Reaching%20Medicare%20Beneficiaries%20with%20Communication%20Barriers

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2004 REACH National Medicare Training Program
Speaker Name Group Name Date
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Reaching Medicare Beneficiaries With a Focus on
Addressing Issues of Language, Literacy,
Location, and Culture

• Module 8

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Session Topics

• Snapshot of Medicare beneficiaries
• Overview of NMEP
• CMS partners
• General communication guidelines and strategies
• Reaching those who are not being reached
• Prototypes and research findings

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Medicare Beneficiaries
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Medicare in 2004

• Serves over 41 million beneficiaries
• Covers 97 of those over 65
• Has impacted life expectancy
• Has improved quality of life

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What the Numbers Show

• By 2030
• Number of beneficiaries will nearly double
• Number will reach nearly 77 million
• 68.2 million over 65
• 8.6 million disabled or ESRD

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Age and Gender in 2000

• Proportion of women increases with age
• Under 65 44 women 56 men
• 65 to 74 54 women 46 men
• 75 to 84 59 women 41 men
• 85 over 71 women 29 men

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Race/Ethnicity in 2000

• Of 35.2 million 65 and older
• 81.6 White non-Hispanic
• 8.1 Black non-Hispanic
• 6.5 Hispanic
• 3.8 Other
• Of 5.5 million disabled
• 68.1 White non-Hispanic
• 17.1 Black non-Hispanic
• 10.1 Hispanic
• 4.7 Other

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Beneficiaries Income in 2000

• Nearly 65 below 25,000
• 25 10,000 or less
• Only 16 over 40,000

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Living Arrangements in 2000

• Nearly half live with a spouse
• 16 live with their children
• 6 live in a long-term care facility
• 29 live alone
• 56 have incomes lt 15,000
• 72 are women
• 15 are over 85

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Self-Reported Diseases/Conditions In 2000

• Significant proportions report
• Arthritis
• Hypertension
• Osteoporosis
• Diabetes
• Pulmonary disease

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Understanding of MedicareIn 2000

• Majority have some or little knowledge of
  Medicare
• Biggest knowledge gap
• Beneficiaries under age 65
• Beneficiaries over 85

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Preference for Receiving Medicare Information,
2000

1. Talking face-to-face
2. Pamphlet
3. Telephone
4. Media
5. Internet

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Remember The Faces Behind the Numbers
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National Medicare Education Program(NMEP)

• The Approach

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NMEP Goals

• Create awareness
• Generate understanding
• Empower beneficiaries
• To help people become more active participants
  in their health care decisions

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Key Components

• Beneficiary print materials
• Toll-free telephone services
• Internet activities
• REACH Campaign
• National Alliance Network
• National training and support
• Enhanced SHIP counseling
• Assessment of Education Model

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Beneficiary Print Materials

• Medicare You handbook
• Mailed each fall since 2000
• Mailed to new enrollees
• Available in multiple versions
• Topic-specific educational pamphlets

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Toll-Free Telephone Services

• 1-800-MEDICARE
• Operators available 24 hours per day
• Can respond to English and Spanish inquiries
• Provide targeted educational pamphlets
• 1-800-MEDICARE (1-800-633-4227)
• TTY/TDD 1-877-486-2048

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Internet Activities

• www.medicare.gov
• Beneficiary-focused website
• Information on topics of interest
• Search tools
• Publications
• Helpful contacts

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REACH Campaign Regional Education About Choices
in Health

• Community-based outreach and education
• Conducted by CMS ROs and partners
• Focus on populations with communication barriers
• Language
• Literacy
• Location
• Culture

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CMS Partners

• Who they are
• Primary mission/responsibility
• Relationship with CMS
• CMS oversight

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Some Key Partners

• Social Security Administration
• Medicare contractors
• End-Stage Renal Disease networks
• Quality Improvement Organizations
• Formerly Peer Review Organizations
• State Health Insurance Assistance Programs

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Social Security Administration

• Federal agency
• Medicare responsibilities
• Take applications
• Determine eligibility
• Issue Medicare cards
• Handle some premium issues

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Medicare Contractors

• Private organizations
• Carriers
• Fiscal Intermediaries
• Durable Medical Equipment Regional Carriers
• Regional Home Health Intermediaries
• Program Safeguard Contractors
• Process payments
• Responsible for program integrity

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ESRD Networks

• Ensure administration of ESRD benefits
• Develop quality standards
• Assess treatment modalities
• Provide technical assistance to dialysis
  facilities

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Quality Improvement Organizations

• Promote quality of health care services
• Evaluate standards of care
• Process Medicare hospital discharge appeals
• Perform reviews

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State Health Insurance Assistance Program (SHIP)

• Provide information
• Provide one-on-one counseling
• Use volunteer counselors
• Operate under a grant program
• Provide free service to beneficiaries

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Other Partners

• Administration on Aging
• State departments of insurance
• State Medicaid offices
• State survey agencies
• State units on aging
• Consumer and elderly advocacy groups

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Administration on Aging

• Agency in HHS
• Federal focal point and advocate for older
  persons
• Works to heighten awareness
• Seeks to educate older people and caregivers
• Works with nationwide network
• Collaborates with
• Federal agencies
• National organizations

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State Departments of Insurance

• Responsible for regulating
• Insurance companies
• Medicare carriers
• Fiscal Intermediaries
• Durable Medical Equipment Regional Carriers
• Rural Home Health Intermediaries
• Enforce insurance-related statutes

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State Medicaid Offices

• Federal government establishes general guidelines
• States administer Medicaid program at local level
• Establish guidelines for eligibility and services
• Process claims
• Names of state Medicaid offices vary
• Social Services
• Public Assistance
• Human Services
• Community Services

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State Survey Offices

• Conduct periodic inspections
• Ensure health care facilities comply with health
  safety standards
• Ensure health care facilities comply with quality
  standards

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State Units on Aging

• Sometimes called departments of aging
• Responsible for enforcing statutes
• Provide services for aged and sometimes for
  disabled
• Administer aging programs
• Information and referral help lines
• Nursing home ombudsman

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Consumer and Advocacy Groups

• Advocates for issues involving elderly
• Provide information about
• Private health insurance
• Managed care
• Medicare and Medicaid
• Other health-related issues

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Reaching Medicare Beneficiaries

• Communication Strategies

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Understanding the Audience

• First step in designing effective products
• Who they are
• Where they live
• Cultural factors that influence behavior
• Behaviors when seeking health information
• Levels of health literacy

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Print Products
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Design, Layout, and Format

• Critical to attracting and holding attention
• Inspires to read and re-read the text
• Is it visually appealing?
• Is message clear, simple, and direct?
• Are photos and illustrations culturally
  appropriate?
• Keep message short, simple, to the point

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Color

• Important for all elderly populations
• Catches the eye
• Helps those with declining vision
• Preferred by all seniors and easiest to read
• Black on a light background
• Additional color for accent

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Typestyle

• Easy to read
• Times or Garamond (serif fonts)
• Ariel or Verdana (sans serif fonts)
• No more than two typefaces
• 14-point font size
• Align text on left (ragged right)

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The Message

• Use simple, basic language
• Use short sentences
• Follow the rules for newspaper articles
• Answer the questions who, what, why, when,
  where, and how
• Include definitions of medical terms
• Avoid jargon and acronyms

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Other Media
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Outdoor Media

• Know travel habits of audience
• Keep message simple and short
• Print should be large, clear, easy to read
• Feature one large graphic
• Make sure it is illuminated
• Choose a high-traffic area

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Educational Videos

• Know your audience
• Keep script simple
• Focus-test the storyboards
• Use animation, music
• Allow for transitions
• Consider using a production company

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Public Service Announcements

• 15-, 30-, or 60-second format
• Feature respected spokespersons
• Negotiate on talent
• Tell who, what, why, where, when, and how
• Use clear, simple language
• Include a call to action and repeat it

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Producing the PSA

• Research local radio and TV production studios
• Discuss budgets honestly with them
• If no budget, visit the public information
  officer
• Make sure everything is included when using a
  production studio
• Background music helps attract attention
• Do not overpower vocals
• Find royalty-free music
• Research the need for a buy-out fee

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Dissemination Strategies
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Assessing Distribution Channels

• Select best channels
• Maximize message distribution
• Assess your audience by researching
• Lifestyles
• Media preferences
• Geographic locations
• Income and education levels

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Media Placement

• With a limited budget, look for free advertising
• Aim for legitimate news coverage
• Ask for free placement
• Call the public information officer
• CMS ROs can refer you to their contacts

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Media Buying

• Buy media with the greatest impact
• Media prices are often inflated
• Ask for the lowest price
• Local television stations have a cadre of
  faithful viewers
• Local radio call-in shows are good channels

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Maintaining Contacts

• Keep your contacts working for you
• Call to say thanks
• Share any feedback or results
• Write a thank-you note on official stationery

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Promoting Your Product

• Post/promote the product on your website
• Make sure government partners know about it
• Federal
• State
• Local
• Make sure everyone in your organization knows it
  exists

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Disseminating PSAs

• Tell them you are sending a PSA
• Send proper format
• Send instructions to run it as often as possible
• Follow up with a phone call
• Make sure he/she received the ad
• Discuss the importance of the message

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Disseminating Print Media

• Submit an article signed by a Medicare official
• Follow up with a phone call
• Scan for related news stories
• Have a strong message with a fresh angle

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Community Programs

• Public events and exhibits
• Especially shopping malls
• Traveling health booth
• Offer basic Medicare information
• Health and nutrition seminars
• Include visuals, a brief video, or charts
• Have experts available

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Other Events

• Speakers series at places seniors congregate
• Neighborhood churches
• Housing facilities
• Community or senior centers
• Nutrition sites
• Health fairs
• Conferences

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Remember The Faces Behind the Numbers
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HORIZONS ProjectReaching Diverse Populations

• Culture- and language-appropriate Medicare
  information
• Overcome communication barriers in diverse
  populations
• African American
• Asian American/Pacific Islander
• Hispanic American
• American Indian/Alaska Native
• Focus on those with the greatest barriers

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Supporting Research

• Minority-owned marketing firms
• Analyzed
• U.S. Census data
• Available CMS data
• Conducted formative research
• On health care information needs
• Product development and testing

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HORIZONS Information

• Communication Toolkit for Serving Diverse
  Communities
• Medicare product prototypes
• Design guidelines and dissemination strategies
• Radio and television
• Brochures, displays and exhibits
• Outdoor advertising and special events
• Research findings
• Send e-mail to
• BSPGHORIZONS_at_cms.hhs.gov

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Beneficiaries Who Are Not Being Reached

• In general, individuals in this group
• Have a higher incidence of many preventable
  diseases
• Have lower literacy levels in English and often
  in a native language
• Are less likely to be aware of Medicare benefits
• Are less likely to practice healthy behaviors

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Other Considerations

• Misunderstanding/mistrust of health care system
• Preference for more familiar traditional remedies
• Fatalistic acceptance of the course of the
  disease
• Lack of culturally appropriate health care
  messages
• Limited English proficiency
• Economic barriers to medical care

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Limited English Proficiency

• Non-English speakers at a disadvantage
• Communicating health care concerns
• Receiving providers instructions

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Developing Products and Strategies

• Research the population
• Can you adapt existing products?
• Is the population familiar with all terms?
• If not, include a glossary
• Work with community organizations
• Target places frequented by the population
• Focus-test the product

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What Is Transcreation?

• Making a product
• Culture-appropriate
• Language-appropriate
• Using nuances, concepts, and phrases familiar to
  the audience

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Adapting Materials forBeneficiaries with LEP

• Dont use a literal translation
• Choose a translator who is bilingual and
  bicultural
• Transcreate
• Back-translate
• Test with the audience
• Involve community partners
• Have several editors review
• Revise and retest as necessary

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African-American Beneficiaries
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Demographic DataAfrican-American Seniors

• In 2000
• 2,822,950
• 62 are women
• 38 are men
• 57 are age 65 to 74
• 43 are 75 or older

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Demographic DataAfrican-American Seniors

• In 1996
• One-fourth had incomes below poverty level
• 43 of eligible not enrolled in Savings Programs
• Over half (55) had lt 12 years of education

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Demographic DataAfrican-American Seniors

• In 1996
• Majority (59) lived in central cities
• 34 lived alone
• 40 of females vs. 23 of males
• Majority of women were widowed
• 82 of those 85 and over

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Where do they live?

• Ten states account for 57 of African-American
  elderly

New York California
Texas Florida
North Carolina Georgia
Illinois Ohio
Virginia Michigan
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Where do they live?

• 42 live in metropolitan areas

New York City Chicago Philadelphia
Washington, DC Detroit Los Angeles
Baltimore Atlanta Norfolk
Cleveland Miami Houston
San Francisco St. Louis Dallas
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Where do they live?

• Insert local information

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Health Status

• Glaucoma 6-8 times more common
• Hypertension rates among highest in the world
• Coronary heart disease most common cause of death
• Stroke mortality is 1½ to 2 two times higher
• Diabetes mortality rates 2 to 3 times higher
• Prostate cancer mortality rate more than double
• Account for 31 of U.S. ESRD

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Other Factors

• Consult with adult children/other relatives
• 16 percent live with their adult children
• Many describe themselves as religious
• Seek aid from significant others

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Focus-Group Findings

• Preferences for receiving Medicare information
• From a knowledgeable spokesperson
• Someone older
• Very few used Internet
• Very few knew of SHIP offices
• Interested and would use them
• Would definitely watch a Medicare video

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Design Strategies

• Portray people with whom they identify
• Incorporate themes from daily life
• Show African-American images
• As the centerpiece of the image
• Not just in the background

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Dissemination Strategies

• Radio is important to many older African
  Americans
• Many African-American seniors enjoy television
• Often in the late afternoons and evenings
• News, gospel programs, court television, game
  shows
• Older African-American readers like
• AARP, African-American, and Christian magazines
• Local newspaper

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Hispanic-American Beneficiaries
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Demographic Data

• Hispanics now largest U.S. minority group
• 12.5 of total population (1 in 8)
• Rapid population growth driven by
• Natural increase (births minus deaths)
• Immigration
• Beneficiary population also growing rapidly

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Demographic DataHispanic-Americans by Origin
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Language

• Spanish is second most common language in U.S.
• Spoken by 10.7 of residents 5 and over
• Many Hispanic-Americans speak English less than
  very well
• Face-to-face education is essential
• A bilingual format is preferred

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Demographic Data Hispanic-American Beneficiaries

• Relatively young
• Less access to newer communication technologies
• VCRs
• Cable TV
• Internet
• More likely to live in metropolitan areas
• More likely to live with children or other
  relatives

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Demographic Data Hispanic-American Beneficiaries

• Reported lower income and education
• 73 reported incomes lt 15,000
• 37 reported lt 5 years of formal education
• 25 were covered by Medicaid
• Only 6 did not have health insurance

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Where do they live?
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Where do they live?

• Insert local information

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Health Status

• Only 56 of seniors receive vaccinations
• Leading disease-related causes of death
• Heart disease
• Diabetes
• Cancer
• Pneumonia
• Influenza
• Cerebrovascular diseases
• HIV infection

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Other Factors

• Great diversity of Hispanic subgroups
• Most share cultural heritage and values
• Spanish language
• Catholic religion
• Central role of family
• May place medical needs of family members over
  their own
• Less likely to have other sources of health
  insurance

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Focus-Group Findings

• Need information about the Medicare program
• Do not know about Medicare Savings Programs
• Want to understand
• Specific benefits covered under their plan
• Costs they are responsible for paying
• How to stay healthy
• Desire more materials and resources in Spanish

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Design Strategies

• Determine language
• Spanish
• Bilingual
• Show Hispanic-American images
• Intergenerational family scenes are appealing
• Reflect the local culture
• Test with the audience

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Design StrategiesBilingual Formats

• Hispanic-American beneficiaries prefer bilingual
  format
• Feature languages side-by-side
• Create both Spanish- and English-language ads
• One to reach Spanish speakers
• One for caregivers or others
• Use simple, basic Spanish

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Design Strategies for PSAs

• Consider using a novela format
• In translating Spanish-language copy will
  generally be longer
• Local talent or Hispanic celebrities are
  effective
• Music considerations
• Soft, classical for serious health care messages
• Livelier tunes to promote a healthy lifestyle

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Dissemination Strategies

• TV and radio preferred over print products
• Television is preferred over radio
• Target places frequented by seniors
• Doctors offices
• Pharmacies
• Senior centers
• Churches
• Grocery stores
• Advertise in Spanish-language newspapers

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Asian-American and Pacific Islander Beneficiaries
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Demographic Data

• Approximately 30 ethnic groups
• More than 50 languages
• Population will triple to 1.9 million by 2010

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Demographic Data
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Where do they live?
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Where do they live?

• Insert local information

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Demographic DataChinese-American Beneficiaries

• 235,995 Chinese U.S. residents age 65 and above
• Many immigrants are from Taiwan
• Speak Min Nan, rather than Cantonese
• Unlikely to join family-based self-help
  associations
• Nearly half live in central cities
• Chinatowns remain important social and cultural
  centers
• Nearly 63 over 65 live in four metropolitan areas

Los Angeles New York City
San Francisco-Oakland San Jose, CA
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Health Status

• Leading disease-related causes of death
• Cancer
• Heart disease
• Stroke
• Chronic lower respiratory disease
• Influenza and pneumonia
• Diabetes
• Nephritis and related conditions

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Health Status

• High prevalence of certain conditions and risk
  factors
• Chronic obstructive pulmonary disease
• Hepatitis B
• HIV/AIDS
• Tobacco smoke
• Tuberculosis

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Focus-Group Findings

• Likely to select a clinician in Western medical
  practice
• Confidence and trust placed in primary care
  physician
• Some use a traditional healer or herbalist
• Extended family is source of individual welfare
  and assistance

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Asian-Born Beneficiaries

• Majority said they do not speak English well
• Most prefer oral communication
• Preferences varied among ethnic groups
• Confused by documentation requirements
• Varied understanding of Medicare eligibility
• Some thought citizenship a prerequisite
• Some thought it a form of charity

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Design Strategies for Print

• Choose language for development
• There is only one written Chinese
• Avoid using colloquial Chinese
• Medicare terms should remain in English within
  the Chinese text
• Use Chinese-American images
• Use appealing/culturally-appropriate colors
• For Chinese, use Ling Song font and 14-pt type

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Design StrategiesBilingual Format

• Decide if a bilingual format is feasible
• Single in-language version might be more
  effective
• If bilingual
• Feature the languages side-by-side
• Dont make one language appear dominant
• Send separate Chinese and English formats for
  radio/TV

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Design Strategies for PSAs

• Create in both Chinese and English
• May have to be produced in several versions
• Mandarin and Cantonese for Chinese
• Tagalog and Ilocano for Filipinos
• Use local talent
• Use of celebrities generally not effective
• After newspapers, TV and radio are most effective

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Dissemination Strategies

• Contact key organizations/partners
• Display and distribute the product
• Newspapers are most effective medium for reaching
  Chinese Americans
• SingTao and World Journal
• Asian supermarkets are frequent gathering places
• Outdoor ads get great exposure
• Direct mail is also effective

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Summary of Key Concepts

• Medicare beneficiaries need information to make
  informed health care decisions
• Some have communication barriers
• It is important to understand the people you are
  trying to reach
• The HORIZONS project has developed guidelines for
  reaching these individuals

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Remember the Faces Behind the Numbers
Remember the Faces Behind the Numbers
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Remember the Faces Behind the Numbers
The People We Serve