Attachment N -- Response to Public Comment

3

AHRQ’s Response to the Public Comment from the APIAHF

August 30, 2010

Deeana Jang

Policy Director

Asian and Pacific Islander

American Health Forum

1828 L Street N.W.

Suite 802

Washington, D.C., 20036

Dear Ms. Jang,

We greatly appreciate you thoughtful letter (of August 19, 2010 ) that well articulates the needs of the Asian American, Native Hawaiian, and Pacific Islander (AA and NHIP) populations, especially as those needs relate to the important issue of transitions in health care. We agree that proper preparation of patients before discharge is necessary so that they are able to care for themselves once discharged from the hospital – and this is something that all people should expect of their health system. Your letter clearly states the numerous additional challenges that the AA and NHPI populations face in health care settings. We also agree that these special challenges can and should be addressed in programs like ours. If fact, it is a primary goal of this project to study how the implementation and dissemination of the results of our randomized controlled trial (that was done under research conditions in a single institution in the northeast part of the US) can be applied to diverse hospitals and communities in other parts of the country.

We will address each of your comments in the order they appear in your letter.

A Selection of Hospitals for Intensive Technical Assistance (TA): We agree that hospitals serving largely minority patients should be represented among the hospitals with whom we assist in implementing the RED program. At this time the hospitals with whom we will be working is not yet finalized. All the hospitals selected to participate in the project will have a significant amount of patient diversity, though they will not all be largely minority serving hospitals. We will not, however, assign hospitals to more or less intensive TA based on whether they are largely minority serving or not. We hope to learn about the relative contribution intensive TA makes over less intensive TA. Hospitals in both groups therefore need to have similar characteristics.

Baseline Needs Assessment: We agree that during the baseline needs assessment that it would be optimal for us to collect information about a participating hospital’s resources for serving patients from diverse linguistic and cultural backgrounds. We plan to collect data on each hospital’s collection of r/e/l data and provision of language assistance. We had not been planning to collect data on staff diversity and CLAS training, but will now add that to our baseline needs assessment.

Monthly Semi-Structured Interviews: One of our priorities for this project to identify how hospitals provide the revised RED toolkit to assist patients from diverse background. The monthly semi-structured interviews with hospitals receiving intensive TA services provide an opportunity for regular feedback on the success of the RED program for diverse populations. Discussion of these issues will be a part of this call and we hope to learn a great deal about what works and what does not work.

Pre- and Post -baseline Semi-structured Interviews: We agree that this project offers a rare opportunity to collect information from frontline health workers with regard to discharging diverse populations. Indeed, collecting information on this aspect of the dissemination and implementation of RED is to talk with a variety of health care workers to determine what is currently done and what can be done better in regards to the proper preparation of patients of varying race and ethnicities. Your comments help to reemphasize this important issue.

Pre- and Post-implementation Patient Survey’s: The surveys will be sent to a random sample of subjects who have received the RED program. Your suggestion about targeting our sampling to be sure we receive sufficient data to be of use in our evaluation patient’s from diverse backgrounds raises an important point. We will explore the possibility of over-sampling certain minority groups, but our ability to oversample depends upon the hospitals’ ability to identify these populations within the administrative data. We will not know if the hospital administrative data contains these variables until the hospitals are chosen.

Medical Record Review of Patient Outcomes: We agree that any summary data that we have collected from the medical record review should be a disaggregated by subpopulation, when the numbers of patients permit it, to more clearly assess the experiences of the various groups.

I would also like to address your suggestion that AHRQ translate HCAHPS into additional languages. The Centers for Medicare and Medicaid Services (CMS) is in charge of translating HCAHPS into other languages. HCAHPS is currently available in English, Spanish, Russian, Vietnamese and Chinese in the mail version, and English and Spanish in the telephone and IVR versions. All translations are available in the HCAHPS Quality Assurance Guidelines V5.0 (see http://www.hcahpsonline.org/files/HCAHPS%20Quality%20Assurance%20Guidelines%20V5.0%20-%20March%202010.pdf). These are the only official, sanctioned translations of HCAHPS. CMS does not track or endorse the use of unofficial translations. CMS has asked that you contact them if you have suggestions for additional translations. Please send your suggestions to Bill Lehrman at [email protected].

We share your concern that if patient surveys are distributed in English and Spanish that non-Spanish –speaking patients with limited English proficiency are unlikely to respond. We will suggest that hospital therefore plan to have interpreter services available when telephone follow-up is conducted with patients who have not returned surveys.

Master Trainer Training and Intensive Training: The trainers – members of the RED research group at Boston University and Boston Medical Center, which is the former Boston City Hospital, have great familiarity with the challenges that diverse populations face in receiving medical care. Boston Medical Center serves a large number of minority groups as indicated by its medical interpretation services which have medical interpreters available in 20 languages on site each day. Finally, a component of the RED program is use of the teach back technique in confirming understanding or medications, appointments, etc. so that we are sure the patients are able to understand the plan for self care after discharge.

Thank you again for submitting your thoughtful and informative letter in response to our proposal. We look forward to sharing with our final results with you.

Sincerely,

Doris Lefkowitz