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

2. 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

3. My Story

4. 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

5. 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

6. 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 Health Literacy: A Prescription to End Confusion
Source: Schwartzberg, J Understanding Health Literacy: Implications for Medicine and Public Health

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

8. 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

9. 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

10. 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

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

12. Is This Equitable Access?

13. 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:

14. 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.

15. 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.

16. 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.

17. 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.

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

19. 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):

20. Distinct health literacy tasks Potential navigation pitfalls15
Distinct health literacy tasks Potential navigation pitfalls
Source: DeWalt, D. A., and J. McNeill Integrating health literacy with health care performance measurement. Discussion Paper, Institute of Medicine, Washington, DC.

21. 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,

22. 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:
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?”

23. 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.

24. 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

25. Health literate personal health record (PHR)

26. 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

27. Health Literate Care 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

28. We can no longer afford this …

29. Jennifer Pearce, MPA Health Literacy Program Manager
Sutter Center for Integrated Care
Sutter Health
Contact: