Michael Paasche-Orlow, MD MA MPH Professor of Medicine ...€¦ · reconciliation, appointments,...

Health Literacy Interventions: Current and Future Exemplars

Michael Paasche-Orlow, MD MA MPHProfessor of Medicine

General Internal Medicine Boston University School of Medicine

3 December 2018Health Literacy Hub - WSLHD Consumer

Enablement Guide -ACI

Peaels Raed Tihs

Mnay plpoee hvae tbuorle wtih the slef-crae tksas tehy need ni oderr to saty hlaehty!

Paesle rasie yuor hnad if you wnat to do snimoehtg aoubt it.

Water Sunlight Protection

Funding Marketing Executive Sponsorship

+ Champions+ Program Management

Federal Funders

NCI NHLBI NIMHD NIAAA NIDA NICHD NIDCR

AHRQ NIMH NHGRI CDC DOD HRSA PCORI

NIDDK NIBIB NLM

https://health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf

National Action PlanTwo core principles:

• All people have the right to health information that helps themmake informed decisions

• Health services should be delivered in ways that are easy tounderstand and that improve health, longevity, and quality of life

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. By focusing on health literacy issues and working together, we can improve the accessibility, quality, and safety of health care; reduce costs; and improve the health and quality of life of millions of people.

Tremendous Attention on Rehospitalization Efficiency Allows for the alignment of improving quality and

decreasing cost Plentiful 2006: 39.5 million hospital discharges with costs totaling

$329.2 billion!

RED ChecklistEleven mutually reinforcing components: Patient education Follow-up appointments Outstanding tests Post-discharge services Medication reconciliation Reconcile dc plan with National Guidelines What to do if problem arises Dc summary to PCP Assess patient understanding Written discharge plan> Telephone Reinforcement

Adopted by National Quality Forumas one of 30 "Safe Practices" (SP-15)

Operationalizing RED

After Hospital Care PlanDischarge EducatorFollow-up phone call

COVER PAGE

MEDICATION PAGE (1 of 3)

MEDICATION PAGE (2 of 3)

MEDICATION PAGE (3 of 3)

APPOINTMENT PAGE

APPOINTMENT CALENDAR

PATIENT ACTIVATION PAGE

Components of RED Intervention In Hospital – Nurse Discharge Educator Interacts with care team: medication

reconciliation, appointments, and nationalguidelines

Prepares and teaches After Hospital CarePlan

Post Discharge – Clinical Pharmacist Calls for follow-up @ 72 hours post-dc Reinforces dc plan and review medications

EnrollmentN=749 Randomization

RED InterventionN=374

Usual CareN=375

30-dayOutcome Data•Telephone Call•EMR Review

Randomized Controlled Trial

Enrollment Criteria:•English speaking•Have telephone•Able to independently consent•Not admitted from institutionalized setting•Adult medical patients admitted to Boston Medical Center (urban academic safety-nethospital) 48% Medicaid + 22% Free Care

Primary Outcome: Hospital Utilization within 30d after dc

Usual Care (n=368)

Intervention (n=370)

P-value

Hospital Utilizations *Total # of visits Rate (visits/patient/month)

1660.451

1160.314 0.009

ED VisitsTotal # of visitsRate (visits/patient/month)

900.245

610.165 0.014

ReadmissionsTotal # of visits Rate (visits/patient/month)

760.207

550.149 0.090

* Hospital utilization refers to ED + Readmissions

Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge

0 5 10 15 20 25 30

0.0

0.1

0.2

0.3

Cu

mu

lati

ve H

azar

d R

ate

Time after Index Discharge (days)

Usual careIntervention

p = 0.004

Outcome Cost Analysis

Cost (dollars)Usual Care

(n=368)Intervention

(n=370) Difference

Hospital visits 412,544 268,942 - 143,602

ED visits 21,389 11,285 - 10,104

PCP visits 8,906 12,617 + 3,711

Total cost/group 442,839 292,844 - 149,995

Total cost/subject 1,203 791 - 412

We saved $412 in outcome costs for each patient given RED

ACP Decisions Video LibraryCategories

Education can Significantly Improve Decision-Making

Video Decision Support Tools for ACP Quality Metrics Knowledge Decision certainty Stability of preferences

Very well accepted by patients Helpful Comfortable Recommend

ACPDecisions.org

• Emulate face-to-face communication usingtouch screen• Develop therapeutic alliance using

EmpathyGazePostureGesture

• Tailored information• Longitudinal conversation

Embodied Conversational Agent

ECA – Educator at the time of discharge from the hospitalWho Would You Rather Receive Discharge Instructions From? N=143

1=definitely prefer doc, 4=neutral, 7=definitely prefer agent

36% prefer agent48% neutral16% prefer doc or nurse

“I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.”

“It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Louise explains everything.”

Intervention to Promote Walking in Older AdultsBased on qualitative methods with members of our target audience, poor older adults, we designed “Tanya” to promote exercise behavior based on Social Cognitive Theory and the Transtheoretical Model of change

The ECA “Talks” and the user responds by touching options on the screen

Bickmore, Silliman, Nelson, Cheng, Winter, Henault, Paasche-Orlow.J Am Geriatr Soc. 2013

Advanced Illness Support

Continual support over six months for Symptom Management Stress Management Physical Activity Promotion Advanced Care Planning Support Spiritual Counseling

Smartphone ECA Afib Kardia

IVR – Post Medication Rx EMC2

-->50% -- >50%!

Thank you! We have talked about a lot. What questions do you have?

mpo@bu.edu