Value-based Healthcare: Health Literacy's Impact on Orthopaedic Care Delivery and Community Viability.

Abstract

The ability of patients to effectively take part in managing their orthopaedic conditions is contingent upon patient and provider communication and easy access to information that patients can discern, interpret, and implement. Our patients’ musculoskeletal function, quality of life, and consequent social and economic productivity are put in jeopardy if the pertinent information we provide is not presented in a way that is easily understood. Yet, online patient education materials often exceed average patient reading levels. A 2018 study found that the majority of online materials on sports injury and prevention are written 2.5 grade levels above national recommendations [8, 9]. This discrepancy hinders our patients’ ability to understand and manage their condition and treatment options. In the United States, about 36% of Americans have low health literacy, defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services needed to make appropriate health decisions” [2]. Low health literacy accounts for about USD 100 billion in incremental healthcare costs annually [7, 11], and is associated with increased hospitalizations, greater use of emergency care services, decreased likelihood that medications will be taken appropriately, and increased length of stay after surgical procedures [1, 12]. The reality is that social, economic, and environmental disadvantages lead to health disparities and impact an individual’s health literacy levels. Therefore, the orthopaedic community must recognize the pervasiveness of this issue and develop solutions that improve patient-clinician communication, increase cultural competencies of providers, and ensure comprehension of material across different population demographics. For example, providers could develop and implement processes to survey the literacy levels of their patient population and the reading level of their materials, and ensure alignment. Institutions can also curate teams that consist of people who come from communities representative of their patient population to vet cultural alignment of patient education materials. Employing these solutions can help mitigate the impact of limited health literacy on musculoskeletal care delivery and patient outcomes. Connecting with Healthcare Services A large majority of orthopaedic services are considered elective and referral based, placing our patients with limited health literacy at a disadvantage because they may not be familiar with how to access a particular healthcare service. For example, we know of anecdotal claims from orthopaedic providers who state that many patients with musculoskeletal complaints use the emergency room as their primary point of care, and after receiving such services, do not follow-up with primary care or in-network specialist physicians due to lack of transportation, unavailability of providers, or lack of trust/comfort with a provider. Clinical decisions are often altered based on insurance restrictions and the difficulties patients have navigating the system. A lack of familiarity with the healthcare process or even key terms like “in-network”, “out-of-network”, “referrals”, “copays”, “coinsurance”, “deductibles”, and “providers” can confuse patients and act as barrier towards establishing and maintaining the continuity of care needed to improve outcomes and mitigate risks. Emergency medicine, primary care physicians, and specialists (including orthopaedic surgeons) should consider using the teach back method (requiring patients to repeat and teach treatment plan back to provider) to maximize patient comprehension. Also, including social work services within the specialty care setting will help connect patients with available resources to ensure proper healthcare navigation. Why Are You Prescribing This Treatment? Physicians are often asked to “interpret” another provider’s treatment instructions. When we ask about following a previously agreed upon treatment plan between our patients and other providers, the frequent response is a combination of the following: • “I didn't do what Dr. X instructed because I didn't understand what he/she was saying.” • “I was told that I couldn't get an appointment for X months.” • “I can't find anyone in my network. All of the providers that I called said they are not in network–even the ones that my insurance company told me to call.” A patient not understanding why a specific treatment is prescribed decreases the likelihood of him or her following treatment instructions in the future, and that’s on us as providers. Implementing a patient-centered, value-based approach to health care involving a multidisciplinary care team that includes social workers, advanced practice providers, and behavioral health specialists focused on the outcomes of importance to patients has the potential to mitigate the effects of limited health literacy on physical function, mental health, and quality of life [5, 6]. Having a co-located multidisciplinary team allows multiple providers to collaborate on the care of a single patient, reducing the economic and psychological burden of healthcare navigation on the patient. Get to Know Your Community As healthcare providers, our goal should be ensuring that any health-related information communicated within our clinical space is suitable to the patients we serve. A critical first is determining the needs of the population that we serve. The University of Chicago (UChicago Medicine) did this by collaborating with private and community-based organizations to develop a community needs assessment [10], which led to the inclusion of new wellness services that prioritized social determinants of health and mental health. The assessment also led to the development of different community-based approaches, including leveraging UChicago Medicine’s resources to increase access to care; the development of educational forums to promote self-management practices; grantmaking to support organizations focusing on UChicago Medicine health priorities; and cultivating community partnerships that leverage technology and multidisciplinary teams to improve health and community engagement. From FY 2017-2019, an average of USD 455 million per year has been invested to support 186 partners in priority issue areas and 41 community-based programs [10]. The impact of such investments improved outcomes in management of chronic health conditions, violence prevention, and food insecurities [10]. Get To Know Your Patients On a much smaller scale, healthcare providers can vary the medium in which condition-specific information is used as a way to reach their patients. For example, if a certain percentage of your patient demographic has osteoarthritis and limited English proficiency, audio visual content, printable information with clear pictures, and culturally competent staff will allow your organization to deliver high-value, equitable care. Institutions can also develop partnerships with community organizations to help design and implement practices that best fit their population demographic. In addition to improving the quality of information, providers must also assess their ability to cultivate relationships with those they serve. By following and implementing the communication standards described above, a rapport can be established that allows patients to share their concerns without fear of judgment and the development of treatment plans that are compatible with their values and needs. From this point, clinicians and healthcare institutions can extend their reach beyond the clinical space and impact the health of communities. By simply improving the relationship a healthcare provider has with their patient, the patient will be able to apply what was learned in the clinical setting and relay it back to the members of their community that face similar health concerns. This domino effect of health information delivery is critical because an organization’s success as an equitable health institution is dependent on improving the health of the entire community, including the poor and vulnerable. The availability of specialty care, especially care for musculoskeletal ailments and other preference sensitive conditions, is extremely limited in underprivileged areas. One way to alleviate this access issue is to diversify and increase the type of healthcare practitioners providing orthopaedic care. For instance, orthopaedic-trained advanced practice nurses and surgeons representative of the area’s patient demographics may be utilized to improve patient-centered care rooted in empathy and cultural competence. By implementing these changes, patient experience and outcomes can be improved [4]. Healthcare providers and payors have a role to play in improving transparency regarding the availability of specialty care and patient out-of-pocket expenses associated with accessing those services. Payors can improve transparency by offering materials to their beneficiaries that clearly inform and educate them of any available options in compliance to their personal needs. The US Department of Health and Human Services (HHS) proposes health literacy now be defined as something that “occurs when a society provides accurate health information and services that people can easily find, understand, and use to inform their health decisions and actions [3]”. HHS’ proposal highlights that health literacy is not just something that involves patients, but something that is dependent on a relationship that includes the recipient of health information, the healthcare provider, and the medium where the health information is accessed. Therefore, the health and prosperity of a community is a reflection of the ability of healthcare institutions to adequately address the needs of the population. Although focusing on social determinants such as health literacy, education, employment, and structural racism may go beyond the purview of health institutions, we as healthcare providers can raise the awareness needed to develop public and private policy to tackle these pervasive issues.