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.
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, PhD
Senior Vice President
for Leadership and
Innovation
America’s Essential
Hospitals
Dean Schillinger, MD
Professor 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
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
Engagement
Network
• 22 hospitals nationwide
• Only safety-net focused
• Special focus on health
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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, MD
Professor 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
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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 20
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
12%
n=19,000 U.S. Adults
Proficient
53%
Intermediate
Below
Basic
14%
Hispanic
Basic
22%
Average
Medicare
National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S.
Department of Education, 2003.
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
Need to Know:
symptoms of low blood
sugar (hypoglycemia)
Low
Moderate
High
Low
Moderate
Need to Do:
correct action for
hypoglycemic symptoms
High
0
20
40
60
80
100
Percent
Williams 1998
*Williams et al., Archive of Internal Medicine, 1998
Literacy is Associated with Glycemic Control, N=408
Inadequate
50
Marginal
Adequate
% of patients
40
Adjusted OR=0.57,
p=0.05
Adjusted OR=2.03,
p=0.02
30
20
10
0
1st Quartile
(Tight Control: HbA1c7.2%)
4th Quartile
(Poor Control: HbA1c>9.5%)
Schillinger JAMA 2002
Lower literacy is associated with self-reported diabetes
complications (N=408)
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)
Schillinger JAMA 2002
Limited Health Literacy Patients
Experience More Hypoglycemia N=14,000
16%
14%
12%
10%
Adequate
Limited
8%
6%
4%
2%
0%
Problems
learning
Help reading
Not
confident
with forms
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 JGIM
Schillinger et al. 2004 Pt Ed and Counseling
Castro et al, Am J Health Beh 2007
Schillinger et al. 2003 Arch Int Med
Schillinger et al 2004. AHRQ Advances in Patient Safety
Diabetes Patients with Limited Literacy
Experience Poorer Quality Communication,
N=408
Inadequate FHL
50
Adequate FHL
40
OR=1.9;p=0.04
OR=3.2;p<0.01
OR=3.3;p=0.02
30
OR=2.4;p=0.02
20
10
0
32%
33%
26%
13%
21%
13%
Doctor Use Words Not Give You Test Results
Understood
w/o Explanation
(Often/Always)
(Often/Always)
20%
13%
Confused About
Medical Care
(Often/Always)
Doctor Understand
Problems Doing Rx
(Never/Rarely/ Sometimes)
Literacy and the Digital Divide in Diabetes*
Kaiser Patient Portal Study N= 14,102
*For difference between those with and without limited health literacy, p for all<0.01
Sarkar, Karter, Schillinger J Health Comm 2010
The Other Side of the Coin:
10 Attributes of “Health Literate”
Healthcare Organizations
Dean 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 Roundtable
http://iom.edu/~/media/Files/Perspectives-Files/2012/DiscussionPapers/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 clinicianpatient 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
Q&A
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Michele Edwards, NP
Heart Failure Program Manager
Grady Heart Failure Clinic
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Addressing
Health
Literacy
MICHELE 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
▪ Assist with seamless transition
from hospital to home
▪ Follow up phone call within 72
hours of discharge
▪ 2 nurse practitioners (NP) under
the direction of medical director
▪ Follow up appointment within 7
days of discharge
▪ Provide heart failure education
▪ Clinical Decision Unit (CDU)
patients
▪ Address barriers to care:
▪
▪
▪
▪
▪
▪
▪
Ability to obtain medication
Transportation
Homelessness
Illiteracy/low literacy
Mental Illness
Lack of insurance
Drug/Alcohol abuse
▪ 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/health
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
Lack of
awareness by
house staff
•Low literacy/illiteracy
• Ex. Taking all meds daily instead of as
prescribed (BID, TID)
•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
Screen ALL patients at time of
HF education
Ask patients to read front cover of heart
failure survival guide “patients survival
guide”
Identify patients that struggle
to read this 5th grade verbiage
Tailor education
Interventions and strategies
Pillboxes
Mark with AM/PM and Sun/Moon
Assist with filling pillboxes
Teach back method
Heart Failure Videos
Easy to understand, real life patient
accounts
Relatable to our patient population
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
• 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
▪ 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)
Key Lessons Learned
▪ LITERACY IS AN ISSUE IN
2013
▪ Our informal method of
literacy evaluation is
opening up dialogue on
literacy
Literacy
▪ Everyone needs to be
screened
Screening
Staff
Awareness
“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 selfmanagement
• Evaluate interventions and
make changes as necessary
• Spread to other clinics at
Grady as literacy is not just a
heart failure patient issue
Thank You!!
Michele Edwards, NP
Heart Failure Program Manager
Grady Heart Failure Clinic
medwards3@GMH.EDU
Q&A
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THANK YOU FOR ATTENDING
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