December 27th, 2012
The author is program director of the John A. Hartford Foundation, a national funder based in New York City. He is editor and contributor for its blog, Health AGEnda.
For more than twenty years, the John A. Hartford Foundation has worked to improve the health of older Americans. And over that time, institutionally, we have shifted from deep skepticism about publicity and communications to what we hope is a balanced sense of how communicating to, and hearing from, the public can improve our work. This year, we extended our efforts to educate the public through two national public polls, through which we asked people older than age sixty-five about their experiences with, and views about, health care.
Given our size (endowment of $500 million) and average grant of almost $1 million over three years, the total cash cost of these polls feels reasonable ($20,000 to $30,000) and is comparable to some of the other “non-grant” ways we have tried to advance our mission (for example, publishing reports, convening grantees and policy audiences, and providing training in capacity building). Of course, it also requires an enormous effort from foundation staff and our outsourced communications colleagues from Strategic Communications and Planning.
Why are we doing this?
In considering any tactic, one should start at the beginning: the definition of the problem and our operating theory of change. Our fundamental thesis has long been that the health care system and the general public are unprepared for our aging society and don’t know what they don’t know. Basically, a lack of demand for expertise in the care of older adults on the part of consumers of care has translated into inattention in the health professions and a lack of serious preparation in the delivery system.
While everyone who faces cancer knows that they should at least consult with an oncologist, how many older Americans and their families facing increasingly complex chronic health and social care issues “know” that they should see an expert in geriatric care? How many people even believe that there is a relevant body of expertise?
An obvious response to this framing of the problem would be a public education campaign—for example, TV ads suggesting that people be aware of common risks such as large numbers of prescription drugs or falls and be more demanding of health care workers: “Did you know that older adults have 1.5 times the risk of having an adverse event in the hospital compared with others? Ask your doctor/nurse/social worker/pharmacist for her training in elder care.”
But the budget needed for such a campaign is well beyond our means, especially because the concepts are so unfamiliar. A stealthier approach is to learn about current public opinion, juxtapose what we learn with best evidence, and thereby generate surprising news that earns coverage in the public media. This strategy will gradually alert the public and thought leaders to particular risks and eventually help people appreciate the special health challenges of aging.
We also have a somewhat idiosyncratic concern. Because, historically, we have been so quiet, and our founder’s name is so easily confused with the Hartford Insurance Company or the Hartford Foundation for Public Giving (in Connecticut), we have heard from many in the media that they hesitate to talk about the foundation and its work because of the complexity of explaining who we actually are (and aren’t). We are faced then with a vicious cycle where lack of name recognition keeps us out of the media and prevents us from establishing a “brand” reputation that adds value to our grantees. We hope that earning coverage inextricably connected to our name will help.
So how have we done?
Not too shabby. In our first poll (which was released in April and planned and executed over the prior six months), our central finding was that while older Americans were very satisfied with their primary care provider, when they were asked about a series of assessments and services (two examples: review of medications for continuing need and/or possible interactions, health promotion recommendations), very few received even a fraction of such services. We got extra attention because the services we asked respondents about were all components of the new Annual Wellness Visit offered to Medicare beneficiaries as part of the Affordable Care Act. The disconnect between the benefit as designed and its low uptake raised intriguing policy questions. We received coverage in a number of media outlets and felt like we had advanced the conversation.
For our second poll, as we worked on selecting a theme and probable story line in June for results to be delivered in the fall/winter of 2012, we thought about a news hook and realized that many media outlets, looking for a dark side to seasonal joy, do stories on “holiday blues.” Given that our most recent annual report focused on mental health issues among older adults, our decision was simple. We also raised the bar for ourselves (and raised the cost) by specifying that our poll ask about treatment quality in mental health care among older adults who had recently been in treatment or faced a mental health diagnosis. This required an “oversample” of 300 people who were added to our national sample of 1,008.
Again, we felt good about our central findings: mental health issues, particularly depression and its close cousin, anxiety, were very common in our representative sample. Eight percent of respondents scored positive for “probable depression” on the brief screening questions we used, and 14 percent reported that they had been told by a professional that they had the condition. Still, 27 percent of respondents thought depression was a natural part of aging, and while people gave us some heartrending descriptions of their suffering, respondents still seemed unaware of some of the broader health risks of depression such as heart disease or mortality. According to our respondents, many of the important steps that are part of high-quality care, such as engaging patients in care, systematically following up on their response to treatment, and modifying the treatment plan, were missing.
This time, our extra surprise factor was that the bugaboo of mental health stigma seemed largely missing. Seventy-seven percent of respondents indicated that they would feel comfortable raising the issue with a health care provider, even if not asked. We think that the gap in care for this common and expensive chronic condition has important implications for how a reformed and redesigned delivery system is staffed and trained.
Unfortunately, timing is everything, and because we just released the results of our mental health poll on December 13, I am fairly sure that the tragic school shooting in Newtown, Connecticut, the very next morning understandably consumed most of the available time of journalists and reporters with any interest in mental health issues as well as most all available space and airtime for that topic in newspapers and on television.
Still, we are learning, and each time we learn more about limiting and sharpening our questions as well as reaching out to the media. We have money allocated in our communications budget for two more polls, and we look forward to helping to raise awareness about our work, our mission, and our founder.
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