Health Literacy & Health Literate Care September 12, 2014 Presented by Jennifer Pearce, MPA Health Literacy Program Manager Sutter Center for Integrated Care, Sutter Health

Presentation Objectives Define health literacy and understand prevalence of low health literacy among adults Understand relationship between health literacy and patient engagement Identify interventions to reduce health system demand/complexity and increase patient skills/ability

My Story

Wall Street Journal December 5, 2006 College educated Health care experience Prepared for medical appointments Had support system PATIENT SKILLS: Multiple providers (12) Had Medicaid, then uninsured Miscommunication led to lack of follow-up care Didn‘t understand options SYSTEM BARRIERS: Nikki didn’t die from lupus, Nikki died of complications of the failing health care system. Dr. Amylyn Crawford PBS Frontline, Sick Around America

How Is “Health Literacy” Different From “Literacy”? Having the basic skills to read, write and compute without regard to context Literacy Reading, writing, computing, communicating and understanding in the context of health care Health literacy “Literacy” and “health literacy” are two distinct terms. They are not interchangeable. “Literacy” means “Having the basic skills to read, write and compute without regard to context.” “Health literacy” means “Reading, writing, computing, communicating and understanding in the context of health care.” Source: Weiss B. Epidemiology of Low Health Literacy. Understanding Health Literacy: Implications for Medicine and Public Health

Health Literacy Includes One’s Ability To Perform Multiple Tasks Obtain Document literacy Process Prose literacy Understand Quantitative literacy Communicate: listen and speak Numeric literacy Many skills are needed to function effectively within a health care setting. To be considered “health literate” and get one’s needs meet in a health care setting an individual must to be able to obtain, process, and understand information. The ability to communicate, to listen and speak, underlies these. Patients need to be able to obtain, process, understand and communicate using: Document literacy – such as navigating appointment slips, nutrition labels or weight charts Prose literacy – such as reading text on a brochure or pharmacy insert Quantitative/Numeric literacy – such as being able to read a nutrition label and figure how much salt is in two servings of ice cream Source: IOM. 2004. Health Literacy: A Prescription to End Confusion Source: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health

Patient skills/ability Mismatch Leads to Harm Health system demand/complexity Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33 Health literacy Patient skills/ability

Patient Skills: Prevalence Of Low Health Literacy In 2003, the US Department of Education surveyed 20,000 adults age 16 and over as part of the National Assessment of Adult Literacy. The assessment included a health literacy component that asked adults to complete certain tasks mirroring those required to navigate the US healthcare system. This graph shows the results of the assessment. Of all those surveyed only 12% of adults scored in the proficient realm. This means that approximately 9 out of 10 adults in this country lack the skills to effectively manage a chronic illness over time, which always includes multiple providers and multiple medications. If you owned a company and 9 out of 10 customers could not figure out how to use your product, you’d go out of business. Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

Adult health literacy by highest level of education Only 1/3 of those with a graduate degree have the skills to effectively manage a chronic illness These are the same National Assessment of Adult Literacy results we saw in the pie chart but this time they are parsed by highest level of education. The last two rows show results for the most well educated. Note that only 1/3 of those with a graduate degree have the skills to effectively manage a chronic illness. You could literally be talking to a rocket scientist who does not possess the skills to manage his chronic illness. Imagine what it would be like to go to his workplace, get instructions, and then have to go home and perform tasks based on directions you didn’t understand. This is all too often the patient’s experience. Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

Adult health literacy by age NAAL (2003) Adult health literacy by age Only 3% of those age 65+ have the skills to effectively manage a chronic illness These are the same National Assessment of Adult Literacy results we saw in the pie chart on the previous slide, but this time they are parsed by age. We see a fairly steady number of individuals above the“0” between ages 16 – 64. This changes after age 65, as shown in the last row. Note that only 3% of those age 65 and above have the skills to effectively manage a chronic illness. Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

Program for the International Assessment of Adult Competencies (PIAAC) 2012 “Using digital technology, communication tools, and networks to acquire and evaluate information, communicate with others, and perform practical tasks.”

Is This Equitable Access?

Health literate tools + training promote shared decision making Patient competencies Provider competencies Find a doctor and define the preferred relationship Articulate health issues Share, access, and evaluate information Negotiate decisions Develop partnership with the patient Identify/review patient preferences and patient’s preferred role Identify choices Present evidence and help patient reflect The application of health literate tools and training help providers and patients develop and refine their skills to be able to partner in pursuit of improved health outcomes. Research shows that when these skills are present on both sides of the equation: Satisfaction improves Outcomes improve; and The quality of decisions improve Improved satisfaction, better outcomes Source: E. Bernabeo and E. Holmboe (2013). Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health Affairs 32, No. 2: 250-258

Is our health care workforce prepared to engage patients? 5 of 35 recent grads said they received no training on health literacy during medical school. Dr. Cliff Coleman et al, 2013 Journal of Health Communication Consensus Study - “curricula needed to produce a health care workforce which is not only aware of the issues around low health literacy, but is also prepared to address them.”  Echoed by 2010 National Action Plan to Improve Health Literacy – workforce objectives. Journal of Health Communication, 18:82-102,2013.

Examples of Health Literacy Competencies Knowledge Knows that educational attainment is an inadequate marker for health literacy skills. Knows that the average US adult reads at an 8th-9th grade level. Knows that patients learn best when a limited number of new concepts are presented at any given time. Journal of Health Communication, 18:82-102,2013.

Examples of Health Literacy Competencies Skills Demonstates ability to recognize, avoid and/or constructively correct the use of medical jargon. Demonstrates ability to recognize plain language principles in written materials. Demonstrates effective use of teach back technique for assessing patient understanding. Journal of Health Communication, 18:82-102,2013.

Examples of Health Literacy Competencies Attitudes Expresses the attitude that effective communication is essential to the delivery of safe, high quality health care. Expresses the attitude that it is a responsibility of the health care sector to address the mismatch between patients’ and health care providers’ communication skills. Journal of Health Communication, 18:82-102,2013.

Health Literate Care Delivery How do you do it? Aware Prepare Health Literate Care Delivery

Single Item Health Literacy Screener “How confident are you at filling out medical forms by yourself?” Extremely Quite a bit Somewhat (cut point) A little bit Not at all This assessment can also be administered during clinical encounters and it has been shown to correlate with the Newest Vital Sign assessment. The patient’s answer is an indicator of their health literacy with: 3, 4, 5 indicating inadequate health literacy 1 and 2 indicating adequate health literacy Results should be used to determine whether additional follow-up support (review of clinical instructions or assistance making appointments or obtaining referrals) would be helpful. Source: Stagliano V, Wallace LS. Brief health literacy screening items predict newest vital sign scores. J Am Board Fam Med 2013;26(5):558-565.

Distinct health literacy tasks Potential navigation pitfalls 15 Distinct health literacy tasks Potential navigation pitfalls Source: DeWalt, D. A., and J. McNeill. 2013. Integrating health literacy with health care performance measurement. Discussion Paper, Institute of Medicine, Washington, DC. http://www.iom.edu/linktoyourpaper.

Best Practice – Universal Precaution Approach to Health Literacy Reading ability Education level Socio- economic status The one question that comes up again and again is, “Won’t a college educated patient be offended if I hand them something written at 5th grade level?” The answer is a resounding NO. In the health literacy literature there is overwhelming evidence that a universal precautions approach is appropriate regardless of reading ability, socioeconomic or education level. Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber, A. (Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266-290.

Evidence: Easy-to-read is Preferred! College educated readers’ response to health information written at 5th grade level: Recall of key messages Satisfaction Source: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145. In study after study involving individuals of all health literacy levels, easy-to-read information is preferred. College educated readers’ recall of key messages and satisfaction increased in response to heath information written at a 5th grade level. When was the last time you handed your patient information and they said “This is too easy. Can you give me something more complex?”

Home care, Palliative & Hospice System Resources One Patient – One Message Disease and condition management (stoplights) Personal health record (electronic & paper) High risk medication tools Acute Ambulatory Skilled & Rehab Home care, Palliative & Hospice Research shows that interventions that build self-care skills can overcome health literacy related health disparities. This is particularly true for those individuals with low health literacy. Becoming a health literate organization includes offering consistent messaging and accessibility across the care continuum.

Stoplight tools Condition specific Symptom management Medication management Heart failure x   COPD Falls Wounds Pneumonia Depression Nausea Constipation Pain Anxiety Diabetes Stroke Shortness of breath Bleeding Coumadin Tamoxifen Lovenox et al Plavix et al Methotrexate Swallowing/Aspiration Weight gain/Edema Skin/Pressure ulcer

Health literate personal health record (PHR)

Where will you hitch your health literacy wagon Where will you hitch your health literacy wagon? Health Literate Care Promotes IOM Aims Patient Timely Safe Equitable Patient centered Efficient Effective

Health Literate Care Resources http://www.health.gov/communication/interactiveHLCM/#resources When a health care organization adopts the Health Literate Care Model, health literacy becomes an organizational value infused into all aspects of planning and operations. Health Aff February 2013 vol. 32 no. 2 357-367

We can no longer afford this …

Jennifer Pearce, MPA Health Literacy Program Manager Sutter Center for Integrated Care Sutter Health Contact: pearcej1@sutterhealth.org www.suttercenterforintegratedcare.org