On Call Magazine, September/October 2006

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Many uninsured and underinsured patients living within 50 miles of Chapel Hill, North Carolina, get their healthcare at the University of North Carolina (UNC) Internal Medicine Clinic. Patients come to this clinic with both urgent medical problems and chronic conditions such as congestive heart failure (CHF) and diabetes. In addition, patients may be struggling with financial or transportation problems and other life stressors, and a number of them also have literacy issues. Despite their health status, life stressors, and literacy level, patients are expected to actively participate in their own treatment and care. To do this, they need to be able to follow self-care instructions, understand risks and benefits, and know what to do when emergencies occur.

When a team at the clinic wanted to make it easier for patients to understand and use important health information, they put together a program based on principles of health literacy to improve communication. At the same time, they realized that putting these principles into practice requires an investment of time and money. So the team also addressed the business side, writing several reports about their efforts, including a recently published study entitled “Labor Characteristics and Program Costs of a Successful Diabetes Disease Management Program.”

Robb Malone, PharmD, is a clinical pharmacist practitioner, certified diabetes educator, and a coauthor of this study. He recently talked with me about lessons the team learned and offered the following suggestions for healthcare providers who want to improve patient communication and health outcomes while also paying attention to an organization’s bottom line.

Health Literacy Principles

The UNC team used several key health-literacy concepts to design an effective program.

Start from the beginning. Malone and his team start from the beginning each time they meet with new patients, even those who have been diagnosed with chronic conditions for many years. While acknowledging that starting from the beginning can lengthen — not shorten — an initial visit, Malone says that it is important to correct any mistakes or inconsistencies before teaching new information. This way, patients are better prepared to achieve treatment goals and possibly prevent costly emergency care.

In initial visits with patients who have diabetes, Malone might ask the following:

• How long have you known that you have diabetes, and what do you know about diabetes? What does having diabetes mean to you? Malone finds that patients diagnosed many years ago often have the most trouble with new information. While they might recall what “Dr. Smith” used to say, patients may be unaware of new treatments, goals, and proper self-care.
• Who else in your family has diabetes? Beyond the designated healthcare team, patients often get advice from family, friends, and well-intentioned others. This question helps Malone find out what patients already know, believe, and understand.
• What should your blood sugar be before and after meals? What do these values mean to you? What blood-sugar values scare you or make you nervous and how do you react? Specific questions like these are a way to gauge patients’ knowledge, self-confidence, and ability to manage self-care tasks.

Present educational materials in ways patients can understand. Patients who were diagnosed with CHF used to be given long manuals filled with information on disease incidence, pathophysiology, lifestyle modifications, dietary changes, medication, and other treatment guidelines. Malone and colleagues sensed that many patients were overwhelmed by all this information and tested it in focus groups. Based on patients’ feedback about content and format, the team rewrote the booklet to not only be educational but also functional. The new booklet now includes simply written text, pictures, and worksheets for patients to use each day.

Make it easy for patients to take action. Patients with chronic conditions have a lot of self-care responsibility. When patients have CHF, their responsibility includes weighing themselves each morning, comparing this weight to the day before, checking their legs for swelling, adjusting their daily dose of diuretics and, if needed, calling the clinic when there are significant concerns. Patients who do these tasks incorrectly, inconsistently, or not at all may need expensive and often avoidable emergency care or hospitalization.

To reduce costs and improve health outcomes, the team created pictorial worksheets. Now patients simply fill in how much they weigh and check off the amount of swelling they have. Then, they look at color-coded (green, yellow, and red) instructions and see what to do. For example, if “Sam” gained two pounds over his “good” or “green-zone weight”, he is in the yellow zone and needs to double his diuretic dose. If he remains in the yellow zone for more than two consecutive days or continues to gain weight and enters the red zone, then he needs to call his doctor. UNC researchers have found that, regardless of reading ability, all patients can benefit by this approach.

Communicate consistently and persistently. Malone says that patients are less apt to have costly “medication misadventures” (taking medication incorrectly) when they know exactly what to do. Clinic staff help by communicating clear and consistent messages. For instance, team members use similar wording (such as “high blood pressure,” not “hypertension”) whether communicating in person, by phone, in writing, or with voice-mail messages. Members of the team also call patients regularly to follow up with them about self-care. And all staff use the “teach-back technique” to confirm patients’ understanding. This is done by asking patients to say, in their own words, what was just discussed.

Making a Business Case

Putting health-literacy principles into place obviously takes time, training, persistence, and money. The clinic offsets these expenses by putting the most cost-effective people in positions where they can do the most good. This means that patients are not always seen by primary care physicians whose time is at a premium. Instead, returning patients may be seen by physician assistants, pharmacists, nurse practitioners, or dieticians.

Patients also work with nonclinical “care assistants” who follow approved guidelines to assist with problem-solving and offer social support. They help in many ways, such as:

• Checking patients’ records just prior to appointments and noting any situations that need extra attention. Even when patients come to the clinic for acute problems, care assistants flag important chronic concerns.
• Taking a brief, targeted health history while patients wait in the examining room. The care assistant then shares this information and other significant concerns with the clinician just prior to seeing the patient, allowing more time for clinicians and patients to focus on healthcare interventions.
• Following up with patients between appointments by calling them to gather information, consulting as needed with clinicians, and then calling patients back with updated instructions.
• Helping with financial, transportation, and other life problems.

Malone and colleagues analyzed the costs and benefits of these and other health-literacy interventions in working with patients with diabetes. The authors found that “For modest labor inputs and a program cost of approximately $37 per patient per month in marginal cost, A1C levels, cardiovascular risks, and satisfaction among patients with diabetes significantly improved during the course of a year.” While acknowledging that these costs add up, Malone also speaks about clinical and business benefits. He says, “All you need to do is prevent one ED visit or hospitalization and you get your money back.”

How to Find Out More

Robb Malone, PharmD, CDE, CTP, is an assistant professor with the University of North Carolina at Chapel Hill’s School of Pharmacy and Medicine. He can be reached by email at Robb_malone@med.unc.edu

Printed and Online Resources

• DeWalt DA, et al.“A Heart Failure Self-Management Program for Patients of All Literacy Levels: A Randomized, Controlled Trial,” BMC Health Services Research. 2006, 6:30. Available online at http://www.biomedcentral.com/1472-6963/6/30
• Rothman RL, et al. “Labor Characteristics and Program Costs of a Successful Diabetes Disease Management Program,” American Journal of Managed Care. Vol.12, No.5. May 2006: 277-283.
• Schillinger D, et al. “Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy,” Arch Intern Med. Vol. 163, January 13, 2003: 83 – 90.