Executive Summary
Ochsner Health, with headquarters in New Orleans, targets patients with low health literacy, along with other readmission reduction programs.
- When patients are readmitted, the case managers administer the Rapid Estimate of Adult Literacy in Medicine (REALM) tool, developed by the Agency for Healthcare Research and Quality (AHRQ) to identify patients who need extra help in understanding their discharge instructions.
- When case managers make post-discharge follow-up calls to at-risk patients, they ask a series of questions that determine if the patient can understand written instructions.
- The staff uses pictographs and videos to educate patients identified as having low literacy and make sure the caregivers understand the discharge instructions.
When an analysis of the cases of patients who were being readmitted showed that a significant number had low healthcare literacy and other social issues, the staff at Ochsner Health developed a project to identify the patients who need extra help in following their discharge plans.
“People in the healthcare industry understand that low health literacy is a driver of readmissions, but we have not done a good job of filling the gaps once we identify them. We set out to identify the gaps and find the patients’ psychosocial needs and tie the two together in order to help manage patients at higher risk,” says Mark Green, MBA, assistant vice president of transition management for the nine-hospital health system with headquarters in New Orleans.
Since Ochsner began its health literacy program along with other projects to reduce readmissions, the readmission rate for at-risk patients has dropped from 17.6% to 10.4%. The population includes patients with low literacy and/or patients who are stratified as high risk due to factors such as multiple readmissions or emergency department visits.
“This is just one initiative to prevent readmissions, so we can’t judge the literacy initiative as a stand-alone program but we do know that it is helping,” Green says.
The health system serves a socioeconomically challenged region and a disproportionate number of people with low health literacy rates and who need help in following their discharge plan, he adds.
“When people don’t understand their instructions, they don’t follow their treatment plans and medication regiments which often results in readmissions. There is also a strong correlation between the number of caregivers in the home and readmissions. We have found that if there are two or fewer people who can provide care in the household, it increases the readmission risk,” Green says.
The health system identifies patients with low healthcare literacy two ways: by administering a test to patients who are readmitted, and during the post-discharge phone calls.
When patients are readmitted, the case managers administer a healthcare literacy assessment test. Ochsner Health uses the Rapid Estimate of Adult Literacy in Medicine (REALM) tool, developed by the Agency for Healthcare Research and Quality (AHRQ). The tool is a list of 10 words associated with healthcare that patients are asked to pronounce.1
“Patients are scored on their ability to pronounce the words. If their score is a 1 or less, it means their literacy is below the third-grade level and no matter how hard we try to teach them, they will not be able to read and understand their discharge instructions and medication regimen,” Green says.
In those cases, the case managers use pictographs and videos to educate the patients on how to manage their conditions.
The goal is to eventually use the REAL tool with every patient leaving the hospital so the staff will know what kind of follow-up the patient needs, Green says.
“When we’re talking to people over the telephone, we can’t use the paper tool but have another way to identify people who need extra help understanding their discharge plan and medication regimen,” Green says.
When case managers make post-discharge follow-up calls, they ask, “How often do you need someone to help you when you read instructions or other written materials from your doctor or pharmacist?” Patients are given a choice of “never,” “rarely,” “sometimes,” “often,” or “always.” If patients answer “sometimes,” “often,” or “always,” the case managers ask to speak to the caregivers and go over the instructions with them.
The hospital case managers follow high-risk patients with low literacy by telephone until they have a follow-up appointment with their provider.
The majority of patients receive just one phone call. But if the provider feels it is appropriate, the case manager makes weekly calls to the patient for 30 days to ensure that the patient is following his or her treatment plans and is not having any problems that could cause a readmission. “They ask general questions like how are they feeling and go over the treatment plan. If at the end of 30 days it’s evident that the patient is still at high risk for another admission, they make a referral to the outpatient complex case management team to pick up management of the patient,” he says.
Ochsner’s case managers use a computerized tool embedded in the electronic medical record to print out discharge instructions that are tailored to each patient’s condition. The instructions are written on a fourth-grade level.
“When we encounter patients that seem to have low healthcare literacy, we use pictographs and videos for our discharge teaching. This also triggers a more detailed follow-up call during which the case manager also explains the instructions to the caregiver in the home,” Green says.
The next step is to partner with community organizations to help manage the care of patients with low literacy, Green says.
“As we continue to mature the process, we will eventually run out of resources to take care of an increasing number of patients. We are exploring ways to leverage community resources to assist us by checking on the patients and looking for early warnings that the patient’s condition is getting worse,” he says.
The health system is already working closely with home health agencies and senior service organizations to have them conduct a home assessment to identify any issues that could send the patient back to the hospital, Green says.
REFERENCE
- Agency for Healthcare Research and Quality. Rapid Estimate of Adult Literacy in Medicine revised, shorter version (REALM-r). http://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/realm-r.html.
When an analysis of the cases of patients who were being readmitted showed that a significant number had low healthcare literacy and other social issues, the staff at Ochsner Health developed a project to identify the patients who need extra help in following their discharge plans.
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