The Role of Health Literacy in Care Transitions

1. The Role of Health Literacy in Care Transitions QualitySync II Together for Healthier Communities April 9, 2013 Richmond, VA

2. Objectives • Provide at least two examples of why current US Health system issues require that individuals become health literate • Identify at least three attributes of health literate organizations • Describe at least three strategies or tools for improving the exchange of information that leads to shared decision-making by patients/families

3. Today’s Demand for Services • More than 80% of elderly individuals have 1 or more chronic disease • More than 20% suffer from 5 or more chronic conditions • Many elderly suffer from rapid and frequent changes in health status • 20% of individuals 65 or older live in rural America • Only 12% of adults have adequate skills to manage their own health care* *AHRQ

4. People With Serious Chronic Conditions Have Trouble Accessing Specific Services Percentage of People With Serious Chronic Conditions Reporting That They Did Not Get Needed Service Source: Serious Chronic Illness Survey conducted by the Gallup Organization, 2002.

5. Outcomes of Hospitalizations • Nearly 20% of Medicare beneficiaries discharged from hospitals are re-hospitalized within 30 days; 34% within 90 days • Nearly13% of Medicare beneficiaries discharged from hospitals involve episodes in which 3 or more transfers among settings of care occurred over a 30-day period

6. Why are so many Readmitted? How is Coordination of Care Related? How is Health Literacy Related?

7. Are We Getting the Health Care We Need? • Approximately 50% of adults and less than 50% of children in America receive care that is recommended for them • Only 14% of new scientific discoveries ever make it into routine clinical practice • It can take 20 or more years before proven innovations are integrated into clinical practices • Evidence-based care is the mantra for the decade

8. Only Four of Ten Adults Are Very Confident in Their Ability to Get Safe, Effective Care Percent of adults ages 19–64 who are very confident that they will be able to get high quality and safe health care when needed Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).

9. How safe is your care? • The average patient is subjected to 1 medication error per day while in the hospital which increases hospital costs $2 billion annually • Nearly 100,000 Americans die each year from preventable medical errors, making medical harm the fourth leading cause of death in the U.S.—more than auto accidents, AIDS, and breast cancer combined (IOM, 1999) • This statistic has not changed, despite 12 years of effort

10. How Can Improving Care Coordination Make a Difference?

11. People With Chronic Conditions Report Not Receiving Adequate Information Percentage of Population With Chronic Conditions Reporting Problems Source: Chronic Illness and Caregiving, a survey conducted by Harris Interactive, Inc., 2000.

12. What about the Information PatientsReceive? • 40-80 % of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect

13. “It is neither just, nor fair, to expect a patient to make appropriate health decisions and safely manage his/her care without first understanding the information needed to do so.” Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. AMA, 2007

14. Patients have the right to understand healthcare information that is necessary for them to safely care for themselves, and to choose among available alternatives Healthcare providers have a duty to provide information in simple, clear, and plain language and to check that patients have understood the information before ending the conversation The 2005 White House Conference on Aging; Mini-Conference on Health Literacy and Health Disparities.

15. There are Two Experts in the Room • The patient knows their preferences and values • The health care team member understands the medical evidence Each expert needs the other to be successful

16. Why is shared decision making critical? • Decisions are often complex • Knowledge can’t be assumed • Risks and benefits are not well understood. • Patients want to make a good choice but may not be sure what to do • Providers can make incorrect assumptions about what patients want

17. HHS Aims of the National Quality Strategy National Quality Forum.org

18. National Quality Strategy

19. National Prevention and Health Promotion Strategy • Building healthy and safe community environments • Expanding quality preventive services in both clinical and community settings • Empowering people to make healthy choices • Eliminating health disparities

20. Partnership for Patients: Better Care, Lower Costs Keep patients from getting injured or sicker {reducing preventable hospital-acquired conditions (HACs) by 40%} Help patients heal without complications {reduce all hospital readmissions by 20%}

21. Patient Activation and Engagement:How they Relate to Literacy

22. What is Patient Activation? “Patient activation is understanding one’s role in the care process and having the knowledge, skill, and confidence to manage one’s health and health care” Judith Hibbard, 2004 Activation differs from compliance, in which the emphasis is on getting patients to follow medical advice

23. Nursing Alliance for Quality Care Definition of Patient Engagement • “Patient engagement is the involvement in their own care by individuals (and others they designate to engage on their behalf), with the goal that they make competent, well-informed decisions about their health and health care and take action to support those decisions.” Sofaer and Schumann, 2013

24. NAQC Guiding Principles to Patient Engagement • Patient engagement is a critical cornerstone of patient safety and quality. NAQC has grounded its approach to this topic by recognizing the primary importance of relationships between engaged patients and families and their clinicians, including but not limited to nurses. The following are principal assumptions that guide NAQC in addressing care that is patient-centered. • There must be an active partnership among patients, their families, and the providers of their healthcare. • Patients are the best and ultimate source of information about their health status and retain the right to make their own decisions about care. • In this relationship, there are shared responsibilities and accountabilities among the patient, the family, and clinicians that make it effective. • While embracing partnerships, clinicians must nevertheless respect the boundaries of privacy, competent decision making, and ethical behavior in all their encounters and transactions with patients and families. These boundaries protect recipients as well as providers of care. • This relationship is grounded in confidentiality, where the patient defines the scope of the confidentiality. • Clinicians must recognize that the extent to which patients and family members are able to engage or choose to engage may vary greatly based on individual circumstances. Acknowledgment and appreciation of diverse backgrounds is an essential part of the engagement process. • Advocacy for patients who are unable to participate fully is a fundamental nursing role. Patient advocacy is the demonstration of how all of the components of the relationship fit together. • This relationship is grounded in an appreciation of patient’s rights and expands on the rights to include mutuality. Mutuality includes sharing of information, creation of consensus, and shared decision making. • Health care literacy is essential for patient, family, and clinicians to understand the components of patient engagement. Providers must maintain awareness of the health care literacy level of the patient and family and respond accordingly. • Developed by the Nursing Alliance for Quality Care • Approved by the NAQC Board of Directors, December 2011

25. Health Literacy • “...the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. “ Ratzan & Parker, 2000 • “…the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment. “ AMA & AMA Foundation, 2003

26. Can we foster engaged and activated patients when they don’t get the information Does that information make sense when or if they receive it? What sources will consumers seek out if they lack information? How do we assess the level of understanding of each individual we serve?

27. AHRQ Universal Precautions Tool Kit

28. What does Low Health Literacy Look Like? • Video

29. What are the Solutions to Improving Health Literacy that will Reduce the Dangers of Poor Care Coordination?

30. Health Literate Organizations • Organizations that makes it easier for people to navigate, understand, and use information and services to take care of their health • Everyone from providers and small groups/teams, to hospitals, community health centers, pharmacies, to payors and health plans like insurance carriers, employee-based plans, the VA & CMS

31. Ten Attributes of a Health Literate OrganizationInstitute of Medicine, Jan 2012

32. 1) Has leadership that makes health literacy integral to its mission, structure and operations Includes policies and standards Sets goals for health literacy improvement Establishes accountability and provides incentives Allocates fiscal and human resources Redesigns systems and physical space

33. 2) Integrates health literacy into planning, evaluation, patient safety and quality improvements Conducts health literacy organizational assessments Assesses impact of programs and policies on individuals with limited health literacy Factors health literacy into all patient safety plans

34. 3) Prepares the workforce to be health literate and monitors progress Hires diverse staff with expertise in health literacy Sets goals for training of staff at every level

35. 4) Includes populations being served in the design, implementation and evaluation of information and services Includes individuals who are adult learners or have limited health literacy Obtains feedback on health information and services from individuals who use them

36. 5) Meets needs of populations with a range of health literacy skills while avoiding stigmatization Adopts health literacy universal precautions Allocates resources proportionate to the concentration of individuals with health literacy skills

37. 6) Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact Confirms understanding Secures language assistance for speakers of languages other than English Limits to 2-3 messages at one time Provides easily understood symbols in way-finding signage

38. 7) Provides easy access to health information and services and navigation assistance Makes electronic patient portals user-centered and provides training on how to use them Facilitates scheduling appointments with other services

39. 8) Designs and distributes print, audiovisual 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 use testing Uses a quality translation process to produce materials in languages other than English

40. 9) Addresses health literacy in high-risk situations, including care transitions and communications about medications Prioritizes high-risk situations (e.g. informed consent for surgery and other invasive procedures) Emphasizes high-risk topics (e.g. conditions that requires extensive self-management)

41. 10) 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 out of pocket costs for health care services before they are delivered

42. What is the Underpinning for Achieving a Health Literate Organization that Supports Active Patient Engagement, Shared Decision-making and Coordinated Care?

43. Work Culture’s Perceptions of the Person Receiving Care

44. Work Culture’s Perceptions of You as Health Professionals

45. Person-Centered Care

46. 1. Engagement of the Person and their Family or those of Primary Significance (may not be legal family) i.e. may even be advocate

47. 2. Respect for Preferences, Values and Beliefs, including Cultural Attributes

48. 3. Communication

49. 4. Holistic Care with Attention to Comfort and Supportive Care

50. 5. Coordination and Integration of Care