Health Literacy and Consumer Roles in Health Care Quality

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Health Literacy and Consumer Roles in Health Care
Quality

• Judith HibbardUniversity of Oregon
• Presented at the Wisconsin Health Policy Forum
• June 16, 2004

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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.

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Roles for Patients and Consumers

• Informed choice Role
• Using performance information to choose providers
• Selecting cost-effective evidenced based
  treatments
• Co-producer
• 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

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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

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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

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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.

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Low literacy Medicare beneficiaries would rather
delegate decisions
Literacy
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Low literacy Medicare beneficiaries find
decisions worrisome.
Literacy
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Using comparative performance reports are

• Difficult to understand
• Too much information to process
• Difficult to bring together into a choice

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Stroke Non-Hemorrhagic
?Significantly higher than expected, ?Not
significantly different than expected,
?Significantly lower than expected
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Getting needed carePercent 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
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Overall Quality of Care and ServicesPercentage
of patients reporting very good or excellent
0 10 20 30 40 50 60 70 80 90
100
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Literacy and ability to interpret the Information
Literacy
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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

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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

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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
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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

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Treatment choicesWhat 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

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The information is weighted and used in choice.
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Roles for Patients and Consumers

• Informed Choice Role
• Using performance information to choose providers
• Selecting cost-effective evidenced based
  treatments
• Co-producer
• 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

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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

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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

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Health literacy necessary for co-producer role.
Literacy
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Literacy
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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.

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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

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Tailoring care plans to individual patients
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.

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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?

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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.

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Roles for Patients and Consumers

• Informed choice Role
• Using performance information to choose providers
• Selecting cost-effective evidenced based
  treatments
• Co-producer
• 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

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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

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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.