Presented by Cindy Brach, MPP, on March 13, 2015 at the fifth Center for Health Literacy Conference: Plain Talk in Complex Times.

1. Becoming aBecoming a
Health Literate OrganizationHealth Literate Organization
Cindy BrachCindy Brach
Center for Delivery,Center for Delivery,
Organization, and MarketsOrganization, and Markets

2. OverviewOverview
 DefinitionDefinition
 Implementing what you’ve learnedImplementing what you’ve learned
 System changeSystem change
 Being a health literate organizationBeing a health literate organization

3. Health Literate OrganizationsHealth Literate Organizations
A health literate organizationA health literate organization
makes it easy for people tomakes it easy for people to
navigate, understand, andnavigate, understand, and
use information and servicesuse information and services
to take care of their health.to take care of their health.
Brach et al. 2012Brach et al. 2012

4. Health Literacy EquationHealth Literacy Equation
Skills/Abilities xSkills/Abilities x Difficulty/ComplexityDifficulty/Complexity = Health Literacy= Health Literacy
XX ==

5. Implementing whatImplementing what
you’ve learnedyou’ve learned

6. Communicate ClearlyCommunicate Clearly
 Warm GreetingWarm Greeting
 Eye ContactEye Contact
 ListenListen
 Use Plain, Non-medicalUse Plain, Non-medical
LanguageLanguage
 Slow DownSlow Down
 Limit ContentLimit Content
 Show How It’s DoneShow How It’s Done
 Use Teach-BackUse Teach-Back
 Repeat Key PointsRepeat Key Points
 Use GraphicsUse Graphics
 Invite PatientInvite Patient
ParticipationParticipation
 Encourage QuestionsEncourage Questions
Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4

7. Implementing ClearImplementing Clear
CommunicationCommunication
 Online training, e.g.,
http://www.teachbacktraining.org/http://www.teachbacktraining.org/
 Practice, e.g., role play
 Assessments
– Communication Self-Assessment
– Communication Observation Form
– Patient Feedback Form
 Reminders: team huddles, poster
Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4 andSource: AHRQ Health Literacy Universal Precautions Toolkit, Tool 4 and
Implementing the AHRQ Health Literacy Universal Precautions Toolkit:Implementing the AHRQ Health Literacy Universal Precautions Toolkit:
Practical Ideas for Primary Care PracticesPractical Ideas for Primary Care Practices

8. Make Action PlansMake Action Plans
 Ask permissionAsk permission
 Determine motivationDetermine motivation
 Patients chooses goalsPatients chooses goals
 Manageable stepsManageable steps
 Assess confidenceAssess confidence
 Identify barriersIdentify barriers
 Follow upFollow up
Source: AHRQ Health Literacy UniversalSource: AHRQ Health Literacy Universal
Precautions Toolkit, Tool 15Precautions Toolkit, Tool 15

9. Implementing Action PlanningImplementing Action Planning
 Watch ACP video and discussWatch ACP video and discuss
 Practice, e.g., role playPractice, e.g., role play
 Address team roles and workflowAddress team roles and workflow
– Who places copies of Action Plan forms inWho places copies of Action Plan forms in
the chart?the chart?
– Who helps patients choose goalsWho helps patients choose goals
– How can EHR support and track ActionHow can EHR support and track Action
Planning?Planning?
– Who follows up with patient?Who follows up with patient?

10. Improving WrittenImproving Written
MaterialsMaterials
 Clear purposeClear purpose
 Everyday languageEveryday language
 No jargonNo jargon
 Active voiceActive voice
 Visuals reinforceVisuals reinforce
messagesmessages
 White spaceWhite space
 Short linesShort lines
 Short sectionShort section
 InformativeInformative
headingsheadings
 Logical flowLogical flow

11. Implementing ImprovementsImplementing Improvements
in Written Materialsin Written Materials
 Establish processEstablish process
 Assess materialsAssess materials
– Formal assessments, e.g., PEMAT, CCIFormal assessments, e.g., PEMAT, CCI
– Review by consumers/patientsReview by consumers/patients
 Replace poor materialsReplace poor materials
– Find better onesFind better ones
– Create better ones, use guides e.g., ToolkitCreate better ones, use guides e.g., Toolkit
for Making Written Material Clear & Effectivefor Making Written Material Clear & Effective
 Consider alternatives to printConsider alternatives to print

12. Improving Informed ConsentImproving Informed Consent
Informed consent informed choiceInformed consent informed choice
Clear, unbiased information about allClear, unbiased information about all
optionsoptions
Help aligning options with patient’s goalsHelp aligning options with patient’s goals
& values& values

13. Implementing InformedImplementing Informed
Consent ImprovementsConsent Improvements
 PolicyPolicy
– Why, who, what, when, howWhy, who, what, when, how
– DisseminationDissemination
– EnforcementEnforcement
 Building systems to improve IC processBuilding systems to improve IC process
– Library of formsLibrary of forms
– Library of decision aidsLibrary of decision aids
– Remove communication barriersRemove communication barriers
– Establish efficient workflowsEstablish efficient workflows

14. SystemsSystems
ChangeChange

15. Koh et al. 2012

18. Health LiteracyHealth Literacy
Universal PrecautionsUniversal Precautions
Structuring the delivery of care as ifStructuring the delivery of care as if
everyone may have limited healtheveryone may have limited health
literacyliteracy
– You can’t tell by lookingYou can’t tell by looking
– Higher literacy skillsHigher literacy skills ≠≠ understandingunderstanding
– Health literacy is dynamicHealth literacy is dynamic
– Everyone benefits from clearEveryone benefits from clear
communicationcommunication

19. Re-EngineeredRe-Engineered
Discharge Program (RED)Discharge Program (RED)
 Evaluated their currentEvaluated their current
discharge process anddischarge process and
re-engineered usingre-engineered using
health literacy principleshealth literacy principles
 RCT: 30% reduction inRCT: 30% reduction in
rehospitalizationsrehospitalizations
 New RED Toolkit forNew RED Toolkit for
serving diverseserving diverse
populationspopulations

20. 1.1. Obtain language assistance for patients/familiesObtain language assistance for patients/families
2.2. Make appointments for follow-up medical appointments and postMake appointments for follow-up medical appointments and post
discharge tests/labs.discharge tests/labs.
3.3. Plan for the follow-up of results from lab tests or studies that arePlan for the follow-up of results from lab tests or studies that are
pending at discharge.pending at discharge.
4.4. Organize post-discharge outpatient services and medical equipment.Organize post-discharge outpatient services and medical equipment.
5.5. Identify the correct medicines and a plan for the patient to obtain andIdentify the correct medicines and a plan for the patient to obtain and
take them.take them.
6.6. Reconcile discharge plan with national guidelines.Reconcile discharge plan with national guidelines.
7.7. Teach a written Discharge Plan the patient can understand.Teach a written Discharge Plan the patient can understand.
8.8. Educate the patient about his/her diagnosis.Educate the patient about his/her diagnosis.
9.9. Assess the degree of the patient’s understanding of this plan.Assess the degree of the patient’s understanding of this plan.
10.10. Review with the patient what to do if a problem arises.Review with the patient what to do if a problem arises.
11.11. Expedite transmission of the discharge summary to cliniciansExpedite transmission of the discharge summary to clinicians
accepting care of the patient.accepting care of the patient.
12.12. Provide telephone reinforcement of the Discharge Plan.Provide telephone reinforcement of the Discharge Plan.
RED ComponentsRED Components

21. RED ImpactRED Impact
 Reduction in readmissions (heart failure,Reduction in readmissions (heart failure,
COPD and facility-wide)COPD and facility-wide)
 Increased HCAHPS Care TransitionIncreased HCAHPS Care Transition
scoresscores
 Increase in patients reporting teach-Increase in patients reporting teach-
backback
 More time spent with patients andMore time spent with patients and
families around transitionsfamilies around transitions
 Changed organizational cultureChanged organizational culture

22. Being aBeing a
health literatehealth literate
health carehealth care
organizationorganization

24. Attribute 1Attribute 1
A Health Literate OrganizationA Health Literate Organization
Leadership:Leadership:
Makes health literacy integral to its mission,Makes health literacy integral to its mission,
structure, & operationsstructure, & operations
Makes clear & effective communication aMakes clear & effective communication a
prioritypriority
Assigns responsibility for health literacyAssigns responsibility for health literacy
oversightoversight
Sets goals for health literacy improvementSets goals for health literacy improvement
Allocates fiscal and human resourcesAllocates fiscal and human resources

25. Attribute 2Attribute 2
A Health Literate OrganizationA Health Literate Organization
Integrates health literacy into planning,Integrates health literacy into planning,
evaluation measures, patient safety, andevaluation measures, patient safety, and
quality improvement.quality improvement.
– Incorporates health literacy into allIncorporates health literacy into all
planning activitiesplanning activities
– Conducts ongoing organizationalConducts ongoing organizational
assessmentsassessments
– Measures success & identifies areas forMeasures success & identifies areas for
quality improvementquality improvement

26. Attribute 3Attribute 3
A Health Literate OrganizationA Health Literate Organization
 Prepares the workforce to be healthPrepares the workforce to be health
literate and monitors progressliterate and monitors progress
– Hires diverse staff with HL expertiseHires diverse staff with HL expertise
– Sets and meets goals for training all staff andSets and meets goals for training all staff and
members of governing bodiesmembers of governing bodies
– Provides HL training and incorporates HLProvides HL training and incorporates HL
into orientations and other trainingsinto orientations and other trainings
– Arranges for staff to take advantage of on-Arranges for staff to take advantage of on-
line HL training resourcesline HL training resources

27. Attribute 4Attribute 4
A Health Literate OrganizationA Health Literate Organization
 Includes populations served in theIncludes populations served in the
design, implementation, and evaluationdesign, implementation, and evaluation
of health information and servicesof health information and services
– Includes members of the population onIncludes members of the population on
governing bodiesgoverning bodies
– Establish advisory groups that involveEstablish advisory groups that involve
individuals with limited health literacy, adultindividuals with limited health literacy, adult
educators, and experts in health literacyeducators, and experts in health literacy
– Collaborate with community members inCollaborate with community members in
design and implementation of interventionsdesign and implementation of interventions
and development and testing of materials.and development and testing of materials.

28. Get Patient FeedbackGet Patient Feedback
 Include patients on HL TeamInclude patients on HL Team
 Shadow patientsShadow patients
 Conduct a walk throughConduct a walk through
 Observe patients using your patientObserve patients using your patient
portalportal
 Ask patients for feedback on forms orAsk patients for feedback on forms or
other materialsother materials
 Have a suggestion boxHave a suggestion box
 Survey your patientsSurvey your patients
Source: AHRQ HealthSource: AHRQ Health
Literacy UniversalLiteracy Universal
Precautions Toolkit, Tool 17Precautions Toolkit, Tool 17

29. Attribute 5Attribute 5
A Health Literate OrganizationA Health Literate Organization
 Meets needs of populations with a rangeMeets needs of populations with a range
of health literacy skills while avoidingof health literacy skills while avoiding
stigmatizationstigmatization
– Adopts health literacy universalAdopts health literacy universal
precautions, such as offering everyoneprecautions, such as offering everyone
help with literacy taskshelp with literacy tasks
– Allocates resources proportionate to theAllocates resources proportionate to the
concentration of individuals with limitedconcentration of individuals with limited
health literacyhealth literacy

30. AHRQ Health LiteracyAHRQ Health Literacy
Universal Precautions ToolkitUniversal Precautions Toolkit
 22ndnd
edition with 21 tools:edition with 21 tools:
– Make Referrals EasyMake Referrals Easy
– Follow up with PatientsFollow up with Patients
– Encourage QuestionsEncourage Questions
– Link Patients to Non-Link Patients to Non-
Medical SupportMedical Support
 New companion guide forNew companion guide for
practice facilitatorspractice facilitators
http://ahrq.gov/qual/literacy

31. Vision of a HealthVision of a Health
Literate SocietyLiterate Society
 Provides everyone access toProvides everyone access to
accurate, actionable healthaccurate, actionable health
informationinformation
 Delivers person-centered healthDelivers person-centered health
information and servicesinformation and services
 Supports life-long learning and skillsSupports life-long learning and skills
to promote good healthto promote good health
The vision informing the NationalThe vision informing the National
Action Plan is of a society that:Action Plan is of a society that:

32. AHRQ HealthAHRQ Health
Literacy InformationLiteracy Information
 AHRQ Health Literacy Topic PageAHRQ Health Literacy Topic Page
 HHS ResourcesHHS Resources
 30,000+ subscribers to AHRQ Email30,000+ subscribers to AHRQ Email
UpdatesUpdates

33. What Questions Do You Have?
www.ahrq.govwww.ahrq.gov