community mental health costs through patient-centered centers’ patient-centered medical medical homes and technology. homes for Medicaid patients. Citing By using predictive modeling, case that many Medicaid participants management and telemedicine, have chronic illnesses, substance Hale described how Mercy has and mental health issues, Muzaffar been able to implement an discussed how being able to track e-ICU program that has reduced cases over time, and determine mortality and decreased lengths gaps in care will help to keep these of hospital stay. In Springfield, Hale patients healthier and out of the pointed out, “congestive heart hospital. failure readmission rate is down to The two health home programs 9.2 percent.” Under the telestroke “coordinate behavioral health program, “in Hot Springs, they and primary care health needs,” have [used] tPA [a clot busting drug Muzaffar said. Through the two needed to save stroke patients] projects, a learning collaborative seven times in one year. And once has been established to help we put telestoke in, they have providers and administrators with [used] it 45 times in three months.” Likewise, Hale shared similar continues on page 23

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A prescription to practice CHP’s Intensive Program for Improving Communication & Retaining Patients for Life

Improvement Program (QIP), a hands-on, intensive training program for doctors and Hudson other health care providers. In November, CHP hosted its first St. Louis-based program at the Saint Louis University Medical Simulation Talk to your patients so they can Center for six doctors from take charge of their health. That Missouri, Texas and North was the central idea behind the Carolina. “Patients and doctors work Center’s Health Literacy Quality

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together to solve health issues, but they don’t always talk together in the same way,” says Center Associate Director Stan Hudson. “That leads to less effective conversation and often, less effective health outcomes. Health literacy is the ability to understand health information and to use that information to make good decisions about your health and medical care. Our training is designed to help doctors understand health literacy and the ways they can improve their own communication


to help their patients.” The need for clear health information is not simply a problem of low literacy or a lower socio-economic status. Health information relayed in a doctor’s office or medical center can easily confuse or overwhelm the most educated or literate people. According to the National Library of Medicine and National Institutes of Health, approximately one-third of the adult population in the United States has limited health literacy. The Center’s program was designed to change this statistic and also improve doctors’ patient satisfaction scores. “Doctors know that patients can vote with their feet. Some may not come back because the patient has trouble understanding what the doctor is saying. Many medical offices use surveys to rate the patient experience and when a doctor has trouble helping a patient understand his or her health, it shows up on these surveys,” says Hudson. Class sizes in the current program are deliberately small due to the intensive nature of the program. Doctors are trained in health literacy principles and techniques and are then asked to try the techniques and tools as they treat a ‘model patient’

in one of the simulation offices. Model patients are trained and standardized to ensure a consistent and valid experience, and the doctors care for these patients as they normally do in their own practices. “In these exchanges, it’s not about the disease, it’s not about doctoring, but trying these tools,” says Center Director Karen Edison, MD. “Practicing these tools can shorten the visit and improve compliance.” To help with the practice, trained health literacy coaches listen to the simulated doctorpatient session in a separate room and observe through a closedcircuit video camera to evaluate the exchange. Afterward, the coaches review their findings with the doctor and they discuss the areas where effective communication happened and where it could be improved. After reflections on the exchanges and another round of treating the model patients, each doctor is asked to develop an improvement plan for their own practice, including ways to collect baseline data and monitor progress over time. At the end of the day-long training, the doctors leave with a portfolio of tools and handouts, as well video clips of their simulated office visits. “The beauty of the program

Successful ABIM graduates earn 20 maintenance of certification (MOC) points, as well as 6.25 AMA PRA category 1 credits TM. ABP graduates earn 25 Part IV MOC points and 6.25 AMA PRA category 1 credits. ABFM graduates earn 20 MC-FP Part IV credits, as well as 6.25 AMA PRA category 1 credits. is that doctors don’t have a lot of time to collect and analyze their own data,” says Hudson. “We do that for them. We provide validated tools, such as the health literacy item set from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Survey. When the docs return to their own practices, they use the survey and send the data back to us. We analyze it for them and provide a report on their opportunities and areas to work on. Then the doctors survey their patients again at six and 12 months to evaluate practice improvement. Again, we analyze those results and give those confidential Kahn data back to the physicians along with feedback on areas for continued improvement.”

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Health Literacy Quality Improvement Program

The Health Literacy Quality Improvement Program gives providers opportunities to practice their communication skills in reallife roleplay situations. Interactions like this one are watched in real-time by trained health literacy and effective communication coaches in the video command center. Coaches, including Associate Director Stan Hudson pictured right, provide feedback to providers after each encounter.

The whole program takes one year to complete, but the initial time investment for doctors is the day-long training for the coursework and simulated experiences. Dr. Uzma Khan, who specializes in endocrinology, diabetes and metabolism at the University of Missouri, participated in the St. Louis training program and shared with the group that

16 | Impact | Winter 2013

meeting her patients where they were with regards to understanding their own health was important. To explain, she shared a story of a patient who just wanted to know how he could manage his diabetes during deer hunting season, and recounted how she showed him how to monitor and use his insulin when far away from home. Two months after the initial

training, Dr. Khan still focuses on her patients. “Originally, I had thought health literacy was for doctors,” she reflects, “but I realized it was really for our patients. The program was very good. After seeing the video clip of myself, I realized I talked too much and sometimes I was a little distracted. It allowed me to really focus on the patient. We may be the best doctors in the world, but if we are not passing it on to the patient, we’re doing the patient a disservice. It’s the patient that has to live with the disease everyday.” The American Board of Pediatrics, the American Board of Internal Medicine and the American Board of Family Practice have all approved the program. To date, the program has drawn national interest from practitioners who recognize that having health literacy skills can lead to successful health outcomes and high patientsatisfaction scores. To learn more about the program or the next training in March, please see: http:// medicine.missouri.edu/policy/ projects-hlmoc.html.


PRESENTATIONS JUNE 2012-DECEMBER 2012 June 14 What You Don’t Know About Privacy and Security Can Hurt You, Webinar, N  ancie

McAnaugh

June 20 Health Literacy - The Keystone to Culturally Effective Care, Presentation, Nursing Education

Forum, University of Missouri Health Care, Columbia, MO, Stan Hudson

June 21 EHR Jumpstart Series: Utilizing an EHR, Webinar, HIT Assistance Center, Nancie McAnaugh July 12 Health Literacy for Families, Communities, Agencies, and the Businesses that Serve Us,

Presentation, Four State Area Employer Group on Health Literacy—Freeman Health System in Joplin, MO, N  ick Butler

July 18 Health Literacy Awareness Session, Presentation, Keene Family Medicine Clinic Columbia,

MO, S  tan Hudson

July 24 Health Literacy, Empowering Patients to Overcome Health Literacy Hurdles, Presentation,

Kansas Family Medicine conference, Wichita, KS, S  tan Hudson

July 24 Health Literacy in Missouri, Presentation, MU Asian Affairs Center, N  ick Butler July 24 Health Care Access in the Community: Perspectives from Refugee and Immigrant Patients,

Presentation, 2012 Community Development Society International Conference, Cincinnati, OH, S  teve Jeanetta, Nancie McAnaugh, Karen Edison, Ioana Staiculescu, Caress Dean and Stan Hudson

Aug 10 Disaster Recovery & HIT: A Lesson from Joplin, Webinar, HIT Assistance Center, Shannon

Canfield

Aug 14 Clear: Conversations—Empowering Patients to Move from Information to Understanding,

Presentation, St. Louis Area Business Health Coalition, St. Louis, Stan Hudson, Nick Butler

Aug 25 Health Literacy Maintenance of Certification, Workshop, Clinical Simulation Center, School

of Medicine, Columbia, MO, S  tan Hudson, Karen Edison, David Fleming, Jim Campbell, Diane Smith, Ioana Staiculescu, Nick Butler and Dave Zellmer

Sept. 5 Health Literacy Awareness, Presentation, Physical Therapy Professional Issues Lecture,

Columbia, MO, S  tan Hudson

Sept. 7 Health Literacy Workshop, Physical Therapy Professional Issues, Columbia, MO, Stan

Hudson, Nick Butler, Dave Zellmer and Ioana Staiculescu

Sept 10 Physician Peer Training- Educate Your Patients and Improve Health Outcomes, Workshop,

Kennett, MO, S  tan Hudson, Karen Edison

Sept. 10 Immunization Registry--The road from MU testing to benefits of ShowMeVax, Webinar, HIT

Assistance Center, Shannon Canfield

Sept. 16 Effective Communication in Medicine: Moving from Information to Understanding,

Presentation, Kansas Patient Center Medical Home Summit, Overland Park, KS, S  tan Hudson Center for Health Policy | 17


Presentations Sept. 19 Access to health care services: perspectives from

patients with mental health illnesses, Presentation, Building Health Equity in Mid-Missouri, Columbia, MO, Ioana Staiculescu

Sept. 20 The Art and Science of Plain Language: Making

sure your patients understand what you are saying, Presentation, 15th Annual Conference for Office and Clinic Nurses and Office Support Staff, Columbia, MO, Stan Hudson

Sept. 21 Empowering Health Literacy, Presentation, Kansas

Association for the Medically Underserved Annual Conference, Wichita, KS, S  tan Hudson

Sept. 26 Clear Understanding: Health Literacy is a public health

issue, Presentation, Missouri Public Health Association Annual Conference 2012, Columbia, MO, N  ick Butler

Sept. 27 Moving Health Care from the Age of Information to the

Age of Understanding, Presentation, 3rd Annual Health Literacy Missouri Summit, Columbia, MO, Stan Hudson

Sept 27 Assessing the Health Literacy of Health Care

Environments: How to Develop a Clinical Assessment, Presentation, 3rd Annual Health Literacy Missouri Summit, Columbia, MO, D  iane Smith

Oct. 2

Moving from Information to Understanding, Presentation, Cole County Senior Group, Jefferson City, MO, S  tan Hudson

A Health Literacy Teaching Tool: The Measuring Cup

In collaboration with the Heartland Telehealth Resource Center, Center Associate Director Stan Hudson explained what health literacy means and how a simple medication measuring cup can create health care challenges. Watch the video online.

Don’t miss

SUMMIT 2013

Oct. 11 Patient Portals and the Patient Service Strategy,

Webinar, HIT Assistance Center, Shannon Canfield

Oct. 12 Moving from Information to Understanding in Health

Care, Presentation, West Central Community Action Fall IN Service, Clinton, MO, Stan Hudson

Oct. 19 Access to Health Care Services: Perspectives from

Patients with Mental Illnesses, Presentation, Building Health Equity in Greater St Louis, St Louis, MO, I oana Staiculescu

Columbia, MO

Speakers and details to be announced soon.

Oct. 23 Health Literacy Competencies for Students of the

Health Professions: A Consensus Study, Presentation, Health Literacy Research Conference, Bethesda, MD, Stan Hudson

Oct. 24 Health Literacy 101, Presentation, Nurse Fellows

Training, University of Missouri Health Care, Columbia, MO, S  tan Hudson

18 | Impact | Winter 2013

Stay tuned to healthpolicy.missouri.edu.


Oct. 24 Clear Understanding, Workshop,

Moniteau County Health Department,, California, MO, Nick Butler

Oct. 25 Clear Understanding, Presentation,

MU School of Health Professions, Sections 1 and 2, Columbia, MO, Nick Butler, Stan Hudson

Nov. 2 Tips to Increase Client

Understanding: Satisfaction and Adherence, Presentation, Missouri Occupation Therapy Annual Meeting, Lake of the Ozarks, MO, D  iane Smith, Stan, Hudson

Nov. 10 Health Literacy Maintenance of

Certification, Training, St Louis University School of Medicine Clinical Skills Lab, St. Louis, MO, Stan Hudson, Karen Edison, David Fleming, Jim Campbell, Diane Smith, Ioana Staiculescu, Nick Butler and Dave Zellmer

Nov. 14 Access to Health Care Services:

Perspectives from Patients with Mental Illnesses, Presentation, Building Health Equity in the Bootheel Region, Sikeston, MO, Ioana Staiculescu

Nov. 15 Access to Health Care Services:

Perspectives from Patients with Mental Illnesses, Presentation, Building Health Equity in the Springfield Region,, Springfield, MO, I oana Staiculescu

Talk Matters Get the tools you need to communicate effectively with patients, and help them understand how to take charge of their health. The Health Literacy Quality Improvement Program is designed for busy health care providers who want to improve health, reduce costs and raise satisfaction scores. This year-long program is approved for Maintenance of Certification credit by the American Boards of Family Medicine, Internal Medicine, and Pediatrics. Learn more at medicine.missouri.edu/policy/projects-hlmoc.html

Nov. 16 Health Literacy, Presentation,

Grand Rounds, Women’s and Children’s Hospital Conference Center, Columbia, MO, K  aren Edison

Center for Health Policy | 19


COLLABORATOR SPOTLIGHT

Molly Vetter-Smith Helping to put the pieces of health puzzles together

As one of the project leaders for the Healthy Community Initiative, Molly Vetter-Smith, PhD, MPH, RD, University Extension, brings a new perspective to this collaborative work in Sedalia. The Healthy Community Initiative (HCI) is a partnership between CHP, MU Extension, the Department of Family and Community Medicine, and local communities. These and other partners work together to improve health outcomes through locally identified priorities and evidencebased solutions. One of the most exciting aspects of the work on the HCI project in Sedalia involves Vetter-Smith’s

20 | Impact | Winter 2013

role in the implementation of a little known component of the Accountable Care Act (Section 5405), the Primary Care Extension Program (PCEP) in Molly Vetter-Smith this community. To understand the PCEP and how it came to Missouri, CHP staff talked with Vetter-Smith.

How did Sedalia/Pettis County become a PCEP site? Five states were funded by Agency for Healthcare Research and Quality (AHRQ) to set up their own


delivery entities and community resources work in silos from one another. This results in care that addresses only part of the patient’s health problem. One big aspect of the PCEP is ensuring patients are connected to needed community resources. The PCEP justifies the need for a type of healthcare employee, named ‘Community Practice Facilitator’ or ‘Health Extension Agent’ that carries out a variety of roles such as collaborating with a broad range community entities to assist primary care practices in getting patients connected What is the PCEP trying to do? to community resources, The general idea of the PCEP is identifying community health to provide support to primary priorities and needs, and taking care practices to improve part in efforts to eliminate a access, quality, and efficiency of community’s health disparities care, which many primary care and strengthen the local primary practices are working to achieve care work force. In this PCEP project, we have through the patient-centered medical home standards. hired a ‘Community Practice Achieving this can only be fully Facilitator’ that is housed in achieved through connecting Sedalia’s Local Public Health primary care practices to Department working closely with the community’s primary community resources. All too often healthcare care practices. This person’s role

statewide PCEPs. Oklahoma was one of the original five, and Principal Investigator, Dr. Jim Mold from the University of Oklahoma Health Sciences Center also committed his project to providing assistance to three other states to implement a PCEP on a smaller scale. Dr. Mold chose Missouri as one of the three states. Through the work of the HCI team at CHP and Department of Family and Community Medicine, Sedalia was selected as the community to work with to implement a PCEP.

will focus on that community support aspect, to make the connection between Sedalia’s community resources and the primary care practices.

What would a PCEP look like in practice? A pediatrician, for example, might see many increases in the cases of children developing asthma. You’re treating them, cases keep coming in, and you write prescriptions, but with all the new cases coming in, you know you need to dig deeper. You contact your local PCEP’s Community Practice Facilitator to investigate this in the community. This person finds out from the local Cooperative Extension Housing Specialist that the flood that occurred a few years ago is likely the culprit of undetected mold in homes. That’s a real problem and it needs to be solved for better health. This program would help because the community practice facilitator can connect clinics to resources

Center for Health Policy | 21


Collaborator Spolight Sedalia boasts many farms, is home to the Missouri State Fair and has an active downtown district. Strategies for improving Sedalia’s overall health are also many and varied. One such approach, the PCEP model, will link health care providers to greater tools and resources to help patients access the many different kinds of help they need.

PHOTO CREDITS: NICKDAWSON, ASCHWEIGERT and MRTICKLES of FLICKR

for their patients, like who to contact to detect and mitigate mold in homes, and asthma selfmanagement resource for families.

What do you hope to achieve through this project? We want to connect primary care practices with community resources, but we really want to help these practices on achieving better patient care and access to resources in their community that can help them not only self-manage their current health conditions but also prevent illness in the first place. This endeavor is a large component of the patient-centered medical home model. We realize this is a huge undertaking and we’re taking it one step at a time. The piece we’re focusing on in the

22 | Impact | Winter 2013

next year is Action 4 of the 2011 patient centered medical home standards [from the National Committee for Quality Assurance]. This piece focuses on community support and patient self-care.

What is happening now with the PCEP in Sedalia? We hired our Community Practice Facilitator, Michelle, in January and she’s working on developing her expertise on the patient-centered medical home, so she can be a resource on this to all primary care clinics in the community. We are currently recruiting all the practice managers from each primary care clinic in Sedalia to meet twice a month as part of a learning collaborative to identify what community resources we

have before we can get people referred to resources. This learning collaborative will address questions like, what community resources do we have around dental care, around mental health, around diabetes selfcare and what are all of our options for people to be physically active? We’ll have them share what they know is available in the community. Michelle, will put this together in an electronic format that is easy to access and use for the primary care practices. The point is for it to be easy to use so they can refer their patients to these resources. There will also be information on if and how certain things can be covered [through insurance]. The other thing Michelle plans to do as part of this project is to work closely with Bothwell Family


Medicine Clinic and help them as they work on other aspects of implementing the patientcentered medical home standards. We have the Katy Trail Community Health Center in Sedalia and they are way ahead of the game, as are most federally qualified health centers are around the state, in achieving patient-centered medical homes. They have some experts there who will help.

in Sedalia to support the work of the HCI, and she will promote the PCEP by asking physicians to encourage practice managers to take part in the learning collaborative. CHP, through the HCI, will work with the primary care clinics to do health literacy trainings, and we know that the communication piece is another key aspect of the patient-centered medical home.

How has working with CHP helped this work?

What has been the best part To contact Molly Vetter-Smith, of working on HCI and the PCEP? see: http://extension.missouri.

Dr. Edison will help in encouraging primary care practice physicians

There’s a lot of really good partnership and collaboration

While details on the cost effectiveness of these approaches Continued from Page 13 are forthcoming, Muzaffar said integrating and coordinating that analysts are looking at the primary and behavioral health care. data from a population standpoint, She explained that the health flagging patients that fall below home programs exist to provide certain benchmarks. Patients comprehensive care management who fall below benchmarks are and coordination, but also to help then flagged to receive more with transitional care as a patient intervention or services. moves from hospital to outpatient As Summit 2012 came to a close, or home setting. Muzaffar also highlighted the presenters and participants both importance of teamwork as a health seemed to agree that in another care home requires the collabora- 10 years, health administrators, tion of a health care home director, providers, and patients will be able the primary care physician, nursing to look back on this period as one of care managers, support staff, com- great change in health care delivery munity support specialists, psychia- and payment. In late 2012, however, trists, family support specialists, pa- none of these aspects looked even close to cooling down. tients and their families.

SUMMIT 2012

in Sedalia. It’s a really amazing community partnership. They all get along and they’re all willing to help each other. Through my earlier work, I helped shape PCEP in Washington, D.C. and took part in a big brainstorming meeting on what the PCEP should be and how to define it nationally. To have the opportunity to be part of it on the ground and in a community is really exciting for me.

edu/hes/people/vetter-smith. htm.

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Impact Winter 2013