Assessing Cultural Competence and Health Literacy from the Patient ’ s Perspective

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

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

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

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

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

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

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

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

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

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

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

Health Literacy Quality Improvement Crosswalk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Assessing Cultural Competence and Health Literacy from the Patient ’ s Perspective