Overview 1. Health Literacy: A Few Basic (but important) Assumptions - - PDF document

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Overview 1. Health Literacy: A Few Basic (but important) Assumptions - - PDF document

Jun 24, 2023 300 likes •585 views

In Older Adults Promoting Health Literacy Michael Wolf, PhD, MPH Professor, Medicine & Learning Sciences Associate Vice Chair, Department of Medicine Associate Division Chief, General Internal Medicine & Geriatrics Director, Health

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1 Promoting Health Literacy

Michael Wolf, PhD, MPH

Professor, Medicine & Learning Sciences Associate Vice Chair, Department of Medicine Associate Division Chief, General Internal Medicine & Geriatrics Director, Health Literacy & Learning Program (HeLP) Northwestern University Chicago, IL USA

In Older Adults

Overview

  • 1. Health Literacy: A Few Basic (but important) Assumptions
  • 2. Challenges of a Rapidly Aging America
  • 3. Making it Simple: A Health Literacy Research Agenda
  • 4. …But Significant: A Healthcare Activation Research Agenda
  • 5. Advancing Health Literacy among Older Adults
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Overview

  • 1. Health Literacy: A Few Basic (but important) Assumptions
  • 2. Challenges of a Rapidly Aging America
  • 3. Making it Simple: A Health Literacy Research Agenda
  • 4. …But Significant: A Healthcare Activation Research Agenda
  • 5. Advancing Health Literacy among Older Adults

Overview

  • 1. Health Literacy: A Few Basic (but important) Assumptions
  • 2. Challenges of a Rapidly Aging America
  • 3. Making it Simple: A Health Literacy Research Agenda
  • 4. …But Significant: A Healthcare Activation Research Agenda
  • 5. Advancing Health Literacy among Older Adults
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Overview

  • 1. Health Literacy: A Few Basic (but important) Assumptions
  • 2. Challenges of a Rapidly Aging America
  • 3. Making it Simple: A Health Literacy Research Agenda
  • 4. …But Significant: A Healthcare Activation Research Agenda
  • 5. Advancing Health Literacy among Older Adults

Overview

  • 1. Health Literacy: A Few Basic (but important) Assumptions
  • 2. Challenges of a Rapidly Aging America
  • 3. Making it Simple: A Health Literacy Research Agenda
  • 4. …But Significant: A Healthcare Activation Research Agenda
  • 5. Advancing Health Literacy among Older Adults
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D e s i g n o f e f f e c t i v e , s c a l a b l e , h e a l t h s y s t e m - b a s e d s t r a t e g i e s t o p r o m o t e p a t i e n t s e l f - m a n a g e m e n t

Since 2004 Since 2004

 Department of Medicine

  • Division of General Internal Medicine & Geriatrics
  • Department of Surgery
  • Department of Medical Social Sciences
  • Department of Psychiatry & Behavioral Sciences
  • Clinical Psychology PhD Program
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Confluence of 2 Age-related Problems

Body Body

80% 80% of

  • f adul

adults over 65

  • ver 65 live

live with with ≥2 chro 2 chronic c co conditions (vs. 18%;

  • s. 18%; 18-44

18-44 years) years)

Min Mind

‘Fluid’ c id’ cognit itiv ive e abi abilities ities necess necessary for self- for self-care are e are known

  • wn to

to decli decline with e with incr increa eased age. age.

Healthcare Demands Self-care Skills

Assumptions

  • 1. A person’s cognitive skills are a major determinant of health literacy skills
  • 2. The requisite heath literacy skills needed to successfully manage health is

determined by the design, accessibility of a healthcare system

  • 3. Reducing ‘cognitive burden’ means…
  • better communication
  • simplified patient roles
  • proactive, learning healthcare systems
  • 4. Addressing cognitive burden alone will not remediate all existing health

literacy concerns

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The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.

– World Health Organization

Health Literacy…

Health, Literacy, and ‘Health Literacy’

Reading fluency Numeracy Communication Memory Problem-solving Self-efficacy Experience Motivation/ Activation Self-care Behaviors

Aging Perspective on Health Literacy

(Chodos & Sudore;Current Diagnosis & Tr eatment 2 n d edition)

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Assumptions

  • 1. A person’s cognitive skills are a major determinant of health literacy skills
  • 2. The requisite heath literacy skills needed to successfully manage health is

determined by the design, accessibility of a healthcare system

  • 3. Reducing ‘cognitive burden’ means…
  • better communication
  • simplified patient roles
  • proactive, learning healthcare systems
  • 4. Addressing cognitive burden alone will not remediate all existing health

literacy concerns

Assumptions

  • 1. A person’s cognitive skills are a major determinant of health literacy skills
  • 2. The requisite heath literacy skills needed to successfully manage health is

determined by the design, accessibility of a healthcare system

  • 3. Reducing the ‘cognitive burden’ of healthcare means…

 better communication

 simplified patient roles  proactive, learning healthcare systems

  • 4. Addressing cognitive burden alone will not remediate all existing health

literacy concerns

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Health Literacy in Older Age

  • Strong, consistent evidence that adults 65+ have more

limited health literacy skills compared to younger adults

  • drivers: cognitive decline + educational attainment +

sensory impairment (hearing, vision)

  • Moderate, increasing evidence of within-subject health

literacy declines

  • Increasing healthcare needs
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Need for a Patient-Centered Approach… Need for a Patient-Centered Approach…

“Keep “Keep watch watch also on the fault also on the faults of

  • f patients, which often make them lie

patients, which often make them lie about the taking of about the taking of things prescribed” things prescribed”

  • Hippocrates

“America’s healthcare sy “America’s healthcare system stem is neither health is neither healthy, caring, nor a y, caring, nor a system.” system.”

  • Walter Cronkite

History

1989

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Our Target – The Burden of Healthcare

Healthcare Demands Healthcare Demands Health Literacy Health Literacy Cognitive Skills Cognitive Skills

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Aligned Conceptual Frameworks

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AHRQ Complexity Model Addressing Healthcare for Patients with MCC

Confusing Confusing People People Less Less Making it Simple.

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$650 MILLION $2.7 Billion

Cognitive Load of Self-Care Tasks

  • Physical health (co-morbidities, functional independence)
  • Mental health
  • Cognitive health
  • Number of healthcare providers, frequency of visits
  • Polypharmacy & regimen complexity
  • Medical devices
  • Involved technologies
  • Monitoring responsibilities
  • Health insurance

Disease Burden Treatment Burden

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Health Literacy 1.0: Cognitive Load of Health Information

  • Incomplete or vague information & instructions
  • Conflicting sources, nature of source
  • Modality (spoken, print, multimedia)/opportunity for re-review
  • Lack of coordinated ‘system’ of information
  • Factual vs. procedural content
  • Amount of content
  • Reading grade level
  • Format, organization
  • Distraction (e.g. extraneous information, discordant imagery, environment)
  • Communication speed (audio, visual)

Deconstructing Self-Care Tasks (NIH/NIA)

  • Active Cohort Study (2008 – present)
  • 900 primary care patients ages 55-74 at baseline, followed every 2.5 years
  • 5 FQHC practices, 1 academic medical center, 1 community hospital
  • Cognitive, psychological, behavioral, socioeconomic, functional status assessments
  • Health literacy and self-management skills assessed
  • Data captured from electronic health & pharmacy records, NDI
  • Caregiver interviews launched in 2018
  • Following multi-step written instructions
  • Consenting to clinical research studies
  • Accessing/navigating online health resources (e.g. portal)
  • Recalling spoken medical instructions
  • Comprehending/recalling multimedia health information
  • Organizing and properly dosing multi-drug regimens
  • Problem-solving around treatment and self-care regimens
  • Long-term care decision making
  • Following multi-step written instructions
  • Consenting to clinical research studies
  • Accessing/navigating online health resources (e.g. portal)
  • Recalling spoken medical instructions
  • Comprehending/recalling multimedia health information
  • Organizing and properly dosing multi-drug regimens
  • Problem-solving around treatment and self-care regimens
  • Long-term care decision making

Cognitive Performance Across Lifespan

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Health Literacy Interventions

A Case Example

Universal Medication Schedule (UMS)

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Universal Medication Schedule (UMS)

  • Provides more explicit guidance as to when to take

prescribed medicine

  • Reduces variable prescribing, dispensing practices that

lead to regimen complexity

  • Aligns with a ‘pill box’ schema
  • Evidence-based: multiple studies have found the UMS
  • reduces dosing errors
  • improves regimen efficiency
  • improves adherence (14% increase)
  • Yet only 1 in 8 prescriptions written using UMS
  • NCPDP, USP, NAM identify it as a best practice
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staying engaged with patients beyond the point of care

Simple and Significant

A c t i v a t e d H e a l t h c a r e S y s t e m , A c t i v a t e d P a t i e n t / F a m i l y

Some Current Projects

NIH/NIDDK NIH/NIDDK NIH/NIDDK NIH/NIDDK AHRQ Eli Lilly NIH/NIDDK AHRQ Eli Lilly NIH/NIDDK AHRQ Eli Lilly Gordon & Betty Moore Foundation Gordon & Betty Moore Foundation Gordon & Betty Moore Foundation

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Treatment Adherence among Kidney Recipients by Engaging Information Technologies

  • Routinely monitor regimen use, adherence & persistence via EHR portal
  • Provide ‘adherence alerts’ to transplant center with specific patient concerns
  • Mobilize appropriate resources to map specific problems to tailored solutions

Treatment Concern?

Cognitive Psychological Medical Regimen Social Economic

YES No

Mobile Med App (Transplant Hero)

1

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Mobile Med App (Transplant Hero)

1 2

Monthly Assessment (Patient Portal) Mobile Med App (Transplant Hero)

1 2

Monthly Assessment (Patient Portal)

3

Transplant Nurse Coordinator Triage

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Mobile Med App (Transplant Hero)

1 2

Monthly Assessment (Patient Portal)

3

Transplant Nurse Coordinator Triage

4

‘Smart’ referral: mobilize resources Psychology Social Work Pharmacy Medical Team Mobile Med App (Transplant Hero)

1 2

Monthly Assessment (Patient Portal)

3

Transplant Nurse Coordinator Triage

4

‘Smart’ referral: mobilize resources Psychology Social Work Pharmacy Medical Team

5

CoV Quarterly Report (tacrolimus)

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Electronic Health Record (EHR)-enabled Complete Communication (EMC2) Strategy

Step 1. Best Practice Alert

Electronic Health Record (EHR)-enabled Complete Communication (EMC2) Strategy

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Step 1. Best Practice Alert Step 2. MedSheet

Electronic Health Record (EHR)-enabled Complete Communication (EMC2) Strategy

Step 1. Best Practice Alert Step 3. IVR Step 2. MedSheet

Electronic Health Record (EHR)-enabled Complete Communication (EMC2) Strategy

Step 4. Lab Report

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  • Meaningful sharing of primary care EHR with

community pharmacies to:

  • Reconcile medication regimens
  • Perform medication reviews
  • Meaningful sharing of primary care EHR

with community pharmacies to:

  • Reconcile medication regimens
  • Perform medication reviews

Provide adherence alerts, updates

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  • Meaningful sharing of primary care EHR

with community pharmacies to:

  • Reconcile medication regimens
  • Perform medication reviews

Provide adherence alerts, updates

  • Offer clinical decision support

Patient Engagement: Keeping Pace

  • Uptake of post-visit patient participation is high:

(~65%) - (IVR, portal, SMS) within 72 hours

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Other Preliminary Evidence

  • Improved quality of life
  • Fewer ED/hospital admissions
  • Better survival

Patient Engagement: Keeping Pace

  • Uptake of post-visit patient participation is high:

(~65%) - (IVR, portal, SMS) within 72 hours

  • Bandwidth of primary care to respond limited

Chronic Care Model

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Advancing Research Priorities Moving Forward

  • Direct more attention to the ‘user interface’ of healthcare
  • Strong evidence base of health literacy best practices
  • Create opportunities to keep older patients engaged
  • leverage technologies, offer multiple modalities
  • Identify/classify individuals at risk
  • screen for low health literacy, low ‘activation’?
  • allocate more resources to those most in need
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“For God’s sake, stop researchi ng for awhi l e and begi n to thi nk”.

  • Sir Walter Hamilton Moberly

British Scholar, Philosopher, 1949

Mic hael Wolf, PhD MA MPH

Pro fesso r, Medic ine & L earning Sc ienc es Asso c iate Vic e Chair, Department o f Medic ine Asso c iate Divisio n Chief Ge ne ral I nternal Me dic ine & Geriatric s mswo lf@no rthweste rn.edu

Thank You!