Transcript Health Literacy & Consumer Roles in Health Care

Health Literacy and Consumer
Roles in Health Care Quality
Judith Hibbard
University of Oregon
Presented at the Wisconsin Health Policy Forum
June 16, 2004
Current health policy aims to
strengthen the role of
consumers in health care.
There is a growing recognition that
our ability to control costs and improve
quality will require an effective
partnership with informed and
engaged consumers.
Roles for Patients and
Consumers

Informed choice Role



Co-producer





Using performance information to choose providers
Selecting cost-effective evidenced based treatments
Self-care
Preventive actions
Collaborating with providers
Vigilant partner in assuring health care safety
Evaluator


Source of data on provider performance
Help to define the parameters of quality care
Virtuous Cycle

When consumers take on these
three roles they likely:
Get better care for themselves and
 Contribute to mechanisms that
improve the quality of care for
everyone

With an aging population and the
increased rates of chronic illness
there is an urgent need to support
patients in these three roles.
Informed and activated patients
represent a tremendous untapped
resource within the health care arena
It is a resource we can no longer afford
to leave untapped

Making choices in health care is
complex-- requiring higher levels of
health literacy

Ultimately we want information to be
used to inform choices.



Comprehend information
Be motivated to use it
Be able to information into choices.
Low literacy Medicare beneficiaries
would rather delegate decisions
80%
70%
60%
50%
40%
30%
20%
10%
0%
I prefer not to have the responsibility for making When it comes to making decisions about my
decisions about my Medicare. (% Agree or
Medicare, I prefer to have someone
Strongly Agree)***
knowledgeable decide for me. (% Agree or
Strongly Agree)***
Literacy:
Inadequate or marginal
Barely adequate
Adequate
Low literacy Medicare beneficiaries find
decisions worrisome.
70%
60%
50%
40%
30%
20%
10%
0%
I have difficulty understanding Whenever I make a choice
I am more likely to make a
the information about my
about my Medicare, I worry it wrong choice if I have lots of
Medicare coverage. (% Agree will be the wrong one. (%
different options to choose
or Strongly Agree)***
Agree or Strongly Agree)*** from. (% Agree or Strongly
Agree)***
Literacy:
Inadequate or marginal
Barely adequate
Adequate
Using comparative
performance reports are:



Difficult to understand
Too much information to process
Difficult to bring together into a
choice
Stroke – Non-Hemorrhagic
Short Length of
Stay
Hospital
Cases
Mortality Length of
Rating
Stay
Long Length of
Stay
%
Rating
%
Readmissions
% for
% for Any Complication Average
Rating Reason or Infection Charge
Methodist Division/TJUH
97

6.3
2.2

13.3

17.2
6.2
$28,516
Astoria Hosp
146

4.6
6.5

3.6

17.3
5.2
$14,420
Barrett
292

6.2
1.4

5.0

16.5
5.0
$25,127
North Bend
112

5.3
3.8

2.9

10.2
4.1
$16,386
Palmerton
70

6.6
1.6

7.9

16.5
8.2
$9,569
Parkview
60

6.0
5.4

5.4

28.4
8.3
$25,048
Northrup
83

5.7
8.9

7.6

10.8
4.6
$29,486
Phoenixville
75

4.7
4.4

1.5

10.9
4.6
$16,771
Memorial
135

4.6
4.7

2.3

10.3
1.5
$16,782
Warrem
100

7.6
4.7

18.6

15.1
8.6
$10,115
Significantly higher than expected, Not significantly different than expected, Significantly lower than expected
Getting needed care
Percent of members who said they had no problem obtaining
a personal doctor they like, a referral to see a specialist,
necessary care, or timely approvals of care:
Plan Average
75%
Plan A
79%
Plan B
77%
Plan C
76%
Plan D
70%
Plan E
77%
Plan F
76%
Plan G
76%
Plan H
76%
Plan I
Plan J
74%
64%
Overall Quality of Care and Services
Percentage of patients reporting very good or excellent
Worse
Better
Medical Group G
Medical Group D
Medical Group C
Medical Group E
Medical Group J
Medical Group H
Medical Group I
Medical Group B
Medical Group F
Medical Group A
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
CHOOSE AMONG FIVE PLANS
Below is the information about how five plans differ (in terms of member ratings and costs). Use the information
in this table to pick the health plans you are most likely to enroll in.
Premium
Member ratings of how well doctors
cost
in the plan communicate
Overall member ratings of the plan per month
Co-pay per
office visit
Co-pay per
prescription
Plan C
$75
$8
$8
Plan D
$100
$10
$8
Plan E
$75
$8
$8
Plan F
$100
$10
$10
Plan G
$75
$8
$8
Literacy and ability to interpret
the Information
60%
50%
40%
30%
20%
10%
0%
Percentage of respondents who scored zero out of two on the criterion
task***
Literacy: Inadequate or marginal
Barely adequate
Adequate
What do people do when faced with
this degree of complexity?



Reduces their motivation
Increases the odds they will stay
with status quo if that is an option
Take short cuts– may leave out
important factors
What can we do to help
consumers make better decisions?

Make information more evaluable
Summarize
 Interpret
 Do much of the cognitive work for the
viewer

What the symbols mean:
Fewer mistakes, complications and deaths than expected
Average number of mistakes, complications and deaths
More mistakes, complications and deaths than expected
Regional Hospitals
Surgery
Non-Surgery
Hip/Knee
Cardiac
Maternity
Hospital A
Hospital B
Hospital C
*
Hospital D
Community Hospitals
Surgery
Non-Surgery
Hip/Knee
Cardiac
Maternity
Hospital F
Hospital G
Hospital H
Hospital I
Hospital J
Hospital K
Hospital L
Hospital M
*
Hospital N
Hospital O
Hospital P
*
Hospital Q
*
With An Evaluable Performance
Report

Consumers more likely to note
differences
Remember high and low performers
Talk to others
Make recommendations based on report

….contributing to the virtuous cycle



Treatment choices:
What else supports good decision-making?

Highlight factors that are often
overlooked



Framing
Vividness
Help people to understand what it
might feel like to live with a choice

Narratives
Decision
support tools
Easier to use.
Information
intermediary
Evaluability
•Comprehension/
interpretation
Moves person
closer to actual
experience.
Narratives
Vividness
Framing
Highlights
meaning.
•Motivation
•Relative valuing of
information
The
information
is weighted
and used in
choice.
Roles for Patients and
Consumers

Informed Choice Role



Co-producer





Using performance information to choose providers
Selecting cost-effective evidenced based treatments
Self-care
Preventive actions
Collaborating with providers
Vigilant partner in assuring health care safety
Evaluator


Source of data on provider performance
Help to define the parameters of quality care
Co-Producer Role

Demands of co-producer role are
different than informed choice–



still must use information.
requires more day to day living and coping
skills
Patients need support and
encouragement from their providers
When it comes to chronic disease the
patient is the “Captain of the Ship”

To be a “captain” or even a
partner in care patients need to
have the necessary:
Knowledge
 Skills
 Confidence

Health literacy necessary for co-producer role.
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
I know the different medical treatment options I am confident that I can find trustworthy sources
available for my health condition. (% Disagree or
of information about my health and health
Disagree Strongly)*
choices. (% Disagree or Disagree Strongly)*
Literacy:
Inadequate or marginal
Barely adequate
Adequate
30%
25%
20%
15%
10%
5%
0%
How likely are you to seek out information to
When your doctor prescribes a new medication
learn about how to cope with health problems? for you, how likely are you to read about possible
(% Unlikely or Very Unlikely)***
complications? (% Unlikely or Very Unlikely)**
Literacy:
Inadequate or marginal
Barely adequate
Adequate
Assessing patients’ capability should be
part of the “vital signs” taken at a visit



Does the patient understand? Does
he/she have the skills and confidence
necessary to self-manage?
Patients who are getting good care
should, overtime be gaining in their
ability to self-manage
Capability to self-manage is an
intermediate outcome of care that
should be tracked.
If it is important then we should be
measuring it!
The Patient Activation Measure (PAM)



Assesses the degree to which patients have
the skills, knowledge and confidence to
manage their condition and to interact
effectively with their providers
The measure is a uni-dimensional, interval
level, Guttman-like scale
The measure is developmental with 4 stages
55
50
45
40
35
1
2
3
4
5
6
7
8
9
Believes Active Role Important
Taking Action
1
9
2
When all is said and done, I am the person who is
responsible for managing my health condition.
Taking an active role in my own health care is the
most important factor in determining my health and
ability to function.
Confidence and Knowledge to Take Action
3
4
5
6
7
8
I am confident that I can take actions that will help
prevent or minimize some symptoms or problems
associated with my health condition.
I know what each of my prescribed medications do.
I am confident that I can tell when I need to go get
medical care and when I can handle a health
problem myself.
I am confident I can tell my health care provider
concerns I have even when he or she does not ask.
I am confident that I can follow through on medical
treatments I need to do at home.
I understand the nature and causes of my health
condition(s).
10
11
10
11
12
13
I know the different medical treatment options
available for my health condition.
I have been able to maintain the lifestyle
changes for my health that I have made.
I know how to prevent further problems with
my health condition.
Staying the Course Under Stress
12
13
I am confident I can figure out solutions when
new situations or problems arise with my
health condition.
I am confident that I can maintain lifestyle
changes like diet and exercise even during
times of stress.
Tailoring care plans to individual
patient’s capabilities would likely
yield better results.


Providers could then be more targeted in
their education and support for patients
When patients are told to take actions
they are not capable of, they are more
likely to do nothing than if they are given
a goal that they can reasonably meet.
Measuring Patient Activation
for QI


Processes measures: Are the
processes in place to support
patient activation?
Outcomes measures: Are patients
becoming more activated over
time?
Supporting the Co-producer
Role



Measurement is the first necessary step
Identify interventions that help patients
at different levels of activation is the
next step
We are currently at square one– have a
steep learning curve ahead.
Roles for Patients and
Consumers

Informed choice Role



Co-producer





Using performance information to choose providers
Selecting cost-effective evidenced based treatments
Self-care
Preventive actions
Collaborating with providers
Vigilant partner in assuring health care safety
Evaluator


Source of data on provider performance
Help to define the parameters of quality care
Evaluator Role




Bring consumers along in the wider
discussion quality gaps and possibilities
(what does good care look like?)
Encourage patient involvement in
defining elements of quality
Expand to all areas of care
Use patient assessments as a basis for
QI
Providers, delivery systems, and purchasers can
do much to support and reinforce these roles
for consumers.





Making the use of information easier
Sanctioning and modeling the use of outcomes
and performance data for informing health care
choices
Measuring patient activation and literacy as part of
the vital signs taken during a visit
Measuring and reporting on how well providers
are supporting patients in their co-producer role
Making wider use of consumers in defining and
measuring quality in all areas of care.