Cathy Meade began the session by discussing ways in which organizations can develop interventions that are tailored to the communities they serve. In order to establish these interventions, Dr. Meade suggests pulling together different members of the community to gather their perspective on issues that surround the community.
Dr. Meade suggested interventions involve a “top down then bottom up” methodology. This methodology implies that an evidence based curriculum is reviewed by the target population and then should be tailored to meet their needs.
To conclude the session, Dr. Meade gave an example from her field work of how utilization of all the components can lead to culturally relevant interventions.
Michael Villaire gave an introduction to the field of health literacy. He began by defining health literacy. His favorite definition is the one from the 2008 Calgary Charter: “Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.” Villaire prefers this definition because “it puts the onus for health literacy on the provider, as well as the consumer.”
The healthcare system is bewildering to many people, Villaire said. He gave the example of the challenges people face in signing up for health insurance under the Affordable Care Act. Villaire talked about the components of health literacy: reading and writing, listening and verbal communication, numeracy, and self-efficacy. He gave some illustrations of how challenging numeracy is for many of us.
Villaire talked about the relationship between health literacy and culture. He noted that there is often a mismatch between provider demand and patient skill level, as well as between reading level and materials. And he discussed health literacy’s strong relationship with safety, quality, and health disparities. It can be hard to move an organization forward to health literacy. But “there are certain terms that will help you move forward with your goals. Two words: safety, quality,” Villaire said.
Examples were shared of how patients can be harmed when providers fail to give clear instructions. He put the burden on providers to improve their communication. “The fact that someone does not understand the way we choose to communicate is not their problem. It’s a barrier. It’s something we need to address,” Villaire said. “Health literacy is about dealing with the barriers.”
Villaire discussed health literacy myths and listed the barriers to health literacy. He also offered health literacy statistics and noted that people don’t like to admit they don’t read well because they are ashamed, therefore limited literacy is under-reported. He closed the session by explaining why health literacy matters and discussed the impact of low health literacy.
Jann Keenan and Janet Ohene-Frempong explained how to integrate health literacy into your organization. They listed issues to consider along the way.
They noted that health literacy reform has worked in pharmaceutical companies, the insurance industry, state health departments, hospitals, and government agencies. They believe that this is “a golden age for organizational change”.
A health literate organization makes it easier for people to navigate, understand, and use information and services so they can take care of their health, the presenters said. They listed the Institute of Medicine’s implied action steps for becoming a health literate organization:
- Make health literacy integral to your mission, structure, and operations.
- Integrate health literacy into planning, evaluation measures, patient safety, and quality improvement.
- Prepare your workforce to be health literate and monitor your progress at doing so.
- Include populations served in the design, implementation, and evaluation of health information and services.
- Meet the needs of populations that have a range of health literacy skills, while avoiding stigmatization.
- Use health literacy strategies in interpersonal communication and confirm understanding at all points of contact.
- Provide easy access to health information and services and navigation assistance.
- Design and distributes print, audiovisual, and social media content that is easy to understand and act on.
- Address health literacy in high-risk situations, including care transitions and communications about medicines.
- Communicate clearly what health plans cover and what individuals will have to pay for services.
The presenters discussed some common roadblocks to integrating health literacy into an organization:
- A lack of compassion and commitment
- A lack of time and money
- Legal and regulatory requirements
- The need to hire, train, and retain staff
- The need for industry specific guidelines
- The challenge of including marginal readers
- The challenges of health system complexity
They offered detailed strategies for how to navigate these roadblocks, based on the IOM’s guidelines.
Dr. Kavita Patel was unable to attend the conference in person due to health problems, but joined the conference by Skype. She talked about problems with healthcare in the U.S. and how “one of the most common myths… is that the U.S. has the best healthcare in the world.” This may be true for some Americans, but compared to other countries, we are not getting good value for our healthcare dollars, she said. That’s why the Affordable Care Act (ACA) is so significant, but sometimes that gets lost in all the discussion about enrollment.
The ACA is bringing sweeping changes to all sectors of healthcare, impacting hospitals, makers of medical devices, health insurance companies, and employers. Although some aspects of the ACA have been delayed, like the employer mandate and applicant verification, many of these changes have already come to pass:
- Expanded access to coverage by building on the existing healthcare system
- More competitive and transparent healthcare markets
- Reformed the health insurance market and hold insurers accountable
- Simplified healthcare administration and reduction in waste, fraud, and abuse
- Improved quality and delivery systems to lower costs
- Focus on prevention and wellness
Dr. Patel talked about polling on the ACA. She noted that while many Americans don’t like “Obamacare,” some specific ACA provisions are very popular — such as getting rid of preexisting conditions and keeping 26-year-olds on their parents’ health insurance. “So there are some messaging problems,” she said.
She discussed how health literacy intersects with the ACA. She listed the Institute of Medicine’s attributes of a health literate organization and laid out a health literacy agenda. Dr. Patel illustrated how low health literacy is costly in both human and financial terms. “You can make a business case, a patient case, and a provider case for health literacy,” Dr. Patel said.
Dr. Patel listed questions every consumer and provider should ask about health insurance. They are based on a project called Let’s Ask 4: What are my choices for health insurance?, How do I get it?, How do I use it?, How much will it cost me? Dr. Patel closed with examples of health literate consumer guides.
Ellen Peters gave an introduction to numeracy. She also discussed how numeracy is relevant to the Affordable Care Act (ACA). Numbers instruct, inform, and give meaning to information about health plans, medicines, and treatments, Peters said.
But not all people can understand and use numbers effectively. Even highly educated people can be innumerate, she said. Less numerate people are more likely to be female, older, less educated, and poor. Plus, they are less likely to have health insurance, Peters said. Thus, the average numeracy skills in the ACA population will be lower than those of currently insured consumers. The newly insured will also have less knowledge and experience in healthcare settings, Peters said. “They may not know as well how to be a good patient — how to interact with doctors and nurses, how to record symptoms.”
Peters talked about numeracy skills that we learn in school. She also listed numeracy skills that we use to make decisions. We use these skills when we:
- Seek information
- Pay attention to numeric information
- Ignore irrelevant information
- Recall numeric information
- Are sensitive to numeric information
- Derive affective meaning from numeric information
Peters gave some examples of using numeracy. “Healthcare providers often underestimate how difficult these tasks are. And patients are often reluctant to admit that they don’t understand,” she said.
The way information is presented can reduce numeracy differences, Peters said. She offered strategies for providers to communicate with less numerate people:
- Provide numeric information. “Numbers help whether you’re more numerate or less numerate,” she said.
- Do the math for people.
- Provide evaluative meaning, particularly when numeric information is unfamiliar. “If people don’t know how good or bad the number is, they’re not able to use the information,” Peters said. But take care when providing evaluative meaning, because it’s a big responsibility.
- Draw attention to important information.
- Set up appropriate systems to assist consumers and patients.
McKinney and Neuhauser moderated a panel discussion with adult literacy tutors and learners from Read Orange County, a local library program. The panel — tutors Barbara, Al and Fritzi, and learners Van and Jay, and Jay’s mother — shared their expertise for communicating health messages respectfully, clearly and effectively.
The co-hosts indicated that the best way to communicate is by interacting as a shared team – on equal footing, as partners who determine goals, barriers and what works well. Tutors have information about their learners before they meet, including an assessment of what the learners can and can’t do and what they want to accomplish. Tutors and learners then meet at a library or another public place for about an hour twice a week.
The tutors first establish short-term goals (perhaps reading a book) and long-term goals (e.g., getting a driver’s license). They establish a rapport and require learners to show comprehension (not yes or no). They explained that it’s important to use open-ended questions and to convey you’re there as a friend to help them. The tutors get to know their learners’ interests and family dynamics so they can relate to them, break down roadblocks and build confidence. Each learner has strengths in other areas – not just challenges with reading and writing.
The co-hosts listed several sources for finding local literacy programs:
- America’s Literacy Directory – lincs.ed.gov
- Proliteracy – proliteracy.org
- Ask your local library
At the end of the panel discussion, Jay, one of the learners, sang several bars of Louis Armstrong’s song – What a Wonderful World!
Catina O’Leary, Kelly Ferrara, and Ryan Barker discussed the strengths and difficulties of the Cover Missouri Coalition and how they collaboratively reached a total of 152,335 enrollments.
The Coalition was established due to the recognition that state was not in full support of Affordable Care Act and as such the state and some county health departments could not participate in outreach and education for the Federal Marketplace.
Although the main goal of the Coalition is to “reduce the uninsured rate to less than 5% in the next 5 years” they believe that “it’s more than that”. Their initiative seeks to “increase access to healthcare, preventative care, and create real change with real peoples’ lives”. In order to accomplish this goal the coalition mentioned that using and understanding health insurance is a multistep process. As such, the coalition worked with different organizations and groups that would help at each step to increase health literacy. This multilayer approach included working with physicians on communication, translating material to be disseminated in outreach, and working with community members to ensure materials were culturally sensitive.
Some of the key ingredients to their success were having an active facilitator who positively and enthusiastically encouraged participation, developing a digital drop box to make material readily available, and face to face interaction, which was vital to outreach and engagement.
Hudson and Butler talked about their experiences leading communication workshops for patients and providers. The workshops train patients on how to be better patients and train providers on how to be better providers. Patients can include people with a certain disease, seniors, new or expectant parents, and LGBT people. Providers can include students and practicing doctors and you can tailor your case to that particular group. The presenters offered some guidelines for holding a workshop. You’ll need partners, time, travel, and money. But it can be done inexpensively, they said.
Before the workshop, you may want to:
- Coordinate and prepare the meeting
- Recruit a group
- Find out what their issues are, and choose an appropriate case
- Recruit and train people to act in role-plays
- Train a facilitator
- Market and promote the workshop
During the workshop, you may want to:
- Conduct a pre-workshop survey
- Talk about health literacy
- Encourage learners to share their stories
- Conduct role-plays
- Discuss in small groups
- Debrief in large group
- Conduct a post-workshop survey
After the workshop, you may want to:
- Report on the process and forms
- Submit completed surveys
The presenters showed public service announcements about being an active consumer. The PSAs show how consumers who are happy to ask questions in other contexts can be very quiet and passive in a doctor’s office. All of us are more likely to have low health literacy during times of stress and in unfamiliar contexts. That’s why we need universal precautions. The presenters have had positive results with their workshops. “In small-group sessions, countless times, I’ve seen the light bulb go on with the simulated doctor,” said Butler. “I think there’s a lot of opportunity within the Affordable Care Act (ACA) to fund some of these initiatives.”
Dr. Michael Paasche-Orlow discussed ways to reduced hospital readmissions. He focused on what Boston University Medical Center has done to lower these rates. He noted that under the Affordable Care Act (ACA), there are incentives for hospitals to avoid rehospitalization. The goal of avoiding rehospitalization is to improve quality and decrease cost, he said.
Hospital discharges are not standardized and are frequently of poor quality. Too often, pending test results are not followed, workups are not completed, and communication is poor. This leads to lack of follow-up care, adverse events, and readmission. This is especially true for patients with poor communication skills, he said.
“We used talk about fee for service; now we talk about fee for value,” he said. “Literacy is a part of that story. There’s a lot of work to be done to transform our organizations.”
Dr. Paasche-Orlow shared the National Quality Forum’s Re-Engineered Discharge checklist:
- Ascertain need for and obtain language assistance.
- Make appointments for follow-up care.
- Plan for follow up of results from pending tests.
- Organize post discharge services and equipment.
- Identify correct medicines and plan for patient to obtain.
- Reconcile discharge plan with national guidelines.
- Teach a written discharge plan that patient can understand.
- Reconcile discharge plan with National Guidelines.
- Educate patient about diagnoses and medicines.
- Assess degree of patient’s understanding of plan.
- Expedite transmission of discharge summary to primary care provider.
- Reinforce through telephone contact.
Studies have found that using the RED checklist is effective and saves money and he offered illustrations of how to put these items into effect.
Transforming a system takes time, and when introducing teachback, “you have to actually supervise it, observe it, and offer feedback.” When working to transform the system, Dr. Paasche-Orlow encouraged attendees to find people who will embrace the work and engage patients.
Hoffman, Rikard and Hughley led a lively interactive session on using Twitter and tweet chat, to communicate with people all over the world.
Twitter is a microblogging platform to access resources you wouldn’t have otherwise — to drive people to your organization’s website, reach experts and stakeholder communities, and connect with them offline. Twitter is also a flexible up-to-the-minute news service; make it whatever you want.
The co-hosts described the culture and language of the twitterverse, including hashtags, retweets, favorites and mentions. They also conducted several activities with the audience, including how to turn a long section into an effective tweet (140 characters or less) with a health literacy focus and setting up an account on tweetchat.com.
They also discussed symplur.com, a measuring company for healthcare tweets, where you can have your hashtags registered and approved at no charge. The company indicates that healthcare tweets are trending upward. Each day, there are 1 million tweets related to healthcare!