Affordable Care Act and Health Literacy: Lessons Learned, Best Practices, and Recommendations

From left to right: Michael Villaire, MSLM (Moderator), Don Rubin, Ph.D., Catina O’Leary, Ph.D., Victor Wu, M.D, Doreena Wong

From left to right: Michael Villaire, MSLM (Moderator), Don Rubin, Ph.D., Catina O’Leary, Ph.D., Victor Wu, M.D, Doreena Wong

Michael Villaire, MSLM (Moderator), Institute for Healthcare Advancement;  Don Rubin, Ph.D., University of Georgia; Victor Wu, M.D, evolent Health; Catina O’Leary, Ph.D., Health Literacy Missouri; Doreena Wong, Asian Americans Advancing Justice

Summary session coming soon

Session K: Using the Universal Precautions Toolkit 2.0

Barry Weiss, MD

Barry Weiss, MD

Barry Weiss, MD, University of Arizona

The Universal Precautions Toolkit was developed by a team of physicians, public health nurses, researchers, and others based on the premise that everyone has trouble understanding difficult and complex information, and that all patients benefit from clear communication.

The AHRQ Universal Precautions Toolkit is a PDF document designed to help health care practitioners and organizations communicate more effectively with patients. It contains 21 tools for improving practice from a health literacy standpoint. The tools are split into groups under headings such as “Improving Spoken Communication” and “Improving Self-Management and Empowerment.”

Dr. Weiss conducted this workshop using the second edition of the toolkit. The purpose of the workshop was to familiarize participants with the toolkit for potential use in their own practices.

Before he started the hands-on part of the workshop, Dr. Weiss explained the AAFP Demonstration Project, which visited medical practices across the country and observed use of the first edition of the toolkit. He showed the example of the Medication Review tool, and how it improved medication review effectiveness in the practices they observed: patients brought in more medications, more problems were identified, more changes in medications made, etc.

The second edition of the toolkit was based on the results of the demonstration project.

Dr. Weiss split participants into groups and had each group choose one tool in the toolkit to explore. The goals were to become more familiar with the content of the tool, discuss how it might be used in participants’ settings, how patients might benefit, what parts of the tool might be harder to use, and how to overcome barriers to implementing the tool.

After working in small groups for about 15 minutes, each group reported back to the main group. Overall, the groups found the toolkit had great potential for use in their practices. They also found it useful to explore the toolkit using the embedded links.

Some teams expressed that certain activities appeared time-consuming and hard to incorporate into their practice. Dr. Weiss said that this observation reflected what they had learned in the demo project; but that practices found that, while it took a lot of upfront work to implement a tool, using it led to better results long-term; e.g., fewer return visits, better patient satisfaction, etc.

AHRQ Universal Precautions Toolkit:

Session L: Integrating Health Literacy into Your Organizational Structure

Emily Briglia, MA

Emily Briglia, MA

Emily Briglia, MA, Community Healthcare Network

Emily Briglia used her experience with Community Healthcare Network (CHN) to walk her attendees through the process of incorporating health literacy best practices into the operations of a healthcare agency. In 2011, CHN, not-for-profit FQHC with 11 health centers in New York City serving over 75,000 patients each year, launched an agency-wide health literacy initiative that aimed to improve patient outcomes by creating an organizational culture based on health literacy principles.

Briglia explained that CHN undertook this initiative because they see health literacy as the responsibility of all healthcare organizations. The traditional definition of health literacy applies to a patient’s own capabilities or skill set. For a health system to be effective, they need to evaluate how they engage consumers in the healthcare process and not put the oneness on the client.

To implement this agency-wide campaign, health literacy initiative leaders helped CHN staff learn and apply important health literacy universal precautions with patients, such as plain language and the teach-back method. Using plain language can increase patient understanding of health information, but its adoption in health organizations has been limited, partially due to a lack of provider training. When facilitated properly, the teach-back method can check for lapses in patient understanding, uncover health beliefs, reinforce health messages, and open a dialogue with patients. The employment of both of these strategies is crucial to ensure providers are communicating with patients effectively.

Participants completed various exercises including viewing teach back training videos, participating in teach back role plays, re-writing statements in plain language, and providing colleagues with constructive criticism on how to improve the facilitation of health literacy universal precautions. In 2014 alone, CHN’s health literacy leaders have presented for and/or trained over 1000 health care providers on health literacy. Upon completion of this session, participants were better prepared to incorporate these strategies into patient care, resulting in improved patient understanding.


Session M: Intergenerational Communication Preferences

Jill Clutter, Ph.D

Jill Clutter, Ph.D

Georgianna Sergakis, Ph.D & Jill Clutter, Ph.D, The Ohio State University

As part of the breakout sessions offered at the IHA Health Literacy Conference, Dr. Georgianna Sergakis and Dr. Jill Clutter of The Ohio State University College of Medicine facilitated a session entitled, “Intergenerational Communication Preferences.”   The session was filled with high energy; utilizing effective visuals to describe the importance of breaking down the barriers and building bridges between all individuals (regardless of differences) in order to achieve success in the workplace.

The session focused on the exploration of generational differences in the workplace, charting the foundations of generation-specific behaviors, and the creating strategies to use to optimize intergenerational interactions in the workplace of the healthcare industry.

Georgianna Sergakis, Ph.D

Georgianna Sergakis, Ph.D

Dr. Sergakis and Dr. Clutter explained how the current – and future healthcare system is now dominated by four generations of individuals:

  • The Veterans / Traditionalists (born 1922 – 1945)
  • Baby Boomers (Born 1946 – 1964)
  • Generation X (Born 1964 – 1982)
  • Millenials (Born 1982 – 2000)

The generation categories were described in brief detail, showing how each generation contributes to the shaping of “shared” history, beliefs, and behaviors.  It was also discussed how the unique experiences from one generation to another has influenced intergenerational interactions and communication preferences.

It is important that in order to have effective intergenerational communication, individual focus must be placed on the “value” that each generation brings to the table in order to create a positive and productive environment.  Intergeneration communication involves finding a “common ground” while respecting one another’s differences when working together.   Simply put, effective intergenerational communication will create “synergy” among everyone.


Session N: Creating a Technology-Based Health Literacy Toolkit

From left to right: Anupama Kapadia, BA, Sara Noble, MA, and Melanie Stone, MPH

From left to right: Anupama Kapadia, BA, Sara Noble, MA, and Melanie Stone, MPH

In this interactive workshop, Melanie Stone, Sara Noble, and Anupama Kapadia guided participants through the process of creating a technology-based health literacy toolkit based on their experiences with Access Care, Texas: ACT Together for Health (ACT). ACT is a community service learning project and interprofessional initiative at The University of Texas Health Science Center at San Antonio. Stone, Noble and Kapadia shared how ACT team collaborated with community partners, the San Antonio Health Literacy Initiative and the Enroll SA coalition, to create a health insurance literacy toolkit app that educates community members and health professionals on how to access and utilize health insurance.

The presenters took the participants through the step-by-step process of creating a technology-based health literacy toolkit. First, they presented a scenario based on the health insurance literacy need they identified in the San Antonio community and described how they determined their target population.

Participants were then guided through the process of establishing community partnerships to address a health literacy need.  Participants broke into small groups to brainstorm each step of the process of creating and evaluating a health literacy toolkit. Then they reconvened in a large group discussion to share their insights and ideas. As each step was presented, the shared how ACT approached this part of the process for the development of their health insurance app. They found success in using health professional students as an innovative way to address community needs, the creation of two academic-community partnerships and building a diverse community health coalition.

Noble, Stone, and Kapadia created and shared a workbook with their participants. It was used as an interactive tool throughout the workshop and a post-session resource for participants. Cultural competency was a major factor in the creation of the toolkit and participants were encouraged in small and large group activities to consider literacy level and cultural appropriateness of their messaging and health communication.

Evaluating and disseminating the toolkit was also discussed in both small groups and together as a class. The presenters emphasized the importance of community feedback and promoting the toolkit on a grassroots level. All three presenters actively engaged participants and answered questions about their health literacy programs and initiatives.


Session O: Teach-back: Make It an Always Event

Mary Ann Abrams, MD, MPH

Mary Ann Abrams, MD, MPH

Mary Ann Abrams, MD, MPH; Nationwide Children’s Hospital

Dr. Abrams began her workshop by showing a true-life video of a mother who had overmedicated her son because she had misunderstood the doctor’s instructions. While the story ended without serious injury to the child, it still effectively illustrated the danger of miscommunication. Dr. Abrams then solicited stories of provider/patient misunderstandings from the audience.

With everyone thus actively engaged, Dr. Abrams set out her objectives for participants of the workshop:

  1. Advocate for health literacy and teach-back as key elements of patient safety and quality care
  2. Incorporate the Always Use Teach-back! Toolkit into initiatives to become a more health literate health care organization
  3. Support colleagues in changing individual provider and organizational behaviour to increase use of teach-back

Dr. Abrams then showed a video of a doctor explaining to a mother and son how to use an inhaler for the boy’s exercise-induced asthma. The doctor used technical jargon, rushed through the explanation, and at the end, asked only if the mother and patient had any questions. Participants then discussed the possible results of the doctor’s poor communication, and how he could have handled things differently.

Dr. Abrams talked about teach-back as a quality and safety factor in health care practice and cited a growing body of research that supports the use of teach-back in various settings and populations. She explained what teach-back is:

  • Asking people to explain in their own words what they need to know or do, in a friendly way
  • NOT a test of the patient, but a measure of how well you explained something
  • A way to check for understanding and, if needed, re-explain, then check again

Dr. Abrams introduced participants to the Always Use Teach-back! Toolkit and its two modules: the first for training oneself to use teach-back, and the second for coaching others.

Dr. Abrams described teach-back as in investment, not an add-on to healthcare. She showed various tools within the toolkit for gauging conviction and confidence among providers in their use of teach-back. She emphasized that it is important to circle back to staff trained in teach-back, to observe how they are doing, to encourage and reward their efforts.

Dr. Abrams recommended incorporating teach-back into training, processes, intakes, order sets, and documentation of visits. She gave some additional tips for using teach-back well:

  • “Chunk and Check” when teaching more than one topic. That is, teach the 2-3 main points of the first topic; check for understanding with teach-back; then go on to the next topic.
  • Support teaching with reader-friendly materials.
  • Use teach-back for all key patient education and communication.
  • Document the use of, and response to, teach-back.

The workshop ended with participants splitting up into small groups to either practice teach-back role-playing or discuss how to implement teach-back in their organizations, followed by a group discussion of the exercise.

Always Use Teach-back! Toolkit:


Closing Keynote

From left to right: Michael Villaire, MSLM and Rima Rudd, Sc.D

From left to right: Michael Villaire, MSLM and Rima Rudd, Sc.D

Rima Rudd, Sc.D., Harvard T.H.Chan School of Public Health & Michael Villaire, MSLM, Institute for Healthcare Advancement

Dr. Rima Rudd and Michael Villaire closed the conference with their final thoughts and major takeaways. Rudd’s first observation was that the conference goers, speakers, and poster presenters have taken a leap outside and we are clearly working outside some of the boxes created in the early years of health literacy.

We are no longer myopically focused on the skills of patients but are taking a clear look at the skills and abilities of health professionals and the characteristics of health and healthcare institutions that erect literacy related barriers to information and care. We are also no longer solely focused on the activities within the clinical encounter or taking place with the hospital or medical setting. Instead, we are engaged in public health work with a clear link to issues of disparities and equity, access to information, access to care and services, and the availability of usable and accessible tools for action.

In spite of this progress, we still tend towards a focus on disease management and will need to look at more distant horizons related to the health of our communities, occupational health and safety, environmental health and climate change, disaster preparedness and management. Additionally, we need to be attentive to the voices here calling on us to be aware of discrimination and bias, and calling out for attention to social justice. Rather than label groups of people as hard to reach, we must improve our skills to reach out to people our society has ignored for too long.

At this year’s conference several speakers and presenters highlighted the ways in which academia and clinicians have worked together to implement health literacy best practices to create better health outcomes for their patients. We clearly know and value the scientific insistence on research based practice – putting into practice the findings from well designed research studies. However, the oddity for us is that practice is ahead of the curve and many research studies are still a bit stuck.

Many studies are still focused on who has or who does not have strong literacy skills. Others are still examining the capabilities of patients without considering the other key variables in the equation, such as the communication skills of the health professionals, the context of institutional environments, the writing skills of those who construct key information, forms, and documents, or the missing rigor in the design, development, and piloting of our health tools and texts.

Practice – as represented here in panels and talks, and on posters – is well ahead of the curve and people present here have been moving ahead:

  • to improve communication skills of health providers despite the lack of tools to measure their skills;
  • to train and provide interpreters and navigators to help people through the difficult waters of poorly delivered and poorly designed information and web sites;
  • to translate messages and key information for actual use by the lay public; and
  • to explore how to make up for the missing components related to caring outreach and dignified exchange.

Many of these efforts are accompanied by rigorous evaluation studies. Dr. Rudd articulated the need to shift the bias in publishing from academia to practitioners who are getting at the deeper causes of low health literacy and disparate health outcomes.

Writing and Designing Effective Communication: A Comprehensive Course

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

Jann Keenan and Janet Ohene-Frempong gave a daylong workshop. They provided detailed strategies for how to communicate effectively through both print and online materials. They used samples to illustrate what works and what doesn’t work.

“Health literacy is a subset of health communication,” said Ohene-Frempong. “How we communicate — across all these different media — that’s the issue. The other issue is navigation.”

The presenters explained the reader-centered approach: to engage, support, and motivate readers. And they offered tips for how to implement this approach.

We all have our preconceptions and ignorance. “Each of us is in our own little universe,” said Ohene-Frempong. “That’s why you need to check with the end-user.”

The presenters discussed how to write effective materials. They offered tips on content, organization, and style. They also discussed effective design and page layout.

It’s important to raise awareness in your designer about why design needs to be done a certain way. “You need to get buy-in early on,” Keenan said.

“There tends to be a tension between information and space,” said Ohene-Frempong. “If the information you’re giving readers is crucial, you don’t want to cut out information just to make space. You need to be an advocate for your reader.”

The presenters explained how to assess the readability of text and design and told how to use readability tools and field-testing. They discussed how to revise text and design to improve readability. They also told how to plan a writing project.

The workshop included two group exercises: a writing exercise and a revising exercise. The presenters led the group through the exercises step by step.

“If you have one takeaway from today, it’s that you really have to write for your reader — write for your end-user,” said Keenan. “That’s the only way to make the material clear and effective.”

Cultural Competency and the CLAS Standards

Marian Ryan, PhD, MA, MPH, CHES

Marian Ryan, PhD, MA, MPH, CHES

Marian Ryan began the session with a discussion on defining culture and cultural competence.  She said individuals view the world through a cultural lens and different thoughts and experiences are perceived differently depending on their culture.   She went on to explain that culture is dynamic and “many of us can evolve if we are open to it”.  She explained cultural competence as the ability to “communicate effectively with people that are different than ourselves” and stressed the importance of recognizing “cultural-based practices that dictate or organize us”.

Dr. Ryan commented that cultural competence is important to consider due to the changing of demographics in the US, the impact it can have on the sustainability of a business, and the critical role it plays in healthcare. The socio-cultural background of our clients can also have a large impact on individual members’ health values, beliefs, behaviors, quality of care and health outcomes.

Dr. Ryan stressed on the importance of understanding health disparities and the individuals that are directly impacted by these inequities, such as those with mental illness or low literacy rates.  Providing culturally competent cross-cultural care is key to combating these inequities and she provided effective frameworks that can be used to facilitate cross-cultural communication, such as the LEARN and BATHE models. She concluded with an explanation of the federal mandates that exist to address cultural competency, such as the CLAS Standards, ADA requirements and NCQA MultiCultural Standards.