Louisville Medicine Volume 66, Issue 2 | Page 7

From the President Wayne Tuckson, MD GLMS President | [email protected] A MODEST PROPOSAL to Improve Health Literacy H ealth outcomes are the yardsticks by which we as physicians are now measured. Fair or unfair, such is the theatre in which we now operate. If we do not perform to standard, then we should be penalized, but we have little or no control over most factors that influence health outcomes. Should we be held accountable for poor outcomes resulting from factors that lie outside our sphere of influence? I say no. The relationship between physicians and hospitals is antagonistic, symbiotic and rarely trusting. This familiar relationship must now be discarded. We are in the age of value-based models where responsibility for care delivery and costs are divided amongst the participants. The more familiar models are Accountable Care Or- ganizations (where providers and hospitals agree to take financial responsibility for the quality of care), Clinically Integrated Networks (often provider-based with better outcomes based upon data driven metrics), Patient Centered Medical Homes (the medical home with patient involve- ment), and Population Health Service Organi- zations (PHSO), where an emphasis is placed on population health management utilizing non-physicians. Of these, the PHSO is unique in that it ad- dresses variables that are outside our sphere of influence, yet still influence outcomes. The 2017 Louisville Metro Department of Public Health and Wellness Health Equity Report grouped the root causes of poor health outcomes into 11 groups: food systems, health and human services, early childhood development, criminal justice, employment and income, housing, transporta- tion, environmental quality, built environment, neighborhood development, and education. Reasonable people can appreciate that these “root causes” can affect health outcomes, but many may not understand or agree on how to address them. Health care is a business, but to paraphrase Jacob Marley, the welfare of mankind is also our business. When we are mandated to perform non-direct patient care work with little or no compensation, can we fault the busy clinician who balks at becoming engaged in one more problem that lies outside the office door? Health literacy is one problem that we can address which negatively impacts health out- comes. Health literacy is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions”. Though literacy and health literacy overlap, there are differences. However, too often those lacking in basic comprehension skills are often ill equipped to be full participants in their own or their family’s health care. Of course, when one adds language and cultural differences, the field is further muddied. The impact of a deficiency in health litera- cy is manifest in failure to keep appointments, failure to take medications as prescribed, failure to complete a course of treatment, failure to get screenings or preventative services, an increase in preventable hospital visits, and inappropri- ate use of the ER. Many, if not all of these, will negatively impact our new value-based system of reimbursement models. Addressing health literacy may have an immediate impact without increasing our costs or workload. Efforts aimed at simplifying information and working with target populations to be sure the material is culturally relevant and available on different media platforms, and available at times convenient for the patient and their family members has shown good results. At the same time, we must be sensitive to the concerns of the patient and the peripheral issues that influence their illness or condition. Time is a precious commodity in the exam room. More has to be done outside the office and hospital doors. Enter the Community Health Worker (CHW). CHW’s are laypeople, often members of a target community, who help pro- vide basic health and medical care, bridge cul- tural and linguistic barriers, and expand access to coverage and care within their community. The use of lay-health workers in a rural com- munity hospital in Appalachian Kentucky result- ed in a 77 percent decrease in 30-day readmission rates for high-risk patients and the reduction in t he 30-day readmission rate resulted in a sig- nificant return which far exceeded the initial investment. Face-to-face interactions between CHW’s and patients resulted in an increase in patient participation in their care and a seven percent increase in patients who sought col- orectal cancer screening following intervention by a CHW. By improving health literacy, CHW’s work- ing with physicians can together improve health outcomes. The utilization of CHW’s cannot be like the interpreter, someone we must have, but a cost that is passed on to the physician. Together physicians, health care systems and insurers, both private and government, must make the initial investment in ideas like CHW’s. Then together we can reap the rewards of cost savings and improved health outcomes. There are many things that lie outside the hospital and physician’s office door with which we must engage to improve health outcomes. Many will overly tax the time and resources of the busy clinician. However, improving the communication between patient and physician through direct interaction or, better still, through resources like CHW’s working with physicians is doable. With CHW’s working with physicians we can improve the health of our community. If another reason is needed, such actions will later improve the bottom line. Ben Franklin said it best, “Do well by doing good.” The community will benefit in the long run. Dr. Tuckson is a practicing colon and rectal surgeon. 1. 2. 3. 4. 5. Louisville Metro Health Equity Report 2017 U.S. Department of Health and Human Services, Office of Disease Prevention and Health promotion. 2010 National Action Plan to Improve health Literacy Cardarelli R, et al. Health Educ Res.2018 Cardarelli R, et al. J Rural Health. 2017 Feltner FJ, et al. Social Work in Health- care.2012 JULY 2018 5