INTRODUCTION

Rehabilitating an ailing health care system is essential to our nation’s public, social, and economic health. In what some have called “the perfect storm,”1 the country’s shifting demographics, declining health literacy, and evolving economy threaten to exacerbate already dire problems related to health disparities, quality, and costs. Two issues receiving increasing attention as both challenges and opportunities are the invigorated efforts to improve health literacy2–7 and advance the patient-centered medical home (PCMH) model of care.8–15 While the two have been loosely linked,16,17 the striking common threads between them have been largely ignored.

As recently noted by Rudd,6 the National Action Plan to Improve Health Literacy 5 shifts attention from the literacy skills of individuals to the health care providers and systems that serve them and calls for system-level changes that support effective communication. DeWalt18 further emphasizes how health systems unwittingly sabotage the effectiveness of the care they provide through suboptimal communication when care is handed over to the patient. The US Surgeon General summarizes the challenge poignantly: “As clinicians, what we say does not matter unless patients are able to understand the information we give them well enough to use it to make good health-care decisions. Otherwise we didn’t reach them, and that is the same as if we didn’t treat them.”7

Enhancing clear, patient-centered communication is a widely endorsed strategy for improving health literacy,4,5,19–22 with organizations such as the Joint Commission urging health systems to “make effective communications an organizational priority” and to “address patients’ communication needs across the continuum of care.”4 We propose that the PCMH model merits consideration as a foundation for achieving both goals. Not only does the model include many features that intrinsically support patient-centered communication along the care continuum, its increasing uptake12–15 and related incentives23–25 may help address challenges that can impede efforts to prioritize effective communication.

With momentum propelling the PCMH model forward, we see a novel opportunity to integrate health literacy into a system-based model of care—and for health literacy researchers to study the impact.

PROBLEMS AND PROMISE: A BRIEF OVERVIEW OF HEALTH LITERACY AND THE PCMH

Briefly summarizing relevant aspects of health literacy and the PCMH will help illustrate the synergies between them. Among many closely related definitions of health literacy evolving from Ratzan’s and Parker’s,26 we endorse the one recently proposed by Berkman et al.27: “the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions.” Regardless of definition, the key point is that at least half of American adults may not understand the overly complex information inherent in medical care, causing wide-ranging negative consequences affecting care quality, disparities, and costs.2,3,28

Evidence from Wynia et al.20 suggests that using patient-centered communication can help mitigate the effects of limited health literacy. As defined by Epstein et al.,29 patient-centered communication “aligns with patients’ values, needs, and preferences, improving understanding and allowing them to provide input and participate actively in decisions regarding their health and health care.” However, a large gap exists between patients’ health literacy and the degree to which most health systems and practices use patient-centered communication20—creating communication breakdowns that contribute to the negative consequence mentioned above (Fig. 1).

Figure 1.
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Gap between patient’s health literacy and health systems’ use of patient-centered communication.

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Like health literacy, the PCMH has many closely related definitions—but few are succinct. At its most basic, the PCMH is simply good primary care enhanced by health information technology (IT) capabilities and innovative payment models.11,30 Joint principles of the model31 emerged separately from policy work at the American College of Physicians and the American Academy of Family Physicians, and were soon endorsed by other primary care professional organizations and the Patient-Centered Primary Care Collaborative.32 The principles include improved access, ongoing patient-provider relationships, whole-person orientation, team-based approaches to care, coordination and integration supported by health IT, enhanced quality and safety, and payment for added value.

A PCMH checklist33 further distills the model’s features into four categories: quality, health IT, practice organization, and patient experience. Later in our discussion, we focus on the checklist’s patient experience elements: clear communication, improved access, shared decision making, and self-management support.

A SYNERGISTIC APPROACH TO COST, QUALITY, AND DISPARITIES

Evidence from successful PCMH demonstration projects12,14 and effective health literacy interventions34,35 suggests a collective potential to curb costs, boost quality, and provide more equitable care—essential priorities if we are to weather the coming storm. Interestingly, the PCMH demonstrations and health literacy interventions found to be most effective often share core features and produce similar outcomes.

For example, experiences in several peer-reviewed PCMH demonstrations36–40 strongly suggest a potential to curb costs—with the savings stemming primarily from decreases in emergency department (ED) utilization and hospitalization, especially for ambulatory care-sensitive conditions. Similarly, the Agency for Healthcare Research and Quality (AHRQ)’s recently updated review35 of health literacy interventions and outcomes concluded that multi-dimensional interventions focusing on self-management and treatment adherence—two PCMH focal points—led to significant reductions in hospital and ED use.

Many other peer-reviewed PCMH demontrations36,37,41–44 have also shown significant health-outcome-related improvements, such as better managed diabetes, asthma, and blood pressure. Among the health literacy interventions AHRQ reviewed, those that demonstrated the potential to effectively improve health outcomes were again focused on self-management and treatment adherence.35 A closer look at the few “effective” health literacy interventions highlighted in the report reveals three randomized controlled trials45–47 that tested strategies particularly well-suited for implementation within a PCMH: individualized communication, scheduled phone follow-up, and team-based care, among others (Table 1).

Table 1 Effective Health Literacy Interventions Well-suited for Implementation in a PCMH
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Authors of the AHRQ report also observed emerging evidence that low health literacy mediates racial disparities in care,48 which suggests that improving health literacy may be a worthwhile strategy for helping overcome disparities. Other findings also support the notion that health systems can promote health equity by addressing health literacy17,45,49–51 and providing patient-centered care.17,52

THERE’S A “ROOM” FOR HEALTH LITERACY IN THE MEDICAL HOME

While health literacy interventions have become increasingly widespread, relatively few high-quality studies have produced significantly positive results.34,35 One key challenge is that health literacy spans multiple domains along the continuum of care: Patients must understand health information (verbal, print, and web-based), navigate health services, make treatment decisions, and participate in self care. However, half the interventions in AHRQ’s updated review addressed just a single domain, for example improving understanding by making information more readable or supplementing it with alternative media.35

We propose that a comprehensive model of care like the PCMH can potentially address the multi-dimensional nature of the health literacy problem. In fact, the patient experience elements from the PCMH checklist (clear communication, improved access, shared decision making, and self-management) align remarkably well with health literacy challenges along the care continuum (understanding, navigation, decision making, and self-care)—an alignment that could potentially bridge the gap between patients’ health literacy and health systems’ communication practices (Fig. 2).

Figure 2.
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The PCMH as a bridge between patients’ health literacy and health systems’ use of patient-centered communication.

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A composite of PCMH attributes derived from the joint principles31 and checklist,33 and exemplified in successful demonstration projects across the country12,14,15 helps further illustrate how the model is well suited to comprehensively address health literacy challenges.

  1. 1.

    Understanding health information. A central feature of the PCMH is clear communication stemming from a robust and ongoing patient-provider relationship.31,33 Patients are viewed through a whole-person approach,31 enabling their care team to understand their needs and preferences around verbal, print, and electronic information.53 In addition, providing health information in plain English or in the patient’s preferred language is expected.33 The model’s team-based approach to care12,31,36,37,41 also facilitates using teach-back to confirm patient comprehension—as do longer appointment times (30 min instead of the typical 12-15) sometimes offered.36,41,53

  2. 2.

    Navigating health services. The PCMH improves access by providing patients with same-day appointments15,33 and options for point of contact: phone, online, or in person.14,33 Supplemental e-mail- and phone-based communication means questions and bi-directional information exchanges can occur easily outside typical in-person visits,53,54 which may encourage clarification of post-visit gaps in understanding. Ongoing care is coordinated by a cohesive team that helps patients find and access needed health services.14,37

  3. 3.

    Making treatment decisions. Shared-decision making is a core feature of the PCMH’s patient experience and quality ideals.31,33 Providers solicit and consider patient values and priorities, involving them as active participants in treatment decisions. Patient decision aids can be used to provide clear, evidence-based information—which has been shown to help adults with limited health literacy boost their knowledge and understanding of treatment options and outcomes.55–58 Patient decision aids are becoming more widely available, and federal agencies such as the National Cancer Institute and the Centers for Disease Control and Prevention are building decision aid clearinghouses.59

  4. 4.

    Participating in self care. The PCMH uses features of the Chronic Care Model,60 such as evidence-based reminders and proactive outreach and follow-up, to address self-management support.12,14,33 This can help mitigate health literacy challenges or other communication breakdowns that might otherwise hinder successful self care or treatment adherence. Importantly, mobile phone-based care management and health applications may present a promising method for reaching disadvantaged or otherwise marginalized populations,61–63 especially considering rapid increases in cell phone use across racial, ethnic, educational, and economic lines.64 PCMHs also emphasize family and caregiver engagement,31,33 enhancing social supports that many patients rely on to boost their self efficacy—especially those with limited health literacy.

HOW THE PCMH ADDRESSES CHALLENGES TO SYSTEMATIC COMMUNICATION IMPROVEMENT

Addressing health literacy through system-based communication-improvement strategies is not a new idea, 4,5,19–22 and tools for assessing and improving communication practices are available (Table 2). However, implementing these tools can be challenging because of time and financial constraints that hinder stand-alone efforts to address health literacy. Because of these constraints and the vast range of competing priorities most organizations face, implementing a communication improvement initiative simply may not make the cut. This is especially true when so few payment models support communication improvement activities.

Table 2 Tools for Assessing and Improving Communication Practices
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Explicitly embedding health literacy into the PCMH would create a unique opportunity to incentivize and streamline communication improvement efforts. First, the cost savings experienced in various PCMH demonstrations12,14,36,37 are likely to appeal to the nation’s many cash-strapped practices and health systems. Boosted by federal funds supporting PCMH expansion allocated in health reform legislation,25 Medicare and Medicaid are also implementing a variety of financial incentives for practices that implement the model.23,24 As part of the PCMH, addressing health literacy appears not as an added cost, but as an integral part of a model proven to conserve precious resources.

Second, growing enthusiasm for the PCMH means health literacy can be made part of a comprehensive model of care that diverse systems and practices are voluntarily moving toward53—or being required to adopt. Notably, federal agencies have been charged with helping all 1,300 federally qualified health centers become PCMHs, and collaborations such as the Safety Net Medical Home Initiative65 are spreading the model to communities in need nationwide. With health literacy embedded in the PCMH, addressing it becomes an integral part of work that may already be planned or undertaken, rather than another stand-alone priority that may not make the cut.

Finally, as diverse stakeholders refine the PCMH, “natural experiments” will provide essential evidence about which features work best to improve outcomes.66 Additionally, guidance and coaching programs are rapidly being developed to support PCMH transformations—signaling a critical time for solidifying health literacy as an explicit component of the model.

INTEGRATING HEALTH LITERACY INTO THE PCMH: SHORING UP OUR FOUNDATION

With the perfect storm approaching, now is the time to consider how integrating health literacy into the PCMH can shore up the foundation of a renovated health care system. Single solutions, such as using teach-back or providing information at a 6th-grade reading level, will not be sufficient. In addition to societal and educational innovations, communication improvements across America’s health systems are crucial.

Integrating health literacy principles into the PCMH is a promising strategy for systematically implementing these improvements. The model’s promise stems from features that address health literacy challenges across the continuum of care, increasing uptake that includes safety net clinics and community settings, incentives that help organizations prioritize communication improvement, and team-based solutions that better connect practitioners with each other and the patients they serve.