Updating Health Literacy for Healthy People 2030: Defining Its Importance for a New Decade in Public Health.

CONTENT: Healthy People 2030, the fifth iteration of the Healthy People initiative, provides science-based national health objectives with targets to improve the health and well-being of Americans. For the first time since its 1979 establishment, the Healthy People framework aims to attain health literacy as an overarching goal and foundational principle to achieving health and well-being. Growing literature on health literacy describes it as a concept not solely reliant on individual capabilities but also on organizations' ability to make health-related information and services equitably accessible and comprehensible. PROGRAM: The US Department of Health and Human Services (HHS) updates the Healthy People objectives each decade based on the most current science. For the development of Healthy People 2030, HHS drew on recommendations from the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary's Advisory Committee), an independent advisory committee of national health experts, to update the 20-year old individual-focused Healthy People definition of health literacy. HHS solicited input from members of the public and users on the proposed changes to that definition. IMPLEMENTATION: HHS published a Federal Register notice to solicit public comments, which were qualitatively analyzed by government staff. EVALUATION: The 2 separate analyses revealed plurality support for improving the definition to focus on both individual and organizational roles in health literacy. Results led HHS subject matter experts to update the definition to include definitions of personal health literacy and organizational health literacy. Healthy People 2030's expanded health literacy definition reflects the most current science and input from the Secretary's Advisory Committee, public comments, and HHS subject matter experts. DISCUSSION: The updated definition is intended to advance Healthy People 2030's health literacy goals particularly as more organizations in public health and other sectors acknowledge their role in the delivery of quality health information and services.

Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children.

Importance: Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting. Objective: To examine the association between parent LCE and adverse events in a cohort of hospitalized children. Design, Setting, and Participants: This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020. Exposures: Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses. Main Outcomes and Measures: The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site. Results: Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2). Conclusions and Relevance: Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

How the U.S. Agency for Healthcare Research and Quality Promotes Health Literate Health Care.

This report traces the U.S. Agency for Healthcare Research and Quality's (AHRQ) strategic approach to promote health literate health care delivery systems. For almost 15 years, the AHRQ Health Literacy Action Plan has served as the framework for the Agency's efforts to: 1) Develop Measures; 2) Improve the Evidence Base and Create Implementation Tools; 3) Create and Support Change; 4) Disseminate and Transfer Knowledge and Tools; and 5) Practice What We Preach. Drawing upon its core competencies in data and measurement, practice improvement, and health services research, AHRQ accelerated the uptake of evidence-based health literacy strategies by health care organizations.

Organizational Health Literacy: Quality Improvement Measures with Expert Consensus.

BACKGROUND: Organizational health literacy (OHL) is the degree to which health care organizations implement strategies to make it easier for patients to understand health information, navigate the health care system, engage in the health care process, and manage their health. Although resources exist to guide OHL-related quality improvement (QI) initiatives, little work has been done to establish measures that organizations can use to monitor their improvement efforts. OBJECTIVE: We sought to identify and evaluate existing OHL-related QI measures. To complement prior efforts to develop measures based on patient-reported data, we sought to identify measures computed from clinical, administrative, QI, or staff-reported data. Our goal was to develop a set of measures that experts agree are valuable for informing OHL-related QI activities. METHODS: We used four methods to identify relevant measures computed from clinical, administrative, QI, or staff-reported data. We convened a Technical Expert Panel, published a request for measures, conducted a literature review, and interviewed 20 organizations working to improve OHL. From the comprehensive list of measures identified, we selected a set of high-priority measures for review by a second expert panel. Using a modified Delphi review process, panelists rated measures on four evaluation criteria, participated in a teleconference to discuss areas of disagreement among panelists, and rerated all measures. KEY RESULTS: Across all methods, we identified 233 measures. Seventy measures underwent Delphi Panel review. For 22 measures, there was consensus among panelists that the measures were useful, meaningful, feasible, and had face validity. Five additional measures received strong ratings for usefulness, meaningfulness, and face validity, but failed to show consensus among panelists regarding feasibility. CONCLUSIONS: We identified OHL-related QI measures that have the support of experts in the field. Although additional measure development and testing is recommended, the Consensus OHL QI Measures are appropriate for immediate use. [HLRP: Health Literacy Research and Practice. 2019;3(2):e127-e146.]. PLAIN LANGUAGE SUMMARY: The health care system is complex. Health care organizations can make things easier for patients by making changes to improve communication and to help patients find their way around, become engaged in the health care process, and manage their health. We identify 22 measures that organizations can use to monitor their efforts to improve communication with and support for patients.

Health Literacy in the Inpatient Setting: Implications for Patient Care and Patient Safety.

Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.

Challenges optimizing the after visit summary.

BACKGROUND: The after visit summary (AVS) is a paper or electronic document given to patients after a medical appointment, which is intended to summarize patients' health and guide future care, including self-management tasks. OBJECTIVE: To describe experiences of health systems implementing a redesigned outpatient AVS in commercially available electronic health record (EHR) systems to inform future optimization. MATERIALS AND METHODS: We conducted semi-structured interviews with information technology and clinical leaders at 12 hospital and community-based healthcare institutions across the continental United States focusing on the process of AVS redesign and implementation. We also report our experience implementing a redesigned AVS in the Epic EHR at the Mount Sinai Hospital in New York City, NY. RESULTS: Health systems experienced many challenges implementing the redesigned AVS. While many IT leaders noted that the redesigned AVS is easier to understand and the document is better organized, they claim the effort is time-consuming, Epic system upgrades render AVS modifications non-functional, and primary care and specialty practices have different needs in regards to content and formatting. Our team was able to modify the document by changing the order of print groups, modifying the font size, bolding section headers, and inserting page breaks. Similar to other health systems, our team found that it is difficult to achieve some desired features due to limitations in the EHR platform. CONCLUSION: Health IT leaders view the AVS as a valuable source of information for patients. However, limitations to AVS modifications in EHR systems present challenges to optimizing the tool. EHR vendors should incorporate learning from healthcare systems innovation efforts and consider building more flexibility into their product development.

Opportunities to Improve Informed Consent with AHRQ Training Modules.

BACKGROUND: Informed consent is a process of communication between clinician and patient that results in the patient's decision about whether to undergo a specific intervention. However, patients often do not understand the risks, benefits, and alternatives, even after signing a consent form. METHODS: Mixed-methods pilot test of two Agency for Healthcare Research and Quality (AHRQ) informed consent training modules implemented in four hospitals. Methods included staff and patient surveys, interviews, site visits, and pre- and posttests of the modules. RESULTS: A low proportion of clinicians reported using teach-back (40.0%) or high-quality decision aids (55.0%). Patients reported limited use of best practices, including being asked to teach-back (58.4%), having other options described (54.9%), viewing decision aids (37.4%), and finding the form very easy to understand (66.8%). Content of the training modules aligned well with identified deficiencies. Barriers to completing the modules included staff turnover, competing demands, and lack of accountability. Facilitators included committed champions with available time, motivation, and release time for staff to take modules. Knowledge increased for leaders (p <0.05) and staff (p <0.001) who completed the training modules. Hospitals reported the effects of piloting the modules included fostering dialogue and identifying opportunities for improvements, identifying and rectifying policy ambiguity and noncompliance, reinforcing the use of interpreter services, and using modules' strategies and tools to improve informed consent. CONCLUSION: Many opportunities exist for hospitals to improve their informed consent practices. AHRQ's two training modules, have face validity, addressed demonstrated deficiencies in hospitals' informed consent policies and processes, and stimulated improvement activity in motivated hospitals.

After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children's Health Care Quality.

Introduction Under the CHIPRA Quality Demonstration Grant Program, CMS awarded $100 million through 10 grants that 18 state Medicaid agencies implemented between 2010 and 2015. The program's legislatively-mandated purpose was to evaluate promising ideas for improving the quality of children's health care provided through Medicaid and CHIP. As part of the program's multifaceted evaluation, this study examined the extent to which states sustained key program activities after the demonstration ended. Methods We identified 115 potentially sustainable elements within states' CHIPRA demonstrations and analyzed data from grantee reports and key informant interviews to assess sustainment outcomes and key influential factors. We also assessed sustainment of the projects' intellectual capital. Results 56% of potentially sustainable elements were sustained. Sustainment varied by topic area: Elements related to quality measure reporting and practice facilitation were more likely to be sustained than others, such as parent advisors. Broad contextual factors, the state's Medicaid environment, implementation partners' resources, and characteristics of the demonstration itself all shaped sustainment outcomes. Discussion Assessing sustainment of key elements of states' CHIPRA quality demonstration projects provides insight into the fates of the "promising ideas" that the grant program was designed to examine. As a result of the federal government's investment in this grant program, many demonstration states are in a strong position to extend and spread specific strategies for improving the quality of care for children in Medicaid and CHIP. Our findings provide insights for policymakers and providers working to improve the quality of health care for low income children.

Health Literacy Universal Precautions Are Still a Distant Dream: Analysis of U.S. Data on Health Literate Practices.

BACKGROUND: Experts have recommended the adoption of health literacy universal precautions, whereby health care providers make all health information easier to understand, confirm everyone's comprehension, and reduce the difficulty of health-related tasks. The U.S. Department of Health and Human Services selected three health literate practices to track progress in the adoption of health literacy universal precautions. OBJECTIVES: This study sought to examine whether there has been an increase in the delivery of health literate care and whether recommendations for health literacy universal precautions are being followed. METHODS: This study used trend and multiple regression analyses of data from 2011 to 2014 from the Medical Expenditure Panel Survey, a national household survey. KEY RESULTS: The proportion of adults in the U.S. who reported receiving health literate care increased from 2011 to 2014, but fell far short of health literacy universal precautions recommendations of delivering health literate care to everyone. In 2014, 70% of the population reported their providers always gave them instructions that were easy to understand, but only 29% were asked to Teach-Back the instructions and only 17% were offered help with forms. Older, less educated, and racial and ethnic minority group members were more likely to report receiving health literate care than more advantaged groups. People who perceived their health and mental health as fair or poor were less likely to report receiving health literate care. CONCLUSIONS: Failure to adopt health literacy universal precautions in the face of the high prevalence of limited health literacy in the general population may perpetuate adverse health outcomes that are costly to society. Greater efforts should be made to increase providers' health literacy skills, particularly those who serve populations that are more likely to have limited health literacy, including those with poor health. PLAIN LANGUAGE SUMMARY: This study shows that some health care providers did not always check that their instructions were clear enough for patients to understand. Even fewer providers always offered help in filling out forms. People who were older, less educated, or members of racial or ethnic minority groups were more likely to be asked to confirm their understanding or be offered help with forms. More patients said that their provider was easy to understand, checked their understanding, or offered help with forms in 2014 than in 2011.

The Journey to Become a Health Literate Organization: A Snapshot of Health System Improvement.

A health literate health care organization is one that makes it easy for people to navigate, understand, and use information and services to take care of their health. This chapter explores the journey that a growing number of organizations are taking to become health literate. Health literacy improvement has increasingly been viewed as a systems issue, one that moves beyond siloed efforts by recognizing that action is required on multiple levels. To help operationalize the shift to a systems perspective, members of the U.S. National Academies of Sciences, Engineering, Medicine Roundtable on Health Literacy defined ten attributes of health literate health care organizations. External factors, such as payment reform in the U.S., have buoyed health literacy as an organizational priority. Health care organizations often begin their journey to become health literate by conducting health literacy organizational assessments, focusing on written and spoken communication, and addressing difficulties in navigating facilities and complex systems. As organizations' efforts mature, health literacy quality improvement efforts give way to transformational activities. These include: the highest levels of the organization embracing health literacy, making strategic plans for initiating and spreading health literate practices, establishing a health literacy workforce and supporting structures, raising health literacy awareness and training staff system-wide, expanding patient and family input, establishing policies, leveraging information technology, monitoring policy compliance, addressing population health, and shifting the culture of the organization. The penultimate section of this chapter highlights the experiences of three organizations that have explicitly set a goal to become health literate: Carolinas Healthcare System (CHS), Intermountain Healthcare, and Northwell Health. These organizations are pioneers that approached health literacy in a systematic fashion, each exemplifying different routes an organization can take to become health literate. CHS provides an example of how, even when the most senior leadership drives the organization to become health literate, continued progress requires constant reinvigoration. At Intermountain Healthcare, the push to become a health literate organization was the natural consequence of organizational adoption of a model of shared accountability that necessitated patient engagement for its success. Northwell Health, on the other hand, provides a model of how a persistent champion can elevate health literacy to become a system priority and how system-wide policies and procedures can advance effective communication across language differences, health literacy, and cultures. The profiles of the three systems make clear that the opportunities for health literacy improvement are vast. Success depends on the presence of a perfect storm of conditions conducive to transformational change. This chapter ends with lessons learned from the experiences of health literacy pioneers that may be useful to organizations embarking on the journey. The journey is long, and there are bumps along the road. Nonetheless, discernable progress has been made. While committed to transformation, organizations seeking to be health literate recognize that it is not a destination you can ever reach. A health literate organization is constantly striving, always knowing that further improvement can be made.

Demonstration of the Health Literacy Universal Precautions Toolkit: Lessons for Quality Improvement.

The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit was developed to help primary care practices assess and make changes to improve communication with and support for patients. Twelve diverse primary care practices implemented assigned tools over a 6-month period. Qualitative results revealed challenges practices experienced during implementation, including competing demands, bureaucratic hurdles, technological challenges, limited quality improvement experience, and limited leadership support. Practices used the Toolkit flexibly and recognized the efficiencies of implementing tools in tandem and in coordination with other quality improvement initiatives. Practices recommended reducing Toolkit density and making specific refinements.

Even In An Emergency, Doctors Must Make Informed Consent An Informed Choice.

When a stroke is suspected, a daughter is pressured to consent to her father's treatment without fully understanding the risks.

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

BACKGROUND: Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. METHODS: The toolkit's "Brown Bag Medication Review" was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. RESULTS: Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. CONCLUSIONS: Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions.

BACKGROUND: The Re-Engineered Discharge (RED) program is a hospital-based initiative shown to decrease hospital reutilization. We implemented the RED in 10 hospitals to study the implementation process. DESIGN: We recruited 10 hospitals from different regions of the United States to implement the RED and provided training for participating hospital leaders and implementation staff using the RED Toolkit as the basis of the curriculum followed by monthly telephone-based technical assistance for up to 1 year. METHODS: Two team members interviewed key informants from each hospital before RED implementation and then 1 year later. Interview data were analyzed according to common and comparative themes identified across institutions. Readmission outcomes were collected on participating hospitals and compared pre- versus post-RED implementation. RESULTS: Key findings included (1) wide variability in the fidelity of the RED intervention; (2) engaged leadership and multidisciplinary implementation teams were keys to success; (3) common challenges included obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation. CONCLUSIONS: A supportive hospital culture is essential for successful RED implementation. A flexible implementation strategy can be used to implement RED and reduce readmissions.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials.

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.

OBJECTIVE: To develop a reliable and valid instrument to assess the understandability and actionability of print and audiovisual materials. METHODS: We compiled items from existing instruments/guides that the expert panel assessed for face/content validity. We completed four rounds of reliability testing, and produced evidence of construct validity with consumers and readability assessments. RESULTS: The experts deemed the PEMAT items face/content valid. Four rounds of reliability testing and refinement were conducted using raters untrained on the PEMAT. Agreement improved across rounds. The final PEMAT showed moderate agreement per Kappa (Average K=0.57) and strong agreement per Gwet's AC1 (Average=0.74). Internal consistency was strong (α=0.71; Average Item-Total Correlation=0.62). For construct validation with consumers (n=47), we found significant differences between actionable and poorly-actionable materials in comprehension scores (76% vs. 63%, p<0.05) and ratings (8.9 vs. 7.7, p<0.05). For understandability, there was a significant difference for only one of two topics on consumer numeric scores. For actionability, there were significant positive correlations between PEMAT scores and consumer-testing results, but no relationship for understandability. There were, however, strong, negative correlations between grade-level and both consumer-testing results and PEMAT scores. CONCLUSIONS: The PEMAT demonstrated strong internal consistency, reliability, and evidence of construct validity. PRACTICE IMPLICATIONS: The PEMAT can help professionals judge the quality of materials (available at: http://www.ahrq.gov/pemat).

Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.

Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence-based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed-methods approach was used to identify common causes of errors for LEP patients, high-risk scenarios, and evidence-based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field-tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention.