William Calnon, D.D.S.
Private Practice General Dentistry
Calnon described his practice as a three-person dental practice in Rochester, New York, which has a broad based group of patients. He is also president of the American Dental Association (ADA),1 which represents 7 out of 10 dentists in this country and, Calnon said, can be viewed as a conduit through which information and education can be provided to dental practitioners in the United States.
One of the attributes listed in the commissioned paper is “Establishing and promoting health literacy as an organizational responsibility.” The ADA has done just that, Calnon said. Its Council on Access, Prevention and Interprofessional Relations has as part of its mission to promote community outreach, cultural competency, and health literacy. The council and its advisory committee, the ADA National Advisory Committee on Health Literacy in Dentistry, developed the Health Literacy in Dentistry Action Plan.2 This is a 5-year plan that focuses on health literacy educa-
1 The views presented here may not necessarily reflect the policies of the American Dental Association.
2 The plan can be found at http://ada.org/sections/professionalResources/pdfs/topics_access_health_literacy_dentistry.pdf.
tion and training, advocacy, research, dental practice, and building and maintaining coalitions.
Another activity of ADA is the National Roundtable for Dental Collaboration. It has representation from all types of organizations that are involved with the profession of dentistry, including industry partners and vendors. The group decided to focus on oral health literacy and is working with the Ad Council on a 3-year oral-health literacy campaign, with ADA contributing $1 million of the campaign’s total cost of $3.2 million. Another potential partner for work in oral health literacy is Scholastic Publishing. It works on literacy issues through its Read and Rise3 program, and it is interested in developing an oral health component for its programs, Calnon said.
Other attributes from the commissioned paper that might be of interest to those in dental practice are concerned with inquiry, innovation, and evaluation and with measurement and assessment. A major activity of the ADA is conducting baseline surveys of its members on communication techniques. The National Advisory Committee on Health Literacy in Dentistry is examining the challenges to implementing health literacy practices and is reviewing research on health literacy. A review of printed educational materials, continuing education for dental team members, and other resources is also under way.
Preparing an effective workforce and improving system navigation are other priority attributes for the ADA. There is a pilot program at the schools of dentistry at Temple University and at the University of Oklahoma that is testing a potential new member of dental teams called a community dental health coordinator.4 Such a coordinator would be, essentially, a patient navigator who would be working directly in communities to help with outreach in oral health literacy. The program is intended to be community-based and culturally and linguistically responsive and to establish linkages with local dental clinics.
Yet another attribute of interest to the ADA is health information technology, Calnon said. The ADA is looking at ways that technology can be used to increase educational effectiveness.
Some of the other attributes listed in the paper are of lower priority for dental providers. Medication safety and communication are not as important for dental providers, for instance, as dentists in private practice tend not to prescribe many medications, mainly just antibiotics and
3 “Read and Rise is a sustainable and systematic literacy engagement program designed to bring families, schools, and communities together to support children’s literacy development, while celebrating the positive impact of family culture and tradition.” http://www.scholastic.com/aboutscholastic/communityreadandrise.htm (accessed January 25, 2012).
analgesics. The bottom line, Calnon said, is that dentists and the ADA are committed to prevention and that oral health literacy and literacy in general are the basis of that preventive work.
Cynthia D. Horton
Visiting Nurses Association of El Paso
The Visiting Nurses Association of El Paso, established in 1967, is a not-for-profit organization that serves about 90 percent of the charitable care provided to the uninsured, homebound people in the community. About 70 percent of that community is Hispanic, Horton said. The core function of the agency is to work with people in their homes and connect them to community resources. The agency is a full-service home health agency with several different core businesses, including hospice, home health, and a private duty side which is private pay. All of these services are provided in the home. But “home” can mean different things, Horton noted, including a rescue mission or a Salvation Army shelter.
A top priority for Horton’s agency is to provide culturally relevant education materials. A mandatory component of home health care is teaching. In order to provide home care there must be someone in the home who can take over that care. If the agency cannot find someone to help with self management, a situation that would put the patient at risk, then in extreme cases Adult Protective Services (APS) must be called. Rather than call APS, the agency wants to empower its patients to take over their own care.
A majority of people in the indigent-care program are Spanish speakers, and many are undocumented. Because they are uninsured they wait a long time before deciding to seek medical care. As a result, their conditions are often more acute, and they frequently require hospitalization, but because they are uninsured they are quickly moved out of the hospital, even if they are still very sick. Under these circumstances, a hospital discharge planner calls the agency to let it know that there is an uninsured patient being discharged who needs assistance.
Horton offered an example of what the agency does. There was a construction worker in his thirties who was married with three children and who lived on the outskirts of El Paso. He had a sore on his finger. He saw the sore, put some antibiotic ointment on it, wrapped it with a bandage, and went back to work. This continued for about 8 weeks, with the sore progressively worsening until someone told him he needed to have it examined by a physician.
There is a small clinic on the outskirts of town, the last building on
the waterline for the county. This worker lived beyond that. He went to the clinic, which serves about 4,000 people a year who have no other source of care. Most of those served are without running water. The clinic discovered that the worker had Stage 4 melanoma. The clinic then called the agency asking for help. The agency sent a social worker and a nurse to his small mobile home to assess his needs. They found that he required hospice care and reported that to Horton, whose job it is to find what he needs and get it to him.
Because the worker was incontinent and it was becoming unhealthy for him to stay in the same bedroom with his wife, it was decided to obtain a hospital bed for him. The worker’s three children were sleeping where the laundry hookups were. It was vital to get him out of that situation. But his mobile home was so small that when the company arrived with the bed they could not fit it through the hallways. There was just no room.
The intervention could not be provided in the home and the hospital would not take him back because he was uninsured and terminal. The agency contacted a partner, the Habitat for Humanity, which has a partnership with a group called Modular Homes. That group put a modular home on his site at no charge so that he could die in peace at home. These are the kinds of problems the agency is faced with and the kinds of strategies it must employ.
Is the agency likely to undertake activities to implement the attributes in the commissioned paper? Yes, absolutely. One activity the agency is undertaking is the development of a user-friendly information technology system that will permit the tracking of patients as they move from program to program, integrating all the services they need.
Another activity concerns communication and building trust. Many of the patients seen by the agency delay visiting a physician and instead self-medicate using remedies that a relative brought back from across the border. Some of these remedies are herbal, and others are items that are over-the-counter drugs in Mexico but prescription medications in the United States (e.g., hydrocodone). Because of the difference, when the patient does see a medical provider he or she generally does not tell the provider about using these medications. Therefore it is important for the agency to communicate with the patient in a way that is comfortable and culturally appropriate so that it can learn about such medication use. It is also important to create trust, to let the patients know that the agency is not going to turn them over to the Immigration and Naturalization Service.
The agency is also planning to undertake company-wide training about health literacy, using the commissioned paper as a base, Horton said.
A major challenge is that despite a high need for community resources,
there is a lack of funding which interferes with providing those resources. To try to overcome the lack of direct funding, the agency partners with other organizations whenever possible. For example, the local diabetes association has developed excellent printed materials, and the agency uses those materials rather than expending resources to develop new ones. Progress is being made in the areas of congestive heart failure, diabetes awareness, comprehensive cancer care, and a community-wide falls prevention program. The agency has worked with the community and with experts in the field to find culturally relevant materials and approaches in multiple languages.
The major incentive to become a health literate organization is the people served, Horton said. The better one is able to communicate and provide relevant, culturally appropriate services and materials, the better it will be for the patients. And the agency is also committed to providing not only medical services, but if a family needs food or needs electricity, the agency will work to provide those things. A family that needs food or is worried about losing electricity is too distracted to listen to a nurse describing how to change bandages or engage in a particular therapy.
Horton concluded by saying that two statements in the commissioned paper were particularly relevant for her. One is that a health literate organization views linking patients and social resources as a fundamental part of providing medical care and ensures there are systems in place to make these connections. The other is that comprehension cannot be assumed to be achieved unless it can be demonstrated.
Roundtable member Patrick McGarry asked Horton whether a home assessment includes an assessment of the level of literacy and the amount of reading materials in the home. Horton said that the assessment involves a number of things, including the role of all the members of the household, their reading levels, and their food risks.
Roundtable member Winston Wong asked Calnon how the ADA will assess the efficacy of the campaign it is conducting in conjunction with the Ad Council. Are there metrics it will use that are associated with patient engagement or the level of prevention or visits for prevention? Calnon responded that members of the organization are working very closely with the Ad Council in this area because too often outcomes are not assessed. The majority of dental disease is preventable, and the campaign is focusing on changing behavior so that prevention of dental problems is paramount.
Roundtable member Benard Dryer asked Calnon what the role of state health departments and other health organizations should be in
promoting understanding about oral health literacy. Calnon responded that all too often professional associations work independently of state dental directors. That should not be the case. Partnerships are needed, particularly in this time of limited resources.
Will Ross, roundtable member, asked both Horton and Calnon about whether patient navigators or community health workers could be used in their organizations’ efforts. Horton responded that her agency does use community health workers, or promotores, to deliver health information in the community. Everyone has a role to play, so the best approach is to discover each person’s passion and figure out how to channel that into community service.
Calnon said that there are enough dentists but that they are not distributed evenly. There are many places in the country that do not have a dental practice. Dental schools have begun to give some preference to individuals from underserved areas with the idea that they might return and practice in those areas. Individuals from a community can assist patients to navigate the system and to be ready to accept dental care. Dental extenders might also play a role. Calnon explained that such individuals, if properly trained and supervised, could provide basic dental care, leaving the more surgical practice to be performed by a trained dentist.
Roundtable member Leonard Epstein asked Horton whether the Visiting Nurses of El Paso work with the community health centers funded by the federal Health Resources and Services Administration. Horton said that they do and that they also work with migrant health programs and the U.S./Mexico Border Commission.
Roundtable member Susan Pisano asked both Horton and Calnon to describe the most persuasive health literacy argument one could make to the leadership of their organizations. Horton said the most persuasive argument is that literacy is not just educational, it is cultural. If one is talking to a patient about diabetes, that patient is running the information through his or her own filter. Developing a health literate organization means identifying the cultural factors and linguistic factors that interfere with or facilitate what patients understand so that information and services are delivered in ways that patients can understand and identify with.
Calnon said that providers need to take into consideration the fact that different patients will hear things differently. Because the outcome sought is better health, it is vital that patients understand what needs to be done. If dentists know that a particular preventive strategy works, it is their duty to educate the public about that strategy.