Appendix C

Improving Health and the Bottom Line: The Case for Health Literacy

By
Stan Hudson, M.A., CDFT
R. V. Rikard, Ph.D.
Ioana Staiculescu, M.P.H., CDFT
Karen Edison, M.D.

Commissioned by the Roundtable on Health Literacy
Health and Medicine Division
of the National Academies of Sciences, Engineering, and Medicine¹

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¹ The authors are responsible for the content of this article, which does not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine.

Stan Hudson, M.A., CDFT

Center for Health Policy

School of Medicine

University of Missouri

DC375.10 MA105D

Columbia, MO 65212

Phone: 573-884-7549

Email: hudsonst@health.missouri.edu

R. V. Rikard, Ph.D.

Department of Media and Information

Michigan State University

409 Comm Arts, 404 Wilson Road

East Lansing, MI 48824

Phone: 919-995-2721

Email: rvrikard@msu.edu

Ioana Staiculescu, M.P.H., CDFT

Center for Health Policy

School of Medicine

University of Missouri

DC375.10 MA105C

Columbia, MO 65212

Phone: 573-882-6486

Email: staiculescui@health.missouri.edu

Karen Edison, M.D.

University of Missouri Health System

DC19, MA111

Columbia, MO 65212

Phone: 573-884-6415

Email: EdisonK@health.missouri.edu

Corresponding Author:

Stan Hudson, M.A., CDFT

Disclaimer: The authors are responsible for the content of this article, which does not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine (the National Academies), the University of Missouri (UM), or Michigan State University (MSU).

Disclosures: The authors report no significant conflicts or financial disclosures related to this work.

Acknowledgments: There are organizations and people we want to thank. First, we thank the National Academies of Sciences, Engineering, and Medicine (the National Academies) for this exciting opportunity to make the case for health literacy. Specifically, we want to thank Lyla Hernandez, National Academies staff, and members of the Roundtable on Health Literacy for their continued support and efforts to promote health literacy in all aspects of life.

In addition, we would like to thank the diverse researchers and practitioners across the field of health literacy who took time out to discuss the case and share their own experiences, work, and findings with us. Thank you Andrew Pleasant, Ann Gakumo, Audrey Riffenburgh, Bet Wong, Catina O’Leary, Chris Trudeau, Christina Cordero, Cliff Coleman, Cynthia Baur, Darren DeWalt, David Fleming, Diane Levin-Zamir, Elizabeth Fogle, Geri Lynn Baumblatt, Glenna Bailey, Greg Smith, Jeff Greene, Jennifer Dillaha, Joy Deupree, Julie McKinney, Katheryn Anderson, Kathleen Meehan, Kristie Hadden, Laura Noonan, Laurie Francis, Laurie Myers, Linda Shepard, Lori Henault, Ludmilla Wikkeling-Scott, Michael Paasche-Orlow, Michael Villaire, Michael Wolf, Michele Erikson, Nick Collatos, Penny Chumley, Polly Smith, Ruth Parker, Shelby Chapman, Steve Rush, Steve Sparks, Terry Davis, and Tonya Meyer. We would also like to thank Jordan Valley Health Center and Southeast Health for allowing us to include their quality improvement work. Last, thank you to Dave Zellmer for his plain language and health literacy assistance in creating the fact sheets and executive summary. Without the assistance and support from every one of these individuals and organizations, this report would not have been possible.

Funding: This work was commissioned by the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Health Literacy.

EXECUTIVE SUMMARY

What Is the Case for Health Literacy?

Health care is a business. At the same time, health literacy is a way to bring down costs and improve value. When health systems and those who work in health care use health literate methods, there is a better chance that patients will know what they need to do and they should be able to act and manage their health.

Health literacy is not just the right thing to do for the patient. It is also the right thing to do to make sure we control costs and improve quality. We need this as we switch our payment model to value-based purchasing. The business model we have now for providing health care is moving from one where we make money by using more health care. Soon, providers will make the most money when they keep people in better health and out of the hospital. Health literacy is a vital tool to aid in this movement.

We looked at many factors to make the case. They include the effect that health literacy has on:

• The quality of care
• The cost of care
• Providing equitable care
• The health of communities
• The care experience of patients and providers

Plus, we tried to find out if changing the way we pay for health care (as well as other rules) would lead to improved health literate methods for health systems and those who work in health care.

Where Did We Find the Information?

We found the information through three distinct ways. To start, we searched for research that showed health literacy’s effect on one of the factors above. Next, we reached out and interviewed those who work in the field of health literacy. We asked them to send us all research they might have that showed the effect of health literacy. Then, we sent out a survey to those who work the field of health literacy. We asked them for their own stories about health literacy programs that work well in communities, clinics, and adult classes.

Why Is Health Literacy So Vital?

Most of the time, health literacy is known as one’s ability to find, know, and use health information to make choices each day. Plus, to be health literate means health systems and health providers must teach patients in such a way that helps the patient use what they have been taught with ease. That means that all who work in health care need to do all they can to help get rid of any health literacy problems patients (or their loved ones and caregivers) may face. The use of good health literacy is vital for all who work in health care from the “top down and bottom up.” Those who work in public health need to do this, too.

The Business Case

In the United States, low health literacy is estimated to cost $105 billion to $238 billion each year in direct health care costs. Indirect costs are between $1.6 trillion and $3.6 trillion each year. Good health literacy plans can take more than one form. All forms are set up to help patients (as well as their loved ones and caregivers) make their way through detailed health information and systems to get the care they need and stay in good health. Health literacy cuts health care costs through:

• Fewer emergency department (ED) visits
• Fewer hospital readmissions
• More screenings to prevent illness and increase medicine adherence
• Fewer dosing errors

Good health literacy plans work to change how patients act, which, in turn, can lead to fewer costs for people, systems, and society. Giving help through written guides and speech helps patients find their way through health systems. Plus, a good plan can help patients get the follow-up care they need. This would be for things like coming in for follow-up visits or to report their weight each day. A good plan can lead to more control of chronic illness such as asthma, diabetes, and high blood pressure. A change in what a patient understands can lead them to do as their doctor or nurse asks and lead to fewer stays in the hospital. Public health literacy plans have been found to reduce the chance for disease.

If done right, a change in the way a patient acts can lead to better health outcomes, both for the patent and for health systems. With more knowledge and better care for chronic illness, health literacy helps to cut down on:

• Days in a hospital
• Needless ED use

• Preventable hospitalizations
• Readmission rates

At the same time, it helps to make the health of communities better. These are just a few of the improved health outcomes. The full report gives this and more evidence for how health literacy can change health outcomes through better care at less cost.

A good health literacy plan also helps the patient make good health choices. They will be more satisfied with their health care, too. This builds trust and rapport for both patients and providers. This trust helps a patient to learn more. Plus, the trust helps to align health care goals set by the patient and doctor. Research has shown that hospitals with more satisfied patients make more money. Furthermore, there are some value-based payment models being designed now. These models have bonus payments linked to how many satisfied patients a health system has. The use of these new models will help make the financial case for health literacy.

The Ethical Case

Health literacy is the right thing to do to reduce health disparities and provide equal care for all. Good health literacy plans have been found to reduce the effect of race and sex for some health outcomes. And good plans tend to reduce racial and ethnic health disparities as well.

Health literacy is also the right thing to do to meet the policy demands we have now. For example, the Patient Protection and Affordable Care Act (ACA) has many terms that must be met that deal with health care that is based on Culturally and Linguistically Appropriate Standards (CLAS). CLAS were designed by the U.S. Department of Health and Human Services. Plus, the ACA makes a point to emphasize that health literacy must be a part of all health care training. The ACA also streamlines the way patients sign up for health insurance. Those who sell health insurance must write summaries in such a way that patients can know what their plan covers and how. And the summary must have clear and concise health information. In much the same way, the rules set up by the Centers for Medicare & Medicaid Services (CMS) state the same thing. The rules state that health care providers must teach patients in a way that gives the patient the chance to know what to do to get to or stay in good health.

The United States does not have a central health agency to set up rules for how best to deliver health care. Because of this, from time to time payment models serve as the main force to shape the way we provide health care. At this time, in the United States we often pay for the amount of health care we give. As payment methods shift, we will soon pay for the quality of health care we give.

As such, we would like to note that the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) set up new rules that pay health systems and clinics to use health literacy methods. These methods help the patient get more engaged to manage their health care, as well as improve the course of their care.

Health Literacy and the Future

There is more and more proof that using health literacy strategies reduces costs while boosting the quality, equity, and access to health care—all while making the health care of the patient better. As payment models change, clinics and health systems need to put good health literacy practices in place that help the health of their patients, communities, and profits. Once we have done that, then we can better meet future health reforms and challenges.

In the appendices of this report you will find fact sheets that show the benefits of health literacy on cost, quality, equity, outcomes, behavior change, and satisfaction. Please use these with local, state, and federal policy makers to allow them to make more informed decisions to prepare patients and health systems for the future.

INTRODUCTION

The Roundtable on Health Literacy, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, commissioned the Center for Health Policy, School of Medicine, University of Missouri, as well as a health literacy expert from Michigan State University, to build the case that health literacy is important for everyone. A key principle of health literacy is to know and understand your audience. Previous roundtable commissioned papers focus on disseminating the latest academic research. Our paper goes beyond the usual readership to gain traction in the corporate offices of hospitals and health systems. This report is accompanied by a health literate, plain language executive summary and fact sheets designed specifically for policy makers.

We expand on a broad definition of health literacy that Sorensen and colleagues (2012, p. 3) developed as our guide:

Add to this that until we begin teaching health literacy as a life skill in elementary and secondary education like reading, writing, and math, we cannot blame the victim by placing the sole responsibility on patients, family members, and caregivers. The health system and health professionals must take responsibility to simplify systems and information, as well as provide support to minimize all potential health literacy challenges that people face.

Many cases could be made for the importance of integrating and addressing health literacy. We make numerous cases, which fall under two primary categories:

• The business case, which includes health literacy’s effect on cost, quality, behavior, access, and patient experience, and
• The ethical case, which includes health literacy’s effect on health equity, as well as the legal/regulatory case.

The roundtable asked us to bring together evidence on the effect of health literacy in achieving the Quadruple Aim (Bodenheimer and Sinsky, 2014). The Quadruple Aim framework focuses on health literacy as a primary way to: (1) enhance the quality of care, (2) improve the health of communities, (3) reduce costs, and (4) improve the care and experience of patients and providers. Health literacy is especially important for those people who experience medication errors, higher rates of hospitalization and emergency room use, poorer health outcomes, and increased illness and early death (Williams and Parker, 1995). Through numerous scoping reviews, a survey of the field, and informal interviews with key health literacy informants, we have attempted to gather as much evidence as possible about health literacy’s best and promising practices and their implications for health care delivery and public health in America. We hope that advocates use this evidence to put into action best practices in places where people live, learn, work, play, and heal together.

METHODS

Best Practices (Peer-Reviewed)

One of the authors maintains an extensive database of peer-reviewed health literacy research. He identified peer-reviewed evidence through a comprehensive review of pertinent literature from his and existing databases for peer-reviewed articles that address at least one or more of the four foundational issues of health literacy within the Quadruple Aim framework. In addition, through scoping literature searches, we incorporated recently published and submitted articles and manuscripts.

We began the citation collection process by searching for the phrase “health literacy” in either the title, abstract, or keywords of peer-reviewed articles published from 1950 to August 2017 and indexed all articles in research databases. The databases included PubMed, ISI Web of Science, Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycARTICLES, Ingenta, ProQuest, and Science Direct. Conducting multiple searches within and across the databases yielded duplicate citation data. Duplicate citations were removed and/or collapsed into a single citation. From 1950 to August 2017 there were 13,509 unique articles that included the phrase “health literacy” in the title, abstract, or keywords. We also used Google Scholar to fill in missing citation information.

Promising Practices (Not Peer-Reviewed)

The team searched the grey literature using MedNar, EthOS, OpenDOAR, and Worldwidescience. The team also reached out to their respective colleagues and networks and posted repeated messages to the Health Literacy Discussion List (HLDL) requesting people to identify any non-peer-reviewed evidence and promising practices of the effect of health literacy on cost, quality, access, satisfaction, equity, behavior change, organizational change, and other issues outlined in the workshop’s Statement of Task. The team also requested that everyone send us any recently published articles and/or manuscripts submitted for peer review that are relevant to the overall project but not in publication yet. We posted the same request to several health literacy discussion groups on LinkedIn as well as Twitter, Facebook, Google+, and Google Newsstand.

We designed and implemented a survey of health literacy professionals to further collect non-peer-reviewed literature and anecdotal evidence (stories) that highlight and humanize best and promising practices from community-based initiatives, clinical quality improvement programs, adult learning settings, and public health campaigns.

Survey Results

The survey was conducted between June 23, 2017, and July 15, 2017. The responses (n = 138) were collected using the online survey application Qualtrics.² The survey was distributed via the HLDL, LinkedIn, and Twitter. If we found existing policies, programs, or initiatives that met the framework criteria outlined in the Roundtable on Health Literacy’s Statement of Task, we contacted the organization and conducted in-depth

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² See https://www.qualtrics.com (accessed February 15, 2018).

interviews via telephone with an identified organizational leader when allowed. Participants were given the option of providing their name and email address at the end of the survey if they were willing to be contacted for follow-up questions; otherwise, their responses were anonymous.

Respondents represented programs and institutions from the United States of America, Canada, Germany, Italy, Taiwan, Australia, Japan, Abu Dhabi, and more. Seventy-seven percent of respondents said that they or their organization had worked on a project exploring the effect of health literacy on any of the following areas: finance, behaviors, health outcomes, quality of care, patient satisfaction, provider satisfaction, equity, organizational culture, or another area related to the Quadruple Aim. The areas explored by the projects were behaviors (16 percent of programs), patient satisfaction (15 percent of programs), health outcomes, quality of care, equity, etc. Sixty-five percent of respondents presented their work at state or national conferences or published the research that resulted from their health literacy programs. Forty-four respondents provided contact information for further follow-up.

The survey also asked about the target population for many of the health literacy projects represented. Most of these studies targeted education or health care. For the projects taking place in educational settings, the populations included were eighth grade, suburban middle school students, adults seeking GED or enrolled in literacy classes, English language learners, and teachers in primary and secondary schools.

For projects that focused on organizational infrastructure and creating health literate institutions, projects targeted leadership, senior leaders and department chairs, and other key decision makers in hospitals, pharmacies, and primary care practices. Other projects focused on frequent emergency room patients; medically underserved patients; hospitalized patients; pediatric patients and their caregivers; patients receiving services for various acute and chronic conditions like asthma, breast cancer, colonoscopy, diabetes, cancer, or HIV; mental health diagnoses; and substance abuse. Some studies have looked at low-income patients, immigrants, refugees, Australian Aboriginal communities, older adults, people with disabilities, and inmates in a county jail setting.

Health care professionals were the focus of programs and interventions for more than half of the survey respondents. They represented doctors, nurses, registered nurses, dentists, dental hygienists, nurse practitioners, dietitians and dietetic interns, and other clinic and hospital providers and staff members.

Thirteen respondents included information about health literacy programs that have not been presented at conferences nor published in peer-reviewed literature. The focus of these projects included

• Building health literacy collaborations between health professionals and community-based organizations serving new immigrants and refugees;
• Determining an overall, basic understanding about health and health care in middle school students;
• Providing medication review to ensure patients understand why they are taking the medicines and answering any questions patients may have;
• Revealing to patients the true risks of proposed procedures;
• Patients rating the health information provided by care team members;
• Providing various educational opportunities for health care providers;
• Integrating health literacy and the teach-back method into clinical practice;
• Providing health literacy workshops for patients and family caregivers; and
• Assessing the organization’s health literacy competencies based on the 10 attributes of a health literate organization (Brach et al., 2012).

Challenges to the Case for Health Literacy

In building the case for health literacy, we identified several potential challenges from a diverse variety of perspectives that need to be acknowledged and contemplated as we continue to strengthen the case.

1. Current volume-based reimbursement and traditional fee-for-service payments for health services do not incentivize good health literacy practices. Value-based reimbursement (for example, the Medicare Access and CHIP Reauthorization Act of 2015) does incentivize health literacy practices. Until we fully move to value-based purchasing, existing reimbursement incentives will be structured against the integration of health literacy principles into practice and may undermine the case for health literacy.
2. Consumer information in health care is not as transparent as in other consumer-based industries. One attribute of a health literate organization directs that an organization “communicates clearly what health plans cover and what individuals will have to pay for service” (Brach et al., 2012). Rarely, if ever, are the out-of-pocket costs for health care services communicated before they are delivered. Duesenberry famously stated: “Economics is all about how people make choices. Sociology is all about why they don’t have any choices to make” (1960, p. 233). Health literacy is a

2. similar paradox in that we expect people to be empowered to use health literacy skills once learned, yet they are confined by complex health systems, structures, policies, and procedures that limit choice and restrict the equitable information exchange necessary to navigate the health care market and insurance marketplaces. Until there is a movement toward cost and quality transparency, implementing comprehensive health literacy practices will be difficult.
3. Research is needed to support the efficacy of health literacy interventions. Many professionals in the field fear that a lack of supporting evidence hampers future funding, initiatives, and interventions. During personal interviews conducted as part of this paper, numerous health literacy experts hypothesize that the lack of research will contribute to the lack of sufficient evidence.
4. There is sufficient evidence of short-term outcomes that support the effectiveness of specific health literacy interventions. To date, however, there are no large-scale longitudinal studies that examine long-term outcomes related to cost, quality, satisfaction, and effects of broad-based health literacy initiatives and interventions. Funding is needed to support such an endeavor.
5. The legal profession has not embraced the literacy movement and can be a barrier in health care. For example, patient consent forms for procedures in health care crafted with health literacy in mind are commonly rejected by the health system legal team. This same dynamic is at play in state Medicaid departments across the United States.
6. There are numerous initiatives and interventions that fall into the broadening scope of health literacy but do not fall under the label of health literacy. As a result, there is available evidence that may not be uncovered by traditional methods (for example, literature reviews, surveys, and informant interviews) when searching more broadly for data in the domain of health literacy.

The Business Case for Health Literacy

The Financial Case

The health literacy field has a long history of forecasting the potential cost savings of addressing health literacy from a societal standpoint. An early systematic review reported a range of an additional 3–5 percent in total health costs attributable to limited health literacy for the health care system and a range of $143–$7,798 of additional expenditures for individual patients with low/limited health literacy compared to those with adequate health literacy (Eichler et al., 2009). In 2017, the United States

was estimated to spend $3.5 trillion on total health expenditures (CMS, 2016b). Translating the reported range into 2017 U.S. health care dollars reflects a potential cost savings of $105–$175 billion per year. Others have estimated that low health literacy costs the U.S. economy between $106 and $238 billion annually in direct health costs and between $1.6 and $3.6 trillion annually when you include the costs of current public health activities (or lack of action) that would result from healthy eating, exercising, smoking cessation, and so on (Vernon et al., 2007). A 3-year retrospective service utilization study of nearly 93,000 veterans found that veterans with marginal and inadequate health literacy cost $143 million more than veterans with adequate health literacy (Haun et al., 2015).

More specific research has demonstrated the financial effect of integrating health literacy in two primary arenas: public health and health care delivery. In public health, savings have been documented using the quality-adjusted life year (QALY) measures that use preference-based measurements of health-related quality of life to provide an assessment of the overall burden of diseases associated with both mortality and morbidity (Neumann et al., 2016). For example, a computer-delivered intervention targeting HIV medication adherence found a net cost savings per user and per QALY for high health users and wider deployment (Ownby et al., 2013). Using the change in QALYs in the first year, the Life Enhancement Program estimated the cost of improved health status for participants was between $376,400 and $570,500 lower than other interventions that would produce similar health gains (Pleasant, 2017).

The Institute of Medicine report A Prescription to End Confusion documented numerous ways that health literacy can potentially reduce health care costs, ranging from underuse of preventive and other services; inefficient access to health services, such as unnecessary ED visits and preventable hospitalizations; medication errors and mismanagement of chronic conditions; patient noncompliance caused by not understanding care instructions; and inappropriate health services (IOM, 2004). In addition, many specific health literacy health care delivery interventions have been found to be cost-effective, including using cell phones to deliver health education via text messaging (Zhuang et al., 2016), a multipronged intervention targeting colorectal cancer screenings involving health literacy training for physicians and establishing a feedback loop to monitor patient compliance (Khankari et al., 2007), a pharmacist intervention for those with heart failure to increase cardiovascular medication compliance (Murray et al., 2007), and a cancer screening intervention among Korean women led by community health workers (Schuster et al., 2015).

Health literacy can be implemented in a variety of ways and can save money in many different ways. For example, first-time colonoscopy patients who watched an educational video had significantly lower anxiety scores

the day of the procedure and as a result required 18 percent less sedation medication and had a 14 percent decrease in procedure time (The Beryl Institute, 2015). Patients were 11 percent more knowledgeable about the procedure, and that increased knowledge saved the system both time and money. Massachusetts General Hospital reported significant savings from employing a community resource specialist (CRS). After hiring a CRS, Mass General reduced ED visits by 13 percent; and combined with a decline in unnecessary hospitalizations, it experienced a 7 percent annual net savings on enrolled patients and generated $2.65 in savings for every dollar spent on the CRS (Vuletich and Farooqi, 2017). Integrating health literacy can also increase incoming revenue. After implementing an automated phone notification to a group of 3,137 patients with recent orders for a colonoscopy or upper endoscopy, one health system found that 18 percent of patients contacted went ahead and got the procedure, resulting in $684,930 of estimated revenue generated during the 2-month campaign, based on national averages (West Healthcare, 2015). A dental diversion program in Missouri led to an additional 3,107 tooth extractions over an 18-month period, increasing clinic revenue by more than $680,000 while providing savings to patients by ensuring the right level of care at the right price (Pfannenstiel and Brown, 2017).

Some long-standing health literacy programs have demonstrated time and again behavior change that results in direct and indirect cost savings to systems, individuals, and society. For example, the guidebook What to Do When Your Child Gets Sick has been deployed in numerous places and ways and continues to provide new findings. In Wisconsin, this book empowered parents to deal with health problems at home instead of calling a hospital or clinic, or visiting an ED or urgent care center, demonstrating that approximately $1.50 was saved in health care usage for every dollar spent on the project (Cook, 2013). In a pilot study in Michigan, parents stating they would seek care in the ED decreased by 14.6 percentage points and a review of claims found that after 1 year of using the books with additional support there was a decrease in ED costs for children younger than 2 years (Molina, 2005). Implementing a What to Do When Your Child Gets Sick program in Kansas led to numerous cost savings to the health system and society, with 46 percent fewer unnecessary doctor visits, 55 percent fewer emergency room visits, 64 percent fewer school days missed by children because of illness or injury, and 56 percent fewer work days missed by parents because of their children’s illness (O’Neal, 2012). Last, a What to Do… partnership between the University of California, Los Angeles, and Head Start in California found that Medicaid can potentially save at least $554 per family annually in direct costs related to clinic/ED visits. Costs were extrapolated from a 42 percent reduction in doctor’s visits and a 58 percent reduction in ED visits after implementation (UCLA, n.d.).

Recommended Areas for Future Study

To date, studies have only examined the short-term effect of specific health literacy practices. Longitudinal studies of broad-based health literacy activities are needed to truly assess the savings from long-term outcomes and behavior change, especially innovative ones that propose a paradigm shift in how we share and teach health education, such as integrating medical curricula normally targeted for medical students into elementary and secondary education (Weinstein et al., 2017). These and similar upstream approaches have the potential for a much greater return on investment once implemented and fully evaluated.

The Behavioral Case

The relationship between health literacy and behavior change has been explored in many studies, from targeted interventions to broader ones that integrate health literacy strategies with social support. For example, a randomized controlled trial found that people with heart failure were more likely to report daily weights when provided picture-based instructions, a digital scale, and follow-up phone support (79 percent in intervention versus 29 percent in control) (DeWalt et al., 2006). The Neighborhood Health Plan began distributing the What to Do When Your Child Gets Sick books to expecting mothers in 2006 and reported statistically significant reductions in total ED visits, especially for common diagnoses such as fever and viral, ear, and urinary tract infections (NHP, 2008). Sometimes, these returns can be realized very quickly. Significant increases (between 28 and 36 percent) in those reporting their daily weights occurred within the first 2 weeks of implementing interactive phone calls for recently discharged heart failure patients (Emmi Solutions, 2016a).

Other studies looked specifically at the links between health literacy and behavior change. Health literacy has been linked to behavior change for people with hypertension through knowledge and self-efficacy pathways (Osborn et al., 2011c). Similarly, health literacy and numeracy were directly and indirectly associated with greater self-efficacy or social support, which was linked to better glycemic control (Osborn and Egede, 2010; Osborn et al., 2010a,b). A 2011 systematic review found that low/limited health literacy was associated with numerous behavior-influenced health outcomes including more use of the ED, increased hospitalizations, and lower use of some types of preventive care such as mammography screenings and flu vaccines (Berkman et al., 2011a). In fact, the evolving definition of health literacy has even included models such as the Calgary Charter definition (Coleman et al., 2009) that posit health literacy as a theory of behavior change, with behavior change as the true outcome of improved health literacy.

Health literacy has also been linked to patient activation (Smith et al., 2013), and patient activation has been shown to improve management of chronic conditions such as diabetes and high blood pressure, healthy behaviors, and preventive screenings, while reducing ED visits and hospitalizations (Smith et al., 2013). Both patient activation and health literacy have been found to be significantly associated with positive effects on decision making and patient engagement in health care–related activities, healthy behaviors, and chronic disease self-management (Greene et al., 2005; Hibbard, 2013). A more recent study found that patient activation mediates or transfers the relationship among education, health literacy, and hospital use, reporting that higher patient activation scores were significantly associated with reduced odds of use among whites (Charlot et al., 2017). Those with higher patient activation scores are more likely to access and use online heath information (Smith et al., 2015). Integrating patient activation into health literacy interventions could not only improve the public’s health information–seeking ability but also further enhance population-based health.

Studies are starting to examine the effect of public health literacy interventions on behavior change. For example, an initiative using education classes, a teach-back call, and interactive voice response calls led to reductions in drinking sugar-sweetened beverages, resulting in small but significant decreases in body mass index (Zoellner et al., 2016). Health literacy has also been associated with increased physical activity in Latinos (Dominick et al., 2013, 2015a,b) and with parents’ preferences for rotavirus vaccination (Veldwijk et al., 2015), suggesting that health literacy plays a role in addressing these and many other public health challenges.

There is also evidence that community-based interventions focusing on the combination of health literacy, self-efficacy, sense of empowerment, self-esteem, and/or social support influence beneficial health behaviors. For instance, adult learners who receive health literacy-based education had increased knowledge about health issues and self-efficacy because of the health literacy instruction (Chervin et al., 2012). Other studies suggest that health literacy and self-efficacy are critical for preventive health screening (Davis et al., 2014; Tiraki and Yilmaz, 2017), intention to take an HIV test (Rikard et al., 2016), smoking cessation (Parisod et al., 2016; Stewart et al., 2013), and diabetes management (Rak, 2014; White et al., 2015). In addition, interventions to increase health literacy that use existing social support resources improve patient–provider communication (Fry-Bowers et al., 2013, 2014).

Recommended Areas for Future Study

With the growing focus on population health under value-based purchasing, more research is needed on the effect of public health literacy and behavior change in three important areas. First, there must be an understanding that people do not live, learn, work, and play in clinics and hospitals. The social determinants of health are significant factors that shape the resources, or lack of resources, for behavior change. It is unclear whether health literacy is a social determinant of health or a result of those social determinants. Second, interventions must focus on increasing public and individual health literacy, as well as self-efficacy, sense of empowerment, self-esteem, social support, mastery, and/or sense of mattering. Third, public health literacy provides an upstream “pay off” in terms of the opportunity to change health behaviors and health outcomes.

The Case for Health Outcomes

Lower health literacy has been found to be clearly associated with poorer health status and a higher risk of mortality for seniors, as well as decreased ability to take medications appropriately and interpret labels and health messages (Berkman et al., 2011b). Health literacy has also been associated with preventable ED visits. Patients with limited literacy had 2.3 times the number of preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 times the number of treat-and-release visits, and 1.9 times the number of total preventable ED visits (Balakrishnan et al., 2017). Interventions to increase health literacy and self-efficacy provide greater improvements in hemoglobin A1c, glucose, and total cholesterol (Kim et al., 2013), regularly taking diabetic medication (Al Sayah et al., 2013; Hofer et al., 2017; Lee et al., 2016), and HIV medication (Colbert et al., 2013). The same connection among health literacy, self-efficacy, and social support improves mental health outcomes, such as depression, among racial/ethnic minorities (Hernandez and Organista, 2013, 2015; Lee et al., 2013).

Videos and multimedia programs have been showing promise on affecting outcomes. Those who viewed a video education program were more likely to have controlled blood pressure regardless of blood control status and experienced shorter length of stay for total knee or hip replacement (Emmi Solutions, 2015b,c). Moreover, coupling online interactive media with automated phone calls resulted in a 15-day delay in readmission for chronic obstructive pulmonary disease with a 69 percent reduction in readmission length of stay and a 4-day delay in readmissions for congestive heart failure with a 51 percent reduction in readmission length of stay (Emmi Solutions, 2016b).

Because CMS started implementing readmission penalties in 2012, there is a plethora of studies that have examined health literacy’s effect on readmission rates. Health literacy has been found to be a significant and independent predictor of 30-day all-cause readmission (Bailey et al., 2015; Mitchell et al., 2012). Medicare enrollees with above basic health literacy had a 12 percent lower risk of 30-day readmission after a heart attack and a 16 percent lower incidence rate compared to those with basic or below basic health literacy (Bailey et al., 2015). Other studies have found health literacy to be a contributing factor to readmissions among individuals with diabetes (Rubin et al., 2014), those receiving maintenance dialysis (Flythe et al., 2017), individuals with heart failure (Cox et al., 2017), those who experience postdischarge falls (Jaffee et al., 2016), and those transitioning to surgical care (Martin et al., 2017).

In addition, numerous evidence-based health literacy practices have been found to reduce readmission rates for many conditions. In a pilot study in an urban pediatric hospital, coupling a discharge bundle with the use of the teach-back method was found to significantly reduce readmission by 8 percent for 7-day readmissions and by 10 percent for 30-day readmissions (Shermont et al., 2016). Implementing a patient navigator program for individuals with heart failure resulted in a 15.8 percent decrease in unplanned readmission (Di Palo et al., 2017). Similarly, individuals receiving postdischarge follow-up from a care transition pharmacist were significantly less likely to be readmitted within 30 days (Fera et al., 2014).

There is quite a bit more evidence for integrating health literacy to improve readmission rates being undertaken by hospital quality improvement programs. However, much of the evidence is not published in the peer-reviewed literature and could not be discovered using traditional literature methods. Also, many hospitals do not call this work “health literacy” even though the work fits within the health literacy umbrella. For example, a two-phase readmission reduction initiative employing the teach-back method and patient admission interviews reduced pneumonia readmission rates by 9.62 percent and heart failure readmission rates by 7.28 percent in phase 1. Phase 2 added the patient readmission interview to their electronic medical record, increased patient support through follow-up phone calls and appointments, and collaborated with local and regional skilled nursing facilities to reduce all-cause readmission by 4.67 percent (SoutheastHEALTH, 2017).

Recommended Areas for Future Study

With the emergence and adoption of information and communication technologies to access eHealth resources, there is a significant gap in studies examining eHealth literacy interventions and their effects on outcomes

(Watkins and Xie, 2014). A recent systematic review (Kim and Xie, 2017) revealed only nine intervention studies examining the effect of websites or online app use on health literacy. Of the nine studies, six education-based interventions among low-literacy adults and older adults reported positive effects on knowledge about health conditions, use of computers and the Web, search skills, confidence finding and using eHealth resources, and use of health information for one’s own health care (King et al., 2013; Mein et al., 2012; Robinson and Graham, 2010; Strong et al., 2012; Xie, 2012). As we continue in the digital age, more research is needed to ensure that these electronic tools translate into better health outcomes.

The Case for Quality of Care

It must be noted that many findings documented in the sections on the case for finance, behavior, outcomes, satisfaction, and equity also provide sufficient evidence of health literacy’s effect on quality of care. To avoid redundancy, the findings documented in those sections are not repeated here. Health literacy has a long-recognized role in patient safety. This is why heath literacy is widely endorsed through initiatives by the Institute for Healthcare Improvement and the National Patient Safety Foundation (NPSF, 2017), the Centers for Disease Control and Prevention (CDC, 2017), the American Medical Association (Weiss, 2007), the Joint Commission (2007), the U.S. Department of Health and Human Services (HHS, 2010), and the Agency for Healthcare Research Quality (AHRQ, 2017). Despite the widespread recognition, when the literature for specific studies linked to medical errors is examined, there is extensive research in only one area and broad gaps in all others.

Numerous studies have examined the role health literacy plays in medication adherence and dosing errors (Davis et al., 2006a,b; IOM, 2008; Mira et al., 2015; Persell et al., 2010). Even employing simple health literacy universal precautions can have an effect, such as listing specific times to take doses (Davis et al., 2009), using milligrams as the standard unit for liquid medication (Yin et al., 2014), and using oral syringes over cups for small doses (Yin et al., 2016). A systematic review of the use of pictograms to assist caregivers in dosing liquid medication found limited but clear evidence that integrating pictograms into verbal or text-based instructions reduced dosing errors and enhanced comprehension and recall of instructions, while improving adherence (Chan et al., 2015).

Likewise, the use of patient-centered medication labels has been found to improve adherence for those with limited health literacy (Wolf et al., 2016). The U.S. Department of Veterans Affairs developed and adopted a patient-centered medication label format in an attempt to improve the quality of care for its more than 9 million veterans (Trettin et al., 2015).

Recommended Areas for Future Study

We point out that most of the direct studies on health literacy and quality only examined liquid medication, and more research is needed to examine the role that health literacy can play in reducing nonliquid dosing errors and adherence. It also must be noted that no study directly links health literacy to medical errors. One study did identify health literacy–related adverse events and found that they led to outcomes such as delaying or cancelling a procedure, surgery, treatment, or test; falls; premature removal of catheters; and wrong procedure or site (Gardner, 2016). The study provided recommendations on health literacy universal precautions to employ to avoid adverse events but did not explore the relationship or causal link between health literacy and adverse events. More research is needed to understand the direct relationship between health literacy and medical errors.

The Case for Health Care Experience

Patient Experience

Inadequate health literacy has been associated with reduced patient satisfaction (MacLeod et al., 2017; Shea et al., 2007). Likewise, interventions addressing health literacy have been found to improve patient satisfaction in medication adherence and management (Graumlich et al., 2016; Murray et al., 2007; Ruiz et al., 2014), hypertension management (Piette et al., 2012), obtaining informed consent (Hallock et al., 2017), eye health education (Rhodes et al., 2016), and maternal health education (Stikes et al., 2015). Shared decision-making models also continue to show much promise in improving patient satisfaction in the health care setting (Bozic, 2013; Joosten et al., 2008; Olomu et al., 2016; Slover et al., 2012).

Using video materials to improve patient knowledge and expectations has been found to enhance patient satisfaction for individuals receiving radiation therapy (Matsuyama et al., 2013), those prepping for a colonoscopy (Hayat et al., 2016), and recent stroke survivors (Denny et al., 2017). In a comprehensive study of nearly 100,000 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from hospitals employing commercially developed and implemented video programs, 100 percent of hospitals had a higher aggregate HCAHPS Top Box percentage, 69 percent of aggregate Top Box answers were 4 percent higher or more, 86 percent of hospitals had higher “doctor communication” dimension scores, 62 percent of hospitals had higher “discharge information” dimension scores, and 59 percent of hospitals had higher “nurse communication” dimension scores (Emmi Solutions, 2015d).

In addition to video, use of Web-based applications has been linked

to enhanced patient satisfaction, such as employing automated illustrations for cardiovascular education (Hill et al., 2016) and using Web-based interventions allowing diabetes patients to better track glucose levels, communicate directly with health providers, and interact with other individuals with diabetes (Brown et al., 2007). Satisfaction can be further enhanced by coupling these with telephone-based education and support services (Emmi Solutions, 2015a; Wolf et al., 2014).

Solutions do not have to be extensive or expensive to develop and implement. Even following simple health literacy universal precautions like rewording MRI reports (Bossen et al., 2013), standardizing emergency room instructions (Isaacman et al., 1992), employing audio-recorded messages (Santo et al., 2005), and encouraging patients to bring a family member or friend with them to the visit (Rosland et al., 2011) have been found to enhance patient satisfaction. Increased satisfaction translates into increased revenue. An analysis conducted by Accenture found that those hospitals that offer a superior patient experience have 50 percent higher hospital margins (Collier and Basham, 2015).

Provider Experience

Perhaps because of the recent addition of provider experience to the Triple Aim to form the Quadruple Aim, there is little evidence published on the direct relationship between health literacy and provider satisfaction. One study reported that orthopedic surgeons were more satisfied with patient visits when patients received a video and written information describing treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach (Bozic, 2013). Another study found higher satisfaction rates for bowel preparation prior to a colonoscopy when patients received a patient-centered educational video versus traditional print materials, with those not receiving the video having higher rates for needing a repeat colonoscopy within 3 years (Hayat et al., 2016). More research is clearly needed to examine the link between becoming a health literate organization and provider satisfaction in communicating with patients, ensuring patient understanding, and overall job satisfaction.

The Ethical Case for Health Literacy

Because It Is the Right Thing to Do (The Regulatory Case)

Numerous articles draw attention to the ethical case for health literacy. Early calls focused on the duty of health care organizations and professionals to ensure that their patients are equipped and provided with

supports to make truly informed and appropriate choices about their health (IOM, 2004; Mayer and Villaire, 2003; Parker et al., 2003), and it is the duty of public health agencies, professionals, and organizations to ensure that critical health messages to the public are actionable and understandable (Gazmararian et al., 2005; Nelson et al., 2005). Mission-based health and public health organizations have a responsibility to meet their patients where they are and provide health information and care with appropriate and adequate supports to empower health and public health consumers. Indeed, addressing health literacy lies at the heart of providing truly patient-centered care.

In addition to the integral role of health literacy in providing patient-centered information and care, health literacy is the right thing to do to comply with current regulatory requirements. Communication is at the core of health care experiences. As such, health literacy is an integral part of the CLAS developed by the U.S. Department of Health and Human Services (OMH, 2013). The Joint Commission adopted these standards and the ACA contains many conditions related to providing culturally and appropriate services. The ACA incorporates health literacy into professional training and streamlines the procedures for enrollment into federal and state insurance programs. Health plans and insurers are now required to provide patient-oriented summaries that give them clear, consistent, and comparable health information in a standardized way (Somers and Mahadevan, 2010).

CMS has integrated patient understanding in numerous regulations. Under Medicare and Medicaid Program: Conditions of Participation for home health agencies (HHAs), § 484.50(a)(1):

According to the CMS State Operations Manual Appendix PP—Guidance to Surveyors for Long-Term Care Facilities § 483.10(b)(3):

Several national medical associations and boards have deemed health literacy as the right thing to do. The American Medical Association has long recognized the importance of health literacy in meeting patients’ needs,

improving quality of care, and enhancing patient safety (Weiss, 2007). The American College of Physicians has also valued the importance of health literacy and through its Center for Patient Partnerships in Healthcare has been developing and implementing innovative health information tools to ensure patient understanding and empowerment (ACP, 2017). The American Board of Pediatrics developed online training modules, including a Practice Improvement Module released in 2013 (ABP, 2013). The American College of Obstetricians and Gynecologists (2016) makes the following recommendations for addressing health literacy to promote quality of care:

As mentioned earlier, under current fee-for-service reimbursement mechanisms there is an actual disincentive to address health literacy. Reimbursement penalties have begun to restructure these incentives. In October 2014, CMS began reducing Medicare payments for hospitals that rank in the lowest quartile regarding hospital-acquired conditions (HACs) (CMS, 2017). In 2011, 21 states already had nonpayment penalties for HACs, and section 2702 of the ACA has prohibited the federal government from providing payments to states for HACs and other provider-preventable conditions since July 2012 (NCSL, 2017).

In October 2017, CMS increased penalties for 30-day readmissions by reducing Medicare payments to facilities whose readmission ratios exceed the national average. This reflects CMS’s continuing commitment “to increasingly shift Medicare payments from volume to value” with a goal of linking half of all Medicare payments to value-based reimbursement by 2018 (Whiteman, 2016). These new reimbursement structures place more risk on hospitals and providers and truly incentivize the integration of health literacy in providing enhanced patient supports to ensure people have the understanding and access to home and community resources to successfully negotiate the road to recovery. As more insurers follow suit, there will be increasing financial pressure to integrate health literacy practices to enhance profit margins. Hospitals are also being compelled to reduce Medicaid readmissions because of payment reforms, such as accountable care organizations and other alternative payment models, and through regulatory actions from state governments that require hospitals to demonstrate reductions in avoidable admissions and readmissions (Boutwell, 2014).

In addition, many state Medicaid programs are starting to implement payment mechanisms that incentivize more continuity and efficiency in care delivery. So far, 22 states have implemented Medicaid payments through health home models, 26 have Medicaid payments through medical homes, and 12 have implemented delivery system reform incentive payment programs (NASHP, 2015). Using bundled and global payment mechanisms shifts financial responsibility and risk to the provider. Integrating health literacy universal precautions into practice can assist providers in reducing risk and strengthening the health of their patients and their bottom line.

The shift toward value-based purchasing will strengthen in the next few years as MACRA replaces the sustainable growth rate formula and establishes “a new payment framework for rewarding health care providers for giving better care and not more care” (CMS, 2015). MACRA began implementation in 2015, and by 2021 physician Medicare payments will be truly aligned to quality and performance measures. Some have suggested that combined with more private-sector attention to inefficiencies in physician payment, MACRA may trigger a “disruptive innovation” in health care delivery (Findlay, 2015). Under MACRA, providers will only be paid through two ways: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Under MIPS, providers will be measured on quality, resource use, clinical practice improvement, and meaningful use of electronic health/medical records. Several 2017 MIPS improvement activities are focused on elements of care that are enhanced by health literacy:

• Engagement of patients, family, and caregivers in developing a plan of care (MIPS activity IA_BE_15),
• Engagement of patients through implementation of improvements in patient portal (MIPS activity IA_BE_4),
• Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities (MIPS activity IA_BE_5),
• Use of toolsets or other resources to close health care disparities across communities (MIPS activity IA_PM_6),
• Evidenced-based techniques to promote self-management into usual care (MIPS activity IA_BE_16), and
• Implementation of medication management practice improvements (MIPS activity IA_PM_16).

These are a few of the MIPS activities that could be supported by health literacy improvement (TCPI, 2017). Under APMs, beginning in 2019 some participating providers will receive lump sum payments through bundled

payment, and accountable care organizations and patient-centered medical home models with higher annual payments being implemented in 2026.

Because It Is the Right Thing to Do (The Case for Health Equity)

Equity or providing equitable health services is one of the six dimensions of quality care defined in a seminal report by the Institute of Medicine (2001). As such, there has been a movement to integrate social justice and health literacy by making the moral or ethical case for the equitable distribution of health information across diverse cultures and communities with a focus on underserved populations, which tend to have higher rates of low/limited health literacy (Marks, 2009; Volandes and Paasche-Orlow, 2007).

Two goals of the 2016 CMS Quality Strategy to eliminate disparities included health literacy:

• Goal 1: Improve safety and reduce unnecessary and inappropriate care by teaching health care professionals how to better communicate with people of low health literacy and more effectively link health care decisions to person-centered goals.
• Goal 3: Enable effective health care system navigation by empowering persons and families through educational and outreach strategies that are culturally, linguistically, and health literacy appropriate.

In fact, one of the desired outcome measures focused on reducing admission and readmission for Goal 3 is increased health literacy (CMS, 2016a).

According to the Robert Wood Johnson Foundation (RWJF), health equity means:

From a health literacy perspective, health equity also means that everyone has equal access to health information that people can act upon. Health information should be targeted, tailored, easy to read, understandable, culturally appropriate, and available where people live, learn, play, work, and worship. Many of the reasons people might not have equitable access to appropriate health information is a lack of access to health care services. For those with some level of access to health care services, the information provided meets the needs of some patients and caregivers, while the needs of others are not met.

The majority of the health literacy research and interventions are focused on clinical outcomes and health care use (Berkman et al., 2011a). Most peer-reviewed and nonpublished work in health literacy is not addressing social determinants of health at the community and individual levels (Logan, 2015).

Perhaps because of its strong relationship with the social determinants of health, health literacy has been found to mediate the effect of race on health outcomes, including conditions that kept people from working, chronic illness, self-reported health status, flu vaccination rates, quality of life, prostate-specific antigen levels, medication adherence, and enrollment in health insurance (Berkman et al., 2011a,b). Health literacy also mediated or transferred the effect of both race and sex in interpreting medication labels (Berkman et al., 2011b). Rothman and colleagues showed that a diabetes disease management program addressing literacy may be particularly beneficial for patients with low literacy, and that increasing access to such a program could help reduce health disparities (Rothman et al., 2004).

A systematic review published in 2015 examining the relationship between health literacy and health disparities found that many studies and interventions do not describe the nature of the disparity that is explored. Most studies looked at racial and ethnic health disparities. Some have found evidence of the mediating function of health literacy on self-rated health status across racial and ethnic disparities, as well as on the potential effect of health literacy and numeracy on reducing racial/ethnic disparities in medication adherence and understanding of medication intake (Mantwill et al., 2015).

In a 2015 discussion paper published by the National Academy of Medicine, health literacy experts provided arguments that health literacy is a necessary element for achieving health equity because of the strong relationship with the social determinants of health and because health literacy interventions and best practices are a contributing factor to achieving health equity and social justice (Logan, 2015). The authors found that tailored and culturally competent programs, delivered where people live and learn using evidence-based health literacy tools, improved participant knowledge, attitudes, and behaviors were also successful in reducing health disparities in the target populations (Aiken, 2010; Herman, 2012; Neuhauser et al., 2007).

Recommended Areas for Future Study

The power dynamic in health care is one subject that needs more research. Specifically, research must focus on the effect of the power dynamic on health equity and on the opportunities that people have to achieve a healthy life. Traditionally, health care providers and institutions have had

more power in health care encounters. To achieve health equity, there must exist a more equal power dynamic in health information exchange that values the knowledge that the provider brings equally with the knowledge that patients, family members, and caregivers bring to the encounter.

IMPLICATIONS FOR HEALTH POLICY AND PRACTICE

In 2012, health policy and health literacy experts analyzed health policy initiatives like the Patient Protection and Affordable Care Act, the National Plan to Improve Health Literacy from the U.S. Department of Health and Human Services, and the Plain Writing Act of 2010 and identified the incredible opportunities that are available to further health literacy research and practice (Koh et al., 2012). The current health policy arena is changing and poses challenges to health care organizations, systems, communities, and patients. These challenges might interfere with many of the health literacy approaches to patient-centered care, provider training, and community-based interventions.

The National Plan to Improve Health Literacy highlights clearly what health care organizations and professionals can do (HHS, 2010). It will take everyone working together in a linked and coordinated manner to improve access to accurate and actionable health information and usable health services.

The plan’s seven goals are:

1. Develop and disseminate health and safety information that is accurate, accessible, and actionable.
2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services.
3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level.
4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community.
5. Build partnerships, develop guidance, and change policies.
6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy.
7. Increase the dissemination and use of evidence-based health literacy practices and interventions.

In 2012, the Institute of Medicine published a discussion paper on the 10 attributes of health literate health care organizations. The paper

highlighted many opportunities and strategies that organizations have to create more opportunities for patients to access health care, access health care information, and be able to use as they navigate the health care system (Brach et al., 2012). The 10 attributes of a health literate organization are:

1. Has leadership that makes health literacy integral to its mission, structure, and operations
2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement
3. Prepares the workforce to be health literate and monitors progress
4. Includes populations served in the design, implementation, and evaluation of health information and services
5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization
6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact
7. Provides easy access to health information and services and navigation assistance
8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on
9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines
10. Communicates clearly what health plans cover and what individuals will have to pay for services

The white paper provides clear examples of how organizations and institutions can take immediate steps to improve how they communicate with patients, caregivers, providers, and staff. Yet, it is unclear how many organizations throughout the country or around the world are implementing these strategies.

As mentioned in the report, health literacy research and practice is mainly focused on clinical interventions, whereas other areas like quality of care, patient safety, cost, outcomes, medication adherence or medication errors, health equity, and health disparities research and practice often do not include health literacy as a major component, with professionals working in these areas often operating in silos. Some interventions take place in clinical settings, others in community-based settings. Many times funding targeting these other areas does not emphasize health literacy and vice versa, so there is little incentive to collaborate with professionals and conduct research across all of these domains. A 2009 review of health literacy and child health promotion research and practice recommended and discussed cross-domain interventions that included targeting all areas of care, from patient care, health system characteristics, educational systems like

preschool and the K–12 curricula, and community-based approaches such as home visiting programs and after-school programs (Sanders et al., 2009).

Along with incentivizing cross-domain collaborations in our organizations and systems, policies should encourage improvement in health care professional competencies that include knowledge about community resources, everyday lived experience, and community partners. A comprehensive approach to integrate appropriate professional and community resources in order to meet the needs of the populations is critical.

Funding Support

When asked about the funding source for health literacy programs on our survey, respondents identified the national ministries of health and the World Health Organization for countries other than the United States. Within the United States, programs were funded by state agencies, realigning resources within health care institutions, operational funding, scholarships and fellowship programs, the National Institutes of Health, the Centers for Disease Control and Prevention, CMS, Adult Learning Centers, public health funding, private foundations, other grants, donations, and in-kind support.

National Institutes of Health (NIH)

One of the primary sources for health literacy research related funding was the “Understanding and Promoting Health Literacy” (PAR-13-130-132) funding mechanisms. However, the funding series was not reissued as of May 2016. We searched the NIH RePORT Expenditures and Results Tool (RePORTER) system for currently funded projects that include “health literacy” in the project title, abstract, or scientific terms.³ The results of the search are presented in Table C-1. The NIH is made up of 27 institutes and centers. Each institute or center focuses on a specific disease or body system and a specific funding strategy for research projects.

We point out that the National Library of Medicine (NLM) actively supports health literacy projects that address the Quadruple Aim framework. For example, the NLM’s Information Resource Grants to Reduce Health Disparities (RFA-LM-17-002) funding opportunity focuses on projects that develop or upgrade usable tailored health information for populations who experience health disparities and increase the information capacity of health care providers.

___________________

³ See https://report.nih.gov (accessed February 15, 2018).

TABLE C-1 National Institutes of Health (NIH)—Number of Currently Funded Health Literacy Projects

Patient-Centered Outcomes Research Institute (PCORI)

The Patient-Centered Outcomes Research Institute (PCORI) is an independent nonprofit, nongovernmental organization authorized by the U.S. Congress in 2010. PCORI supports comparative clinical effectiveness research focusing on outcomes important to helping patients, caregivers, clinicians, employers, insurers, and policy makers make better-informed health decisions. PCORI is not allowed to fund research projects that examine cost-effectiveness outcomes for any interventions. PCORI involves

patients and other health care stakeholders during the research process with the goal that the resulting evidence addresses the most important questions and concerns. The team searched the PCORI Funding Portfolio for all projects with the phrase “health literacy.” Table C-2 provides a list of health literacy-funded projects, specifically the names of the organizations, budget amount, type, and related funding announcement.

TABLE C-2 Patient-Centered Outcomes Research Institute (PCORI) Funded Health Literacy Projects

SOURCES: Patient-Centered Outcomes Research Institute (PCORI) Funding Portfolio Search. See https://www.pcori.org/research-results?keywords=%22health%20literacy%22&f%5B0%5D=field_project_type%3A320#search-results (accessed February 15, 2018).

Summary of Funding Support

With some exceptions, funding support for health literacy research and practice is primarily focused on clinical interventions to reduce health care disparities and facilitate preventive screening and treatment. Both areas are critical to inform the shift in reimbursement and regulatory policy. However, as stated above, there remains little incentive for professionals across a range of disciplines to collaborate and examine health literacy across a range of domains. Funding agencies and organizations should invest in interdisciplinary research and practice that is inclusive of new and experienced investigators. In addition, funding portfolios need to emphasize involving participants in the initial phase of the research project, sharing the research findings with participants and listening for participant feedback, and translating findings to policy makers.

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Vuletich, D., and N. Farooqi. 2017. A win-win: How Mass General cut ED visits by 13% and addressed health disparities. https://www.advisory.com/research/market-innovation-center/the-growth-channel/2017/04/health-disparities (accessed February 15, 2018).

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THE FISCAL CASE FOR HEALTH LITERACY

In the United States, low health literacy is estimated to cost $105 to $238 billion each year in direct health care costs. Indirect costs are between $1.6 to $3.6 trillion each year [1]. A 3-year study of close to 93,000 veterans found that those with low or limited health literacy cost $143 million more that those with ample health literacy [2].

There are lots of diverse ways that health literacy can be used to cut costs or boost profits. Some ways to do this are:

• Increase the use of preventive health care
• Lower unneeded emergency room (ER) visits
• Lower preventable stays in the hospital and readmissions
• Lower dosing errors and poor management of chronic conditions [3].

More in depth examples are:

• Massachusetts General Hospital hired a Community Resource Specialist (CRS). This move cut ER visits by 13%. At the same time, they increased annual net savings by 7%. For each $1 spent on the CRS, Mass General saved $2.65 [3].
• About 18% of those who received an automated phone call to remind them to have a cancer screening, were screened. This led to an increase of close to $684,930 in income in just 2 months [4].
• A program to divert those who showed up at the ER for dental problems to a nearby clinic led to a more than $680,000 in revenue for the clinic. And it gave those patients the right kind of care at the right price [5].
• Patients who got their first colonoscopy and watched an education video had much less anxiety scores the day of the procedure. This lead to 18% drop in sedation medicine, as well as, a 14% drop in procedure time [6].
• The What to Do When Your Child Gets Sick book gave parents the knowledge to know what to do to deal with their child’s health care at home. This is instead of taking their child to urgent care. An average of close to $1.50 in health care costs for each $1 spent was saved [7].
• A What to Do When Your Child Gets Sick partnership by UCLA and Head Start in California found that Medicaid can save at least $554 per family each year in direct costs. The savings were attributable to less clinic and ER visits [8].

Health literacy gives a broad range of schemes and tools to support patients, their loved ones, and caregivers. This helps the health of patients while strengthening the bottom line of clinics and health systems.

1. Vernon, J.A. and U.o.C.D.o. Finance, Low health literacy: Implications for national health policy. 2007: University of Connecticut, Department of Finance.

2. Haun, J.N., et al., Association between health literacy and medical care costs 2 an integrated healthcare system: a regional population based study. Bmc Health Services Research, 2015. 15: p. 249.

3. Vuletich, D. and N. Farooqi, Awin-win: How Mass General cut ED visits by 13% and addressed health disparities, in Growth Channel Blog. 2017, The Advisory Board Company.

4. Healthcare, W., Ochsner Improves Colorectal Test Screening Rates through West Outreach. 2015, Author.

5. Pfannenstiel, N. and A. Brown, ER Diversion Programs Right Care. Right Place. Right Time, in Missouri Rural Health Conference. 2017: Camdenton MO.

6. The Beryl Institute, Reducing Patient Anxiety and Improving Patient Knowledge. 2015, Author.

7. Cook, M., “What to Do When Your Child Gets Sick” Book Combined Projects Report. 2013, Wisconsin Literacy.

8. UCLA/Johnson & Johnson Health Care Institute, A Breakthrough Health Literacy Program Empowering Parents - Benefiting Children - Improving the Health Care System.

THE BEHAVIORAL CASE FOR HEALTH LITERACY

There is proof that health literacy programs helps patients get healthy. Some programs try to change one behavior at a time. Other programs try to change more than one behavior at the same time.

Low or limited health literacy can lead to patients acting in ways that negatively affect their health. Patients such as this might use emergency rooms (ER) for care when they don’t need to. Or they may spend more days in the hospital. Or they may avoid some types of preventive care such as screenings for cancer and flu shots [1]. Health literacy is a way to help the patient act in ways that can lead to better health.

Here are some ways health literacy has helped:

• The What to Do When Your Child Gets Sick books to were given to new moms who would soon give birth to a child. This led to less ER use [2].
• An interactive phone call was made to patients who had heart failure. In the first 2 weeks, the percentage of patients who called in to tell their daily weight increased from 28% to 36% [3].
• An adult education class added health literacy into the course. This gave a boost in knowledge of health to the learners [4].
• Health literacy is linked to patient activation. Patient activation helps the patient to know how to treat their chronic conditions such as asthma and high blood pressure. Plus, patients from a study were more likely to act in healthy ways like getting screened for breast cancer and not having to stay in the hospital [5].
• Health literacy plays a role in addressing public health burdens. These would be things like more exercise for people who need to lose weight [6-8], or parents might make the choice to have their child get a flu shot [9].
• Good health literacy plans and having faith in one’s ability to care for one’s health are key to better health outcomes. As a result, patients tend to get more health screenings when they need them [10, 11]. Plus, patients tend to be more willing to take an HIV test [12], stop smoking [13, 14], care for their asthma [15, 16], and be more honest with their doctor [17, 18].

As we move more towards payment models that are based on value, health literacy gives an upstream payoff in terms of the chance to change patient and population health outcomes.

1. Berkman, N.D., et al., Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine, 2011. 155(2): p. 97-W41.

2. Neighborhood Health Plan, Reducing Non-Emergent ER Utilization: Intervention Addressed to Mothers of Newborns. 2008.

3. emmi Solutions, EMMI Helps Drive Positive Behaviors Post-Discharge. 2016.

4. Zoellner, J.M., et al., Effects of a behavioral and health literacy intervention to reduce sugar-sweetened beverages: a randomized-controlled trial. The international journal of behav- ioral nutrition and physical activity, 2016. 13: p. 38.

5. Smith, S.G., et al., Skill Set or Mind Set? Associations between Health Literacy, Patient Activation and Health. Plos One, 2013. 8(9): p. e74373.

6. Dominick, G.M., et al., Health Literacy Predicts Change in Physical Activity Self-efficacy Among Sedentary Latinas. Journal of Immigrant & Minority Health, 2013. 15(3): p. 533- 539.

7. Dominick, G.M., et al., Health Literacy Moderates Change in Physical Activity among Latinas in a Randomized Trial. Annals of Behavioral Medicine, 2015. 49: p. S220-S220.

8. Dominick, G.M., et al., Moderating Effects of Health Literacy on Change in Physical Activity Among Latinas in a Randomized Trial. Journal of racial and ethnic health disparities, 2015. 2(3): p. 351-357.

9. Veldwijk, J., et al., Preferences for Vaccination: Does Health Literacy Make a Difference? Medical Decision Making, 2015. 35(8): p. 948-958.

10. Tiraki, Z. and M. Yilmaz, Cervical Cancer Knowledge, Self-Efficacy, and Health Literacy Levels of Married Women. J Cancer Educ, 2017.

11. Davis, T.C., et al., Improving mammography screening among the medically underserved. J Gen Intern Med, 2014. 29(4): p. 628-35.

12. Rikard, R.V., R. Head, and M.S. Thompson, Know Your Status: Health Literacy, Self-Efficacy & HIV Testing Attitudes. Journal of Behavioral and Social Sciences, 2016. 3: p. 52-62.

13. Stewart, D.W., et al., Associations between health literacy and established predictors of smoking cessation. Am J Public Health, 2013. 103(7): p. e43-9.

14. Parisod, H., et al., Determinants of tobacco-related health literacy: A qualitative study with early adolescents. International Journal of Nursing Studies, 2016. 62: p. 71-80.

15. White, R.O., et al., Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting. Patient Educ Couns, 2015. 98(2): p. 144-9.

16. Rak, E.C., Employment Outcomes in Persons With Diabetes: The Role of Health Literacy and Diabetes Management Self-Efficacy. Rehabilitation Counseling Bulletin, 2014. 57(3): p. 159-169.

17. Fry-Bowers, E.K., et al., Health literacy and interpersonal interactions as predictors of maternal perception of ambulatory care for low-income, Latino children. Patient Educ Couns, 2013. 91(2): p. 213-20.

18. Fry-Bowers, E.K., et al., The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers. J Pediatr Nurs, 2014. 29(4): p. 309-20.

THE HEALTH LITERACY CASE FOR HEALTH OUTCOMES

Low health literacy has been found to have a strong link with worse health. It increases the risk of death for seniors. Plus, it can make a person less likely to know how to take their medicine like they should. And there is less of a chance they will know what a health label or message means [1]. A good health literacy plan will yield improved health outcomes and better 30-day readmission rates [2].

Plus, those with low health literacy have been known to use the Emergency Room (ER) more than they should [3]. Those with low health literacy had:

• More than twice the number of ER visits that led to a stay in the hospital,
• 1.4 times the number of hospital visits where they were seen and released, and
• Almost twice the number of total ER visits that were not needed.

A patient who has a good health literacy plan and who feels like he or she knows how to control their health care can do better with:

• Hemoglobin A1c, glucose, and total cholesterol [4]
• Regularly taking diabetic medication [5–7], and
• HIV medication [8].

The same connection between health literacy, self-efficacy, and social support improves mental health outcomes, such as depression, among racial/ethnic minorities [7, 9, 10]. What is the impact on readmission rates?

• Health literacy has been found to be a great source for predicting readmissions that occur in thefirst 30 days [11, 12].
• Medicare patients with more than basic health literacy had a 12% less risk of coming back to the hospital after a heart attack in the first 30 days. The same group was 16% less likely to actually come back [11].

More studies have found health literacy to be a factor to readmissions. They found it to affect the rates for those who:

• Have diabetes [13],
• Get maintenance dialysis [14],
• Have had heart failure [15],
• Have had a post-discharge fall [16], and
• Are moving to surgical care [17].

There is strong support that addressing health literacy can improve health outcomes.

1. Berkman, N.D., et al., Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine, 2011. 155(2): p. 97-W41.

2. Shermont, H., et al., Reducing Pediatric Readmissions: Using a Discharge Bundle Combined With Teach-back Methodology. Journal of Nursing Care Quality, 2016. 31(3): p. 224-232.

3. Balakrishnan, M.P., et al., The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 2017.

4. Kim, M., et al., The Effect of a Community-based Health Literacy-enhanced Behavioral Intervention in Korean American Seniors With High Blood Pressure. Circulation, 2013. 128(22).

5. Al Sayah, F., et al., Health literacy and health outcomes in diabetes: a systematic review. J Gen Intern Med, 2013. 28(3): p. 444-52.

6. Hofer, R., et al., Mediators and Moderators of Improvements in Medication Adherence. Health Educ Behav, 2017. 44(2): p. 285-296.

7. Lee, Y., et al., Pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with type 2 diabetes mellitus. Patient Educ Couns, 2016. 99(2): p. 287-94.

8. Colbert, A.M., S.M. Sereika, and J.A. Erlen, Functional health literacy, medication-taking self-efficacy and adherence to antiretroviral therapy. J Adv Nurs, 2013. 69(2): p. 295-304.

9. Hernandez, M.Y. and K.C. Organista, Entertainment-education? A fotonovela? A new strategy to improve depression literacy and help-seeking behaviors in at-risk immigrant Latinas. Am J Community Psychol, 2013. 52(3-4): p. 224-35.

10. Hernandez, M.Y. and K.C. Organista, Qualitative Exploration of an Effective Depression Literacy Fotonovela with at Risk Latina Immigrants. Am J Community Psychol, 2015. 56(1-2): p. 79-88.

11. Bailey, S.C., et al., Health literacy and 30-day hospital readmission after acute myocardial infarction. Bmj Open, 2015. 5(6): p. e006975.

12. Mitchell, S.E., et al., Health Literacy and 30-Day Postdischarge Hospital Utilization. Journal of Health Communication, 2012. 17: p. 325-338.

13. Rubin, D.J., et al., Early readmission among patients with diabetes: A qualitative assessment of contributing factors. Journal of Diabetes and Its Complications, 2014. 28(6): p. 869-873.

14. Flythe, J.E., et al., Psychosocial Factors and 30-Day Hospital Readmission among Individuals Receiving Maintenance Dialysis: A Prospective Study. American Journal of Nephrology, 2017. 45(5): p. 400-408.

15. Cox, S.R., et al., Association between health literacy and 30-day healthcare use after hospital discharge in the heart failure population. Research in Social & Administrative Pharmacy, 2017. 13(4): p. 754-758.

16. Jaffee, E.G., et al., Postdischarge Falls and Readmissions: Associations with Insufficient Vision and Low Health Literacy among Hospitalized Seniors. Journal of Health Communication, 2016. 21: p. 135-140.

17. Martin, L.A., S.R.G. Finlayson, and B.S. Brooke, Patient Preparation for Transitions of Surgical Care: Is Failing to Prepare Surgical Patients Preparing Them to Fail? World Journal of Surgery, 2017. 41(6): p. 1447-1453.

THE HEALTH LITERACY CASE FOR QUALITY CARE

The role health literacy plays in patient safety is well known. This is why heath literacy is widely endorsed by:

• Institute for Healthcare Improvement and the National Patient Safety Foundation [1],
• Centers for Disease Control and Prevention [2],
• American Medical Association [3],
• Joint Commission [4],
• U.S. Department of Health and Human Services [5], and
• Agency for Healthcare Quality [6].

Health literacy can enhance all six aims of quality improvement [7] and can make health care more:

1. Safe,
2. Effective,
3. Patient centered,
4. Timely,
5. Efficient, and
6. Equitable.

Many studies have looked at the role health literacy plays to help patients take their medicine like they should [8–12]. Some things that help patients are:

• Use universal precautions such as giving exact times to take medicine [13].
• Use only milligrams as the set unit for liquid medicine [14].
• Use oral syringes, not cups, when the dose is small [15].
• Add pictures to voice or text instructions. This will cut down on dosing errors. This helps the patient know and recall what they’ve been told to do. Both lead to better adherence [16].
• Use medicine labels that are clear and easy to read [17, 18].

Most studies on health literacy and quality focus only on medicine in liquid form. We need more research to understand the role health literacy can play in reducing dosing errors and improving adherence for medicine in other forms.

1. National Patient Safety Foundation, I.f.H.I. Health Literacy. 2017 9-25-2017]; Available from: http://www.npsf.org/?page=healthliteracy.

2. CDC. Health Literacy: Accurate, Accessible, and Actionable Health Information for All. 2017; Available from: https://www.cdc.gov/healthliteracy/index.html.

3. Weiss, B.D., Health literacy and patient safety: Help patients understand. Manual for clinicians (2nd edition). American Medical Association Foundation and American Medical Association. Nedlastet, 2007. 24.

4. The Joint Commission, “What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety. 2007: The Joint Commission.

5. DHHS, U.S., National Action Plan to Improve Health Literacy., O.o.D.P.a.H.P. U.S. Department of Health and Human Services, Editor. 2010.

6. AHRQ. Health Literacy. 2017 9-25-2017]; Available from: https://www.ahrq.gov/professionals/clinicians-providers/resources/health-literacy.html.

7. IOM, Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, Institute of Medicine: Washington, D.C.

8. Davis, T.C., et al., Low literacy impairs comprehension of prescription drug warning labels. Journal of General Internal Medicine, 2006. 21(8): p. 847-851.

9. Davis, T.C., et al., Literacy and Misunderstanding Prescription Drug Labels. Annals of Internal Medicine, 2006. 145(12): p. 887-W246-887-W246.

10. Institute of Medicine, Standardizing Medication Labels: Confusing Patients Less: Workshop Summary, ed. L.M. Hernandez. 2008, Washington, DC: The National Academies Press. 116.

11. Mira, J.J., et al., A systematic review of patient medication error on self-administering medication at home. Expert Opinion on Drug Safety, 2015. 14(6): p. 815-838.

12. Persell, S.D., et al., Medication Reconciliation and Hypertension Control. The American Journal of Medicine, 2010. 123(2): p. 182.e9-182.e15.

13. Davis, T.C., et al., Improving Patient Understanding of Prescription Drug Label Instructions. JGIM: Journal of General Internal Medicine, 2009. 24(1): p. 57-62.

14. Yin, H.S., et al., Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics, 2014. 134(2): p. E354-E361.

15. Yin, H.S., et al., Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics, 2016. 138(4): p. e20160357.

16. Chan, H.K., et al., Using pictograms to assist caregivers in liquid medication administration: a systematic review. Journal of Clinical Pharmacy and Therapeutics, 2015. 40(3): p. 266-272.

17. Trettin, K.W., et al., Implementation of VA patient-centered prescription label and patient medication information. Vol. 3. 2015, Amsterdam: Elsevier Science Bv. 1-5.

18. Wolf, M.S., et al., A Patient-Centered Prescription Drug Label to Promote Appropriate Medication Use and Adherence. Journal of General Internal Medicine, 2016. 31(12): p. 1482- 1489.

IMPROVING PATIENT EXPERIENCE: THE CASE FOR HEALTH LITERACY

Low health literacy has been linked to low patient satisfaction with their health care [1, 2]. Tackling health literacy has been found to boost patient satisfaction in:

• Medicine adherence and management [3-5],
• High blood pressure management [6],
• Getting informed consent [7],
• Eye health education [8], and
• Maternal health education [9].

Plus, when a patient can give their say on their own health care (which is a big part of health literate care), patient satisfaction grows [10–13].

In a recent study of close to 100,000 Hospital Consumer Assessment of Healthcare Providers and Sys- tems (HCAHPS) surveys from hospitals that used videos made by experts:

• 100% of hospitals had a higher aggregate HCAHPS Top Box percentage scores,
• 69% of aggregate Top Box answers were 4% higher or more,
• 86% of hospitals had a higher “doctor communication” dimension scores,
• 62% of hospitals had higher “discharge information” dimension scores, and
• 59% of hospitals had higher “nurse communication” dimension scores [14].

Plus, the use of web-based tools has been known to boost patient satisfaction too. These tools are things like:

• The use of pictures to teach about heart disease [15], and
• The use of web-based tools to help patients with diabetes better track glucose level, talk directly to health care providers, and talk to other patients with diabetes [16].

Satisfaction can be helped by pairing these tools with education and support through the phone [17, 18].

Solutions do not have to be large scale, nor do they need to cost a lot to start. Just the use of simple health literacy universal precautions has been known to help with patient satisfaction. These would be things such as:

• Putting MRI reports into plain language [19],
• Using standard emergency room instructions [20],
• Using audio-recorded messages [21], and
• Urging patients to bring a friend or loved one with them to the visit [22].

Increased satisfaction improves patient experience and leads to more profits. A study done by Accenture found that hospitals whose patients felt their health care was great, made 50% more money [23].

1. MacLeod, S., et al., The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults. Geriatric Nursing, 2017. 38(4): p. 334-341.

2. Shea, J.A., et al., Health literacy weakly but consistently predicts primary care patient dissatisfaction. International Journal for Quality in Health Care, 2007. 19(1): p. 45-49.

3. Graumlich, J.F., et al., Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial. Journal of Diabetes Research, 2016: p. 2129838.

4. Murray, M.D., et al., Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Annals of Internal Medicine, 2007. 146(10): p. 714-725.

5. Ruiz, J.G., et al., Computer-Based Programmed Instruction Did Not Improve the Knowledge Retention of Medication Instructions of Individuals With Type 2 Diabetes Mellitus. Diabetes Educator, 2014. 40(1): p. 77- 88.

6. Piette, J.D., et al., Hypertension Management Using Mobile Technology and Home Blood Pressure Monitoring: Results of a Randomized Trial in Two Low/Middle-Income Countries. TELEMEDICINE AND E-HEALTH, 2012. 18(8): p. 613-620.

7. Hallock, J.L., R. Rios, and V.L. Handa, Patient satisfaction and informed consent for surgery. American Journal of Obstetrics and Gynecology, 2017. 217(2): p. 181.e1-7.

8. Rhodes, L.A., et al., Eye Care Quality and Accessibility Improvement in the Community (EQUALITY): impact of an eye health education program on patient knowledge about glaucoma and attitudes about eye care. Patient-Related Outcome Measures, 2016. 7: p. 37-48.

9. Stikes, R., K. Arterberry, and M. Cynthia Logsdon, A Leadership Project to Improve Health Literacy on a Maternal/Infant Unit. Journal of Obstetric, Gynecologic & Neonatal Nursing, 2015. 44(5): p. E20-E21.

10. Joosten, E.A.G., et al., Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy and Psychosomatics, 2008. 77(4): p. 219-226.

11. Olomu, A., et al., Implementing shared decision making in federally qualified health centers, a quasi-experimental design study: the Office-Guidelines Applied to Practice (Office-GAP) program. Bmc Health Services Research, 2016. 16: p. 334.

12. Slover, J., J. Shue, and K. Koenig, Shared Decision-making in Orthopaedic Surgery. Clinical Orthopaedics and Related Research, 2012. 470(4): p. 1046-1053.

13. Bozic KJ, B.J., Chan V, Youm J, Zhou T, Dupaix J, Bye AN, Braddock CH 3rd, Chenok KE, Huddleston JI 3rd., Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. J Bone Joint Surg Am, 2013. 95(18): p. 1633-1639.

14. emmi Solutions, Improved HCAHPS Scores at 29 U.S. Hospitals: A comprehensive study of nearly 100,000 HCAHPS surveys reveals patients who viewed an Emmi program had higher HCAHPS scores. 2015, emmi Solutions.

15. Hill, B., et al., Automated pictographic illustration of discharge instructions with Glyph: impact on patient recall and satisfaction. Journal of the American Medical Informatics Association, 2016. 23(6): p. 1136-1142.

16. Brown, L.L., M.L.A. Lustria, and J. Rankins, A Review of Web-Assisted Interventions for Diabetes Management: Maximizing the Potential for Improving Health Outcomes. Journal of diabetes science and technology (Online), 2007. 1(6): p. 892-902.

17. emmi Solutions, EMMI Helps Drive Positive Behaviors Post-Discharge. 2015.

18. Wolf, M.S., et al., Clinic-based versus outsourced implementation of a diabetes health literacy intervention. JGIM: Journal of General Internal Medicine, 2014. 29(1): p. 59-67.

19. Bossen, J.K.J., et al., Does Rewording MRI Reports Improve Patient Understanding and Emotional Response to a Clinical Report? Clinical Orthopaedics and Related Research, 2013. 471(11): p. 3637-3644.

20. Isaacman, D.J., et al., Standardized Instructions: Do They Improve Communication of Discharge Information from the Emergency Department? Pediatrics, 1992. 89(6): p. 1204.

21. Santo, A., A.M. Laizner, and L. Shohet, Exploring the value of audiotapes for health literacy: a systematic review. Patient Education and Counseling, 2005. 58(3): p. 235-243.

22. Rosland, A.M., et al., Family and Friend Participation in Primary Care Visits of Patients With Diabetes or Heart Failure Patient and Physician Determinants and Experiences. Medical Care, 2011. 49(1): p. 37-45.

THE HEALTH EQUITY CASE FOR HEALTH LITERACY

The term equity (or to give health care that is the same for all patients) is one of the six aims of quality care [1]. To reach health equity, we must take out all barriers to good health care. These barriers include things such as being poor or facing discrimination, the result of which might include feeling helpless to change one’s life. Or it might be a lack of access to good jobs with fair pay, good education, a safe place to live, and having good health care [2].

Plus, health equity means that we all have the same access to health care knowledge. Health information should be:

• Targeted, tailored, easy to read, understandable, and culturally appropriate, and
• Available where people live, learn, play, work, and worship.

There has been a movement in health justice to make the moral or ethical case for equal access to health information for all patients. This includes the underserved. They tend to lack the means that others have to get and stay healthy [3, 4].

Findings:

• Most of the health literacy research looks at clinical outcomes and the way we use health care [5].
• Most peer-reviewed work (as well as work not published) in health literacy does not look at the social determinants of health at the community nor the patient level [6]
• Health literacy has been found to mediate the effect of race on such health outcomes as:

  • Illness that keeps people from working,

  • Chronic disease,
  • Self-reported health status,
  • Flu vaccination rates,
  • Quality of life,
  • Prostate-specific antigen levels,
  • Medicine adherence, and
  • Enrollment in health insurance [5].

Health care should fit each patient’s own life. And they should get the health information where they live and learn. The use of health literacy can improve patient knowledge, attitudes, and skills. And it can be a path to health equity for all [9–11].

1. IOM, Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, Institute of Medicine: Washington, D.C.

2. Braveman, P., et al., What Is Health Equity? And What Difference Does a Definition Make?, N.R.W.J.F. Princeton, Editor. 2017.

3. Marks, R., Ethics and Patient Education: Health Literacy and Cultural Dilemmas. Health Promotion Practice, 2009. 10(3): p. 328-332.

4. Volandes, A.E. and M.K. Paasche-Orlow, Health Literacy, Health Inequality and a Just Healthcare System. American Journal of Bioethics, 2007. 7(11): p. 5-10.

5. Berkman, N.D., et al., Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine, 2011. 155(2): p. 97-W41.

6. Logan, R.A., W.F. Wong, M. Villaire, G. Daus, T.A. Parnell, E. Willis, and M.K. Paasche- Orlow, Health literacy: A necessary element for achieving health equity. 2015, Institute of Medicine, Washington, DC.: Discussion Paper.

7. Mantwill, S., S. Monestel-Umaña, and P.J. Schulz, The Relationship between Health Literacy and Health Disparities: A Systematic Review. PLOS ONE, 2015. 10(12): p. e0145455.

8. Rothman, R.L., et al., Influence of patient literacy on the effectiveness of a primary care- based diabetes disease management program. Jama, 2004. 292(14): p. 1711-6.

9. Aiken, N., L. Tarullo, L. Hulsey, et al., A year in Head Start: Children, families and programs. 2010, Administration for Children and Families, Office of Planning, Research, and Evaluation.

10. Herman, A., Nelson, B. B., Teutsch, C., & Chung, P. J., “Eat Healthy, Stay Active!”: A Coordinated Intervention to Improve Nutrition and Physical Activity among Head Start Parents, Staff, and Children. American Journal of Health Promotion, 2012. 27(1): p. e27-e36.

11. Neuhauser, L., et al., Promoting Prenatal and Early Childhood Health: Evaluation of a Statewide Materials-Based Intervention for Parents. American Journal of Public Health, 2007. 97(10): p. 1813-1819.

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