Case Managers Address America’s Health Literacy Problem
           Literacy is the ability of an individual to read, write, and comprehend.  Fundamental skills necessary in every aspect of life, from the mundane to the complex. One’s level of literacy influences the ability to communicate and share in social skills.
As reported by Lake, (2016), 32 million- 14% of the adult population in America cannot read. Approximately 20% to 23% of adults in the United States are at basic or below basic proficiency level. Older adults, 65 and older, were the largest group with the lowest literacy rate.
Health Literacy is not just limited to reading and writing, but it’s an individual’s ability to understand and process basic health information in order to make informed decisions about one’s health. According to the National Network of Libraries of Medicine, (2017), health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, and doctor’s directions.
America is facing a serious health literacy problem. Low health literacy is a silent/hidden epidemic, as it cannot be detected via physical exam or through other diagnostic testing. In 2003, “A national assessment of adult health literacy (NAAL) identified 36% of adults as having serious limitations in their literacy skills. That’s more than 77million people who would be challenged to perform what NAAL deemed as common health tasks such as following their prescription directions “(Mullahy, 2016, p. 14). This means that approximately 77 million Americans lack the skills necessary to manage their health adequately and prevent illness and disease. Lack of health literacy is a barrier to chronic disease management.
                              Low Health Literacy – Case Managers Dilemma
The roles and responsibilities of case managers are many. They are patient advocates, financial and resource managers, clinical care managers, and educators. Utilizing some of the above mentioned characteristics, case managers can positively assist in bringing awareness to and improve patient and family health literacy. To assess a patient’s health literacy level, case managers can ask the patient to read a medication bottle, and ask if they know the dosage, purpose, and actions of prescribed medications. Case managers must be aware of the grave implications of health literacy such as, “poorer health outcomes, increased incidence of preventable hospital visits and admissions, and higher rates of emergency services” (Mullahy, 2016, p. 14). When this occurs, resources are used inefficiently, causing further increase of cost of care. This goes against the very goal of case management, which is to maintain and improve health outcomes while containing cost.
“The opportunities for case managers to teach are endless. Topics for education of patients, families, or significant others are wide ranging and varied, including medication administration and side effects, disease processes and treatment, and insurance coverage and non-coverage” (Powell & Tahan, 2009, p. 60). Before the case manager can begin to educate the patient, he/she must first assess the patient’s knowledge of their condition, and identify those who are unable to process and understand health information. In their research, Egbert and Nanna, (2009), suggested that identifying such patients is not always easy, as some are in denial about their limitations in reading and understanding health information. Other patients may admit their limitations, but try to hide them to avoid embarrassment.
Case managers and other members of the health care team must pay close attention to and learn to identify signs that are indicative of low literacy. As per the National Patient Safety Foundation, 2003, the following are signs of low health literate individuals,
- Forms improperly completed
- Patients who do not read any printed material during the patient-healthcare provider interaction
- Statements such as “I will read this at home”, or “ I can’t read this now; I forgot my glasses”
- Patients who are unable to assume the self-management role successfully.
Other red flags as per Mullahy, 2016, include,
- Patient frequently misses appointments
- Patient does not follow through on tests or referrals
- Patient does not comply with medication
- Patient identifies pills by looking at them rather than reading the labels
- Patient unable to name medications or explain their purpose or dosage
- Patient asks few questions.
Once the knowledge deficit has been identified, “the case manager then help promote health literacy by creating a safe environment for patients and their family to ask questions, and share what they know and don’t know, or are afraid to ask” (Mullahy, 2016, p. 18). The case manager must encourage the patient and family, and reassures them that they are not alone. Once a safe and judgment-free zone is instituted, barriers will be broken, trust will be established, and the door to better communication and health literacy will be unlocked.
Teaching Points to Improve Health Literacy
Prudent case managers and health care providers must avoid the usage of medical terminology and jargon when communicating with patients and family members. Even the most literate individual may not be familiar with or understand medical terminology. Language must be kept simple and plain. Mullahy, (2016), suggest instead of saying, “swallow that pill”, say, “Take that pill”. Use the word “belly” not “abdomen” and “harmful” not “adverse”. Limit the amount of information given in one session. Focus on key points avoiding information overload.
Kountz, (2015), suggests providing patient and family with written material at a fifth grade level or lower (patient-friendly). He states, “seventy-six percent of patient education materials available are written above the average reading level of American adults, which is about an eighth grade level” (Kountz, 2015, p. 174). Brooke and Graham, (2008), suggest that health care professionals should read handouts with the patient and highlight or circle important parts. Speaking slowly, drawing pictures and using videos to supplement written material are also helpful tools.
Throughout the educational session, the case manager encourages the patient and family to ask questions, assures them that there is no such thing as a dumb question, and listen to their needs without interruption. The patient will then feel empowerment and motivation to achieve their health goals.
Assessing  if learning objectives were met and understood, the case manager should ask the patient to return demonstration, and explain in their own words what was explained to and discussed with them. Mullahy, (2016), suggest that case managers should thoroughly evaluate patient’s understanding, before, during, and after providing health care information and services.
The ramifications of low health literacy are not only grievous to patient health outcomes, but also to the health care system. “Low health literacy costs the U.S. health care system up to $73 billion annually” (Brooke & Graham, 2008, p. 1). Those who are health illiterate are usually unaware of how to properly use and navigate the health care system. Such individuals often report to the E.R. for non-emergency conditions and usually have a high readmission rate. As part of the education process, the case manager makes certain that patient and family understand the discharge instructions, as a preventive measure to decrease readmission.
                           Tools to Improve Health Literacy
In an article published by Anonymous, (2016), the Vice President of a hospital in New Orleans is identified as implementing steps to target patients with low health literacy, along with other readmission reduction programs. The case managers administer a tool, Rapid Estimate of Adult Literacy in medicine (REALM), to identify patients who need additional support in understanding discharge instructions. The REALM tool is a list of ten words associated with health care and patients are asked to pronounce the words. The patients are scored based on their ability to pronounce the words. A score of 1 or less is indicative of literacy level below 3rd grade. With such patients, the case managers will use pictographs and videos to educate them. The case managers, also make follow-up phone calls to the patients, and asks questions that will reveal if the patient can understand written instructions. Mark Green, the hospital’s VP, reported that since implementing the health literacy program, the readmission rate dropped from17.6% to 10.4%.
Case managers are at the frontline of improving the health literacy of the patient. Through careful and astute assessment, the case manager is able to identify patients with low health literacy skills, and takes the necessary steps to combat this epidemic. Communication and listening skills must be sharpened and the case manager encourages other members of the health care team to sharpen their communication skills as well. Patient comprehension will be facilitated; the patient will gain the confidence to navigate the complex health care system, thus promoting healthier individuals and communities.
Importance of Knowing the Culture
Another area of importance relative to health literacy is culture. According to Leinenger, (2002), culture is the learned, shared, and transmitted knowledge of values, beliefs, and lifeways of a particular group that are generally handed from generation. It influences one’s thinking, decisions, and actions. The United States is a vast melting pot of individuals from different parts of the world. “Immigrants make up a growing segment of the U.S. population. Approximately 26.3 million immigrants now live in the U.S.; the largest number recorded yet- a 33 percent increase since 1990” (Kimbrough, 2007, p.94).
As a result of the growing population of immigrants, case managers and other members of the health care team must provide care that is culturally competent. “ Health care providers must recognize, respect, and integrate clients’ cultural beliefs and practices into health prescriptions to eliminate or mitigate health disparities and provide client satisfaction” (Purnell, 2009, p.1).
Shaw, Huebner, Armin, Orzech, & Vivian, (2009), declare that cultural beliefs around health and illness contribute to an individual’s ability to understand and act on a healthcare provider’s instructions. In order to provide adequate services, prudent case managers “must be aware of their patients cultural and religious differences and evaluate differences and evaluate patients according to their beliefs, value systems, and traditions” (Powell & Tahan, 2009, p.217).
Comprehending the appropriate manner in which to take medications is a problem among immigrants. According to Andrulus & Brach, (2007), limited English proficiency (LEP) patients are more likely to report having trouble understanding medication labels and report bad medication reactions. They provide the following example of a Hispanic man who was seen in the emergency room, due to confusing the English word once with the Spanish word for 11, which is also once.
Andrulus & Brach, (2007), further states that cultural differences may also lead to medication errors. They provide the following example of an Asian mother who was instructed to give her child a teaspoon of medicine. Instead of giving the child the desired dose, she instead gave the child a large soup spoonful of the medicine, as the only utensils available in her house were chopsticks and soup spoons. To avoid such undesirable outcomes, case managers/clinicians assigned to the Hispanic patient should have plainly shown him how many pills to take and provided the Asian mother a medicine cup, and instructed her to pour the medicine up to the one teaspoon line. Before discharge, both individuals should have also returned demonstration, to ensure instructions were fully understood.
Another example of medication errors caused by cultural differences is one told to me by a nursing instructor while I was on orientation. An Asian male diabetic patient was taught how to administer insulin by injecting oranges. The patient was discharged home, as he demonstrated accuracy in drawing up the correct dosage of insulin in the syringe and administering it to the orange. He also was able to verbalize the appropriate body location where the insulin should be administered.
Shortly after being discharged, the patient was readmitted with a diagnosis of Uncontrolled Diabetes Mellitus. It was discovered that the patient was administering the insulin to oranges as opposed to himself. As case managers, we must stress the importance of utilizing the teach-back method. Patients must return demonstration multiple times before discharge, to confirm teaching was understood, and avoid unnecessary readmissions that can be costly to the institution and detrimental to the patient’s health.
Conclusion
Patients, including those of different cultures (immigrants), must be treated with respect. Case managers must show the patient that they care by becoming familiarized with the values and beliefs of each of their patient, and incorporate them in the plan of care. “Both providers and their entire staffs have an opportunity to make a difference in the lives and health of immigrant patients. By cultivating trust and respect, a healthcare environment which support immigrants has the potential to lead to better outcomes in terms of treatment compliance and quality of life for the individual” (Kimbrough, 2007, p.102).
Case managers are at the frontline of improving the health literacy of the patient. Through careful and astute assessment, the case manager is able to identify patients with low health literacy skills, especially those of another culture, and take the necessary steps to combat this epidemic. We must all be sensitive and respectful of differences in culture, race, and ethnicity amongst our patients.
Communication and listening skills must also be refined and the case manager encourages other members of the health care team to refine their communication skills as well. Patient comprehension will be facilitated, and the patient will gain the confidence to navigate the complex health care system; thus promoting healthier individuals and communities.
References
Andrulus, D., & Brach, C. (2007). Integrating Literacy, Culture, and Language to Improve Health Care Quality for Diverse Populations. American Journal of Health Behavior, 31 (1), 122-133.
Anonymous, (2015). Targeting Low Literacy Patients Pays off for Health System. Hospital Case Management, 23(11), 148-149.
Egbert, N., & Nanna, K.M. (2009). Health Literacy: Challenges and Strategies. The online Journal of Issues in Nursing, 14(3), 1-14.
Graham, S., & Brookey, J. (2008). Do Patients Understand? The Permanente Journal, 12(3), 67-69.
Kimbrough, J. (2007). Health Literacy as a Contributor to Immigrant Health Disparities. Journal of Health Disparities Research and Practice, 1(2), 93-106.
Kountz, S. D. (2009). Strategies for Improving Low Health Literacy. Postgraduate Medicine, 121(5), 171-177.
Lake, R. (2016). Shocking Facts: 23 Statistics on Illiteracy in America. Retrieved on March 16, 2017 from http:www.creditdonkey.com/illiteracy-in-america.html.
Leinenger, M., & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research, and Practice, New York: McGraw-Hill.
Mullahy, C. M. (2016). How Case Managers are Addressing America’s Health Literacy Problem. Care Management, 22(6), 14-18.
National Network of Libraries of Medicine. Health Literacy. Retrieved on March 16, 2017 fromhttp://nnlm.gov/professional-development/topics/health-literacy.
Powell, S. K., & Tahan, H. A. (2009). Case Management: A Guide for Education and Practice, New York: Lippincott: Williams and Wilkins.
Purnell, L. D. (2008). A Guide to Culturally Competent Health Care, New York: F.A. Davis Company.
Shaw, S. J., Huebner, C., & Armin, J., Armin, J., Orzech, K., & Vivian, J. Â (2009). The Role of Culture in Health Literacy and Chronic Disease Screen and Management. Journal of Immigrant and Minority Health, 11(6), 460-467.
