Building the Case for Health Literacy Proceedings of a Workshop (2018) / Chapter Skim
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Appendix C: Improving Health and the Bottom Line: The Case for Health Literacy
Appendix C: Improving Health and the Bottom Line: The Case for Health Literacy
Pages 95-152
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Ioana Staiculescu, M.P.H., CDFT Karen Edison, M.D. Commissioned by the Roundtable on Health Literacy Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine1 1 The authors are responsible for the content of this article, which does not necessarily rep resent the views of the National Academies of Sciences, Engineering, and Medicine.
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Department of Media and Information Michigan State University 409 Comm Arts, 404 Wilson Road East Lansing, MI 48824 Phone: 919-995-2721 Email: rvrikard@msu.edu Ioana Staiculescu, M.P.H., CDFT Center for Health Policy School of Medicine University of Missouri DC375.10 MA105C Columbia, MO 65212 Phone: 573-882-6486 Email: staiculescui@health.missouri.edu Karen Edison, M.D. University of Missouri Health System DC19, MA111 Columbia, MO 65212 Phone: 573-884-6415 Email: EdisonK@health.missouri.edu Corresponding Author: Stan Hudson, M.A., CDFT
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We would also like to thank Jordan Valley Health Center and Southeast Health for allowing us to include their quality improvement work. Last, thank you to Dave Zellmer for his plain language and health literacy assistance in creating the fact sheets and executive summary.
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would lead to improved health literate methods for health systems and those who work in health care. Where Did We Find the Information?
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make their way through detailed health information and systems to get the care they need and stay in good health. Health literacy cuts health care costs through: • Fewer emergency department (ED)
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The Ethical Case Health literacy is the right thing to do to reduce health disparities and provide equal care for all. Good health literacy plans have been found to reduce the effect of race and sex for some health outcomes.
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3) developed as our guide: Health literacy is linked to literacy and entails people's knowledge, motiva tion, and competencies to access, understand, appraise, and apply health information in order to make judgments and make decisions in everyday life concerning health care, disease prevention, and health promotion to maintain or improve quality of life during the life course.
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Many cases could be made for the importance of integrating and addressing health literacy. We make numerous cases, which fall under two primary categories: • The business case, which includes health literacy's effect on cost, quality, behavior, access, and patient experience, and • The ethical case, which includes health literacy's effect on health equity, as well as the legal/regulatory case.
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If we found existing policies, programs, or initiatives that met the framework criteria outlined in the Roundtable on Health Literacy's Statement of Task, we contacted the organization and conducted in-depth 2 See https://www.qualtrics.com (accessed February 15, 2018)
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Respondents represented programs and institutions from the United States of America, Canada, Germany, Italy, Taiwan, Australia, Japan, Abu Dhabi, and more. Seventy-seven percent of respondents said that they or their organization had worked on a project exploring the effect of health literacy on any of the following areas: finance, behaviors, health outcomes, quality of care, patient satisfaction, provider satisfaction, equity, organizational culture, or another area related to the Quadruple Aim.
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One attribute of a health literate organization directs that an organization "communicates clearly what health plans cover and what individuals will have to pay for service" (Brach et al., 2012)
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The Business Case for Health Literacy The Financial Case The health literacy field has a long history of forecasting the potential cost savings of addressing health literacy from a societal standpoint. An early systematic review reported a range of an additional 3–5 percent in total health costs attributable to limited health literacy for the health care system and a range of $143–$7,798 of additional expenditures for individual patients with low/limited health literacy compared to those with adequate health literacy (Eichler et al., 2009)
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. In addition, many specific health literacy health care delivery interventions have been found to be cost-effective, including using cell phones to deliver health education via text messaging (Zhuang et al., 2016)
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. Some long-standing health literacy programs have demonstrated time and again behavior change that results in direct and indirect cost savings to systems, individuals, and society.
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The Behavioral Case The relationship between health literacy and behavior change has been explored in many studies, from targeted interventions to broader ones that integrate health literacy strategies with social support. For example, a randomized controlled trial found that people with heart failure were more likely to report daily weights when provided picture-based instructions, a digital scale, and follow-up phone support (79 percent in intervention versus 29 percent in control)
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. Integrating patient activation into health literacy interventions could not only improve the public's health information–seeking ability but also further enhance population-based health.
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. Moreover, coupling online interactive media with automated phone calls resulted in a 15-day delay in readmission for chronic obstructive pulmonary disease with a 69 percent reduction in readmission length of stay and a 4-day delay in readmissions for congestive heart failure with a 51 percent reduction in readmission length of stay (Emmi Solutions, 2016b)
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For example, a two-phase readmission reduction initiative employing the teach-back method and patient admission interviews reduced pneumonia readmission rates by 9.62 percent and heart failure readmission rates by 7.28 percent in phase 1. Phase 2 added the patient readmission interview to their electronic medical record, increased patient support through followup phone calls and appointments, and collaborated with local and regional skilled nursing facilities to reduce all-cause readmission by 4.67 percent (SoutheastHEALTH, 2017)
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. A systematic review of the use of pictograms to assist caregivers in dosing liquid medication found limited but clear evidence that integrating pictograms into verbal or text-based instructions reduced dosing errors and enhanced comprehension and recall of instructions, while improving adherence (Chan et al., 2015)
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. Likewise, interventions addressing health literacy have been found to improve patient satisfaction in medication adherence and management (Graumlich et al., 2016; Murray et al., 2007; Ruiz et al., 2014)
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. More research is clearly needed to examine the link between becoming a health literate organization and provider satisfaction in communicating with patients, ensuring patient understanding, and overall job satisfaction.
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. Mission-based health and public health organizations have a responsibility to meet their patients where they are and provide health information and care with appropriate and adequate supports to empower health and public health consumers.
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. The American College of Physicians has also valued the importance of health literacy and through its Center for Patient Partnerships in Healthcare has been developing and implementing innovative health information tools to ensure patient understanding and empowerment (ACP, 2017)
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Integrating health literacy universal precautions into practice can assist providers in reducing risk and strengthening the health of their patients and their bottom line. The shift toward value-based purchasing will strengthen in the next few years as MACRA replaces the sustainable growth rate formula and establishes "a new payment framework for rewarding health care providers for giving better care and not more care" (CMS, 2015)
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(Braveman et al., 2017) From a health literacy perspective, health equity also means that everyone has equal access to health information that people can act upon.
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. In a 2015 discussion paper published by the National Academy of Medicine, health literacy experts provided arguments that health literacy is a necessary element for achieving health equity because of the strong relationship with the social determinants of health and because health literacy interventions and best practices are a contributing factor to achieving health equity and social justice (Logan, 2015)
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2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services.
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Yet, it is unclear how many organizations throughout the country or around the world are implementing these strategies. As mentioned in the report, health literacy research and practice is mainly focused on clinical interventions, whereas other areas like quality of care, patient safety, cost, outcomes, medication adherence or medication errors, health equity, and health disparities research and practice often do not include health literacy as a major component, with professionals working in these areas often operating in silos.
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funding opportunity focuses on projects that develop or upgrade usable tailored health information for populations who experience health disparities and increase the information capacity of health care providers. 3 See https://report.nih.gov (accessed February 15, 2018)
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The Patient-Centered Outcomes Research Institute (PCORI) is an independent nonprofit, nongovernmental organization authorized by the U.S.
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TABLE C-2 Patient-Centered Outcomes Research Institute (PCORI) Funded Health Literacy Projects Organization Project Budget Project Type Funding Announcement Boston Medical $249,821 Engagement in Meeting and Conference Center Research Project Support, Engagement Award Colorado Center $13,930 Engagement in Tier I, Pipeline to for Primary Care Research Project Proposal Innovation University of $249,999 Engagement in Engagement Award Maryland Research Project University of Alabama $1,339,684 Research Project Addressing Disparities at Tuscaloosa American Institutes Research for Research Dissemination and Implementation Project El Poder de Decidir $14,996 Engagement in Tier I, Pipeline to Research Project Proposal Matrix Institute on $14,966 Engagement in Tier I, Pipeline to Addictions Research Project Proposal Spina Bifida San Diego $50,000 Engagement in Tier III, Pipeline to Research Project Proposal Multicultural AIDS $15,000 Engagement in Tier I, Pipeline to Coalition Research Project Proposal The $46,500 Engagement in Meeting and Conference Cholangiocarcinoma Research Project Support, Engagement Foundation Award Trustees of Dartmouth $2,089,937 Research Project Communication and College Dissemination Research University of New $2,053,631 Research Project Addressing Disparities Mexico Health Sciences Center continued
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See https://www.pcori.org/research-results? keywords=%22health%20literacy%22&f% 5B0%5D=field_project_type%3A320#search-results (accessed February 15, 2018)
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In addition, funding portfolios need to emphasize involving participants in the initial phase of the research project, sharing the research findings with participants and listening for participant feedback, and translating findings to policy makers.
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2011a. Low health literacy and health outcomes: An updated systematic review.
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2017. Health literacy: Accurate, acces sible, and actionable health information for all.
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BMC Health Services Research 6:30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1475568/ pdf/1472-6963-6-30.pdf (accessed February 15, 2018)
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2009. The costs of limited health literacy: A systematic review.
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": A coordinated intervention to improve nutrition and physical activity among Head Start parents, staff, and children. American Journal of Health Promotion 27(1)
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2008. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status.
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2007. Pharmacist inter vention to improve medication adherence in heart failure: A randomized trial.
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Health Information & Libraries Journal 27(4)
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2015. The association between patient activation and accessing online health information: Results from a national survey of US adults.
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2014. eHealth literacy interventions for older adults: A systematic review of the literature.
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n org/10.1186/s12966-016-0362-1 (accessed February 15, 2018)
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. A 3-year study of close to 93,000 veterans found that those with low or limited health literacy cost $143 million more that those with ample health literacy [2]
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and N Farooqi, A win-win: How Mass General cut ED visits by 13% and addressed health disparities, in Growth Channel Blog.
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Patient activation helps the patient to know how to treat their chronic conditions such as asthma and high blood pressure. Plus, patients from a study were more likely to act in healthy ways like getting screened for breast cancer and not having to stay in the hospital [5]
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Journal of racial and ethnic health disparities, 2015.
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. There is strong support that addressing health literacy can improve health outcomes.
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Insufficient Vision and Low Health Literacy among Hospitalized Seniors. Jour nal of Health Communication, 2016.
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E Many studies have looked at the role health literacy plays to help patients take their medicine like they should [8–12]
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DC. Health Literacy: Accurate, Accessible, and Actionable Health Information C for All.
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Just the use of simple health literacy universal precautions has been known to help with patient satisfaction. These would be things such as: • Putting MRI reports into plain language [19]
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4. Murray, M.D., et al., Pharmacist intervention to improve medication adherence in heart failure: a randomized trial.
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Laizner, and L Shohet, Exploring the value of audiotapes for S health literacy: a systematic review.
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Health information should be: Targeted, tailored, easy to read, understandable, and culturally appropriate, • and Available where people live, learn, play, work, and worship. • There has been a movement in health justice to make the moral or ethical case for equal access to health information for all patients.
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5. Berkman, N.D., et al., Low Health Literacy and Health Outcomes: An Updated Systematic Review.
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