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Health LiteracyCynosure Health Summit
May 21, 2012
Jennifer Pearce, MPAHeart Failure Program Coordinator & Health Literacy Consultant
Sutter Health
Wall Street Journal December 5, 2006
College educated
Health care experience
Prepared for medical appointments
Had support system
Multiple providers (12)
Had Medicaid, then uninsured
Miscommunication led to lack of follow-up care
Didn’t understand options
PATIENT SKILLS:
SYSTEM BARRIERS:
Outline Definition of health literacy Prevalence Why it matters (quality/compliance/safety) Readmissions Care Transitions Team for Heart Failure plan for
addressing health literacy Measurement Universal precaution approach: written Nuanced approach: verbal Expectations
What you can do now
How is “health literacy” different from “literacy”?
Literacy refers to having the basic skills to read, write and compute without regard to context
Health literacy is the concept of reading, writing, computing, communicating and understanding in the context of health care
Source: Weiss B. Epidemiology of Low Health Literacy. Understanding Health Literacy: Implications for Medicine and Public Health
Posted at the entrance to the ED of a Bay Area hospital: the county’s “major source of acute care for medically indigent and uninsured patients”
Notice for emergency services: This Hospital must provide emergency services and care to any individual, including women in labor, who requests services, examination or treatment, or for whom services, examination or treatment is requested, regardless of the individual’s ability to pay for these services, so long as the Hospital has appropriate facilities and qualified personnel available.
In no event shall the provision of emergency services and care be based upon, or affected by, the individuals race, ethnicity, religion, national origin, citizenship, immigrant status, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent preexisting medical conditions or physical or mental handicap is medically significant to the provision of appropriate medical care to the individual.
Is this equitable access?Notice for emergency services: This Hospital must provide emergency services and care to any individual, including women in labor, who requests services, examination or treatment, or for whom services, examination or treatment is requested, regardless of the individual’s ability to pay for these services, so long as the Hospital has appropriate facilities and qualified personnel available.
In no event shall the provision of emergency services and care be based upon, or affected by, the individuals race, ethnicity, religion, national origin, citizenship, immigrant status, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent preexisting medical conditions or physical or mental handicap is medically significant to the provision of appropriate medical care to the individual.
Flesch-Kinkaid Grade Level: 12
Evolving definitions of health literacy
A person’s ability to obtain, process and understand basic health information and services needed to make appropriate health decisions
Prose literacy: texts Document literacy: appointment slips Quantitative literacy: nutrition labels
Sources: IOM. 2004. Health Literacy: A Prescription to End Confusion
Evolving definitions of health literacy: Dual nature of communication in health literacy
Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33
Patient’s skill
and ability
Health system’s demand and complexity
Health Literacy
Lack of concordance
Source: Rudd, R. 2010. “Literacy and Health.” Harvard School of Public Health
Most health materials are written at a level that exceeds the reading skills of the average high school graduate.
Health Literacy
Patient’s skill
and ability
Health system’s demand and complexity
Prevalence: 9 out of 10 adults lack the skills needed to manage their health
2003 National Assessment of Adult Literacy
Proficient12%
Below Basic14%
Intermediate52%
Basic22%
2003 National Assessment of Adult Literacy
Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy
Adult health literacy by highest level of education
Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy
Adult health literacy by age
Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy
Being able to understand matters to patientsLow health literacy associated with:
Adverse health outcomes Increased risk of hospitalization Increased mortality rates Increased cost to U.S. economy: estimates vary but all are in the
billions; due to increased utilization
Why? Individuals with low health literacy are more likely to:
skip necessary medical tests use the emergency room more often have a harder time managing chronic diseases like diabetes or high
blood pressure
Source: IOM Report on Health Literacy: A Prescription to End ConfusionSource: Baker et al. AJPH. 2002. 92:1278
Source: JAMA, April 27, 2011 – Vol. 305, No. 16Source: Low Health Literacy: Implications for National Health Policy. University of Connecticut, 2007
Source: Rudd, R . E., et al (2007). Health literacy: An update of public health and medical literature. In J. P. Comings, B. Garner, & C. Smith. (E ds.), Review of adult learning and literacy (vol . 7) (pp 175–204).
Health literacy matters to CMSQuality
HCAHPS survey:
Health literacy matters to HHSCompliance
Affordable Care Act established statutory definition of health literacy
Plain language requirement for health insurers
Health literacy matters to the Joint CommissionSafety
The Joint Commission: “Effective communication is a cornerstone of patient safety.”
Sentinel event database: 65% of identified adverse events have communication failures as the underlying root cause
Source: The Joint Commission (2007)“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
Care Transitions Team for Heart Failure: Our reality
At least 54% of our heart failure patients may have limited health literacy
Source: AHRQ Limited Health Literacy Prevalence Calculator
Literature strongly supports considering health literacy as part of a plan to reduce heart failure readmissions
Care Transitions Team for Heart Failure: Program Design
Hospital Telemanagement at home
Heart Failure admission
assess readmission risk
24-48 hrs.
•medication reconciliation
•education
•care transitions assistance
60 – 90 days on service
Assess health literacy during inpatient stay
Score determines pace of teaching post-discharge
Our plan: Universal precaution approach
Take a universal precaution approach in our written material and a nuanced approach in our verbal communication1. Measure: Newest Vital Sign tool2. Distribute: tested and clearly
written/illustrated material that corresponds with education goals
3. Pace and prioritize: teaching according to patient motivation and capability
4. Offer additional resources on demand
Measure: Newest Vital Sign health literacy assessment
ICE CREAM
Distribute one set of materials for all literacy levels: Heart Failure Discharge Tool
Distribute one set of materials for all literacy levels: Self-care booklet
Self-care booklet divided into: What is heart failure? My medications My diet My exercise plan My daily check-up
Interventions that build self-care skills can overcome health literacy related health disparities
Source: Pignone, M. 2008. Literacy and Adherence. http://nchealthliteracy.org/teachingaids.html
Pace and prioritize: TeachingPrinted materials + oral interaction = most effective results
Health literacy score provides and idea of where patient is starting from
What sort of “cognitive Velcro” is already present? Should information be presented in smaller chunks? What vocabulary and concept load are appropriate?
Score should be taken in context (Example: Older adults, regardless of socioeconomic status, have higher rate of limited health literacy; struggle with “mental multitasking” and “fluid intelligence”)
Source: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health and Speros, C. 2011. http://www.healthliteracyoutloud.com/2010/12/14/health-literacy-out-loud-50-communicating-about-health-
with-older-adults/
Offer additional resources on demand
Video, print, or interactive - depending on the patient’s learning style
ExpectationsWe expect to conduct up to 500 inpatient health literacy assessments by end of 2013
By proactively addressing health literacy: Gain greater insight into readmission risk Offer more complete picture to outpatient providers Enhance care experience for heart failure patients
Disease management Health system navigation Self-advocacy
Reduce readmissions
Knowing this, what can you do now?1. Assess
How accessible are your current patient education materials?
Why are you giving them out? 2. Ask
What do your patients do with the materials when the get home?
What information do patients wish they had? What questions are staff getting?
3. Revise Language, font, white space, organization, graphics
4. Test Patients are your partners
5. Refine
