BOWLING GREEN, Ky. – The idea that people will be healthier if they can better navigate the boggy, confusing landscape of health care and insurance is gaining traction in Kentucky – which, relatively speaking, has poor health and low literacy.
On Thursday and Friday, scores of health professionals and their allies in the health-literacy cause gathered in Bowling Green for the annual Kentucky Health Literacy Summit. It was the second such gathering, but the first was by invitation, so this was the first opportunity for anyone interested in health literacy to attend a statewide conference about it. The first conference resulted in the formation of Health Literacy Kentucky, an alliance of more than 35 groups.
Health literacy is the “degree that an individual can obtain, communicate, process and understand” basic health information, said Dr. Linda Harris, a Bowling Green native who leads the health communication unit in the U.S. Department of Health and Human Services. Only 12 percent of U.S. adults are considered proficient in health literacy, while 21 percent have basic knowledge and 14 percent are below basic. About half of adults have intermediate knowledge, between basic and proficient.
Health literacy has become an increasing problem as health care has become more technical and complex, and as America has more people for whom English is a second language. If people can’t understand what they’re being told about their health, they are more likely to get sick — and less likely to get better once they’re ill, Harris said.
She illustrated her point with the story of “Mrs. Jones,” a composite individual with issues requiring health literacy: a 62-year-old woman with diabetes, heart failure, low income and a history of depression. She gets sick, goes to the doctor, is prescribed several medications she doesn’t know how to take, avoids taking them and eventually needs to be hospitalized. Then she is given a second set of prescriptions that she also doesn’t understand. She is re-hospitalized “and the cycle continues,” Harris said.
Harris said the issue is at a “tipping point” because it has gone from simply being discussed among advocates to being made policy in legislation like the Patient Protection and Affordable Care Act; the National Action Plan for Health Literacy, the Plain Writing Act of 2010; and Healthy People 2020. “We really think this is the moment,” Harris said. “It’s not just those people who have been laboring in the vineyards for so long.”
Insurance companies making headway
Some of the most innovative health-literacy work is being done by insurance companies, most of which are taking steps to make sure their policyholders understand the forms and documents they’re sending them, Humana Inc. marketing consultant Betsy Shirey said. In the past year, Humana has simplified more than 400 of its documents, most of which have been rewritten at a sixth-grade level, as determined by a computerized assessment tool, she said.
To test the rewritten materials, Humana had some of its Medicare members look at the new documents. One person said a form could be simplified if it only had a date at the bottom of it. “They told us about really simple things, and yet we hadn’t done it,” Shirey said.
The new forms are better designed, with headlines and age-appropriate photography, and “always have a P.S., because everyone always reads the P.S,” Shirey said. The document that gives patients a rundown of their to-date expenses, medications and doctors’ visits looks like a credit-card statement. “You have a complete picture both financial and medical,” Shirey said.
(Humana was the major sponsor of the summit, along with the University of Kentucky and Western Kentucky University.)
Revelations among providers
Simplifying documents was also the goal at People’s Community Clinic in Texas, when Special Projects Supervisor Dana Carpenter came across a form that detailed how to take birth control pills. “Someone with a Ph.D. would have trouble understanding it,” she said. With help from patients, Carpenter simplified the form, adding photos and “plenty of white space.”
About 80 percent of the clinic’s patients are Hispanic, so Carpenter was shocked to learn that, when she called the clinic, there was no telephone prompt asking the caller if they wanted to converse in Spanish. “You had to listen to the entire English menu before it would roll into Spanish,” she said, and the clinic’s directional signs were all in English and hidden by clutter. New signage is bilingual and prominently displayed.
Christine Nagy and Diane Sprowl said they went through a similar process in a joint venture between Western Kentucky University and the Barren River District Health Department. The goal was to get participants in the Women, Infants and Children food program to eat more fruits and vegetables. Patients were asked to fill out surveys, which needed to be designed for people who did not speak English well. Nagy, Sprowl and WKU students designed materials with bullet points, white space and culturally appropriate graphics. They kept the reading level low by using words with few syllables. They also met with patients face to face to help avoid communication breakdown.
More than just rewriting forms, health literacy involves making sure people understand what they’re being told. To that end, insurance firms like Humana and providers like the People’s Community Clinic are teaching employees how to communicate in a simple, uniform way. Often this involves the “teach-back technique,” where you “have them explain back what you’ve gone over,” said Dr. David Susman, psychology services coordinator at Eastern State Hospital.
Susman said it’s important to look for clues that a person is having difficulty understanding, such as incomplete forms, lack of adherence to directions, or even looking in a pill bottle to determine what pill they’re taking rather than reading the label.
Ultimately, the goal is to keep patients from the fate of Mrs. Jones. “No one is going to say, ‘Oh by the way, I have limited health literacy,'” Susman said. “And no one complains about information being too simple.”
For a list of advance registrants for the summit, click here.