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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%!
