From Health Literacy Evidence and Tools to Patient Understanding, and Navigation: The Imperative to Take Action to Improve Health Care Outcomes Cindy Brach Center for Delivery, Organization, and Markets
Disclosures I work for the Agency for Healthcare Research and Quality The statements in this presentation are those of the author, who is responsible for its content, and do not necessarily represent the views of AHRQ. No statements in this presentation should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
What AHRQ Does AHRQ invests in research to understand how to make health care safer and improve quality AHRQ creates materials to teach and train health care professionals and systems to improve care for their patients AHRQ generates measures and data used to track and improve performance and evaluate progress of the U.S. health system WWW.AHRQ.GOV
Overview Health Literacy and Universal Precautions Health Literacy Tools Throughout the Continuum of Care Health Literate Systems Opportunities to Improve Health Literacy
Health literacy and universal precautions
A Definition of Health Literacy 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. Adult Health Literacy 12 14 21 53 Below Basic Basic Intermediate Proficient Source: 2003 NAAL 35% Limited Health Literacy
Health Literacy is an Issue for All Racial/Ethnic Groups
Consequences of Limited Health Literacy People with limited health literacy are: likely to get preventive care likely to have well controlled diabetes likely to be hospitalized and use the ER likely to have followed pre-operative instructions
Not Just Reading Health literacy includes: Written communication Verbal communication Numbers and math Using health information Navigating the health care system
Health Literacy Equation Skills/Abilities x Difficulty/Complexity = Health Literacy
Informed Consent OK, you can choose regal equine therapy, OR fragment adhesion cranioplasty. Which would you prefer?
Koh et al. 2012
Health Literacy Universal Precautions Structuring the delivery of care as if everyone may have limited health literacy You can t tell by looking Higher literacy skills understanding Health literacy is a state not a trait Everyone benefits from clear communication
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Health literacy tools across the care continuum
AHRQ Health Literacy Universal Precautions Toolkit 2 nd edition with 21 tools New companion guide for practice facilitators http://ahrq.gov/qual/literacy
Welcoming Environment Clear signage Friendly demeanor Offers of help Ask about language preferences No walls of words Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 13
Clear Communication Warm Greeting Eye Contact Listen Use Plain, Nonmedical Language Slow Down Limit Content Repeat Key Points Show How It s Done Use Graphics Invite Patient Participation Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4
An Always Event
Addressing Language Barriers 156 language spoken in Dallas metro Among TX LEP: Vietnamese, Chinese, Korean, Arabic, Tagalog Language preference & interpreter data Prevent errors: use only acceptable language assistance services Written materials Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4
Establish process Assess materials Replace poor materials Find better ones Implementing Improvements in Written Materials Create better ones using guides Consider alternatives to print
Action Plans: Teaching Self-Management Ask permission Determine motivation Patients chooses goals Manageable steps Assess confidence Identify barriers Follow up Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 15
Follow Up Why follow up Who follows up How you follow up Monitor Reinforce knowledge & plans Confirm Medicine taking Appointments Referral completion Share lab results Physician Physician Assistant Nurse Medical Assistant Pharmacist Office Staff Phone Secure email Texting Postal mail Automated calling system Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 6
Re-Engineered Discharge Program (RED) Evaluated their current discharge process and re-engineered using health literacy principles Randomized control trial: 30% reduction in subsequent emergency visits and readmissions Tested only with English speakers
New RED Toolkit for Serving Integrated into RED implementation tools Separate tool for serving diverse populations Added 12th component: Ascertain need for and obtain language assistance Diverse Populations
RED Components 1. Obtain language assistance. 2. Make appointments for follow-up. 3. Plan for the lab follow-up. 4. Organize post-discharge outpatient services and medical equipment. 5. Identify the correct medicines and a plan for the patient to obtain and take them. 6. Reconcile discharge plan with national guidelines. 7. Teach a written Discharge Plan the patient can understand. 8. Educate the patient about his/her diagnosis. 9. Assess the degree of the patient s understanding of this plan. 10. Review with the patient what to do if a problem arises. 11. Expedite discharge summary. 12. Provide post-discharge telephone reinforcement.
RED Impact Reduction in readmissions (heart failure, COPD and facility-wide) Increased HCAHPS Care Transition scores Increase in patients reporting teach-back More time spent with patients and families around transitions Changed organizational culture
Patient-Centered Prescription Label Standardized instructions in 5 languages
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Health Literate Systems
My Dad
Improving Informed Consent Informed consent informed choice Clear, unbiased information about all options Help aligning options with patient s goals & values
Policy Implementing Informed Consent Improvements Why, who, what, when, how Dissemination Enforcement Building systems to improve IC process Library of forms Library of decision aids Remove communication barriers Establish efficient workflows
Based on Koh, et al. 2013
Assessment Tools
Health Literate Organizations A health literate organization makes it easy for people to navigate, understand, and use information and services to take care of their health. Brach et al. 2012
Brach et al. 2012
Patient Engagement at the Organizational Level Obtain patient feedback Patient shadowing Surveys Observed use (e.g., patient portal) Suggestion boxes Engage patients as partners Patient advisors Feedback on materials Training Source: AHRQ Health Literacy Precautions Toolkit, Tool 17
Koh et al. 2012
Opportunities for Health Literacy Improvement
Texas Exchange Opportunities: Affordable Care Act Choosing among 13 plans Using insurance o 5.2 million Texans with expanded mental health and substance abuse benefits o 5.8 million Texans gained free preventive services $80 million in grants from the Prevention and Public Health Fund, e.g., tobacco cessation, obesity prevention
Opportunities: Accountability Plain Writing Act of 2010 All federal agencies Use plain language Accountability Training
Opportunity: Patient-Centered Prescription Labels Medication misuse has resulted in more than 1 million adverse drug events per year U.S. Pharmacopeia issued standards to promote patient understanding AHRQ has published tested instructions in 5 languages Study showed patient-centered labels benefited patients with limited literacy or multi-drug regiments
Opportunity: State-Level Action CA: Legislation mandated standardized, patientcentered" prescription drug container label LA: Legislation created the Interagency Task Force on Health Literacy AL: Executive Order established the Health Literacy Partnership of Alabama
Opportunity: Language Barriers Payment: Medicaid FFS and MCO, DSH, Requiring Language Access MA Emergency Room Interpreter Law CA Bilingual Services Act CA expansion of public language access requirements to private plans. MD Equal Access to Public Services for Individuals with Limited English Proficiency Act
Opportunity: Private-Public Partnerships State Health Literacy Coalitions have included: State health and education agencies Health plans Health delivery systems Adult education, Head Start, and other education agencies Literacy organizations Universities, pharmacy colleges Foundations AHECs Community-based organizations County health organizations Libraries
National Action Plan to Improve Health Literacy Goal 1: Patient education materials Goal 2: Tools to implement health system change Goal 3: Health education in school Goal 4: Adult Ed, ESOL Goal 5: Partnerships Goal 6: Fund research and build the field Goal 7: Dissemination www.health.gov/communication/hlactionplan/
Opportunity: Network CDC Health Literacy Activity by State
The Vision A society that: Provides everyone access to accurate, actionable health information Delivers person-centered health information and services Supports life-long learning and skills to promote good health
Win Hearts and Minds
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