building health literacy: essential steps and practical solutions
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Building Health Literacy: Essential Steps and Practical Solutions. Essential Hospitals Engagement Network. October 10, 2013. Our new Name. We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals . - PowerPoint PPT PresentationTRANSCRIPT
Building Health Literacy: Essential Steps and Practical SolutionsEssential Hospitals Engagement Network
October 10, 2013
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OUR NEW NAME
We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response.
This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org
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SPEAKER INFORMATION
David Engler, PhDSenior Vice
President for Leadership and
InnovationAmerica’s Essential
Hospitals
Dean Schillinger, MDProfessor of Medicine in
Residence at the University of California San Francisco Chief of the UCSF Division
of General Internal Medicine at San Francisco
General Hospital
Michele Edwards, NP
Heart Failure Program Manager
Grady Heart Failure Clinic
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AGENDA
• EHEN health equity overview
• Health Literacy, Health Outcomes and Health Literate Organizations - Dean Schillinger, MD
• Addressing Health Literacy - Michele Edwards, NP • Q & A
• Wrap-up and announcements
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PARTNERSHIP FOR PATIENTS
Partnership for Patients
(PfP)
• CMS-funded• Reduce 9 hospital-acquired conditions by
40%• Reduce readmissions by 20%
Hospital Engagement
Networks(HENs)
• 26 contracted organizations
• 3,700 U.S. hospitals
Essential Hospitals
Engagement Network (EHEN)
• 22 hospitals nationwide
• Only safety-net focused HEN
• Special focus on health equity
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WHY SHOULD WE FOCUS ON HEALTH LITERACY?
• 75 million English-speaking adults have limited health literacy
• Annual cost to U.S. economy of up to $238 billion• Health literacy levels affect health outcomes
» Increased use of emergency room and acute care services » Less likely to get flu shots» Lower use of mammography» Greater likelihood of taking medicines incorrectly » Higher rates of readmission
• Elderly, non-whites, immigrants and low income adults most affected
Health Literacy Interventions and Outcomes: An Updated Systematic Review. March2011. Agency for Healthcare Research and Quality, Rockville, MD.
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EHEN: MOVING TOWARDS ACTION
• Health equity educational series» Next equity webinar: January 2014
• November 2013: EHEN data feedback report on selected outcome measures stratified by race and ethnicity
• Offer training to hospital staff on standardizing self-reported REAL data
• Disseminate “bright spots” in achieving equity
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Dean Schillinger, MDProfessor of Medicine in Residence at the University of California San
Francisco Chief of the UCSF Division of
General Internal Medicine at San Francisco General Hospital
Health Literacy, Health Outcomes and Health Literate Organizations
Dean Schillinger, MD UCSF Professor of Medicine in Residence
Chief, Division of General Internal Medicine, SF General Hospital
Director, Health Communications Program,
UCSF Center for Vulnerable Populations
Objectives
Describe prevalence of limited health literacy/numeracy give examples of how it can affect health outcomes, using diabetes as an exemplar condition
Because health literacy represents a balance between individuals' health literacy skills and the health literacy demands and attributes of the healthcare system, we describe» 10 Attributes of health literate healthcare organizations
What is Health Literacy?
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make [informed] health decisions.”
-Institute of Medicine, 2004
3 domains: oral (speaking, listening); written (reading, writing); numerical (quantitative)
?Web? Capacity/Preparedness Demand Mismatch
Schillinger Am J Bioethics 2007
1st National Assessment of Health Literacy n=19,714
Below Basic: Circle date on doctor’s appointment slip
Basic: Give 2 reasons a person with no symptoms should get tested for cancer based on a clearly written pamphlet
Intermediate: Determine what time to take Rx medicine based on label
Proficient: Calculate employee share of health insurance costs using table
National Center for Educational Statistics, U.S. Department of Education, 2003
1st Health Literacy Assessment
Basic
Below Basic
Proficient
14%
12%
53%
22%
National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Department of Education, 2003.
Intermediate
AverageMedicare
Hispanic
n=19,000 U.S. Adults
Prevalence of Limited Literacy
in Diabetes
In public hospital settings, between 2/3 -3/4 of diabetes patients over 65 have limited literacy
In private managed care settings, between 1/3-1/2 of diabetes patients over 65 have limited health literacy
Patients with Diabetes and Low Literacy Less Likely to Know Correct
Management
0 20 40 60 80 100
Percent
Need to Know: symptoms of low blood sugar (hypoglycemia)
Need to Do:
correct action for hypoglycemic symptoms
*Williams et al., Archive of Internal Medicine, 1998
Low
ModerateHigh
LowModerate
High
Williams 1998
0
10
20
30
40
50
1st Quartile 4th Quartile
% o
f p
ati
en
ts
Inadequate
Marginal
Adequate
Literacy is Associated with Glycemic Control, N=408
(Tight Control: HbA1c7.2%) (Poor Control: HbA1c>9.5%)
Adjusted OR=0.57, p=0.05
Adjusted OR=2.03, p=0.02
Schillinger JAMA 2002
Complication n** AOR 95% CI
Retinopathy 111 2.33 (1.19-4.57)
Nephropathy 62 1.71 (0.75-3.90)
Lower Extremity Amputation 27 2.48 (0.74-8.34)
Cerebrovascular Disease 46 2.71 (1.06-6.97)
Ischemic Heart Disease 93 1.73 (0.83-3.60)
Lower literacy is associated with self-reported diabetes complications (N=408)
Schillinger JAMA 2002
Limited Health Literacy Patients Experience More Hypoglycemia
N=14,000
0%
2%
4%
6%
8%
10%
12%
14%
16%
Problemslearning
Help reading Notconfident
with forms
Adequate
Limited
P for all<0.001
Sarkar, Adler, Schillinger, JGIM 2010
Limited literacy associated with higher adjusted mortality (OR 2.03, AOR 1.75)
How Does Limited Literacy Affect (Verbal) Clinical
Interactions?
Impedes understanding of technical information and explanations of self-care
Impairs shared decision-making Speed of dialogue, extent of jargon, lack of
interactivity determinants of effectiveness of communication
Impairs medication communication, jeopardizing patient safety (medication “discordance”)
Fang et al. 2006 JGIMSchillinger et al. 2004 Pt Ed and CounselingCastro et al, Am J Health Beh 2007Schillinger et al. 2003 Arch Int MedSchillinger et al 2004. AHRQ Advances in Patient Safety
Diabetes Patients with Limited Literacy Experience Poorer Quality
Communication, N=408
0
10
20
30
40
50
%
Doctor Use Words NotUnderstood
Give You Test Resultsw/o Explanation
Confused AboutMedical Care
Doctor UnderstandProblems Doing Rx
Inadequate FHL
Adequate FHL
(Often/Always) (Often/Always) (Often/Always) (Never/Rarely/ Sometimes)
OR=3.2;p<0.01OR=3.3;p=0.02
OR=2.4;p=0.02
OR=1.9;p=0.04
32%
13% 13% 13%
26%21%
33%
20%
Literacy and the Digital Divide in Diabetes*Kaiser Patient Portal Study N= 14,102
Sarkar, Karter, Schillinger J Health Comm 2010
*For difference between those with and without limited health literacy, p for all<0.01
The Other Side of the Coin:10 Attributes of “Health Literate”
Healthcare OrganizationsDean Schillinger, MD
Division of General Internal Medicine and Health Communications Program, Center for Vulnerable Populations at San Francisco General
Hospital, University of California San Francisco
Commissioned by IOM Health Literacy Policy Roundtablehttp://iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_Ten_HLit_Attributes.pdf
Rationale for Focusing on Health Literacy on the Organizational Level
• Most HL research has focused on characterizing patients’ deficits, how best to measure a patient’s health literacy, and on clarifying relationships between a limited health literacy and outcomes
• Growing appreciation that health literacy represents a balance between individuals' health literacy skill and the health literacy demands and attributes of the healthcare system
Rationale for Focusing on Health Literacy on the Organizational Level (continued)
• Interest and commitment from multiple stakeholders to address system-level factors contributing to the high literacy demands of the healthcare system.
• Enactment of the Patient Protection and Affordable Care Act (ACA) provides both opportunities and challenges for individuals with limited health literacy.• Insurance reform and Medicaid expansion• Patient Centered Medical Homes• HITECH Act
Health Literate Organizations Defined
A health literate organization makes it easier for people to navigate, understand, and use information and services to take care of their health.
Brach, Schillinger et al. 2012
10 attributes of a health literate health care organization
Attribute 1: A Health Literate Organization
1. Has leadership that makes health literacy integral to its mission, structure, and operations. Leadership: » Makes clear and effective communication a priority » Assigns responsibility for health literacy oversight » Sets goals for health literacy improvement» Allocates fiscal and human resources
Attribute 2 A Health Literate Organization
2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement.» Incorporates health literacy into all planning
activities» Conducts ongoing organizational assessments » Measures the success in achieving the health
literacy attributes and identifies areas for quality improvement
Attribute 3 A Health Literate Organization
Prepares the workforce to be health literate and monitors progress» Hires diverse staff with health literacy expertise » Sets and meets goals for training all staff and
members of governing bodies» Provides health literacy training and incorporates
health literacy into orientations and other trainings» Arranges for staff to take advantage of on-line health
literacy training resources
Attribute 4 A Health Literate Organization
Includes populations served in the design, implementation, and evaluation of health information and services» Includes members of the population on governing
bodies» Establish advisory groups that involve individuals
with limited health literacy, adult educators, and experts in health literacy
» Collaborate with community members in design and implementation of interventions and development and testing of materials.
Attribute 5 A Health Literate Organization
Meets needs of populations with a range of health literacy skills while avoiding stigmatization» Adopts health literacy universal precautions,
such as offering everyone help with literacy tasks
» Allocates resources proportionate to the concentration of individuals with limited health literacy
Attribute 6 A Health Literate Organization
Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact» Refrains from using medical jargon» Confirms understanding (e.g. Teach-Back)» Secures language assistance for speakers of
languages other than English » Limits to two to three messages at a time » Encourages questions
Attribute 7 A Health Literate Organization
Provides easy access to health information and services and navigation assistance» Facilitates scheduling appointments with other
services » Uses clear signage» Offers assistance with all literacy related tasks» Makes electronic patient portals user-centered and
provides training on how to use them
Attribute 8 A Health Literate Organization
Designs and distributes print, audio/visual materials, and social media content that is easy to understand and act on» Involves diverse audiences, including those with
limited health literacy, in development and rigorous user testing
» Uses a quality translation process to produce materials in languages other than English
Attribute 9 A Health Literate Organization
Addresses health literacy in high risk situations, including care transitions and communications about medicines» Prioritizes high-risk situations (e.g., informed
consent for surgery and other invasive procedures) » Emphasizes high-risk topics (e.g., conditions that
require extensive self-management)
Attribute 10 A Health Literate Organization
Communicates clearly what health plans cover and what individuals will have to pay for services» Provides easy-to-understand descriptions of
health insurance policies » Communicates the out-of-pocket costs for
health care services before they are delivered
Concluding Thoughts
Limited Health Literacy is common in public hospitals and has a range of untoward health consequences, some of them mediated by poor clinician-patient communication
Health literacy represents a balance between individuals' health literacy skills and the literacy demands and attributes of the healthcare system
The IOM paper offers a set of attributes, aspirational goals and foci for institutional investments for organizations striving to become more ‘health literate’
We recognize that it reflects a utopian vision; the list is not exhaustive and should be seen as the continuation of a conversation re: how healthcare organizations can address health literacy on the institutional level
Provides a roadmap to advance an optimistic vision of how organizations should evolve to be more responsive to the needs of populations with limited health literacy in tangible ways
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Q & A
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Michele Edwards, NPHeart Failure Program Manager
Grady Heart Failure Clinic
Addressing Health LiteracyMICHELE EDWARDS, ACNP
HEART FAILURE PROGRAM MANAGER
GRADY MEMORIAL HOSPITAL
Grady Memorial Hospital
▪ 953 bed public academic hospital
▪ Located in the heart of downtown Atlanta
▪ Emory and Morehouse School of Medicine
▪ Patient demographics▪ Largely African American population▪ Mostly uninsured and underinsured▪ 12% of patients are limited English proficient (LEP)▪ 5,104 patients seen in ER are homeless▪ 1,202 patients admitted/seen (inpatient, outpatient) are homeless▪ 51 patients seen in heart failure clinic are homeless (using date range 01/01/2013-09/15/2013 data pulled from EPIC)
Overview of the Heart Failure Program
▪ Inception March 2011
▪ Focus on improving quality of care for heart failure patients and reducing readmission rates
▪ 2 nurse practitioners (NP) under the direction of medical director
▪ Provide heart failure education
▪ Address barriers to care:▪ Ability to obtain medication▪ Transportation▪ Homelessness▪ Illiteracy/low literacy▪ Mental Illness▪ Lack of insurance▪ Drug/Alcohol abuse
▪ Assist with seamless transition from hospital to home
▪ Follow up phone call within 72 hours of discharge
▪ Follow up appointment within 7 days of discharge
▪ Clinical Decision Unit (CDU) patients▪ NP sees patient in CDU▪ Patient given heart failure clinic
(HFC) follow up within 3 days
▪ Patients see in HFC by NP
▪ Heart failure NP’s have touched >1300 patients since March 2011
Health Literacy Problems
Patients who are more apt to have poor literacy/healt
h literacy
• Patients that are homeless• Limited English proficient
Recognizing there is an
issue
• Stumbled upon when asked patients to read front of heart failure survival guide
Mislabeled non-
compliant
• Low literacy/illiteracy• Ex. Taking all meds daily instead of
as prescribed (BID, TID)
Lack of awareness by
house staff
• Using medical jargon when discussing care with patient
• Ex. “What beta blocker are you taking?
Interventions and strategies
▪ Heart Failure Survival Guide▪ Written on 5th grade
reading level▪ Illustrations▪ Incorporates aspects of
Project RED
Interventions and strategies
REINFORCE EDUCATION WHEN PATIENT SEEN IN CLINIC USING WRITTEN MATERIAL, VIDEOS,
VERBAL
Outcomes to Date
▪ Increasing awareness of staff in turn increases quality of care of our patients
▪ GAGE award for quality 2013: Analysis of first 300 patients in Heart Failure Program▪ ED visits decreased from
baseline 254 to 154 visits▪ The cases of 30 day readmission
rates decreased from 81 to 38 during this evaluation period
▪ More patients kept their post discharge appointments; the did not keep appointment (DNKA) rate decreased from 75% to 22%
▪ Readmission rate decreased from 14.2% to 9.7% for all payer source, HF related admissions (data from UHC March 2011-March 2012)
• Tailoring education and interventions through a health literacy lens has positively impacted our heart failure program
• Increasing patients knowledge of own health
• Improving self management• Empowering patient• Improving compliance
Key Lessons Learned
StaffAwarene
ss
Screening
Literacy ▪ LITERACY IS AN ISSUE IN
2013
▪ Our informal method of literacy evaluation is opening up dialogue on literacy
▪ Everyone needs to be screened“assuming a patient is literate only harms the patient if in fact they need tailored education”
▪ ALL staff need to be educated on literacy ▪ Awareness is an issue
Next Steps / Sustainability
• Develop metrics and collect heart failure program literacy data
• Number of patients that are able to read the front cover vs. total patients seen
• Number of patients able to repeat instructions
• Data on ability for self-management
• Evaluate interventions and make changes as necessary
• Spread to other clinics at Grady as literacy is not just a heart failure patient issue
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Q & A
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THANK YOU FOR ATTENDING
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