Promoting Health Literacy Strategies

Promoting Health Literacy
Strategies and Tools to
Enhance Patient Experience
Kevin Progar | Project Manager | RHLC
PICUP Health Disparities Conference 2015

Disclosures
Healthcare Council of Western Pennsylvania is the financial sponsor of the
Regional Health Literacy Coalition and to date has awards from the following:
 Highmark Foundation
 The Fine Foundation
 FISA Foundation
 UPMC Health Plan
 University of Pittsburgh – Clinical & Translational Science Institute
Grant Support
Consultant
With Health Care Improvement Foundation is support of creating a
Pennsylvania Health Literacy Coalition
No Commercial Interests to Disclose
RHLC | ahealthyunderstanding.org

Learning Objectives
 Demonstrate a nuanced understanding of
what health literacy is
 Explain the impact health literacy has on
patient experience
 Identify strategies and tools that address
health literacy and should have a positive
impact on patient experience scores
RHLC | ahealthyunderstanding.org

Plain Language Act of 2010
Straub, Kath. “2014 Federal Plain Language Report Card.” Center for Plain Language. Sourced 09/18/15:
http://centerforplainlanguage.org/wp-content/uploads/2013/08/Who-made-the-grade_-2014-Federal-Plain-Language-Report-
Card-wExamples-2.pdf
In 2014, compliance with the Plain
Writing Act increased. 19
departments fulfilled the
requirements of the Plain Writing
Act, earning A’s for Compliance,
compared with only 12 in 2013.
Only 3 Departments— Education,
Interior, and State—failed…
“
“

Patients Leave Office with Understanding
Rochon, Delia.“Health Literacy: A System Approach to Improve Health.” Presentation to IOM Roundatable. March 2007:
http://iom.nationalacademies.org/Activities/PublicHealth/HealthLiteracy/2007-MAR-29.aspx#sthash.xKctHmHx.dpuf

Rochon, Delia.“Health Literacy: A System Approach to Improve Health.” Presentation to IOM Roundatable. March 2007:
http://iom.nationalacademies.org/Activities/PublicHealth/HealthLiteracy/2007-MAR-29.aspx#sthash.xKctHmHx.dpuf
Health
Literacy
100%

“has a consistent, albeit weak relationship with
patient satisfaction. Future work is needed to clarify
if patients … really receiving different care than
those with higher literacy and to pinpoint the
sources of their more negative responses.
…health literacy…
“
Shea et al. “Health literacy weakly but consistently predicts primary care patient dissatisfaction,”
International Journal for Quality in Health Care 2007; Volume 19, Number 1: pp. 45–49

Can you pinpoint the source
of a negative response?
American Medical Association Foundation, “Health literacy and patient safety: Help patients understand.” Self Produced
Video. 2008. Accessed: https://www.youtube.com/watch?v=cGtTZ_vxjyA&feature=youtu.be&list=PLHUAep-
IIOHFMv0mA0_SZ653L63YocwWF&t=344
/4RHLC

You can’t tell by looking
• White, S., and Dillow, S. (2005). Key Concepts and Features of the 2003 National Assessment of Adult Literacy (NCES 2006-471). U.S. Department of Education.
Washington, DC: National Center for Education Statistics.
• iTriage. “Tracking American Health Literacy and Prescribing Improvement” February 2015: https://about.itriagehealth.com/wp-content/uploads/2015/02/Health-
Literacy-White-Paper_February-2015.pdf

We <3 Health Literacy Blog: http://communicatehealth.com/ RHLC | ahealthyunderstanding.org

We <3 Health Literacy Blog: http://communicatehealth.com/2014/10/wanted-plain-language-consent-forms/

Selected Composites - PA Average
HCAHPS Survey Results (July 2013 to June 2014)
80 80 86
51
0
10
20
30
40
50
60
70
80
90
100
Comm. with
Nurses
Comm. with
Doctors
Discharge
Information
Care Transition
https://data.medicare.gov/Hospital-Compare/Patient-survey-HCAHPS-State/

Selected Composites - PA Average
HCAHPS Survey Results (October 2013 to September 2014)
80 80 87
51
0
10
20
30
40
50
60
70
80
90
100
Comm. with
Nurses
Comm. with
Doctors
Discharge
Information
Care Transition
https://data.medicare.gov/Hospital-Compare/Patient-survey-HCAHPS-State/

Average HCAHPS Response Rate for PA Hospitals

Is that a representative sample?
José Luis Calderón, MD RAND Corporation, Santa Monica UCLA Division of General Internal Medicine & Health
Services Research | Sourced 09/18/15: http://cmore.med.ucla.edu/archive/CAHPS_Cogn_Design_Barriers_CMORE.pdf
Reading Level - CAHPS 5.0 PCMH Item Set

Flesch-Kincaid Grade Level: 14
Flesch Reading Ease: 53
Grade Level: 3
Reading Ease: 82

• White, S., and Dillow, S. (2005). Key Concepts and Features of the 2003 National Assessment of Adult Literacy (NCES 2006-471). U.S. Department of Education. Washington,
DC: National Center for Education Statistics.
• University of Pittsburgh University Center for Social & Urban Research. "Health Literacy Survey of the Pittsburgh Metropolitan Statistical Area." prepared for Regional Health
Literacy Coalition, September 2012.
• iTriage. “Tracking American Health Literacy and Prescribing Improvement” February 2015: https://about.itriagehealth.com/wp-content/uploads/2015/02/Health-Literacy-White-
Paper_February-2015.pdf
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
UCSUR 2012 NAAL 2003 iTriage 2015
Low Marginal Average +
50%
“Proficient”

White, S., and Dillow, S. (2005). Key Concepts and Features of the 2003 National Assessment of Adult Literacy
(NCES 2006-471). U.S. Department of Education. Washington, DC: National Center for Education Statistics.

http://kff.org/quiz/health-insurance-quiz/

1. Your health plan covers in full if you get blood tests in-network
2. But only pays 60% of allowed charges if you go out-of-network
3. You forget to check and go get your blood test out-of-network
4. The lab bills you $100 for the blood test
5. Your health insurance allowed charge is $20 for that test
How much do you pay out of pocket for that test?
a) $ 0
b) $ 40
c) $ 80
d) $ 88
e) Not Sure

How much do you pay
out-of-pocket for that test?
d) $88
You Pay = Bill – 60% of Allowed Charge
= $100 – ( 60% of $20 )
= $100 – $12
= $88

Information & Comfort
Langer Research Associates. “Empowerment and Engagement among Low-income Californians: Enhancing
patient-centered care.” 2012 Blue Shield of California Foundation Survey. Sept 2012.

What topic are we
reading about?
Contest… Out loud. And together…

Dloh eldnah, dna ediug ssolf neewteb hteet gnisu
a eltneg kcab-dna-htrof noitom. Evom ssolf pu
dna nwod tsniaga ruoy htoot ot pleh evomer
euqalp dna doof selcitrap evoba dna woleb eht
enilmug. Esnir ssolf sa dedeen, dna taeper rof
hcae htoot. Ot esu eht kcip, ecalp eht pit fo eht
kcip neewteb ruoy hteet ta eht enilmug…

https://www.pinterest.com/ambilow/kindergarten-dental-health/

Strategy 1
Don’t Rely on
Documents

Auditory Visual
Read / Write Kinesthetic
Learning Styles

http://www.graphicmedicine.org/tag/diabetes/

Understand
Clarify
Assess
Explain

www.teachbacktraining.org
 Factsheets
 Online Learning Modules
 Conviction and Confidence Scales
 Coaching Tips & Tricks
 Guidance to Make It an Always Event

Carolinas Heath System Collaborative
Noonan, Laura. “On Becoming a Health Literate Organization: A Journey with Urgency.”
Presentation: Wisconsin Health Literacy Summit 2015.
Goal 6: Patient Feedback Question #4
Comfortable Asking Questions
0%
25%
50%
75%
100%
May
(n=4)
Jun
(n=7)
Jul
(n=9)
Aug
(n=11)
Sep
(n=13)
Oct
(n=16)
Nov
(n=19)
Dec
(n=20)
Jan
(n=18)
Feb
(n=18)
Mar
(n=15)
Apr
(n=14)
Month (n= # of teams reporting)
Avg%YesReponses
Percent Indicating Comfortable Asking Questions Goal = 100% Yes
Goal 7: Achieve a Team Rating of 4.0
(4.0 = Significant Improvement)
0.00
1.00
2.00
3.00
4.00
5.00
May
(n=25)
Jun
(n=25)
Jul
(n=25)
Aug
(n=25)
Sep
(n=25)
Oct
(n=25)
Nov
(n=25)
Dec
(n=25)
Jan
(n=23)
Feb
(n=23)
Mar
(n=21)
Apr
(n=21)
AvgTeamRating
Mean Goal = 4.0
Goal 1: Successful Use of Teach Back
0%
25%
50%
75%
100%
May
(n=6)
Jun
(n=5)
Jul
(n=9)
Aug
(n=10)
Sep
(n=13)
Oct
(n=17)
Nov
(n=17)
Dec
(n=20)
Jan
(n=19)
Feb
(n=19)
Mar
(n=18)
Apr
(n=16)
Avg%SuccessfulTeachBack
Demonstration
Avg % Observing Successful Teach Back Demonstration Goal = 75%
Goal 2: Successful Use of Ask Me 3
0%
25%
50%
75%
100%
May
(n=5)
Jun
(n=5)
Jul
(n=9)
Aug
(n=10)
Sep
(n=14)
Oct
(n=17)
Nov
(n=17)
Dec
(n=19)
Jan
(n=18)
Feb
(n=17)
Mar
(n=17)
Apr
(n=15)
Avg%ObservingSuccessfulAskMe3
Demonstration
Avg % Observing Successful Ask Me 3 Demonstration Goal = 75%
Goal 3: Completion of HL Education Module
0%
25%
50%
75%
100%
May
(n=11)
Jun
(n=14)
Jul
(n=18)
Aug
(n=17)
Sep
(n=25)
Oct
(n=25)
Nov
(n=23)
Dec
(n=22)
Jan
(n=19)
Feb
(n=21)
Mar
(n=20)
Apr
(n=19)
Avg%CompletingHLEducationModule
Avg % Completing HL Education Module Goal = 100%
Goals 4-5: Achieve a Change Score of 11.00
1.00
3.00
5.00
7.00
9.00
11.00
13.00
May
(n=22)
Jun
(n=24)
Jul
(n=23)
Aug
(n=22)
Sep
(n=23)
Oct
(n=21)
Nov
(n=21)
Dec
(n=21)
Jan
(n=17)
Feb
(n=21)
Mar
(n=18)
Apr
(n=15)
AvgChangeScore
Mean Goal = 11
MD Communication
0%
25%
50%
75%
100%
May
(n=4)
Jun
(n=7)
Jul
(n=9)
Aug
(n=11)
Sep
(n=13)
Oct
(n=16)
Nov
(n=18)
Dec
(n=20)
Jan
(n=17)
Feb
(n=17)
Mar
(n=14)
Apr
(n=14)
Avg%ExcellentResponse
Excellent Goal = 75% Excellent
Non-MD Communication
0%
25%
50%
75%
100%
May
(n=4)
Jun
(n=7)
Jul
(n=9)
Aug
(n=11)
Sep
(n=13)
Oct
(n=16)
Nov
(n=19)
Dec
(n=20)
Jan
(n=17)
Feb
(n=17)
Mar
(n=14)
Apr
(n=14)
Avg%ExcellentResponse
Excellent Goal = 75% Excellent
Questions Were Encouraged
0%
25%
50%
75%
100%
May
(n=4)
Jun
(n=7)
Jul
(n=9)
Aug
(n=11)
Sep
(n=13)
Oct
(n=16)
Nov
(n=19)
Dec
(n=20)
Jan
(n=18)
Feb
(n=18)
Mar
(n=15)
Apr
(n=14)
Avg%YesResponses
Percent Indicating Questions Encouraged Goal = 100% Yes

0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Percent
Weeks
Percentage of Patients requiring Repeat Teach Back
Percentage Goal Median

0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Rating
Weeks
Patient and Staff Satisfaction
Patient Satisfaction Staff Satisfaction Goal

http://25.media.tumblr.com/tumblr_mc183cq5YN1rnvzfwo1_r1_500.jpg

When in doubt… Don’t
 Italicize anything
 PUT IT IN ALL-CAPS
 Or bold things at random
Especially don’t MIX your emphasis

Generally … Do
 Chose action verbs
 Avoid jargon
 Test it
Engage the people you write for

Basic Design for Print
• THE Message
Headings
• Sans Serif
Type
• One Idea / LineBullets /
Chunks
• Less is More
White Space
• Or Don’t Use ThemImages Tell a
Story

Tool 2
Clear
Communication
Index

Clear Communication Index
 4 Questions
 20 Scored Items
 1 Easy Objective Tool
Is an evidenced-based tool developed by
the CDC based on the most popular and
effective checklist and readability measures.

It is the style of Abraham Lincoln,
Mark Twain, and Winston Churchill
Plain language has to do with clear
and effective communication—
nothing more or less
Kimble J. Answering the critics of plain language. The Scribes Journal of Legal Writing 1994-1995;5:51-85.
Available at www.plainlanguage.gov/whyPL/arguments_in_favor/index.cfm.
“ “

Strategy 3
Take Universal
Precautions

10 Attributes 1. Leadership Promotes
2. Plans, Evaluates, and
Improves
3. Prepares Workforce
4. Includes Consumers
5. Meets Needs of All
6. Communicates Effectively
7. Ensures Easy Access
8. Designs Easy to Use
Materials
9. Targets High Risk
10.Explains Coverage and Cost
Brach C, Keller D, Hernandez LM, et al. Ten Attributes of
Health Literate Health Care Organizations. Washington,
DC: National Academy of Sciences, 2012.

Tool 3
Guidebook to Achieving
Organizational Change

Building Health Literate
Organizations:
https://www.unitypoint.org/health-literacy-guidebook.aspx

“We can never get the resources to comprehensively
change literacy, never mind health literacy, at population
levels—that is unrealistic. What health systems can do is
employ the methods of user-centered design to make
things easier—and in this way help to transform the
culture of medicine.
“
Dominick L. Frosch & Glyn Elwyn (2014) Don't Blame Patients, Engage Them:
Transforming Health Systems to Address Health Literacy, Journal of Health Communication:
International Perspectives, 19:sup2, 10-14. http://dx.doi.org/10.1080/10810730.2014.950548

Recap
It’s Time. There Are Tools.
And It Improves Patient Experience.
Teach-back to Confirm Understanding
Everyone Likes It Better
Don’t Rely on Documents…
Write Simply…
Take Universal Precautions…

ahealthyunderstanding.org
kevin@ahealthyunderstanding.org
724.772.8343
Working with communities, health care providers,
universities, and you to make the health system
person-centered and easy to use

Promoting Health Literacy Strategies

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