A Model Collaboration to Develop a Health Literate Care Curriculum: Preparing the Next Generation of Physicians to Deliver Excellent Patient Outcomes and Experiences
Health care systems are operating in an environment that is increasingly moving toward value-based payments that reward good health outcomes and patient experience. An impediment to success in this environment, however, is that both health care delivery systems and health information are extremely complicated. The level of complexity stymies many people and hinders them from making informed preventive care and self-management decisions. Health systems are finding that they cannot achieve improved patient outcomes or experiences without improving how health care professionals communicate with and support patients.
Health care systems must also consider the fact that some Americans struggle more than others to find, understand, and use health information. Over a third of US adults—or 77 million people—have difficulty with common health-related tasks, such as following directions on a drug label or using a chart to figure out when a child should be immunized . These adults have limited health literacy, meaning that they have trouble understanding and using basic health information and services. However, even those with adequate health literacy are often challenged to understand health information and navigate the health care system. According to a national assessment, nearly nine out of ten adults in the United States could not perform health literacy tasks that people are frequently asked to complete, such as finding the information required to define a medical term by searching through a complex document .
Health systems have begun to respond to the mismatch between patients’ capabilities and the health literacy-related demands of the health care system. A new term has emerged – the health literate organization – that describes organizations that aspire to make it easier for people to navigate, understand, and use information and services to take care of their health . Health literate organizations, in turn, need health care professionals who have health literacy knowledge and skills, such as being able to communicate effectively, break down health goals into manageable steps, and connect people with the resources they need to be successful (see Table 1).
Physicians require these health literacy skills to effectively communicate with patients, foster shared decision-making, and promote behavior changes that avert disease, such as healthy eating, exercise, and tobacco cessation. Training health care professionals in health literacy has long been recognized as a key component of any organizational strategy to meet patients’ and caregivers’ communication and navigation needs . For over a decade there have been calls for evidence-based health literacy curricula for health care professionals [5,6]. In 2013, experts in health professional education reached a consensus on a set of health literacy knowledge, skills, and attitudes that, if
included in curricula, would prepare health care professionals to work with patients and caregivers of all health literacy levels [7,8].
Medical schools can respond to the urgent need for physicians well-versed in health literacy skills by integrating health literacy knowledge and skills throughout their curricula. Many medical schools have introduced some teaching on health literacy into their curricula in the past decade, but the average amount of time spent on health literacy is small (e.g., between two and five hours per year) . To our knowledge, no medical school has taken a systematic and comprehensive approach to integrating health literacy knowledge and skills throughout its curriculum—until now. This commentary describes how the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell (ZSOM) transformed its curriculum, and the model collaboration that guided the creation of ZSOM’s Health Literate Care Curriculum.
A Model Collaboration for Developing a Health-Literate
Representatives from the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (ODPHP) and Agency for Healthcare Research & Quality (AHRQ); health literacy experts from the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Health Literacy; and ZSOM’s curriculum team formed a collaboration to use the Health Literate Care Model  and the AHRQ Health Literacy Universal Precautions Toolkit (AHRQ Toolkit)  to establish the comprehensive Health Literate Care Curriculum that is being piloted by ZSOM starting in the fall of 2019.
ZSOM’s Approach to Medical Education
ZSOM provides an integrated, person-centered medical learning experience. Medical students learn how to translate knowledge into action from the beginning of ZSOM’s experiential curriculum. As part of the core curriculum students learn how to:
- Integrate basic science with effective patient communication to solve clinical problems using a person-centered, evidence-driven, and case-based approach;
- Treat and educate patients about the why’s and how’s of their health conditions in small-group role-playing sessions with peers, simulated patients, and faculty; and
- Care for real patients weekly in ambulatory practices under the guidance of preceptors beginning in their first year of medical school.
Experiential learning has been recommended for training health care professionals in health literacy, making ZSOM particularly well suited to design and launch a comprehensive health-literate care curriculum . From the outset, ZSOM’s curriculum included health literacy skills in an ad hoc manner, but initially, it did not address health literacy systematically.
The Health Literate Care Model and Health Literacy Tools
The collaborators used the Health Literate Care Model as a roadmap for the skills that medical students need to deliver health-literate care. Like the Care Model (an expansion of the Chronic Care Model)  upon which it is based, the Health Literate Care Model highlights system elements that are key to delivering high-quality care (e.g., delivery system design, self-management support). The Health Literate Care Model advises the use of health literacy strategies to achieve productive interactions between informed, activated patients and families and prepared, proactive health care teams. The Model embraces the principle of “health literacy universal precautions”— that is, the need to approach all patients with the assumption that they are at risk of (1) not understanding information relevant to maintaining and improving their health, or (2) getting lost in the intricacies of the health care system.
The Health Literate Care Model demonstrates how each of 20 tools—from the AHRQ Health Literacy Universal Precautions Toolkit (1st edition) —can be used to address the Care Model elements. Mastery of each of these tools, therefore, becomes a professional competence to which medical students can aspire.
A Focus on Prevention
The collaborators decided to put extra emphasis on applying health literacy skills in the area of prevention. Key strategies to improve health are promoting behavior changes that avert disease and delivering recommended clinical preventive services (which include screening tests, immunizations, and behavioral counseling) to people before they suff er from debilitating but preventable chronic conditions, such as heart disease and diabetes. Unfortunately, Americans receive only one-half of recommended preventive services .
Tools (e.g., AHRQ’s Electronic Preventive Services Selector – ePSS) exist to make clinicians aware of the recommendations of the U.S. Preventive Services Task Force (USPSTF), the panel of experts that makes evidence-based recommendations about clinical preventive services. Many patients, however, do not understand the risks and benefi ts of preventive services, and traditionally medical students don’t receive enough training in how to help patients make informed decisions about them.
The Collaborative Process
Over nine months (2018–2019), the collaborators worked together on blending the health literacy strategies from the AHRQ Toolkit with the existing ZSOM curriculum (see Table 1).
In an iterative fashion, during multiple collaborative conference calls:
- Collaborators reviewed and discussed ZSOM’s current First 100 Weeks (first two years) curriculum and existing elements that addressed health literate communication, as well as the tools from the AHRQ Toolkit;
- Collaborators created a matrix that shows in which areas each of the competencies that arise from the AHRQ health literacy tools could be taught during ZSOM’s First 100 Weeks curriculum;
- Health literacy experts identified additional opportunities to integrate health literate communication strategies and approaches into ZSOM’s curriculum; and
- ZSOM’s curriculum team responded with ways to integrate all the health literacy competencies into their curriculum.
The curricular enhancements were planned in a developmentally appropriate sequence and integrated into the curriculum to fi t thematically with the basic and clinical science content. For example, during the first-year course “Fueling the Body,” students learn about metabolism, the gastrointestinal system, and Myhealthfinder . Myhealthfinder, developed by ODPHP, is a health literacy tool that helps doctors engage patients in high-value preventive care conversations. Myhealthfinder, shown to increase the uptake of USPSTF recommendations , provides patients with guidance tailored to their age, sex, and pregnancy status. It offers a plain-language vocabulary that can facilitate discussions about which preventive services are high value—and which are not. Collaborators paid special attention to enhancing the curriculum by using prevention examples to teach health literacy skills, and added training on using Myhealthfinder with patients.
Students are expected to use Myhealthfinder when identifying appropriate clinical preventive services for patients, and to use other tools that support health literate communication between patients and providers, including encouraging questions (Tool 14) when conducting a nutrition assessment, using clear communication (Tool 4) when showing patients how to use a body mass index calculator, and employing teach-back when counseling a patient with diabetes (Tool 5).
ZSOM’s curriculum team developed a comprehensive assessment plan aimed at assessing student knowledge and skills in health literate communication to match each competency from the AHRQ Toolkit. Stakeholders from across the ZSOM curriculum team were involved in the process to optimize feedback and build support for the program. Student input was gathered to ensure that the learners judged the curriculum to be relevant and cohesive.
ZSOM’s Health Literate Care Curriculum is being implemented and evaluated during the 2019/2020 academic year. The collaborators plan to report on the curriculum’s implementation and evaluation upon completion in 2020.
The advent of value-based payment is creating a new opportunity for embedding health literacy in health professional curricula. Health systems are increasingly investing in removing barriers to good health. For example, we are witnessing an unprecedented increase in the number of health systems launching nutrition and housing programs to address patients’ social determinants of health. These same market forces cause health systems to seek physicians who can use health literacy skills effectively to engage patients in prevention and self-management. Integrating health literacy throughout a medical school curriculum, particularly regarding prevention of chronic diseases, is a prerequisite to preparing doctors to practice medicine in today’s health care environment. It also prepares physicians to serve as champions that propel organizations to become more health literate .
A collaboration between health literacy experts and medical school faculty produced a Health Literate Care Curriculum that provides an important model for medical schools nationwide by demonstrating how health literacy knowledge and skills can be comprehensively integrated into curricula using an innovative, systematic process that applies the Health Literate Care Model and the AHRQ Health Literacy Universal Precautions Toolkit. The authors of this commentary believe person-centered, practice-based learning that is grounded in health-literate care curricula will prepare students to thrive in value-based environments and in any clinical setting that aspires to deliver excellent patient outcomes and experiences.
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