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The University of Missouri Center for Health Policy, through funding from Health Literacy Missouri, a nonprofit organization based in St. Louis, incorporated AHRQ's "Health Literacy Universal Precautions Toolkit" into a practice improvement module that provides simulation training and health literacy coaching for physicians. This training assists clinicians in developing and implementing a health literacy action plan for their clinics.

Stan Hudson, Associate Director at the University of Missouri Center for Health Policy, serves as Senior Advisor on Education for Health Literacy Missouri. He led the development of the training and coordinates implementation of the program. Hudson says, "In line with AHRQ, we gear our system and practice improvement training to focus on the universal precautions approach. Addressing health literacy is seen as a communication strategy that assumes that all clinical encounters are at risk for communication errors. The strategy aims to minimize this risk for everyone."

The training includes a 1-day health literacy workshop where physician attendees participate in peer discussions and training in a simulation laboratory at the University of Missouri. The simulation training is coupled with a planning session in which participants are introduced to AHRQ's "Health Literacy Universal Precautions Toolkit." They work one-on-one with a trained health literacy expert, who coaches and assists physicians to develop a basic plan for addressing health literacy in their particular practice by using some of the tools outlined in the toolkit. Once a plan is finalized, physicians are provided with an abbreviated and customized survey to give their patients. This survey is based on items from AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) health literacy item set and includes standard demographic data, along with a subset of general health literacy questions that are included on all patient surveys for comparison. An additional three to six items are selected based on the specific tools from the toolkit that the physician chooses to include in his/her plan.

For example, say a physician wants to incorporate the "teach-back method," an evidence-based health literacy technique to assess how well a patient understands instructions and knows what to do. In this case, the survey would include the CAHPS supplemental item that specifically asks, "In the last 12 months, how often did this doctor ask you to describe how you were going to follow these instructions?" After the initial baseline measures are established, patients are surveyed again 6 and 12 months after implementation of their physician's plan.

Hudson says, "We have found the CAHPS health literacy item set to be very useful. The patient's perceptions are paramount to examining health literacy. A physician or a clinic may think they are doing a good job addressing health literacy, but this can only be confirmed through the patient experience. For health literacy, there is no better instrument than the CAHPS survey."

The module developed by the Center for Health Policy and Health Literacy Missouri is one of the first board-certified health literacy programs for physicians. The module is approved as a Maintenance of Certification program by the American Board of Internal Medicine (ABIM). Internists and subspecialists certified in or after 1990 renew their certificates through ABIM's Maintenance of Certification program every 10 years.