Exploring Health Literacy: Improving Patient Outcomes & Reducing Resources
Introduction
The tones drop. It’s 2am. The Paramedic and EMT climb out of bed, gearing up for the outside weather before heading to the ambulance. Dispatch comes across on the radio, announcing the call reason and location. “Medic 10, dispatched to 100 Lancaster Road for reports of sick person: new onset immobility.” The crew loads themselves up, pulls out of the station, and heads down the road with lights and sirens as they make their way to the caller about 20 minutes away. It’s a rural county, and one of 4 ambulances for miles has just gone out of service and committed to a call.
Upon arrival, the crew is met by a frantic neighbor on the porch. The neighbor explains that the caller has always had bad health, but had been declining rapidly for about a week. They report that the caller called them earlier in the morning asking for help repositioning, as the caller was unable to breathe lying flat and didn’t have the strength to sit themselves upright without help. The crew begin their scene assessment as they walk into the home and make their way towards the patient. Family photos throughout the hallways and living rooms are juxtaposed with countless pill bottles, home oxygen machines, wheelchairs, and other assorted home medical equipment. An inhaler sits out on one of the hallway tables. The telltale signs of polypharmacy are abundant.
The crew make their way to the patient. The 65 year old male is lying back in bed, struggling to take a breath. His legs are swollen and distended, the product of edema buildup throughout the week. He normally sleeps in the recliner, he says, but he got so weak last night that he just fell into bed and tried to make it through the night. 4 pillows are laid behind his head, but it’s not enough for his comfort.
The crew go to work, beginning their assessment and treatment. The patient reports a history of both COPD and CHF. When asked about his medications, the patient says there’s a list somewhere - and is only to recount two. When asked about medication compliance, he reports he forgets often. He states that they prescribe so many to him that he doesn’t know what to do anymore. Assessment reveals crackles throughout the lungs bilaterally, pitting edema in the lower extremities, dependent edema in the sacral area, peripheral cyanosis, and oxygen saturation of 83 percent. The crew goes to work - CPAP goes on, oxygen starts flowing, access is obtained - and the patient is moved out of the home with the assistance of a responding volunteer fire station. The patient is transported 40 minutes away to the closest capable hospital, keeping the unit out of service for another 2 hours by the end of the call.
The story described above is familiar to anyone with a bit of time in EMS. Patients with chronic, and sadly sometimes unmanaged, health conditions make up a large majority of EMS calls for service. These calls are often nonemergency, but ignoring the underlying health conditions as they decline can lead to the true emergencies described above.
This article seeks to confront the issue of health literacy, not only in EMS but in the broader medical field overall. Patients with chronic health conditions take up a large amount of resources, but as a medical system we often fail to include the patient themselves when assessing their needs and providing treatment. By increasing health literacy in the community, we can reduce unnecessary EMS calls and emergency room visits, reduce resources required for these chronic patients, provide better care overall, and catch treatable conditions before they progress into life-threatening emergencies.
What is health literacy?
The CDC defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (CDC 2021). Essentially, it is the level of knowledge that a patient has about their health conditions, navigating the health system, and the proper continual management of their conditions. Patients with adequate health literacy are able to communicate more effectively with medical providers, understand the reasons behind things like follow-up appointments and medication schedules, and can comply with lifestyle-based treatment plans effectively. Inversely, patients with poor health literacy often have difficulty navigating the health system or finding resources, trouble maintaining medication compliance, and have worse health outcomes than their counterparts.
The importance of health literacy
United Health Group research shows that improving health literacy in the United States could decrease hospital visits by up to 1 million visits per year (United Health Group, 2020). A study in the Journal of Medical Internet research found emergency room visits declining by 32 percent when a web-based health literacy program was established (Greene et al., 2019) At a time when hospital resources are near peak or overloaded nationally, decreasing unnecessary patient volume is invaluable. Health literacy efforts also save taxpayer, hospital, and patient resources; over 5 billion dollars annually is used specifically for patients with health literacy issues (Accenture, 2018).
There are two major types of health literacy: organizational and individual. Individual health literacy is the ability of the individual patient to navigate the health system and understand their health conditions effectively. On the other hand, organizational health literacy describes the health literacy of entities like hospitals, community organizations, and health departments - it is the measure of how easy it is for the average patient to navigate the health system. Overall health literacy is a combination of both the individual own health literacy in combination with the ease of access that organizations provide to patients (National Institute of Health).
The theoretical patient written about above is a good example of the outcomes of poor health literacy. The patient in question has CHF - a severe life-altering condition - has been prescribed polypharmacy, has little understanding of his medications or medication regimen, and ultimately was noncompliant with his treatment plan. Many chronic health conditions require polypharmacy in their management, with varying medication schedules and multiple doses throughout the day. They also require frequent adjustment and regular contact by the primary care provider to remain effective. For instance, diuretics specifically may need dose adjustments depending on the progression of the patient’s CHF. The emergency and the patient’s decline overall could have been avoided with proper health literacy and regular medication adjustments.
The case for health literacy campaigns
As detailed above, the costs of poor health literacy as astronomical - both for patients and for the organizations that treat them. Conservative estimates, as described in George Washington University’s Low Health Literacy: Implications for National Policy, place the cost nationwide for poor health literacy at 106 billion dollars yearly. That includes costs to both organizations and patients. That is over 6 times the CDC’s suggested operating budget of 15.4 billion for all of 2022 (CDC). Patients with poor health literacy also make up a large majority of repeat, consistent EMS and emergency department use. Not only do they make use of the ER more often - they also have higher emergency department recidivism (Griffey et al., 2014). These EMS and emergency room resources could be better allocated to serve critical patients and improve the level of focus providers can give to each individual patient. This is especially relevant at the time of writing, as COVID19 remains a pandemic within the United States in 2022 and continually stresses both EMS and hospital systems alike with overloading. These resources are especially sparse in underserved rural areas, which have less resources to begin with.
In addition to financial costs, poor health literacy costs and destroys patient lives. The scenario described in the introduction paints a grim, but realistic picture of the end results of poor health literacy at their extremes. Most health systems attempt some form of health literacy advocacy, but it often falls short. Patients with poor health literacy face a range of issues in navigating the health system and their treatment plans. For instance, patients with poor health literacy often fail to understand the timing, dose, or even reason behind their prescribed medications. WIthout adequate knowledge of the reasons for their medication regimens, patients often fail to understand the severity of modifying doses or failing to take medications on time. Patients with poor health literacy are often marginalized and low income, incentivizing them to try to prolong their medications by any means possible. These same patients often are unable to maintain adequate, regular contact with their primary care physicians - leaving medications like diuretics, hypertension medications like beta blockers, and antibiotics regimes out of date with their changing health.
With geriatric and medically fragile patients, poor health literacy can have extremely negative outcomes. Poor health literacy is directly related to increased hospitalizations (Baker et al., 2002). Any hospital stay has the potential to be detrimental for a patient’s overall life, but geriatrics have an even higher risk of hospitalizations and already have slower recovery times on average. Having adequate health literacy in addition to other good health habits can be the difference between a struggling 60 years of life versus having good quality of life well into a patient’s 80s and 90s. Studies show that poor health literacy increases the risk of premature adult death within 5 years by up to 50 percent (Bostock and Steptoe, 2012).
Solutions for health literacy, and what EMS can do
EMS providers often find themselves divided between the realms of medicine and emergency response and social work. We wear many hats. EMS providers are often the first, and sometimes only, point of contact for many patients entering the healthcare system. This is especially true with chronic patients as their health conditions decline - many of these patients simply do not communicate with the healthcare system or engage in follow up with their primary care providers. Their only continued connection to the healthcare system overall is going to the pharmacy and ensuring their regular prescriptions remain filled. Appointments go unbooked, regular examinations undone, and medication dosing unchanged.
EMS providers can have a valuable impact by mending the gap between the traditional healthcare system and patients. Initiatives such as mobile telehealth already exist, but EMS providers can go a step further. EMS providers are not only tasked with emergency treatment, but also being the liaison for all further healthcare. EMS providers also are one of the only branches of healthcare to have direct, close contact with patients in the comfort of their own home. This offers perspectives and a view into the patient’s lifestyle that primary care providers and hospital staff cannot get. With future innovations, this information can be efficiently collected and passed along to primary care providers for further assessing the patient’s health status and making adjustments. In addition, EMS system can develop more progressive protocols to include at home telehealth, providing referrals to local PCPs and community resources, and treat and release.
Community paramedicine and Mobile Integrated Health teams can be effective tools for EMS systems to accomplish these goals. Community paramedicine uses specifically trained paramedics to respond to patient homes, conduct ALS-level assessments, and then work with the patient on a personal level to understand health afflictions, medications, treatment plans, and connect them with further resources. Community paramedics can serve as a point of contact for patients with follow up questions, allowing them to gain health literacy and get involved in more education programs as the provider-patient relationship grows. This close relationship also allows community paramedics to continually monitor and report on the health status of a patient and initiate more invasive treatment if a patient shows signs of decline. In addition, the information gathered from community paramedicine programs can be included in patient charts, allowing both other responding EMS crews and the hospital to have a better history than any patient could provide on their own. Mobile Integrated Health teams add on to community paramedicine and bring in other professionals including social workers, community healthcare nurses, hospital systems, and primary care providers to the mix to ensure the patient receives specialized care for any issues that arise.
Community paramedicine can be used to address a broad span of different patient populations and health afflictions. Community paramedicine programs often start looking at a small category of specific target populations, but can expand to meet the needs of a growing population as needed (RuralHealthInfo). For instance, the patient described in the introduction would be well-served by participation with a community paramedicine program. A community paramedicine could have established contact with the patient after several repeat 911 calls, made contact with the patient’s primary care provider for a full history and chart, and then assisted the patient both in sticking to a medication regimen and understanding the need behind each prescription. The community paramedic could make repeat visits at set intervals to gather findings for the patient’s PCP, update his health records as needed, and ensure that the patient remains compliant with treatment. If a low acuity issue arose during the course of the paramedic’s treatment of the patient, the paramedic could use treat and release protocols without the patient ever leaving their home - avoiding hospitalization and freeing up resources for other patients. Common treat and release protocols include wound care and diabetic complications management, but further research continues to bring additions.
Community paramedics can additionally work with nurses for increasing public health awareness and patient education at local hospitals, clinics, and other entities. Nurses often, besides EMS providers, the first healthcare clinician that many patients see and speak to intimately about their health problems. Nurses build a rapport with patients similar to EMS providers, and form a critical part of the healthcare system overall.
With effective community paramedicine programs and increasing communication between components of the healthcare system, EMS systems can reduce call volume and save resources for more critical patients. In addition, EMS systems can prevent emergency situations from developing in the first place. Hospitals and other healthcare entities can benefit from reduced patient volume and cost savings, also.
What can I do?
The best tool in our toolbox as members of the public is awareness. That awareness helps build action - and this article was all about generating that awareness in the first place. EMSAware encourages you, the reader, to reach out to your local EMS jurisdiction about their plans for similar community paramedicine and integrated health programs. You are also recommended to reach out to your local city government leaders about diverting additional funding towards EMS systems to allow for the creation of such programs.
In addition, check in with family members about their health conditions. Let them know that programs are available to help further manage chronic conditions can often can be found through local health departments and similar institutions. Every little step can help improve health literacy in communities and in individual patients.
This article was written off the author’s pre-existing knowledge, with works cited for supporting arguments and providing additional information for the reader.
Works Cited
Baker, David W., et al. “Functional Health Literacy and the Risk of Hospital Admission among Medicare Managed Care Enrollees.” American Journal of Public Health, vol. 92, no. 8, 2002, pp. 1278–1283., https://doi.org/10.2105/ajph.92.8.1278.
Bostock, S., and A. Steptoe. “Association between Low Functional Health Literacy and Mortality in Older Adults: Longitudinal Cohort Study.” BMJ, vol. 344, no. mar15 3, 2012, https://doi.org/10.1136/bmj.e1602.
“CDC Statement on President's Fiscal Year 2022 Budget.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 May 2021, https://www.cdc.gov/media/releases/2021/s0528-fiscal-year-2022.html.
“Clear Communication.” National Institutes of Health, U.S. Department of Health and Human Services, https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication.
Greene, Jeffrey C, et al. “Reduced Hospitalizations, Emergency Room Visits, and Costs Associated with a Web-Based Health Literacy, Aligned-Incentive Intervention: Mixed Methods Study.” Journal of Medical Internet Research, vol. 21, no. 10, 2019, https://doi.org/10.2196/14772.
Griffey, Richard T., et al. “Is Low Health Literacy Associated with Increased Emergency Department Utilization and Recidivism?” Academic Emergency Medicine, vol. 21, no. 10, 2014, pp. 1109–1115., https://doi.org/10.1111/acem.12476.
“Healthcare System Complexity.” Accenture, 6 Sept. 2018, https://www.accenture.com/us-en/insights/health/hidden-cost-healthcare-system-complexity.
“Rural Health Information Hub.” Community Paramedicine Overview, https://www.ruralhealthinfo.org/topics/community-paramedicine#mobile-integrated-healthcare.
“Understanding Health Literacy.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 29 Mar. 2021, https://www.cdc.gov/healthliteracy/learn/understanding.html.
