The Development of a Health Literacy Assessment Tool for Health Plans

Journal of Health Communication ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20 The Development of a Health Literacy Assessment Tool for Health Plans Julie A. Gazmararian, Katherine Beditz, Susan Pisano & Rita Carreón To cite this article: Julie A. Gazmararian, Katherine Beditz, Susan Pisano & Rita Carreón (2010) The Development of a Health Literacy Assessment Tool for Health Plans, Journal of Health Communication, 15:S2, 93-101, DOI: 10.1080/10810730.2010.499986 To link to this article: https://doi.org/10.1080/10810730.2010.499986 Published online: 15 Sep 2010. Submit your article to this journal Article views: 954 View related articles Citing articles: 6 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=uhcm20 Download by: [37.44.197.206] Date: 23 November 2017, At: 18:17

Journal of Health Communication, 15:93 101, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2010.499986 The Development of a Health Literacy Assessment Tool for Health Plans JULIE A. GAZMARARIAN AND KATHERINE BEDITZ Rollins School of Public Health, Emory University, Atlanta, Georgia, USA SUSAN PISANO AND RITA CARREÓN America s Health Insurance Plans, Washington, D.C. Despite growing information on the magnitude and consequences of low health literacy, there is little information about the role health plans are playing and the activities they undertake to address this problem. Our goal was to develop a health literacy organizational assessment tool for health plans that could be used as a benchmark and encourage further work. The existing tool consists of six evaluation areas: (1) information for members=navigation; (2) member services=communication; (3) web navigation; (4) forms; (5) nurse call line; and (6) nurse case= disease management. During May and June, 2009, a pilot was conducted with eight diverse health plans, including national, regional, and local plans serving commercial, Medicare, and=or Medicaid members. After incorporating feedback from the pilot, the full assessment was launched in June 2009. Feedback from the participating plans has been very positive about using this tool as a benchmark and using the results to help strengthen health literacy efforts within their health plans. The variety of health plans that have utilized this assessment tool suggests that widespread use is possible. Evaluation of health literacy efforts using this comprehensive tool can help bring attention to areas in need of improvement and help plans better engage consumers in their own health. It is estimated that 50% of adult Americans lack functional health literacy, which the U.S. Department of Health and Human Services defines as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (U.S. Department of Health and Human Services, 2000). This high prevalence is of particular concern since research indicates that individuals who do not understand and cannot act on medical information and instructions are more likely to have poorer health status (National Center for Education Statistics, 2006; Baker, Parker, Williams, & Clark, 1997) and develop We would like to thank the health insurance plan professionals who enthusiastically participated in the activities resulting in the final development of the health literacy assessment tool. Address correspondence to Julie A. Gazmararian, PhD, MPH, Associate Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA. E-mail: jagazma@sph.emory.edu 93

94 J. A. Gazmararian et al. conditions that result in unnecessary costs, such as hospitalizations and emergency room visits (Baker et al., 1997; Baker, Parker, Williams, & Clark, 1998; Baker et al., 2002). Moreover, health literacy skills have a major role in the ability of individuals to carry out medical instructions. For example, studies indicate that only 50% to 60% of patients take their prescribed medications correctly, and those with limited health literacy are more likely to indicate confusion about their medication regimen (Berkman et al., 2004). Adverse health outcomes and significant patient harm caused by medication errors and non-adherence annually cost the U.S. health system approximately $100 billion (Office of the Surgeon General, 2006). The Institute of Medicine s (IOM) landmark report, Health Literacy: A Prescription to End Confusion, was a milestone in placing health literacy in the top tier of health system issues (Nelson-Bohlman, Panzer, & Kindig, 2004). The 2004 report identified several issues with respect to health literacy that are important aspects in the health system context, such as chronic disease care, self-management, and patient-provider communication (Nelson-Bohlman, Panzer, & Kindig, 2004). However, despite growing information on the magnitude and consequences of low health literacy, there is little available information about what health organizations are doing to address this problem and little to assist them as they begin and advance their programs. There are many reasons why health plans are interested in addressing health literacy with the populations they serve. Members of health plans often rely on multiple agents such as physicians, nurses, pharmacists, employers, and their health plans to provide information about specific health topics, disease information, benefits and coverage, available services, and community resources. Moreover, patient-centered health care is based on the important concept that health plan members will play a major role in their own health and health care, which requires clear information that individuals can understand and act on. Health plan customer service representatives, nurses, case managers and care coordinators, and health coaches frequently communicate with members through various outlets including print materials, phone conversations, and web-based communication. Members who do not understand and cannot act on medical information and instructions are more likely to have poorer health status, and develop conditions that result in unnecessary costs, such as hospitalizations and emergency room visits. Clearly, the success of health plans hinges on the engagement of their members, and that requires providing information that they can understand and act on. To ensure clear and understandable communication with members, assessing the current state of health literacy programs is an important step for all health plans. By conducting an organizational assessment and acting on the results to improve their efforts, health plans can improve their ability to engage patients with clear, actionable information. These efforts can have far reaching benefits and may have great effects on appropriate self-management of care, patient safety, health-care quality, and access to timely health care and preventive services. Through collaboration with America s Health Insurance Plans (AHIP), Emory University was provided the tremendous opportunity to work with diverse health insurance plans throughout the country on the development of the health literacy assessment tool for health plans that is described in this paper. AHIP is a national trade association who members provide coverage for more than 200 million Americans. Member companies represent large national companies who may offer a diverse array of products as well as regional and local companies, some of which are small and may serve specific populations such as Medicaid or Medicare enrollees.

Health Literacy Assessment Tool for Health Plans 95 The primary goal of this project was to develop a health literacy organizational assessment tool for individual health plans that they could use to set as a benchmark and inform further work. Specific aims of this project were to develop, implement, evaluate and promote a health literacy assessment tool that health plans can utilize when developing educational and instructional materials for, and interacting with members. Methods Participation of Plans Through communication with members of the AHIP s Health Literacy Task Force, health plans were offered the opportunity to participate in a preliminary survey to assess their current health literacy activities and assist in the development of the assessment tool. Several months later, plans were given the option to participate in either the initial pilot of the assessment tool or a second pilot phase of the assessment tool, which was slightly revised based on the experience with the initial pilot phase. Health plans which were active in health literacy and health equity efforts were invited to participate in this project. These included members of AHIP s Health Literacy Task Force, as well as its Addressing Disparities in Health Workgroup, and the National Health Plan Collaborative (a coalition of twelve health insurance companies, led by AHIP, committed to reducing racial and ethnic disparities and improving the quality of care for diverse populations). Development of Assessment Tool One of the first steps in developing the tool was to determine the primary assessment areas of focus within the health plan. Two activities were conducted to identify these areas: (1) discussion among the project staff and representatives from the health plans and (2) a brief survey of health plans. A 10-question survey was distributed to gauge the current presence and practical use of health plans health literacy knowledge. Invitations to complete the survey were sent to 43 companies, and approximately 30 completed the survey. From this information, combined with input from members of the AHIP Health Literacy Task Force and Emory University, areas to be assessed were outlined. These areas were Information for Members, Web Navigation, Verbal Communication, Forms, Nurse Call Lines, and Case and Disease Management. Through further discussion and review of information typically provided through each of these services, specific questions were developed to inquire about the use of health literacy policies and principles in each of these specific areas. Pilot Test During May and June 2009, eight plans with Commercial, Medicare and=or Medicaid products completed and returned the assessment along with their comments and suggestions on how the tool might be improved. One plan completed the tool for two separate products, so a total of nine completed assessments were reviewed during the pilot phase. Five of the plans were represented in single states, one had membership in several states, and two had national membership. The plans that participated in the pilot test jointly represent over 11 million members.

96 J. A. Gazmararian et al. Based on the comments provided by participating health plans, as well as continued discussion between AHIP and Emory University, the tool was revised for an expanded implementation. The final assessment tool consists of six evaluation areas: (1) information for members=navigation; (2) member services=communication; (3) web navigation; (4) forms; (5) nurse call line; and (6) case=disease management. Care was taken to develop the tool so that it would be useful for a variety of different types of health insurance companies, products, including those at local, regional and=or national level. Main Assessment In June 2009, the revised assessment tool was sent to a second group of participating health plans. It was completed by 10 different plans, one of which completed it for three different products, resulting in twelve completed assessments. Similar to the pilot test, of the plans participating in the main assessment, three plans represented Table 1. Print member information section, health literacy assessment tool for health plans 1. Reading level guidelines 2. Font and=or size guidelines 3. Clear language guidelines 4. White space guidelines 5. Graphics and illustrations guidelines 6. Pilot testing of materials by limited literacy individuals 7. Seek feedback outside the organization 8. Staff training to prepare material in plain language 9. Proportion of information available in non-english languages 10. Presence of contact information 11. Collaboration and sharing of health literacy tools, instruments, guidelines with provider networks 12. Use of outside vendors to develop materials Table 2. Web navigation section, health literacy assessment tool for health plans 1. Listing of web address on company materials 2. Font and=or size guidelines 3. Guidelines for ease of navigation 4. Assessment of website for ease of navigation when new info is added 5. Gathering of website feedback from members with limited health literacy 6. Website available in different languages 7. Easy accessibility of contact info on website 8. Website provision of health and wellness info 9. Website available member benefits=services info 10. Availability of assistance for members with difficulty navigating website 11. Requirement that vendors doing web development follow guidelines and requirements for clear health communication 12. Use of AHIP s checklist on developing better websites

Health Literacy Assessment Tool for Health Plans 97 Table 3. Member services=verbal communication section, health literacy assessment tool for health plans 1. Option to speak to a live person in first menu option when a member calls 2. Health literacy friendly guidelines for verbal communication 3. Guidelines identifying words=phrases to be avoided or explained in plain language 4. Guidelines regulating use of acronyms=nicknames unique to company 5. Employee training for recognition of indications that a member may not understand 6. Percentage of staff who has received training in: Communicating using simple language Checking for understanding members in single states, three plans had representation in multiple states, and four plans had national membership represented. The plans that participated in the pilot test collectively represented over 9 million members. Feedback revealed that the changes implemented between the pilot phase and this full implementation had alleviated nearly all confusing questions and also provided a more complete range of response options (e.g., other responses besides just yes or no ). Based on these results and final conversations between AHIP and Emory, the tool was finalized for general use by health plans. Tables 1 6 summarize the key areas for each section of the health literacy assessment tool for health plans (see www.ahip.org, for a copy of the health literacy assessment tool). Table 4. Forms section, health literacy assessment tool for health plans 1. Readability guidelines in form development 2. Reading level guidelines for forms 3. Font=Size guidelines for forms 4. Clear language guidelines to ensure simple clear language, and avoidance of complicated jargon 5. White Space guidelines 6. Use of outside vendors in form development Table 5. Nurse call line section, health literacy assessment tool for health plans 1. Guidelines for identifying jargon to be avoided 2. Guidelines regulating use of acronyms=nicknames unique to company 3. Appointments=phone calls scheduled so members have enough time to ask questions or obtain extra information 4. Members provided contact info for questions or confusion after the interaction 5. Employee training for recognition of indications that a member may not understand 6. Percentage of staff who has received training in: Effectively organizing verbal information Communicating using simple language Checking for understanding

98 J. A. Gazmararian et al. Table 6. Case=disease management section, health literacy assessment tool for health plans 1. Reading level guidelines 2. Font and=or size guidelines 3. Clear language guidelines 4. White Space guidelines 5. Graphics and illustrations guidelines 6. Pilot testing of materials by limited literacy individuals 7. Seek feedback outside the organization 8. Staff training to prepare material in plain language 9. Proportion of Information available in non-english languages 10. Guidelines for identifying jargon to be avoided 11. Appointments=phone calls scheduled so members have enough time to ask questions or obtain extra information 12. Members provided contact info for questions or confusion after the interaction 13. Employee training for recognition of indications that a member may not understand 14. Percentage of staff who has received training in: Effectively organizing verbal information Communicating using simple language Checking for understanding 15. Use of outside vendors in form development To provide additional information and resources to the participating health plans, the Emory researchers developed a resource document based on each section of the assessment tool. Publicly available web and print health literacy resources were grouped by category and suggested as additional sources of information for use by the plans interested in creating or improving their health literacy efforts. (see www.ahip.org for the resource document). Analysis and Results Data collected from the plans in both the pilot and main assessment phases was entered into an excel spreadsheet to determine where participating health plans are in their health literacy efforts. A summary of some of the overall responses for each section of the assessment tool are provided below. Information for Members Most of the responding plans indicated that they have reading level guidelines, typically at grade 6 or below, and that they have clear language guidelines available, but they frequently are not always used. Member Services About two-thirds of responding plans indicated that they provide training to employees on recognition of indications when a member does not understand what is being said.

Health Literacy Assessment Tool for Health Plans 99 Web Navigation More than one-third of plans indicated guidelines exist to ensure ease of website navigation; however, the guidelines are not always used. Almost all of the plans responded that their websites often include information in languages other than English. Forms Most plans have clear language guidelines to ensure forms are simple=clear and without medical jargon. However, very few plans had guidelines for the amount of white space provided in forms. Nurse Call Line Few plans have guidelines for identifying medical and scientific jargon that should be avoided when discussing health information with members. However, most organizations have provided training to nurse call line employees in recognition of indicators that the member does not understand the information the member is receiving. Case and Disease Management Most plans have guidelines for using graphics and illustrations in case=disease management materials that enhances readability. Feedback to Participating Plans Areas for improvement and areas of advanced performance were identified for each individual plan. For example, areas of advanced performance that were identified included the availability of guidelines for reading level, clear language, graphics= illustrations, and website navigation; and existing training to employees on the recognition of indications or scenarios when a member does not understand what is being said. Two areas identified as opportunities for improvement for a few plans are the need to use available guidelines as standard practice, and the need for guidelines to identify medical and scientific jargon that should be avoided when discussing health information with members. De-identified aggregate results were also sent to health plans so that they could see where they are in comparison with the efforts of other similar companies. Follow-up discussions with the participating health plans were very positive. Many plan representatives spoke about using the assessment tool as a benchmark to help identify, prioritize, and support targeted activities within their health plans, and numerous plans noted that the results of their assessments would be used to increase staff awareness and education about their most pressing health literacy issues. Conclusion Based on the pilot and assessment phase experiences and results from the assessment tool, there are several key observations. First, while health plans have been

100 J. A. Gazmararian et al. addressing component pieces around member communications, readability, staff training, and quality within their organizations, only recently has there been broader awareness that health literacy is the appropriate framework for improvement. As a result, a sizeable number of health plans are aware of health literacy and its key components, and are actively involved in reaching out to all their members. Second, in response to meeting their member s needs, health plans aim to infuse clear health communication across departments and organizational structures and into key member contact areas such as customer service, prevention and wellness, disease management programs, and community outreach. This concept is known as universal health literacy precautions (The Joint Commission, 2007). Third, plans that currently collaborate in a variety of initiatives with providers, employers, federal=state agencies and communities, are very receptive to extending these partnerships to health literacy efforts. Finally, plans that are developing targeted programs and policies in response to the health literacy needs of their membership are interested in sharing their successes and lessons learned, including best practices with other health plans and organizations, an important effort for the overall health care system to emulate. To the best of our knowledge, this is the first tool developed to assess health literacy activities and components of these programs in health plans in the United States. Through the partnership between Emory researchers and AHIP staff, we had access to a group of health insurance professionals who represented a diverse group of health plans to assist in the development of the organizational assessment tool. The ability to pilot and obtain feedback from such a variety of plan types and sizes, which in some cases represent very different populations and communities, helped create an organizational assessment tool useful for health plans of all types nationwide. The tool is now being distributed to AHIP s membership, focusing on professionals within executive departments, clinical=quality departments, member services, and communications departments. It is our intention for the health literacy assessment tool to serve as a resource to assist health plans with initiating and=or expanding=strengthening their health literacy activities. Despite the contribution of this assessment tool, there are two notable limitations. First, we recognize that participating health plans were likely to have more knowledge and=or more advanced activities related to health literacy, and that these plans may not be representative of all health plans. However, the participating plans in our assessment (both pilot and main assessment phases) represent over 20 million insured members. Second, the assessment tool is only meant to assist plans with identifying opportunities for improvement. The pilot testing and assessment phase does suggest that the tool can have widespread utility within the community of health insurance plans that are starting up and=or advancing their health literacy programs. An organizational tool is needed, especially at a time when the role of organizations in health literacy is gaining prominence. References Baker, D. W., Parker, R. M., Williams, M. V., & Clark, W. S. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87(6), 1027 1030. Baker, D. W., Parker, R. M., Williams, M. V., & Clark, W. S. (1998). Health literacy and the risk of hospital admission. Journal of General Internal Medicine, 13(12), 791 798.

Health Literacy Assessment Tool for Health Plans 101 Baker, D. W., Gazmararian, J. A., Williams, M. V., Scott, T., Parker, R. M., Green, D., Ren, J., & Peel, J. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health, 92(8), 1278 1283. Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L., Sutton, S. F., Swinson, T., & Bonito, A. J. (2004). Literacy and health outcomes (AHRQ Publication No. 04-E007-2). Rockville, MD: Agency for Healthcare Research and Quality. The Joint Commission. (2007). What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety. Available at: http://www.jointcommission.org/nr/rdonlyres/ d5248b2e-e7e6-4121-8874-99c7b4888301/0/improving_health_literacy.pdf. Accessed February 1, 2010. National Center for Education Statistics. (2006). The Health Literacy of America s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, D.C.: U.S. Department of Education. Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.) (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press. Office of the Surgeon General. (2006). Proceedings of the Surgeon General s Workshop on Improving Health Literacy. Washington, DC: U.S. Department of Health and Human Services. Available at: http://www.surgeongeneral.gov/topics/healthliteracy/toc.html. Accessed January 15, 2010. U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: U.S. Government Printing Office. Originally developed for Ratzan, S. C., & Parker, R. M. Introduction. In C. R. Selden, M. Zorn, S. C. Ratzan, & R. M. Parker (Eds.), National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.