Enhancing Health Literacy Across a Health System

From left,Terri Ann Parnell, DNP, RN, Joanne Turnier, MS

From left,Terri Ann Parnell, DNP, RN,
Joanne Turnier, MS

Terri Ann Parnell and Joanne Turnier focused on the optimization of health literacy programs and education in healthcare settings. The presenters shared strategies for improving patient-centered care using health literacy in the North Shore LIJ Health System.

Their campaign focused on diversity and developing patient-centered and individualized care, and it recognized that health literacy is a key component of improving their healthcare system. In 2010–2011, they conducted an in-depth needs assessment, and in 2013 they began to integrate programs and the process of outcome measurement. They engaged stakeholders across sectors, including clinicians, medical students, public health workers, administrators, and people in marketing and advertising.

The overall process of implementing a broad-scope health literacy intervention at the program level required the work of many dedicated individuals. Buy-in from stakeholders was key, and particular focus was paid to the inclusion of diverse cultures and health needs. The process started with a rigorous needs assessment and progressed by developing resources and standards. The resources were delivered to the appropriate people.

There was also a focus on teaching and training around health literacy. Training and practice of health literacy for patient care was made mandatory where possible, and subsequently taken to the bedside for integration. Measurement and assessment were initiated, and quality improvement is continuous.

Numeracy: Exploring Strategies to Convey Quantity, Time and Risk

Helen Osborne, MEd, OTR/L

Helen Osborne, MEd, OTR/L

Helen Osborne outlined overall strategies to increase understanding for patients who struggle with numeracy. They included:

  • Knowing the science (or the study design)
  • Knowing and understanding the data
  • Knowing what your audience may or may not know
  • It’s important to know why you are using numbers as well as to know that there can be multiple reasons to use them, to persuade, inform or compel recognition of danger or to make sense out of conflicting data. It might be possible that you don’t need to use numbers at all.

    Osborne offered specific strategies for conveying quantity, time, risk, and comparison data. When it comes to quantity, it’s important to confirm the measurement system you’re using. She mentioned a number of visual comparisons, including the compartmentalized plate and the Wong Baker Pain Scale, and comparisons with common objects like ping pong balls. She cautioned that mathematical symbols can be a form of jargon, and suggested that if you are meeting in person, you can actually do the math with the client. For conveying time, she suggested creating schedules that revolve around a person’s daily habits, rather than the clock, and including visuals representing time, such as sunrise and sunset, as exemplified by the AHRQ pill card.

    Osborne concluded the session with an exercise that paired a set of instructions requiring some kind of numeracy with an imagined client. The exercise gave participants the opportunity to employ some of the strategies and provoked lively discussion.

    How Do You Know They Know? Methods for Evaluating Teaching and Training

    Sabrina Kurtz-Rossi, MEd.

    Sabrina Kurtz-Rossi, MEd

    Education is a core component of health literacy. We routinely rely on health curricula that are valuable for students, but that also have measurable outcomes — a crucial tool for quality improvement and for seeking funding.

    This session helped attendees better understand the principles of adult education and demonstrated techniques that could be easily and readily measured. The application of these theories to curriculum development is two-fold. First, the pros and cons of various curriculum development methods should be assessed and the appropriate method chosen for the context. Second, the objective of the education needs to be identified. 

    In setting curriculum objectives, ask: what will participants know, and at what point will they know it? This question focuses on the audience, not on the curriculum.

    She provided steps to help create measurable observation criteria for evaluation:

    • Include action verbs in these objectives and target one expectation at a time.
    • Match the goals to the learning activities and the learning strategy.
    • Identify the indicator that the learning has been accomplished, making the objectives achievement based and measurable.
    • Be careful to include only one indicator at a time.

    There are two main types of evaluation that can be used: formative evaluation and outcome-based evaluation. It may include alternative assessments such as telling stories or “teach-backs,” portfolio review, self-assessment, or peer review. These are methods of goal-free program evaluation in which the evaluator does not know program goals, and are related in particular to Transformation Learning theory.

    Creating Unbiased, Understandable Shared Decision Materials: Is It Possible?

    Geri Lynn Baumblatt, MA

    Geri Lynn Baumblatt, MA

    Patient decision aids “prepare patients to make informed, values-based decisions with their practitioner,” said Geri Lynn Baumblatt, who works with decision scientists, clinicians, and patients to create multimedia decision aids. She gave a broad and detailed explanation of why they are being used now, what’s involved in creating them, and how to avoid bias.

    Shared decision making is a new practice. Patients may not be aware of multiple options, and understanding risk in the face of increasing amounts of data is a challenge. The patient’s quality of life may be significantly affected, and, as Baumblatt pointed out, practitioners are not particularly good at knowing what their patients want. Most patients now, 71% as opposed to 51% in 2000, want to be involved. 

    In order for shared decision making to happen, more than one reasonable option, including no treatment, needs to be in place, and values need to be recognized. Providers need to be open to the possibility that they may not agree with the patient’s choice. Allowing enough time for discussion is a factor, making the emergency room an inappropriate setting.

    Baumblatt finished with an in-depth and compelling set of strategies that can be used to create unbiased decision making aids. She feels it’s impossible to avoid influencing people’s choices. The goal when creating shared decision making tools is to create them in a way that’s most likely to help and least likely to inflict harm.

    Cultural Competency Training – A Collaborative Project

    Crystal Duran, MPH, MCHES

    Crystal Duran, MPH, MCHES

    Crystal Duran framed her session by noting that 25% of individuals choose not to seek care when sick or injured, and 76% of individuals don’t understand how the healthcare system works. For example, Rose doesn’t follow her treatment plan because she cannot read and is embarrassed to tell her doctor. Maria needs kidney dialysis treatments three times a week, but she doesn’t speak English and has trouble scheduling appointments. “These are the people we deal with every day, and it is a very confusing and frustrating system for patients to navigate themselves. That is why it is so important that patients can receive culturally competent care so that they better understand and can make informed decisions about their coverage and treatment plans.” 

    Unfortunately, she said, not everyone in your workplace will feel the same way. “There are a lot of people internally who will think it’s the patient’s problem and they need to figure it out. Sadly, we want them to have access to preventive care and to be healthy, but there is unwillingness on the part of physicians to want to be trained in this area. Sometimes they don’t understand and they don’t want to understand. It can be a lose-lose.”

    To combat internal opposition, she advised against calling it cultural competency training, but rather patient safety or equitable care training. “Cultural competency training tends to be a turn-off for doctors,” said Duran.

    There are also models for training that have already been done, and it would be beneficial to “expand your literature, research, and partnerships as you acquire ideas on how to develop your trainings.” When you think about partners, some of you may be reluctant to reach out to your competitors. But in this field, insurance companies are willing to come together for these values and mission,” assured Duran. “Step out of your comfort zone and make some time to phone one of your competitors to see what they have been doing for cultural competency health literacy training. You’ll be surprised!”

    The Language Tipping Point: Identifying the Drivers of Language Access

    Elizabeth Abraham, M.A., M.Sc., C.Tran.

    Elizabeth Abraham, MA, MSc, CTran

    Language access in health care involves finding ways to ensure that language barriers do not affect health outcomes. Ms. Abraham focused first on building a case for health care systems to improve safety and quality of care for patients with limited English proficiency (LEP). She identified five important building stones: quality, risk management, compliance with federal and state law, equity and cost management.

    Risk can’t be managed effectively without proper language access. Two leading causes of errors are deficient consent and inadequate medication instructions. Without a qualified medical interpreter, you do not have informed consent. These problems are disproportionate among LEP patients. Errors of clinical consequence can often be attributed to improperly trained interpreters. Abraham identified several hallmarks of poor communication leading to torts. One lawsuit, she said, would pay for many interpreters. 

    Federal and state laws that compel language access include Joint Commission requirements, Title VI of the Civil Rights Act, language access legislation in every state, and the Hill-Burton act of 1946. 

    Abraham cited a long list of costs attributed to lack of language access for limited English speakers. The list included entering the healthcare system in advanced and more costly stages of disease because of limited access to primary care, a higher likelihood of being hospitalized, and disproportionate use of emergency services. 

    Abraham also spoke about health inequalities. She told the story of Willie Ramirez, whose life was changed due to a mistranslated word, resulting in damages of $71 million dollars. (The story can be found at the Health Affairs Blog: “Language, Culture, And Medical Tragedy: The Case of Willie Ramirez” by Gail Price Wise.) Abraham pointed out that interpretation is recreating language live, as it happens. Without interpreters, there is no possibility for clarification — wrong meanings do not get changed.

    Following an interactive exercise in which participants exchanged horror stories involving lack of language access at their places of work, Abraham wrapped up the session with four steps for creating a comprehensive language access plan.  Enlisting champions from both the legal and finance departments is crucial. Ways of achieving long term solutions without project-killing expense include shared hires of interpreter and creating consortiums of HCOs who can negotiate bulk purchase of services. 

    But, she said, there are also ways to accomplish short-term solutions; creating a staff Language Access Task Force and Communication Plan, using over the phone interpretation, and video interpretation (her organization uses ipads).

    Finally, she said, there are quick wins — specifically, there are steps to make phone interpretation work. They include staff training, instructions posted on phones for how to use phone interpreters, department “champions,” and concentration on high demand areas like the emergency room and family medicine. There are wonderful ways, she concluded, to make systems transformation in small steps.

    How to Get Your Health Literacy Program Funded

    S. Eric Anderson, Ph.D.

    S. Eric Anderson, PhD

    Dr. Anderson explained how to calculate the break-even point for a program, determine whether the program is targeting theoretical or risks, evaluate programs where odds can be calculated and each decision has a value, assign dollar values to costs and benefits to determine if program benefits exceed costs, assign dollar values to benefits to determine which program is cost effective in a per-unit outcome and compare alternatives where program benefits are expressed with a quality-of-life adjustment.

    Break-even analysis (BEA) identifies the volume at which point operations change from being a loss to profitable. Costs are classified as either fixed or variable, depending upon whether they vary with the volume of output. Profits occur when total revenues exceed total costs – fixed costs plus variable costs. The break-even point is the point at which total revenue is equal to total costs. In one scenario, Dr. Anderson explained when it is beneficial to continue programs that don’t break-even and strategies on how to price appropriately.

    Risk management (RM) attempts to maximize areas where one has control over the outcome while minimizing areas where one has little control. It should be realized that risks can’t be eliminated only reduced. Dr. Anderson provided insight on the risks of allocating funds targeting unlikely risks (bio-terrorism) at the expense of likely dangers (vaccines).
Expected value (EV) provides a rational means for selecting the best alternative if the odds can be calculated and each decision has a value. Dr. Anderson evaluated dozens of risk reduction measures to see if they valued out (exceeds 100%) and provided insight on determine if a healthcare service or prevention program values out (exceeds 100%).

    Cost benefit analysis (CBA) assigns dollar values to costs and benefits to determine whether the benefits realized exceed costs for a particular a program. Results of CBA are expressed as net benefits (benefits minus costs). Dr. Anderson showed us how to calculate and determine if the economic benefits exceed the costs (exceeds 100%) for a variety of programs: stop smoking programs, weight management, vaccinations, etc.

    Cost effectiveness analysis (CEA) is better than CBA in situations when assigning dollar values to benefits for which market prices do not exist, such as a person’s life. In these scenarios, CEA may be a more appropriate method since it uses a cost-per-unit outcome. Units of measurement for CEA might include disease prevented, head injuries averted, number of lives saved or cost per year of life. Dr. Anderson pointed out that government agencies assess the value of life at $7.5 million, but how much they spend money is an entirely different story. They will spend millions to save the life of a single miner trapped in a cave, but balk at an extra $20,000 on a highway guardrail that would save an average of one life per year. Superfund hazardous waste clean ups prevent cancer at a cost of $5 billion per life saved.

    Cost utility analysis (CUA) compares alternate strategies where net benefits are expressed as the number of life years saved, with a quality-of-life adjustment. The common measurement for CUA is quality-adjusted life years (QALY). Rather than relying on implicit judgments about the quality of life, CUA makes these values explicit in the calculation. However, Dr. Anderson noted that QALY are subjective determinations, are difficult to measure and not universally accepted.

    Designing Health Information: What Every Health Professional Needs to Know

    From left: Xanthi Scrimgeour, MHEd, MCHES,
Stacy Robison, MPH, MCHES

    From left: Xanthi Scrimgeour, MHEd, MCHES,
Stacy Robison, MPH, MCHES

    Too often as health professionals, we take care of the content of our messages but give away the power of design when we send it off to someone else. In their presentation, Stacy Robison and Xanthi Scrimgeour encourage health professionals to take back their power for the benefit of their audiences by learning the basic elements of design to create documents and resources that are not only useful and usable but also attractive — because “attractive things work better.” If in creating attractive, well-designed materials we can ease the mental burden placed on the user, we can free up space for them to better use in trying to understand and absorb the material.

    To do this, Robison and Scrimegour offer the following ten basic tips for health professionals:

    1. Create an obvious path for the eye to follow.
    2. Use visual hierarchy.

    3. Use a grid to keep content and images aligned.

    4. Incorporate white space.

    5. Use bulleted and numbered lists.

    6. Use conceptual cues.

    7. Use images to facilitate understanding.
    8. Use icons or images to call out important content.
    9. Consider sans serif fonts.

    10. Increase your font size.

    Design is about much more than appearances. If we can successfully utilize tools of visual communication, we can help the readers of our materials to find what they need, understand it when they find it, and remember it after they have read it.

    Tools to Assess and Teach Child Health Skills to Parents with Low Basic Literacy

    From left: Deborah Boulware O'Neal, PhD, Doris Ravotas, PhD.

    From left: Deborah Boulware O’Neal, PhD, Doris Ravotas, PhD.

    As a dynamic duo, Dr. Deborah O’Neal and Dr. Doris Ravotas lead the session on “Tools to Assess and Teach Child Health Skills to Parents with Low Basic Literacy.” Though the session was divided in halves for each speaker to present on her own research and findings, both found common ground in implementing pilot programs that measured the effects of parents using the book, ‘What To Do When Your Child Gets Sick,’ as one of the first “hands-on” resource they can use when their child becomes ill. The book covers over 50 common childhood illnesses, injuries, and health problems including fever, sore throat, cold and flu, throwing up, stomach pain, and more.

    O’Neal began the session by mentioning that the U.S. racks up between $106 to $238 billion in unnecessary medical expenditures every year due to poor health literacy. Such costs account for the excess use of hospital emergency services, medication and treatment errors, minimal use of preventive services, and a lower chance in following through with prescribed treatment plans.

    With these statistics in mind, Ravotas and O’Neal were very eager in finding a solution for decreasing the number of ED visits by parents and children through the promotion of the ‘What To Do When Your Child Gets Sick’ book.

    O’Neal began using the book in head start programs. As time progressed, she hoped to expand the book’s usage in doctor offices, hospitals, and WIC centers.  As a result, O’Neal began developing a health education program that she was determined would reach the masses. The 4-hour program would train health professionals on: health literacy and the impact of low health literacy skills, how to identify and effectively instruct low literacy parents, the organizational format of the book, and the curriculum materials needed to help educate parents. Subsequently, parents would then receive 20-minute trainings on how to use the book and the importance of using it as a first-hand resource. From her efforts, O’Neil succeeded in hosting 18 trainings across Kansas with over 288 health professionals from 98 different clinical sites. The effects of this program were far-reaching with a decrease in doctor’s visits by 46%, a decrease in ER visits by 55%, a decrease in the number of school days missed by 64% and the number of work day missed by over half. O’Neal exclaims, “This shows that this program and book really impacts the quality of lives for families in Kansas.” Although a success story has already been written, O’Neal hopes to expand this program across the rest of Kansas and touch as many lives of her fellow Kansans as she possibly can.

    Although Ravotas shared a very similar mission with O’Neal, her research approach differed in many respects. Ravotas’ research targeted Kalamazoo County with a low basic literacy population exceeding 13%. Ravotas sought to identify which training approach would be most effective in getting parents to use the book and ultimately, reduce the number of ER visits and days of work and school missed due to illness. Three training models were tested on individuals who varied in their reading proficiency score. Study group #1 was given the ‘What To Do When Your Child Gets Sick’ book and received no how to use the book. Study group #2 was given the book and received basic training on common care topics and how to use the book. Study group #3 was given the book, received training in common care topics and how to use the book, and received literacy tutoring on vocabulary, language skills, computation skills, inferential skills, text search skills, and application skills. Although Ravotas is in the process of collecting data for her study, her insight and findings will be ground-breaking in informing health professionals of the best practices for educating parents on how to handle the day-to-day ailments and illnesses of their children. We look forward to her research findings in the near future!

    Challenging Traditional Legal Communication: A Drafting Toolkit for Non-Lawyers

    Christopher R. Trudeau, JD

    Christopher R. Trudeau, JD

    Mr. Trudeau began his presentation by leading his audience through his Prezzi “Swimming with the Sharks,” a detailed list of strategies for convincing lawyers to adopt plain language. He includes lawyers on the list of causes of low health literacy. Among the rational arguments for using plain language are that plain language is economical and the public prefers it, including lawyers themselves, according to a study conducted by Trudeau. He cited several examples of proof that plain language is economical, including a clarified billing statement that resulted in an 80% increase in patient payments at the Cleveland Clinic. 

    Trudeau outlined the process and results of conducting a survey with 376 respondents, including details about the respondents’ education level and specifics about the kinds of language choices they preferred. Interestingly, as the education level of the respondents increased, so did the preference for plain language. He asked participants to choose between “traditional’ language examples and plain language examples. Eighty percent of the participants preferred the plain language version, which included choosing between active vs. passive constructions, strong verbs vs. nominalizations, plain words vs. complex words, and explaining vs. not explaining legal terms.

    Trudeau also discussed common myths about using plain language, among them that using plain language prohibits the use of legal terms, and creates vagueness or ambiguity. He elaborated on ways to challenge these myths in the second part of his presentation, in which he described the drafting process from the lawyer’s point of view. 

    He spoke in sentence level detail about fixes for problems with three different types of ambiguity (syntactic, semantic and contextual ambiguity) and gave examples of each. In opposition to the usual rule of using fewer words, he recommended giving time and space to define legal terms. Trudeau spent the remainder of his presentation discussing examples. He included an example of a consent form, an ever-present challenge to plain language and health literate communication.