1. Health Literacy Cynosure Health Summit May 21, 2012 Jennifer Pearce, MPA Heart Failure Program Coordinator & Health Literacy Consultant Sutter Health

2. Wall Street Journal December 5, 2006 College educated Health care experience Prepared for medical appointments Had support system Multiple providers (12) Had Medicaid, then uninsured Miscommunication led to lack of follow- up care Didn’t understand options PATIENT SKILLS: SYSTEM BARRIERS:

3. Outline  Definition of health literacy  Prevalence  Why it matters (quality/compliance/safety)  Readmissions  Care Transitions Team for Heart Failure plan for addressing health literacy Measurement Universal precaution approach: written Nuanced approach: verbal Expectations  What you can do now

4. How is “health literacy” different from “literacy”? Literacy refers to having the basic skills to read, write and compute without regard to context Health literacy is the concept of 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

5. Posted at the entrance to the ED of a Bay Area hospital: the county’s “major source of acute care for medically indigent and uninsured patients” Notice for emergency services: This Hospital must provide emergency services and care to any individual, including women in labor, who requests services, examination or treatment, or for whom services, examination or treatment is requested, regardless of the individual’s ability to pay for these services, so long as the Hospital has appropriate facilities and qualified personnel available. In no event shall the provision of emergency services and care be based upon, or affected by, the individuals race, ethnicity, religion, national origin, citizenship, immigrant status, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent preexisting medical conditions or physical or mental handicap is medically significant to the provision of appropriate medical care to the individual.

6. Is this equitable access? Notice for emergency services: This Hospital must provide emergency services and care to any individual, including women in labor, who requests services, examination or treatment, or for whom services, examination or treatment is requested, regardless of the individual’s ability to pay for these services, so long as the Hospital has appropriate facilities and qualified personnel available. In no event shall the provision of emergency services and care be based upon, or affected by, the individuals race, ethnicity, religion, national origin, citizenship, immigrant status, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent preexisting medical conditions or physical or mental handicap is medically significant to the provision of appropriate medical care to the individual. Flesch-Kinkaid Grade Level: 12

7. Evolving definitions of health literacy A person’s ability to obtain, process and understand basic health information and services needed to make appropriate health decisions Prose literacy: texts Document literacy: appointment slips Quantitative literacy: nutrition labels Sources: IOM. 2004. Health Literacy: A Prescription to End Confusion

8. Evolving definitions of health literacy: Dual nature of communication in health literacy Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33 Patient’s skill and ability Health system’s demand and complexity Health Literacy

9. Lack of concordance Source: Rudd, R. 2010. “Literacy and Health.” Harvard School of Public Health Most health materials are written at a level that exceeds the reading skills of the average high school graduate. Health Literacy Patient’s skill and ability Health system’s demand and complexity

10. Prevalence: 9 out of 10 adults lack the skills needed to manage their health

11. 2003 National Assessment of Adult Literacy Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

12. Adult health literacy by highest level of education Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

13. Adult health literacy by age Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

14. Being able to understand matters to patients Low health literacy associated with: Adverse health outcomes Increased risk of hospitalization Increased mortality rates Increased cost to U.S. economy: estimates vary but all are in the billions; due to increased utilization Why? Individuals with low health literacy are more likely to: skip necessary medical tests use the emergency room more often have a harder time managing chronic diseases like diabetes or high blood pressure Source: IOM Report on Health Literacy: A Prescription to End Confusion Source: Baker et al. AJPH. 2002. 92:1278 Source: JAMA, April 27, 2011 – Vol. 305, No. 16 Source: Low Health Literacy: Implications for National Health Policy. University of Connecticut, 2007 Source: Rudd, R. E., et al (2007). Health literacy: An update of public health and medical literature. In J. P. Comings, B. Garner, & C. Smith. (E ds.), Review of adult learning and literacy (vol. 7) (pp 175–204).

15. Health literacy matters to CMS Quality HCAHPS survey:

16. Health literacy matters to HHS Compliance Affordable Care Act established statutory definition of health literacy Plain language requirement for health insurers

17. Health literacy matters to the Joint Commission Safety The Joint Commission: “Effective communication is a cornerstone of patient safety.” Sentinel event database: 65% of identified adverse events have communication failures as the underlying root cause Source: The Joint Commission (2007)“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety

18. Care Transitions Team for Heart Failure: Our reality At least 54% of our heart failure patients may have limited health literacy Source: AHRQ Limited Health Literacy Prevalence Calculator Literature strongly supports considering health literacy as part of a plan to reduce heart failure readmissions

19. Care Transitions Team for Heart Failure: Program Design HospitalTelemanagement at home Heart Failure admission assess readmission risk 24-48 hrs. medication reconciliation education care transitions assistance 60 – 90 days on service Assess health literacy during inpatient stay Score determines pace of teaching post-discharge

20. Our plan: Universal precaution approach Take a universal precaution approach in our written material and a nuanced approach in our verbal communication 1. Measure: Newest Vital Sign tool 2. Distribute: tested and clearly written/illustrated material that corresponds with education goals 3. Pace and prioritize: teaching according to patient motivation and capability 4. Offer additional resources on demand

21. Measure: Newest Vital Sign health literacy assessment ICE CREAM

22. Distribute one set of materials for all literacy levels: Heart Failure Discharge Tool

23. Distribute one set of materials for all literacy levels: Self-care booklet Self-care booklet divided into:  What is heart failure?  My medications  My diet  My exercise plan  My daily check-up Interventions that build self- care skills can overcome health literacy related health disparities Source: Pignone, M. 2008. Literacy and Adherence. http://nchealthliteracy.org/teachingaids.html

24. Pace and prioritize: Teaching Printed materials + oral interaction = most effective results Health literacy score provides and idea of where patient is starting from  What sort of “cognitive Velcro” is already present?  Should information be presented in smaller chunks?  What vocabulary and concept load are appropriate? Score should be taken in context (Example: Older adults, regardless of socioeconomic status, have higher rate of limited health literacy; struggle with “mental multitasking” and “fluid intelligence”) Source: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health and Speros, C. 2011. http://www.healthliteracyoutloud.com/2010/12/14/health-literacy-out-loud-50-communicating- about-health-with-older-adults/

25. Offer additional resources on demand Video, print, or interactive - depending on the patient’s learning style

26. Expectations We expect to conduct up to 500 inpatient health literacy assessments by end of 2013 By proactively addressing health literacy:  Gain greater insight into readmission risk  Offer more complete picture to outpatient providers  Enhance care experience for heart failure patients  Disease management  Health system navigation  Self-advocacy Reduce readmissions

27. Knowing this, what can you do now? 1. Assess  How accessible are your current patient education materials?  Why are you giving them out? 2. Ask  What do your patients do with the materials when the get home?  What information do patients wish they had?  What questions are staff getting? 3. Revise  Language, font, white space, organization, graphics 4. Test  Patients are your partners 5. Refine

28. Questions? Jennifer Pearce, MPA pearcej1@sutterhealth.org