Building a Health Literacy Improvement Plan With an Interprofessional Team

Saturday, 28 October 2017

Denise Isibel, DNP
School of Nursing, University of North Carolina Wilmington, Wilmington, NC, USA


The project assessed the health literacy knowledge of an Interdisciplinary team (IDT) and developed a health literacy improvement plan for the IDT at the using the “Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit (Brega et al., 2015). The interdisciplinary health care team includes medical, nursing, social work and various therapy professionals who work collaboratively to meet the needs of low-income elderly patients.


Health professionals expect patients to be actively involved in their care but a

problem occurs when patients have difficulty understanding oral or written health care

instructions. Chronic illnesses such as hypertension, cardiac disease, chronic obstructive pulmonary disease, asthma and diabetes require patients to understand complicated and lengthy health regimens related to medication adherence, dietary needs, and exercise. Information and instructions provided at a level that is easy to understand will support patients’ efforts to manage their chronic conditions. Health literacy is a systems issue. If health care professionals lack an understanding of health literacy and its components, patient outcomes may be compromised (Parnell, McCulloch, Mieres, & Edwards, 2014). Health care providers must be able to communicate effectively with patients utilizing principles of health literacy. Health care organizations need to provide information that all patients can use regardless of their level of health literacy. Acknowledgement of this responsibility and an emphasis on health literacy at the system level may result in improved patient outcomes, decreased cost, medication errors, emergency room visits, and hospital admissions.

Provisions in the Patient Protection and Affordable Care Act (ACA) address the need for greater attention to health literacy including clear communication of health information, assurance of equity in health care access, improvement in quality of care, and cost reduction (USDHHS, 2010b). It is imperative for nursing and all health care providers in practice, research, and education to have the tools to promote and increase health literacy. Key health literacy education competencies for health professionals should include knowledge, skills, and attitudes for effective health literacy practices (USDHHS, 2010b). Health literacy education and heightened awareness of health literacy strategies may be necessary components of a standardized process to assist an organization to consistently apply health literacy strategies that increase the safety of their patients, improve the delivery of health care information, and provide health management instructions that are clear to the patient.

Health literacy is related to health outcomes. The lack of attention to health literacy costs 106-2833 billion dollars annually (Vernon, Trujillo, Rosenbaum & De Buono, 2007). Without attention to or an emphasis on health literacy, quality care and initiatives to improve health outcomes may fail (Nielson-Bohlman, Panzer & Kindig, 2004). Readmission after discharge increases health care costs for hospitals, health care providers, patients, and insurance companies. According to an AHRQ study, 1.8 million readmissions cost the Medicare program $24 billion and privately insured readmissions totaled 8.1 billion dollars annually (USDHHS, 2014). Patients with low health literacy had a higher incidence of readmission 30 days post discharge (Mitchell, Sadikova, Jack, & Paasche-Orlow, 2012). Organizations that focus on making the entire system health literate have decreased costs, increased communication, patient and provider satisfaction (Brach et al., 2012; Parnell et al., 2014; Schillinger & Keller, 2011; USDHHS, 2010a). Health literate organizations create an environment where there is increased understanding of patient care needs, heightened communication, increased teamwork, and more efficient use of resources (Brach et al., 2012).

The consensus from these national sources is that health literacy needs to start at the organizational level. All individuals will benefit when all levels of an organization utilize health literate strategies in communication techniques, plain language, and technology that are culturally appropriate (Brach et al. 2012; IOM, 2012; Koh, Brach, Harris & Parchman, 2013;Rudd, 2010; USDHHS, 2010a). Organizational changes that accommodate various levels of health literacy have increased patient engagement, decreased hospital readmissions, and improved communications (Cawthon, Mion, Willens, Roumie & Kripalani., 2014; Mitchell et al., 2012; Ryan et al., 2014). Organizations considered to be health literate integrate health literacy principles through all services.

Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit

The AHRQ Health literacy Universal Precautions Toolkit is a comprehensive coordinated program that supports education of health literacy at the organizational level. The AHRQ Health Literacy Assessment Questionnaire is designed to determine baseline understanding of the current health literacy practices health in an organization. The “Health Assessment Literacy Questionnaire” contains 51 questions addresses five domains: spoken communication, written communication, self-management and empowerment, and supportive systems. Responses to each question are doing well, needs improvement, not doing or unsure. The toolkit suggests that the first part of the process is to develop a path for improvement beginning with a designated team and baseline assessment. Instruments for implementation address (a) oral communication (b) written materials; (c) guidelines to connect patients with needed resources and (d) processes for patient feedback.

Health Literate Care Model

The Health Literate Care Model focuses on the health literate organization that supports delivery system redesign, self- management, shared decision-making, and patients as partners in care. It is believed the health literate organization will improve outcomes by having informed, health literate, engaged activated patients and families in organizations that have a prepared proactive health literate care team (Koh et al., 2013). The use of the Universal Precautions Toolkit developed by the AHRQ is designed to build the health literate organization as described in the Health Literate Care Model. The tools presented are expected to strengthen interactions across all levels of organizations that can improve health outcomes. The employment of health literate principles must exist across all areas of the organization.

The potential of The Health Literate Care Model is to provide both patient and organization with a seamless, positive health care experience. The model expects to encompass all areas of an organization including administrative personnel in areas such as finance, insurance, scheduling, registration and those most often associated with patient care such as nurses, primary care providers and specialists. The Health Literate Care Model incorporates community resources, support groups and interactive learning activities that contribute to the patient’s health care.


The Assessment Questionnaire from the AHRQ toolkit was completed by the IDT. The IDT is considered a convenience sample. The questionnaire determined the IDT’s baseline understanding of the current health literacy practices in the PACE program along with focused priorities for the implementation of the tools provided in the toolkit. The Health Care Literate Model guided the project design, implementation, and evaluation. The project design specifically addressed the strategies for health literate organizations.

Limitations included the small convenience sample and small number of members in an IDT. This limitation may not allow a generalization of the results. The purpose was to develop a plan showing the application of the AHRQ Health Literacy Universal precautions toolkit.


Results were tabulated noting areas that were identified as doing well, needs improvement, not doing or not sure or not applicable. Priority interventions were those labeled as not doing or not sure. Areas labeled as areas of needing improvement were considered as a second priority. Priority areas included the need for a health literacy team, improve spoken communication, and improve written communication. Results from the assessment were used to create a health literacy plan for the organization. The improvement plan aligns interventions with specific priorities identified from the initial assessment.


This project impacted the IDT by providing a measurement of the current understanding of health literacy, clarifying the need for an improved health literacy program, and assisting the IDT with making changes that support a more health literate approach to their patient population. The ongoing impact will be measured over time in the form of implementation of the toolkit tools and patient responses. Understanding and training in health literacy may increase patient safety; improve health care information, and health care delivery.


With an organized plan for implementation, the organization will be well positioned to focus on the health literacy skills and knowledge for the health of the organization. Future research and implementation of the AHRQ Health Literacy Universal Precautions toolkit builds evidence-based practice for health literacy. The continued use of the toolkit also builds on the domain to translate research into practice integrating knowledge to improve healthcare practice and outcomes.