Oct 13 2011
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Health Literacy: Reducing the Burden of a Complex Healthcare System

CindyBrach_ LindaHarris Cindy Brach, Agency for Healthcare Research and Quality and Linda Harris, Office of Disease Prevention and Health Promotion

Nearly 9 out of 10 adults have difficulty using the health information from doctor’s offices, hospitals, online and in the media, according to background in the National Action Plan to Improve Health Literacy. People with low health literacy are more likely to skip medical screenings, end up in the emergency room and struggle with chronic conditions. As more people gain access to preventive services through the Affordable Care Act (ACA), now is a critical time to reduce the burden of complexity in the healthcare system and beyond.

NewPublicHealth spoke with Linda Harris, Ph.D., Health Communication and eHealth Team Lead in the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion (ODPHP) and Cindy Brach, MPP., Senior Health Policy Researcher for the Agency for Healthcare Research and Quality (AHRQ) about efforts to improve health literacy. ODPHP will co-host a Health Literacy Month Twitter chat on health literacy’s role in promoting prevention provisions in the health care reform law. Learn more about the chat and join the discussion on October 20 at 2 p.m. EST, using the hashtag #healthlit.

NewPublicHealth: Tell us about the burden of health literacy and the impact it has on the health of our nation.

Cindy Brach: We have a population that does, by and large, not have the skills needed to function in the current healthcare environment. Only about 12% of Americans, according to national data, are proficient in health literacy. In fact, all of us struggle at one time or another; it may be because we’re sick or we’re stressed or it may be because we have trouble reading or understanding medical concepts, but we struggle with the health information that’s presented to us.

There is a mismatch between the skills that American adults have and the demands the healthcare environment makes on people – to navigate the system, to parse out what is being said to them [by healthcare providers], and to read those dense documents that have critical medical instructions. What we strive to do when we talk about improving health literacy is to not only try and raise individual’s abilities and skills through adult education and other programs, but also to reduce the complexity of the health information and the navigation that is required for patients to be able to get the healthcare they need.

Linda Harris: I would remind us that related to the ACA, about 32 million Americans, half of whom have limited health literacy, will be eligible for free preventive services through ACA coverage in 2014. It’s a very specific population that we’re aiming to assist in reducing their burden, if possible, before the coverage begins.

NPH: What is the role of health literacy in getting the word out about these services and reducing the burden on those looking to get preventive care?

Cindy Brach: Weknow that health will improve if Americans have access to and use preventive services that have been recommended by the U.S. Preventive Services Task Force. Where health literacy fits into this is that we don’t always do a brilliant job of explaining what is available, why it’s important, what are the relative risks and benefits, and helping people make the decision about preventive services.

Linda Harris: The appropriate use of preventive services is one of the important areas where health literacy improvement really makes a difference. There’s some good data supporting that. Whatever assistance we can provide to help people make good decisions about the preventive services that are right for them is one of the responsibilities we’re trying to take on with our online decision support tool, called myHealthfinder. It helps people who are thinking about preventive services make good decisions about which ones they need, and also the kind of self-care wellness decisions they can make.

NPH: What should the role of different sectors be in engaging people with low health literacy in better health – from physicians to health departments to employers and community organizations?

Linda Harris: As you know, we have produced a National Action Plan for Improving Health Literacy, and that offers a strategic framework that we hope will help all of those stakeholders in health literacy to assume the strategies and tactics that are evidence-based for improving health literacy. We’ve looked to the National Action Plan as guidance for everybody so we can all be on the same page for the kind of system changes each one of these kinds of organizations needs to enact.

Cindy Brach: Certainly in healthcare delivery settings, there are a variety of areas in which we can do a better job. One is in the area of spoken communication – getting that jargon out of what we’re saying, confirming that an individual understands what’s been explained to them, encouraging them to ask questions and engage in shared decision-making. We can also greatly improve our written communication, which is much more than getting the reading level down to fifth grade or focusing on the font size, but really making sure our health materials are understandable and actionable so that after reading them people know what to do or how to make the decision they’re confronted with. We at HHS see this as very much a joint partnership with other public and private organizations. It’s going to take all of us to turn the ship around and to reduce the complexity.

NPH: What is HHS doing to improve health literacy?

Cindy Brach: One of the things we’ve realized is that as awareness of health literacy issues has increased, people are hungry for tools that can help them address their patients’ needs. At AHRQ, one of the tools we’ve developed is the Health Literacy Universal Precautions Toolkit. It’s a series of 20 brief tools that can help better promote understanding by all patients. Another toolkit AHRQ funded is for hospitals to change the process by which they discharge patients. It’s called the Re-Engineered Discharge, or RED toolkit. That toolkit uses health literacy principles to educate the patient throughout their stay, not just in the hour before they’re going to leave the hospital. Discharge educators talk to patients about their condition, the next steps they should take when they leave the hospital, the warning signs, and make it easier for them by making appointments for follow-up care before they leave the hospital. The toolkit includes a template for creating a plan that patients can easily understand called the After-Hospital Care Plan. So rather than a discharge summary full of jargon that patients can’t make heads or tails of, it uses graphics and very clearly puts out the information that they can take home with them and bring to their subsequent appointments. It’s putting the information into the patients’ hands in a way that they can act upon it.

NPH: Is this toolkit in use now? Have you heard back from hospitals that are using it?

Cindy Brach: Yes, it is in use. It started out as a randomized controlled trial where it was shown to reduce rehospitalizations, that is admissions or subsequent emergency room visits, by 30%. Since then, it’s been used in a number of Care Transition programs that are demonstration projects by the Centers for Medicare and Medicaid Services. We’ve also had hundreds of hospitals taken advantage of technical assistance that AHRQ has sponsored to implement the program.

NPH: How are you tracking progress in improving health literacy?

Linda Harris: In collaboration with AHRQ, we are through Healthy People 2020 tracking progress in some aspects of health literacy, specifically the quality of communication between provider and patient. We are essentially tracking how well providers perform the teach-back method [a proven method of ensuring patient comprehension by having patients explain back key concepts in their own words], and we’ll be able to track that over the next decade. We’re looking forward to seeing improvements in that. There are also a number of other related objectives, like prescribing information at the point of service delivery and increasing the meaningful use of electronic medical records – and other objectives that really do support, as Cindy was saying, more the systems view of the need for everybody to make life a lot simpler.

NPH: Anything else to add about health literacy?

Linda Harris: Health literacy is not just a sidebar to improving healthcare – it is integral to transforming healthcare into the kind of cost-effective, high-quality experience that everyone should have access to. One of the ways we describe that is the role of improving health literacy in reducing unnecessary hospitalizations. Health literacy improvement can play a critical role in something that’s really an important healthcare system improvement strategy, including efforts to reduce unnecessary hospitalizations.

Cindy Brach: Hearing the word literacy sometimes gets people focused on grade level and the written word, whereas health literacy is so much broader, encompassing lots of different kinds of communication and navigation. This video from the ACP Foundation has been a real eye-opener for many people, and helps to illustrate that. It’s also important to remember that everyone – regardless of education or socio-economic status – can face health literacy challenges. We as a country are not going to achieve our healthcare goals of improving access and quality while containing costs unless we figure out how to redesign our systems to eliminate these challenges.

Tags: Access to Health Care, Barriers to care: language and literacy, Health Literacy, Prevention, Q&A