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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:


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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


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 6


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 7


• 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.


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 9

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


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


 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 2007



National Assessment of Health Literacy n=19,714

Below Basic:

Circle date on doctor’s appointment slip 


Give 2 reasons a person with no symptoms should get tested for cancer based on a clearly written pamphlet 


Determine what time to take Rx medicine based on label 


Calculate employee share of health insurance costs using table

National Center for Educational Statistics, U.S. Department of Education, 2003



Health Literacy Assessment

n=19,000 U.S. Adults 12% Proficient 14% 53% Intermediate Below Basic Basic 22% Hispanic 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

Need to Do:

correct action for hypoglycemic symptoms


Low Moderate High

20 40 60


80 100

Williams 1998 *Williams et al., Archive of Internal Medicine, 1998

Literacy is Associated with Glycemic Control, N=408

50 40

Adjusted OR=0.57, p=0.05

Adjusted OR=2.03, p=0.02

Inadequate Marginal Adequate 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

Retinopathy Nephropathy Lower Extremity Amputation Cerebrovascular Disease Ischemic Heart Disease

n **

111 62 27 46 93

AOR 2.33





95% CI

(1.19-4.57) (0.75-3.90) (0.74-8.34) (1.06-6.97) (0.83-3.60) Schillinger JAMA 2002

Limited Health Literacy Patients Experience More Hypoglycemia

N=14,000 16% 14% 12% 10% 8% 6% 4% 2% 0%

Adequate Limited 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

50 Diabetes Patients with Limited Literacy Experience Poorer Quality Communication, N=408 Inadequate FHL Adequate FHL 40 OR=3.2;p<0.01

30 % 20 OR=3.3;p=0.02

32% 26% 10 13% 13% 0 Doctor Use Words Not Understood


Give You Test Results w/o Explanation



21% 13% OR=1.9;p=0.04

33% 20% Confused About Medical Care


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 Papers/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


» » » » 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


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 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

Q & A 45

Michele Edwards, NP

Heart Failure Program Manager Grady Heart Failure Clinic


Addressing Health Literacy


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 ▪ 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

Health Literacy Problems

Patients who are more apt to have poor literacy/health literacy Recognizing there is an issue Mislabeled non-compliant Lack of awareness by house staff •Patients that are homeless •Limited English proficient •Stumbled upon when asked patients to read front of heart failure survival guide •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 5 th level Illustrations grade reading 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 5 th 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

• 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 ▪ Increasing awareness of staff in turn increases quality of care of our patients ▪ ▪ ▪ ▪ ▪ 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

Screening Literacy Staff Awareness ▪ LITERACY IS AN ISSUE IN 2013 ▪ Our informal method of literacy evaluation is opening up dialogue on literacy ▪ Everyone needs to be screened

“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 self management 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 [email protected]

Q & A 57


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