Utilization of the medical librarian in a state Medicaid program to provide information services geared to health policy and health disparities

Abstract

Objective: The role of two solo medical librarians in supporting Medicaid programs by functioning as information specialists at regional and state levels is examined.

Setting: A solo librarian for the Massachusetts Medicaid (MassHealth) program and a solo librarian for the New England States Consortium Systems Organization (NESCSO) functioned as information specialists in context to support Medicaid policy development and clinical, administrative, and program staff for state Medicaid programs.

Brief Description: The librarian for MassHealth initially focused on acquiring library materials and providing research support on culturally competent health care and outreach, as part of the United States Department of Health and Human Services Culturally and Linguistically Appropriate Services in Health Care Standards. The NESCSO librarian focused on state Medicaid system issues surrounding the implementation of the Health Insurance Portability and Accountability Act. The research focus expanded for both the librarians, shaping their roles to more directly support clinical and administrative policy development. Of note, the availability and dissemination of information to policy leaders facilitated efforts to reduce health disparities. In Massachusetts, this led to a state legislative special commission to eliminate health disparities, which released a report in November 2005. On a regional level, the NESCSO librarian provided opportunities for states in New England to share ideas and Medicaid program information. The Centers for Medicaid and Medicare are working with NESCSO to explore the potential for using the NESCSO model for collaboration for other regions of the United States.

Results/Outcomes: With the increased attention on evidence-based health care and reduction of health disparities, medical librarians are called on to support a variety of health care information needs. Nationally, state Medicaid programs are being called on to provide coverage and make complex medical decisions regarding the delivery of benefits. Increasing numbers of beneficiaries and shrinking Medicaid budgets demand effective and proactive decision making to provide quality care and to accomplish the missions of state Medicaid programs. In this environment, the opportunities for information professionals to provide value and knowledge management are increasing.

INTRODUCTION

This paper documents the unique aspects of two medical librarians operating as information specialists in context (ISICs) for state Medicaid programs. Library services support Medicaid staff in developing evidence-based health policy with a focus on the quality and delivery of health care to individuals served by the Medicaid program. The ultimate goal of the Medicaid program is to improve the health of its members. Providing access to health care and providing health communication are two objectives of Healthy People 2010 [1], and these objectives are key to reducing health disparities. Nationally, the Medicaid program is one of the largest purchasers of health care for the poor and underserved. As such, the Medicaid program is an integral part of the national goal of reducing health disparities.

BACKGROUND

In 1965, Medicaid came into existence under title XIX of the Social Security Act [2]. Medicaid is a joint federal and state program aimed at providing health insurance coverage for low-income children and their parents, elderly, people with disabilities, and people who are categorically eligible. The Medicaid program has experienced an average growth rate of 8% from 2000 to 2003. As the Medicaid rolls increase, the increased costs of the program are a target for lawmakers eager to reduce spending. By virtue of the populations served under Medicaid as well as the skyrocketing costs to deliver benefits to these populations, issues addressing quality of care and health care disparities have gained increased attention.

The Institute of Medicine (IOM) report Unequal Treatment documents the following challenges in addressing health disparities [3]:

• raising public and provider awareness of racial and ethnic disparities in care

• expanding health insurance coverage

• improving the number and capacity of providers in underserved communities

• improving the quality of care

• increasing the knowledgebase on causes and interventions to reduce disparities

The current focus on health disparities as a health policy and public health issue has found a strong voice in political leaders such as Senators Bill Frist (R-TN) and Edward Kennedy (D-MA) [4, 5]. The US political agenda is currently very crowded. However, with such strong advocates and a commitment from federal and state authorities to track measures related to quality and the effectiveness of care, it is not likely that the issue will be pushed to a back burner [6, 7]. Information on health disparities continues to grow, and, by virtue of the complexity of the subject, access to the information is challenging. [8]. Medical information professionals have a unique opportunity to assist in mining information related to disparities and to deliver the information to those individuals and entities who may affect policy development [9–12].

The following definitions of health disparities are prominent in current literature on the topic [1]:

• National Institutes of Health (NIH): “Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.”

• IOM: Disparities in health care are racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, patient preferences, and appropriateness of interventions.

• National Library of Medicine (NLM): Health policy is the development by government and other policy makers of present and future objectives pertaining to health care and the health care system and the articulation of arguments and decisions regarding these objectives in legislation, judicial opinions, regulations, guidelines, standards, etc., that affect health care and public health. [13]

The field of health policy has undergone tremendous change in the last twenty-five years [14]. In 1979, US health officials provided an opportunity to begin health policy discussions with the report, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, which called for the Healthy People 2000 project. In 1985, the Secretary's Task Force on Black and Minority Health (The Heckler Report) documented, for the first time, health disparities in the United States [1]. Since 1984, the “Healthy People Movement” has gone through two iterations: Healthy People 2000 and Healthy People 2010. In 2001, the US Department of Health and Human Services published the Cultural and Linguistic Appropriate Health Care Services Standards. In 2002, IOM released Unequal Treatment, which documented the extent of health disparities. Congress has also mandated that the study of health care disparities continue. In 1999, Congress directed the Agency for Health Care Research (AHRQ) to produce an annual report providing data related to health care disparities among racial, ethnic, and socioeconomic groups in the United States. The 2004 National Health Care Disparities Report and the 2004 National Health Care Quality Report document the quality of health care that individuals receive from and the places that disparities exist in the US health care system [15]. Through these annual reports, progress will be tracked by longitudinal data analysis and data gaps will be identified. The second edition of the National Health Care Disparities Report found that health disparities were closely related to the quality of health care that a person received and closely related to health care quality.

Public Law (P.L.) 106–525, “The Minority Health and Health Disparities Research and Education Act of 2000,” required that NIH produce a long-range plan to address health disparities. Because NLM falls under NIH, NLM and the National Network of Libraries of Medicine (NN/LM) have contributed to this plan by offering training on consumer health and health literacy through the regional library system, along with public health information outreach and infrastructure grants [16]. As part of the long-range plan, NLM and NN/LM will work through the Regional Medical Library system toward providing access to health information to address health disparities.

EXPERT SEARCHING AND INFORMATION TRADING

As an ISIC, a health policy librarian in the Medicaid environment functions not only as an expert searcher but also as a knowledge broker. In this exchange of knowledge, an opportunity exists to learn from other states and to improve Medicaid programs. This facilitates a better understanding of the business needs of the program and expands the role of the librarian in the program to include more health policy development and implementation at a state level. In New England, a regional information professional expands the role further by identifying and sharing Medicaid activities in New England through a nonprofit organization solely focused on promoting regional collaboration.

Typically, an expert searcher is consulted when users cannot meet their information needs. The needs may be attributed to lack of time or resources, deadlines, or an inability to navigate the breadth and depth of sources available. This concurs with the research Alpi conducted in 2005 showing that health policy knowledge workers (e.g., program staff, elected officials, and administrators) need information about existing health policy and information to formulate health policy [12]. These workers do not have the time or staff to conduct their own research. Staff often suffers from information overload from the voluminous federal guidelines and legislative mandates disseminated to state Medicaid program staff and administration. The ability to identify, analyze, and summarize information for Medicaid staff and state policymakers becomes an identifiable asset in the organization and many times is shaped by pressures from political and budgetary constraints or advocacy agendas. Librarians are called to put information into context, often by conducting a preliminary analysis. This analysis requires experience working in the institution and understanding the clients' business needs. Those working in a health policy setting also need to be attuned to the political climate. An awareness of potential barriers for disseminating information increases the likelihood of success for knowledge transfer.

Research on knowledge transfer is not limited to library and information science literature. Lavis and colleagues from the Knowledge Transfer Group at McMaster University document the knowledge transfer process [17, 18]. The individual, or group of individuals, transferring the knowledge assumes the role of messengers. Over time, the librarian may be able to demonstrate added value to the organization through the depth of questions the librarian has asked and the librarian's searching abilities. This demonstration of value can result in the organization's increased awareness of creative solutions and the librarian identifying related areas that need investigation. Often, the librarian will need to work collaboratively with other staff to produce reports and electronic presentations or facilitated meetings. Through these collaborative activities, the information professional becomes a recognized component of the knowledge transfer process.

The vital role of the information professional as “information consultant” is not always obvious in a health policy setting. Unlike a corporate environment driven by for-profit goals, the health policy and government environments do not have an obvious correlation to “the bottom line,” but rather to budgetary limitations. More deliberate outreach efforts may be necessary to create an awareness of the resources and skills available to the staff. Outreach activities articulating the core competencies of the information center and professional can streamline the knowledge transfer process as well as refresh the institution's memory of past projects and potential project elements identified as best practices. The librarian may be used as a resource person to conduct research for agency projects, especially in areas or topics with little internal knowledge or diffused knowledge. The librarian may be asked to attend meetings to highlight key points in articles for staff to consider in their policy recommendations. Use of current awareness tools, such as news updates, continually remind staff and partners that a 24/7 mechanism is in place to monitor the information flow in their organizations.

Organizations not only need to acquire knowledge, but also to manage what they know. However, in the fragmented, multidisciplinary world of Medicaid and health policy, an information professional's ability to combine advanced information science training and subject matter expertise provides a unique opportunity for knowledge management. Librarians who work behind the scenes may be called on to provide internal reference and consultation to committees to ensure institutional priorities have adequate resources. Librarians can also fill the need to keep a collective history of what information is used for projects, especially in a policy setting, allowing for knowledge transfer even when staff turnover occurs. Staff turnover is currently increasing in the Medicaid environment with some states operating at 30% vacancy rates. Although these histories will ultimately reside in department collections or in off-site archives, knowledge of this information must be transferred and allow for updated searches on a regular basis. With the changing nature of state budgets and politics, information and evidence will constantly be needed to lead decision makers to policy outcomes. By approaching health policy research with an evidence-based approach, the librarian provides the policy maker or program staff with information that supports the health policy development process.

Information professionals in a health policy setting encounter customers from a variety of levels. The information professional must feel comfortable working with staff at all levels and with other customers, including politicians, community partners, affiliated state agencies, or corporations. It is not uncommon to call a vice president of quality in commercial health care plans to obtain information on best or promising practices for state Medicaid programs. This contact requires skills not only in written communication but oral communication and presentation development. With an increasing number of electronic resources and remote services, the library staff is answering questions that are more complex. They are brought into meetings and provide recommendations to staff based on search results. The complexity of these tasks requires that a librarian evaluate the search results and provide synthesized search results. A request may require that a librarian not only conduct a literature search, but contact internal and external experts in the subject matter to obtain the needed information. Policy makers are challenged with sorting through numerous studies and reports to determine their relevance to the program.

MASSACHUSETTS EXPERIENCES

The original collection development goal of the MassHealth library was to acquire materials geared to support implementation of the Cultural and Linguistic Appropriate Services in Health Care (CLAS) Standards in the Medicaid program [19]. The CLAS standards are a tool to improve systems in health care for individuals from different racial and ethnic backgrounds or with limited English proficiency. These standards are used to ensure that individuals receive culturally competent care to improve health care quality and outcomes [8]. The standards are broken down into mandated requirements for organizations receiving federal funds, guidelines, and voluntary recommendations.

In this focus, the MassHealth librarian assisted a variety of units on varying policy needs depending on the project or administrative responsibilities, and cultural competence was recognized as important. A movement to balance the policy needs of the staff, while keeping them informed of current research on health disparities, as it impacts the Medicaid program, was also a critical component. In supporting research on CLAS standards, the library was involved with providing background research for program staff about the CLAS standards and trends in cultural competence in health care. During 2001 and 2002, requested searches focused on member education, health literacy, and clinical practice guidelines for providing culturally competent care, medical interpreters, and medical coverage policies. The librarian supported developing consumer health materials for postpartum depression, prenatal health, and men's health.

This support evolved to ongoing support to the clinical staff at MassHealth and to member education and outreach. Region I of the US Department of Health and Human Services holds a biannual minority health conference [20]. As part of this work, the librarian assisted in traditional continuing medical education activities and spearheaded a panel on health literacy. In the conference, the librarian facilitated a panel of experts on the library's role in health literacy and successful outreach projects.

The librarian also collaborated with member services and clinical staff to develop television specials and focus groups for the Spanish-speaking population served by MassHealth to improve the health status of Medicaid recipients. In 2001, the MassHealth program undertook a large quality improvement project on prenatal and postpartum care. As part of this project, the librarian assisted in research for a television special on the importance of postpartum care. Staff utilized the librarian to conduct targeted literature searches on postpartum and prenatal care. The 2003 Health Plan Employer Data and Information Set measures found that 83% of women enrolled in MassHealth receive timely prenatal care [21]. This type of analysis moves away from traditional use statistics to link the literature search and work of an information specialist to the organizational outcome. Using outcomes data to supplement usage statistics has the potential in other organizations to make a business case for the importance of information specialists.

In 2003, Massachusetts passed legislation to establish a statewide commission on health disparities. The commission is made up of fifteen members appointed by the legislature from among the Executive Office of Health and Human Services, MassHealth, Department of Public Health, members of the House and Senate, American Cancer Society: Massachusetts Division, American Heart Association: New England Division, Massachusetts General Hospital, Brigham and Women's Hospital, Massachusetts League of Community Health Centers, Massachusetts Medical Society, Boston Public Health Commission, Springfield Health Department, Massachusetts Nurses Association, Massachusetts Association of Health Plans, Harvard School of Public Health, Boston Medical Center, and eight members from the community. The commission focuses on: social context of health disparities, access to health care, health care quality and services, and work force diversity. The MassHealth librarian supports commission members by providing access to relevant journal articles to frame a discussion on health disparities. The librarian also supports the commission by working with members on drafting potential policy recommendations on health literacy. In these commission meetings, it is important to obtain expert testimony from outside organizations and to capture internal knowledge as well. Testimony from consumers, government officials, health care industry representatives, community coalitions, and staff of the Regional Medical Library, Region I, have been offered to address health care disparities in the New England Region.

NEW ENGLAND REGIONAL EXPERIENCES

The New England region has a unique mechanism to facilitate sharing health policy knowledge among states <http://www.nescso.org>. In 2000, the New England States Consortium Systems Organization (NESCSO) was created to encourage the states in the region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) to share information on the Health Insurance Portability and Accountability Act and the future of Medicaid Management Information Systems. This nonprofit organization is administered by the University of Massachusetts Medical School and employs a member of the university's library staff. When NESCSO was organized, the original board members felt strongly that hiring an information professional was key to the organization's mission. More specifically, the position required experience in knowledge management as well as traditional library skills such as database searching. The NESCSO knowledgebase would not only be organized by this individual, but the mechanisms for identifying users and successfully delivering information to those users would also be a function of the position. NESCSO is unique as no other region of the United States has a formal organization focused solely on collaborative efforts related to health and human services.

NESCSO employs traditional methods for knowledge sharing such as an electronic library of documents available to the public as well as to member states. However, NESCSO has also created a Web-based knowledge management tool, known as Ontrak, that is project focused for member states. Individuals from the states' health and human services organizations are registered as users with various permission levels. The users then post documents and information related to specific subject interests. As an administrator of this system, the NESCSO information professional is apprised of the activities of the states and able to identify opportunities for collaboration. Thus, the New England region has the ability to share Medicaid and health policy best practices across state borders. NESCSO has a multistate project focused solely on sharing information related to health disparities. Documents as well as notification of meetings are posted to the site. The existence of such a platform for knowledge transfer provides the New England states a greater ability to share best practices and openly discuss the challenges and successes of their Medicaid programs. The information professional relies on communication and knowledge-management skills to alert members of relevant information for project team members.

Health policy settings rely on less traditional library resources such as personal reference collections, journal articles, gray literature, guidelines from the Joint Commission on Accreditation of Healthcare Organizations, and health policy reference books. A physical library of traditional medical books organized by call number is not as important as a small reference collection of seminal works and cooperation with sister agencies and academic partners to provide the traditional health sciences texts for developing clinical practice guidelines. In addition, access to gray literature or information such as internal working documents plays a greater role. NESCSO posts summaries or full-text documents of research to its online library. Through key word searches, researchers, policy makers, and consumers may access the summaries and analysis on topics requested by other states. It is difficult to measure the impact of the availability of such materials. The impact of a research request might be only identified as the announcement of a new Medicaid program or the formation of a collaborative workgroup on a particular topic.

CONCLUSION

Health policy has become a driving force in health care for the twenty-first century. The financing and delivery of health care services relies heavily on evidence-based policies that are designed with the goal of providing quality medical care to citizens and reducing health disparities in the community, state, and nation as well as worldwide.

An ISIC in the health policy setting is in the unique position of having the tools and expertise to disseminate and manage knowledge in the institution to shape policy behind the scenes. Librarians' skills are effective tools for collaborating with health policy professionals and partners, enabling them to integrate evidence-based practices into their programs to ultimately improve access to and quality of health care.