October 13, 2015 — Blog Post
Improve Healthcare Transitions by Addressing Health Literacy
I have had an incredibly blessed life. However, I also know that I have experienced tremendous privilege. There was never any hunger or housing insecurity, violence or social dislocation. From a young age my parents told me, “The world is your oyster. You can do whatever you want.” And I believed them! And they said, “Really, you can be a cardiologist, or a pulmonologist, a radiologist, even a pediatrician, anything you want!” And so, I am an internist, clinical epidemiologist and health services investigator with a research focus on health literacy. My parents say, “He’s a doctor, AND he tries to make the health care system easier to use – you agree, it’s too complicated.”
What is health literacy and why would it have anything to do with care transitions? Well, in a sense, health literacy means being drawn to circumstances that are complicated for patients and their families – and figuring out how to make things easier – in particular, easier for people who have had limited education. And care transitions are extremely complicated! Liminal moments are anxiety provoking enough – and then we in healthcare pile on a tremendous amount of unneeded complexity and confusion.
If I were selling used cars and 20 percent of them came back on the lot broken down within a month, you’d say I was a scoundrel and invoke ‘lemon’ laws to shut me down. Well, about 20 percent of Medicare patients are readmitted to the hospital within 30 days! It is a bad product. These events are costly and many of them are avoidable and bad for patients. We can and must do better.
I have been involved with a series of projects over the past decade to improve care transitions and have seen that an amalgam of patient safety and health literacy principles can have a significant impact. In Project RED (Re-Engineered Discharge), we reduced coming back to the emergency department or hospital by a third. We have implemented this approach in other hospitals and other types of facilities, such as acute rehab settings.
These types of projects demand and deserve a dedicated energetic interdisciplinary team, an executive sponsor that gives the project the power it will need to succeed, and a project manager that holds people accountable to their commitments and timeline (whew!). Some of the key observations regarding health literacy in this context:
- Massively increase support for patient education and empowerment. This needs to be done throughout the hospital stay and continue afterwards with telephone follow up and at a post-discharge visit in primary care.
- Stop giving patients materials that they cannot and will not use. Create care plans that are personalized, easy to understand, and oriented to action. Less is more! Use these as tools in your work with patients so they can see their care plan as a tool for their empowerment.
- Shift the default. Instead of patients having the responsibility to ask questions if they do not understand something, establish a new paradigm in which it is our responsibility to make sure that patients understood their care plan. This can be done with the teach-back (e.g., “I want to make sure I explained this well, tell me please, what medicines you will be taking…”).
- Establish a plan for when things do not go right. Despite the best laid plans, there are many things that can and do go wrong and become complex navigation challenges for patients. What should the patient do? Understand common failure modes, figure out a plan that will work for your organization, and then make it easy for patients with one number they can call at all times to get help.
What is health literacy? It is the realization that health care and public health systems have been designed by and for highly educated and empowered people. And that it will take work to design better systems.
What is health literacy? It is a movement for health equity. It is a challenge to the basic underlying injustice of a society that perpetuates an educational caste system that promulgates massive disparities in health outcomes.
What is health literacy? It is a challenge: What will you do with your educational privilege? How will you use your creativity and energy to ameliorate health literacy barriers, remove unneeded complexity, and massively improve education and empowerment for our most vulnerable patients? Find things that you are passionate about and that are complicated for patients and their families and you are doing health literacy.