Building Health Literacy: Essential Steps and Practical Solutions

1. Building Health Literacy: Essential Steps and Practical Solutions Essential Hospitals Engagement Network October 10, 2013

2. 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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5. Speaker information 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 David Engler, PhD Senior Vice President for Leadership and Innovation America’s Essential Hospitals Michele Edwards, NP Heart Failure Program ManagerGrady Heart Failure Clinic 

6. 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

7. Partnership for patients

8. 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.

9. 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

10. 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

11. 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

12. 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

14. 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

15. 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

16. 1st Health Literacy Assessment n=19,000 U.S. Adults 12% Proficient 14% Below Basic 53% Intermediate Hispanic Basic 22% Average National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Department of Education, 2003. Medicare

17. 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

18. Patients with Diabetes and Low Literacy Less Likely to Know Correct Management Need to Know: symptoms of low blood sugar (hypoglycemia) Need to Do: correct action for hypoglycemic symptoms Low Moderate High Low Moderate High Percent Williams 1998 *Williams et al., Archive of Internal Medicine, 1998

19. Literacy is Associated with Glycemic Control, N=408 Adjusted OR=2.03, p=0.02 Adjusted OR=0.57, p=0.05 (Tight Control: HbA1c7.2%) (Poor Control: HbA1c>9.5%) Schillinger JAMA 2002

20. Lower literacy is associated with self-reported diabetes complications (N=408) Schillinger JAMA 2002

21. Limited Health Literacy Patients Experience More Hypoglycemia N=14,000 P for all<0.001 Sarkar, Adler, Schillinger, JGIM 2010

22. Limited literacy associated with higher adjusted mortality (OR 2.03, AOR 1.75) Sudore, Schillinger. 2006

24. 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

25. Diabetes Patients with Limited Literacy Experience Poorer Quality Communication, N=408 OR=1.9;p=0.04 OR=3.2;p<0.01 OR=3.3;p=0.02 OR=2.4;p=0.02 32% 33% 26% 21% 20% 13% 13% 13% (Often/Always) (Often/Always) (Often/Always) (Never/Rarely/ Sometimes)

26. 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

27. 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/Discussion-Papers/BPH_Ten_HLit_Attributes.pdf

28. 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

29. 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

30. 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

31. 10 attributes of a health literate health care organization

34. Attribute 1: A Health Literate Organization • 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

35. Attribute 2 A Health Literate Organization • 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

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. Q & A

46. Michele Edwards, NP Heart Failure Program ManagerGrady Heart Failure Clinic 

47. Addressing Health Literacy Michele Edwards, ACNP Heart Failure Program Manager Grady Memorial Hospital

48. 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)

49. 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

50. Health Literacy Problems