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Institute for Healthcare Advancement
Canyon Ranch Institute Life Enhancement Program is an evidence-based, integrative health and health literacy program that demonstrates significant and healthy outcomes across diverse cultures. This session will illustrate how formative research is used to tailor the program to local communities. Tailoring program materials to each community is a health literacy best practice. Canyon Ranch Institute Life Enhancement Program employs extensive formative research in the training of health care professionals and revision of program materials with our partner healthcare provider organizations. Participant guides are tailored through a series of narratives describing people reflective of the local population experiencing healthy changes.
Andrew Pleasant, Ph.D
Senior Director for Health Literacy and Research, Canyon Ranch Institute
Jennifer Cabe, M.A.
Executive Director and Board Member, Canyon Ranch Institute
Ana Lucero-Liu, Ph.D
Program and Evaluation Manager, Canyon Ranch Institute
Canyon Ranch Institute Life Enhancement Program
Canyon Ranch has an integrative approach to health to understand the personal and emotional connections.
They always have a local partner in every community where they work.
For any program: Engage people early and often. You will get to know them. Include their whole lives (integrative health). That will take you upstream from health care to prevention.
Finding Partners for the LEP program: You need an established health care organization to deliver the program to their people.
- Match program design and materials to realities of people’s lives
- Not a one-size-fits-all approach
- Tailered interventions are more likely to create change than non-tailored programs.
- Must be evidence-based. That’s why you need formative research.
Food desert example:
Sometimes they have to go into the community. E.g., they convinced a vendor to start selling fruits and vegetables, and said they would buy whatever wasn’t sold in the day. They had to buy back for about a week and a half. Now there are plenty of places to buy produce in that community.
In a community with a lot of unemployment: They partnered with Project HOPE to work on work skills with teens.
Canyon Ranch Institute Life Enhancement Program Process:
- They take the core team to Canyon Ranch for a week.
- They have individual interviews with audience.
- They determine the key concepts and messages: eg. Access to food, recreation, behavioural therapy etc.
- They focus on the causes of the problems for each individual.
- Then they recruit actual participants. And they engage with the core team weekly to check progress.
Evaluations: post, +3 months, +1 year
Find info, understand, evaluate, communicate, re-assess.
The LEP program takes a 2-sided approach by addressing challenges in both the health system AND the public.
Rather than always using the Plain Language standard of putting the most important message first, they recognize that sometimes people aren’t ready to hear the most important message. Sometimes they need to find a path to their true goal.
Rather than removing complexity, LEP works to make complexity understandable and actionable.
Use narratives: opening situation, a changing situation, a closing situation.
Stories are culture.
A good story:
- Is understandable
- Has context and cohesion (story holds together)
- Has relevance to the listener’s life
So each LEP has a program guide (among other materials) that incorporates a number of unique narratives.
They test the stories with the community.
The core team comes from the participating health organization. Participants are recruited from the patient population.
- Research to find issues
- Find a local person to represent the population
- Have one-on-one with members of the core team
- Team members report back to one another
- Evaluation of the “hand-off” happens onsite and through written feedback and video of the session.
A lot of information is given that is not directly related to the expertise or question of the specific person they’re meeting, but that is relevant to another person on the team.
The research process takes about 3 months.
Core team of 20. Each participant group is 100.
Presenters, Georgianna Sergakis and Jill Clutter, from Ohio State University, discussed the importance of using a logic model for program evaluation. The breakout session began with both presenters sharing about their backgrounds and moving into an interactive activity with the attendees. Georgianna, a respiratory therapist, stated that she trains new trainees’ at Ohio State University who are becoming respiratory therapists. Most of her work and knowledge is on Tobacco and the phenomenon of e-cigarettes.
Jill is a professor at Ohio State University at the School of Health Science and works closely with the Rehabilitation Division as well. She teaches graduate students and explains that science is in everything we do and everywhere.
The presenters led the group into a pole activity where attendees were asked few questions about program evaluation. Then, attendees answer the questions and they were able to visually see what others thought about program evaluation. This sparked a conversation among attendees and the presenters.
During the breakout session, Jill explained the importance of the logic model and explains the benefits of using this tool. She stresses that the logic model is a tool used to clarify an initiative and to graphically depict a plan for future program evaluation. The logic model serves as a foundation for planning, communicating and evaluation. Although there are many different types of logic models, it is important to understand that one size does not fit all. In addition, she stressed how it is very important to start with the end in mind when sorting out a plan for program evaluation.
Presenters discussed about evidence-based practices such as the literature of CDC Framework for Program Evaluation. This framework explains the importance of working backwards to connect all the gaps and find the missing pieces that may need additional evaluation to have a successful program. By using a logic model, it visually provides a big picture of evaluation. Recognizes what has been done and what still needs improvement for future evaluation.
The presenters shared with the attendees three different types of evaluation. The first was context evaluation. This particular evaluation method looks closely at the issues of the program relationships and reevaluates the needs assessment. Second, implementation evaluation is the implementation of the program, what activities were executed and to what extent, and the quality of the overall program. Lastly, outcome evaluation initiates a base to discuss the overall progress and what still remains unresolved for future evaluation.
The breakout session concludes by attendees engaging in a active program evaluation activity.
Susan Cosgrove HCIF Philadelphia, PA
Cindy Hall, Carolinas Healthcare system, 60k employees
Shelby Chapman, Children’s Hospital, Colorado
Mary Ann Abrams, Ohio State University College of Medicine, Moderator
Understand and identify effective methods for a group focussed on Health Literacy.
This was an extremely informative discussion. We recommend consulting the handouts from each of the presenters. Below are some of the key points made.
Background from each presenter:
Shelby: I was hired specifically to start a HL program. I had some high-level support. I needed to understand how the place works and how to craft messages to different groups. E.G., execs want savings, lowered readmissions and higher patient/family satisfaction. Nurses want to communicate better with patients. I need to figure out how to work with different departments on integrating health literacy.
Susan: I had to get a bunch of hospitals working together.
Cindy: I started in 2008 with no strategic plan, so we failed. So they realized they needed a system. They set a goal to train 10K nurses in 1 year. They met it. Eventually they got their board to support getting to 10 Attributes by 2020. Having champions, support from senior leadership and a plan are all key.
Question: How do you assess/measure progress?
Cindy: See tool kit handout.
- How many teammates trained
- Observe staff using teachback & Ask me 3 – You must observe and assess in order to hardwire behaviour.
- Tie this data to Press Gainey and HCAPS.
- Tell powerful stories about patients.
Shelby: We simplified discharge instructions and trained staff to use teachback to reduce 72-hour returns to Emergency Department.
It’s harder to tie to outcomes, so tracking readmissions is good to measure. But how much credit can you claim for reduction? It’s harder to measure these higher measures. Stories are also very helpful.
Susan: We gathered tons of process data on how many people trained, and how many trainers have been trained, etc. Again, it’s hard to prove that you’re responsible for this. We collect activity reports on a regular basis that tie in to the 10 Attributes. We share progress with the people who are making it.
Key aspects of your work:
Susan: The partners make success possible. Our program will offer a mix of resources and schedule trainings. We offer webinars and forums to report success. Community based organizations are important partners, such as senior orgs and refugee orgs. They are much smaller orgs than the health system and can really use seed funding. Recognize that they are the experts on the populations they serve.
- You really need to use improvement science techniques. Use PDSA cycles. Don’t be afraid of very small change.
- Be flexible: What works for one unit may not work somewhere else.
- Make things easy: e.g., they use a colourful schedule that mirrors the PDSA. Every project gets a checklist for each team member (trainers, managers, leaders).
- Hardwiring is essential. Co-branding is a wonderful thing. “Steal shamelessly but give credit.” Give them tools.
Shelby: Recognizing strengths that already exist in your organization is very important. For example, we are working with medical interpreters on improving discharge instructions.
Pilot test procedures, such as teachback. We worked with a group that was already doing a great job of teaching patients.
Include the right audiences from the start. Include patients and families. Include the clinic director when developing new materials for that clinic.
Get provider buy-in from the beginning.
How do you spread and sustain your efforts?
Shelby: It’s hardest to sustain efforts, e.g. get people to continue using teachback. We are identifying a “health literacy liaison” in the departments. We are offering once a month meetings on progress which the HL liaison attends and reports back twice a year to their department.
Susan: I have been asked to build a statewide HL coalition. We have been working on this for 2 years in addition to our work in our corner of the state. The challenge is balancing growth with continued support to regional partners.
Cyndi: Every month we has another group starting. New groups get interested and suggest things, which creates organic growth.
Right now we are working hard on Attribute #3, preparing workforce. We want to work on #9, high risk transitions, next.
Susan: Spread is inevitable with success.
Why not online?
Role-playing is a critical part of Cyndi’s training, so live training is important, but refresher training can be online.
Shelby used both live and computer-based, but people who did it online had to go through a live check-up of skills.
Susan’s team is developing their own online training modules. They have to cover a large state. They also use train-the-trainer.
Christopher Trudeau, J.D., Professor, Thomas M. Cooley Law School
Risk means something different to each of us: Lawyers think of risk as how to prevent the hospital from getting sued. Providers wonder, how do we communicate the info to patients so they can make good decisions?
What is risk communication? Helping people understand the nature and seriousness of a certain action so they can make an informed decision.
When someone is selling us something, they’re very clear and direct, but when they need to give us information, it can be very complicated.
Key components of risk communication:
- What we communicate
- How much patients want to know
- When we communicate it (ex. After you’ve prepped for a colonoscopy is not the time to ask for consent — The patient doesn’t care at this point.)
- How we communicate it.
Communicating risk is a process, not just documents to sign. We have to keep in mind both these factors:
- What is legally required for consent?
- How much info does the patient want?
Legal disclosure requirements differ for clinical procedures and research trials. There are a lot more legal requirements for research trials.
- The requirements for clinical procedures are state-based and grow out of the common law (lawsuits, etc.).
- The requirements for research studies were developed in response to bad acts by researchers and are federally controlled.
For procedural informed consent, we use the “reasonable physician-standard” and “reasonable-patient standard” as legal guidelines. But communicating risk goes way beyond the legal requirements.
Written communication does not substitute for in-person conversations that incorporate teach-back. So writing good consent forms isn’t enough. The process of informed consent has to be developed.
Design the consent process first, before you design the consent form. Example:
- Patient and provider discuss.
- Patient gets handout and consent form.
- Patient preps for the procedure.
- Patient goes to appointment.
- Patient and provider further discuss consent form, using teach-back (before anesthesia is given).
It’s important to create hierarchies of information: Prioritize the information so that it emphasizes the key risks to patients. Prioritize risk in the document by creating risk hierarchies.
- The most important info needs to go first, such as the fact that you need someone to drive you home after a colonoscopy.
- People decide for themselves how much attention to pay to a document.
- Documents are not novels; they are not meant to be read cover-to-cover. You may look at it when you get it, but when you consult it later, you’re only going to look for the information you’re after at that time. (You’re not going to read it through again.)
- People actively interpret AS THEY READ. They don’t wait till the end to get the big picture, so organization is KEY.
Structure all documents as if everyone has limited health literacy.
- Consider intended users (focus group? User testing afterwards?)
- Write down what your intended users would want to know.
- Rank the info from most important to least important.
- Then write down any other info you have to disclose by law.
How do you lobby the document owner for clearer documents? Get the owner to focus on the content, rather than the words. They will be more likely to buy in.
How to convey numbers?
Every medical decision requires some statistical literacy. Aim for communicating with a minimal need for statistical literacy. Minimal literacy focuses on the main concepts, such as absolute risks.
Tips on numbers:
- Focus on what you want the patient to do. The patient needs to get the gist. Include a call to action and relate the message to everyday life. Then you can reinforce with data or visuals that relate directly.
- Start with the most important info and group logically.
- Less is more, but underscore the gist.
- Round numbers are easier to understand and remember.
- Keep denominators consistent, eg. 1 in 10, 2 in 10.
- How you frame the question influences the patient’s decision.
- Talk about absolute risk rather than relative risk. (Relative risk: If you don’t take this medication, your risk of stroke will double. Absolute risk: Your risk of stroke will increase from 5% to 10%.)
- Use visual aids and cues. Icon arrays help people personalize/humanize numbers. You can create an icon array at: www.iconarray.com.
- Think about questions patients SHOULD ask: risk of death? Time frame? How big is the risk? Do the studies apply to me and my demographic? What are the benefits and harms of treatment?
Chris showed a rewritten consent form that has places for the provider to fill in the patient’s answers to teach-back questions. This forces the provider to use teach-back. This is also helpful as legal evidence of understanding. And if the patient has to initial statements, he or she is more likely to read them.
Ayelet Baron, MA Futurist, CreatingIs LLC
Sheila Repeta, MA, Senior Consultant, FutureSense, LLC
This presentation was intended to summarize the results of brainstorming sessions held with participants at the IHA conference.
Presented background and conclusions:
“Safe is risky.”
People like routine, so being a futurist is uncomfortable.
Nothing changes until the mindset changes. We don’t need more programs. We need people to come together.
- Bring communities together
- Have conversations (2-way)
- Bring holistic solutions
- Build trust and relationships
In 20th century, we looked at the middle of the bell curve. In the 21st century we need to be on the edges.
Think about the shifts taking place in the world. How much time are you spending connecting with people and having conversations? Learning about what’s going on?
How do we have a shared purpose, not just a shared vision? The hierarchy in organizations is beginning to fall apart. Managers will manage projects, rather than people.
Think of health Literacy as music: You want your audience to be engaged and excited like the audience at a rock concert.
New Model of Leadership
- Shared purpose (rather than dictating)
- Build community (rather than dictate)
- Collaborates (rather than competing)
- Two-way conversations (instead of 1-way communication)
- Integrating tools in business and part of work (rather than leading with technology) We will integrate what we value (e.g. instant messaging)
- Measure impact and makes co-creating (rather than measuring activity)
Need more working out loud: sharing, iterating, legacy, collaborating
21st century is not B2B or B2C; it’s H2H = human to human
We’re going to be looking more at “experiences” rather than products and services.
For the first time in history, we have 5 generations working together. Also, business and society are fusing.
Connectivity can help with equity.
Look for unlikely partners with which to collaborate.
Thriving 21 century orgs:
- Have Conscious Leaders
- Know their Purpose
- Becoming Whole – ask new questions to become whole as an individual and an organization – merge the person with the profession
- Integration – How do you integrate what you’ve learned into what you are creating?
- New ways of being – how do we work? Outloud? Quietly?
- Co-creating – meet the people you need to talk to
Results of sessions
- Shape the future of health literacy together by creating a shard vision that outlines a path forward.
- Listen in and engage in community to generate ideas and prioritize opportunities
- Co-create an agreed-upon plan of action
It’s like climbing a mountain: Diligent, intentional purposeful steps move us forward. Look to the side once in a while, and even backward to see where you’ve been. Don’t always look uphill, but look at where you are as well.
What they brainstormed about:
What are the opportunities? How do we remove the barriers? What does success look like in 2026?
Success is not a straight-line route. It’s a squirrely path.
Goals arrived at (words evolving):
We are empowering all people to holistic health and vitality.
Currently we live in a climate of fear and stress, scarcity and competition. We need to build on trust, awareness, and openness.
In 20th century, we started with a structure. In 21st century: We need to start with purpose, and the structure will follow.
We need more awareness of health literacy.
We need to be more open and share information, including failures.
How to remove barriers?
- Create awareness
- Provide early and professional education (both to professionals and to children for self-care)
- Develop skills. Ask questions. Best practices are not always completely successful. Use technology to enable skills and awareness.
- Be accountable – not just to the organization but to one another
- Connect communities – create unlikely partnerships. Share mindsets and practices internationally
- Remove biases from providers and clinicians
- Establish equity – Making sure we don’t have haves and have-nots, but that everyone has access to care.
There was an outcry from the audience:
Xanthi Scrimgeour of Communicate Health challenged the framing of the question.
Katina O’Leary of Health Lit Missouri questioned whether we can identify as a single community and have a shared vision. Lots of things happening at the same time: A journal, a credentialing process…
Presenters stressed that this is a conversation. We are ALL leaders. We all have the power to make change. Set up groups to create what you want to create in the world.
Key Success Factors:
- Health literacy is fully integrated and implemented in life.
- HL is institutionalized (not an add-on)
- Everyone is empowered to health and vitality.
- There is shared understanding beyond one-way communication.
- There is health equity across all demographics.
- There’s mutual respect and lack of stigma.
Do we need to brand Health Literacy? HL should be integrated into all curricula. Measure results. We should integrate HL education with technology.
Advocacy: Out of the box community outreach
Creating opportunities: create an umbrella association. Increase PR, track and measure. Focus on better health at lower cost and with equity.
Success factors: Increased PR. Organizations sharing messages accurately.
Rima Rudd, Sc.D., Harvard T.H.Chan School of Public Health & Michael Villaire, MSLM, Institute for Healthcare Advancement
Dr. Rima Rudd and Michael Villaire closed the conference with their final thoughts and major takeaways. Michael began his summary of the conference proceedings with noting that this was the 15th anniversary of IHA’s Health Literacy conference. This conference has always been a place to get information but also to connect and be together with our “tribe” and health literacy community.
Rima then acknowledged that there is a lot of passion in the room and it had been evident in every conversation she’d been a part of or overheard. But she also noted a loneliness of each professional in their own org/sector and how grateful we all are for the ability to catch up, reconnect, learn best practices from colleagues.
Rima questioned “Where to next?” and surmised that we don’t know where health literacy is going to go. She shared some thoughts from Ceci Doak:
- I want to see health literacy become more a part of and integral to the reading community.
- Keep up with what’s going on in the field of literacy.
- We need to develop partnerships
Imagining next steps can bring us to something exciting and new, somewhere that’s currently unimaginable.
In looking to the future, Michael quoted Peter Druker: “The best way to predict the future is to create it”. He noted that this is not the end result of our future visioning process, but it is a very important first step.
Feedback from attendees recognized a need for dialogue, connection, and ability to have uncomfortable discussions and to push each other’s boundaries. The Health Literacy Discussion Listserv can serve as a safe place to have these conversations.
Another attendee suggested that we are all futurists because this field has grow so much in recent years and did not exist 40 years ago and now we need for action plans for getting to our shared goals. Everyone at this conference and in this field works tirelessly and we are all actors trying to move this field forward.
This conference is all about getting together and working together. We are also bringing new partners and advocates onboard and educating future professionals who will be part of this shared future. Keynote panelist, Susan Reid, summed up the proceedings with a saying from the late Māori elder Sir James Henare: “Kua tawhiti ke to haerenga mai, kia kore e haere tonu. He tino nui rawa ou mahi, kia kore e mahi nui tonu. We have come too far, not to go further. We have done too much, not to do more.”
Presenter: Mary Ann Abrams
Dr. Mary Ann Abrams hosted an informational and engaging session that encouraged organizational change. She began her discussion with a brief overview of the health literacy field and the immediate need of implementing health literacy principles into organizational structure. She then moved into describing the 10 Attributes of Health Literate Health Care Organizations; a guide with 9 chapters dedicated to help organizations implement and spread health literacy related improvements. Dr. Abrams began the discussion of this guide by providing the 3 questions that are asked in every chapter: 1) Why do you need to address health literacy issues in this area? 2) What would success in this area look like? 3) How could one accomplish these successes?
When using the guide, Mary Ann encourages individuals to start with the chapter that would achieve the most organizational support. She suggests that the guide does not need to be used in chronological order and each chapter can be used as a standalone. After this description, Mary Ann moved into group activities. She divided the room into groups to discuss chapters 3-7 and gave specific questions to each group to report on. Once the groups reconvened, each group reported their responses to their assigned questions. This interactive discussion led participants to collaborate on shared experiences and resources.
The Task Force on Migrant-friendly and Culturally Competent Healthcare has developed a set of standards aimed at monitoring and measuring equity in health care for immigrants and other vulnerable groups. The Standards for Equity in Healthcare provide opportunity for staff and services to question what they do, why they do it, and whether it can be done better. The Standards is a free self-assessment tool which produces valuable data on your organization’s practices, its strengths as well as its gaps, enabling effective quality improvement. Data is rolled up by country. Your organization’s results are confidential.
Elizabeth Abraham, Vice President, Critical Link International
How do we make sure Health Care is accessible, effectively utilized, that health care staff have the skills and knowledge to deliver care equitably?
We have CLAS standards, but they are only recommendations. Elizabeth’s team developed a tool that organizations can use to measure these factors.
The tool was developed in Europe and uses European terms. Such as “migrant” where in the U.S. we would say “immigrant.”
It was started by the Migrant-Friendly Hospital project involving hospitals in 12 countries in Europe.
Outcomes for the Task Force hospitals:
- Whole organizational development
- Interpreting/mediation services
- Patient education and information
- Staff training
The MFH task force was charged to create a framework for measuring and monitoring for continuity.
What constitutes a vulnerable population? Examples:
- Mentally ill
- Victims of domestic violence
- Low education
- Ethnic minorities
- People living with AIDS (PLA)
- Chronically ill
- Sex professionals
- People living with addiction
- Indigenous people, etc.
The tool was revised after the first pilot test. The second-generation tool is now available for download.
It’s a Free tool: If you submit results to the Task Force, they will show how you compare with other organizations in your country and compared to Canada and some other countries.
Standards for Equity that the tool is designed to measure:
- Equity in policy
- Equitable access and utilization
- Equitalble Quality of Care
- Equitable Participation
- Promoting Equity
In 2012, 45 orgs participated in the pilot test. They gave feedback on the tool.
The second pilot was carried out in 16 countries and 54 organizations.
It takes 2-3 meetings to get through the 7 phases of the assessment.
- General information
- Identify and describe areas of improvement.
- Describe an action plan.
This self-assesment tool has not been used in the U.S. You are invited to download the tool and use it. If you think you can get your organization to use and report from the tool, or if you would like more information, contact Elizabeth Abraham at email@example.com or Antonio.firstname.lastname@example.org.
See also the handouts for this presentation, which include the Self-Assessment Tool.
Xanthi Scrimgeour and Stacy Robison of Communicate Health
Online Health information should incorporate:
- Plain language
- Health Education Theory
- User-centered design
90% of adults are online in the U.S.
Those who don’t have broadband are accessing internet on their phones.
72% of internet users looked online for health info in 2013.
Half of people looking for health info are looking for someone else.
69% said their most recent search had an impact on their health or the way they care for someone else.
More often it’s a poorly designed website, rather than user’s poor health literacy that get in the way.
Voice features can help with dexterity and communication challenges.
Alerts and auto reminders can help compensate for short-term memory loss.
http://health.gov/healthliteracyonline (second edition) See the class handout.
What we know about users with limited literacy skills:
- Web users with limited literacy skills are on line and willing to look for info there.
- They are prone to skipping and focussing on the center of the screen.
- They are easily overwhelmed and have a limited working memory.
- They struggle with search functions. Spelling is an issue, ads get in the way, not knowing what to look for, not knowing what sites are reputable. They will only click on 1 or 2 results.
- Low-literacy users are more likely to be smartphone dependent. 1 in 5 adults rely on their phones for internet access. Visually impaired people often prefer the smaller screen of a smartphone.
Strategies for clear online communication:
- Write actionable content. (Information, not documents)
- Answer users’ questions
- Help users complete a task
- Help users make a decision
- You have about 15 seconds to grab the user’s attention.
- Put the most important information first.
- Provide specific action steps (bite, snack, meal – user can drill down as far as they want).
- Limit paragraph size, use bullets and short lists
- People will often skip paragraphs of 3 lines or more.
- Chunking information is important for people with limited working memory.
- It’s critical to design for small screens! Website needs to be responsive to variable screen sizes.
- Place key info and buttons either near enter or center bottom. Many people cover lower right corner with hand.
- Limited lit users like radio buttons. Make as much of the choice active as possible (more than just the circle).
- Make your site accessible (works with screen readers and other assistive technologies, navigate with keyboard only; strong color contrast, etc.).
- Create a linear information path: Give meaningful labels, such as “track meals ->” rather than “next”
- Label information clearly.
- Include a simple search function. Some users just hit the search button without entering any text. Allow for common misspellings, using auto-complete, most actionable content should come up first, avoid scrolling, clear page titles, brief plain language descriptions of URL.
- Limited literacy users like to browse more than they like to search. Putting the alphabet across the top is helpful.
Engage users with interactive content:
- Let them share and print info; give them info about themselves, e.g., calculate the user’s BMI index, etc.
- You can use multi-media online.
- Super simple quizzes work well.
- Online information can be tailored by collecting just a little information such as age and sex.
- Make the content printer-friendly.
- Test your site with users.
- Usability testing with 5 participants will reveal 85% of usability problems.