What happens to seniors? If the Medicare cuts are put into place, Doctors will immediately stop seeing Medicare patients or restrict the number of Medicare patients they see. We have already seen this take place in offices around the country in states that drastically cut Medicaid. Even though there are some crutches to incentives clinicians to see these patients, there will never be enough incentive to wait on government reimbursements being stretched out over 6-8 months post visit.

What is the answer for the patient? Start evaluating the doctors and products needed. Patients will need to start shopping around for doctors that plan to participate in Medicare if cuts go through. If your physician, pt, ot, homehealth, etc… plans to continue taking Medicare, make appointments far out in the future to establish security with that clinician. This will give you some planning in the case of changes in your healthcare that are out of your control.

The best way to prepare is to get prepared. Make time to visit with each of your providers and know what to expect with each aspect of your healthcare.

HCSPCS Code            Item Description
A4335                Disposable Sheets and Bags
A4490                Surgical Stockings above Knee Length, Each
A4495                Surgical Stockings Thigh Length, Each
A4500                Surgical Stockings below Knee Length, Each
A4510                Surgical Stockings Full Length, Each
A4520                Incontinence Garment, Any type, (E.G. Brief, Diaper), Each
A4554                Disposable Underpads, All Sizes
A4565                Slings
A4570                Splint
A4670                Automatic Blood Pressure Monitor
A6413                Adhesive Bandage, First-Aid type, Any Size, Each

A6533-A6541   Gradient Compression Stockings ( See List for Specific Lengths and sizes)

A9275                Home Glucose Disposable Monitor (Includes Test Strips)
A9280                Alert or Alarm Devise, Not otherwise Classified
A9281                Reaching/Grabbing Devise, Any Type, Any Length, Each
A9300                Exercise Equipment
B4100                Food Thickener, Administered orally, Per Ounce
E0191                Heel or Elbow Protector, Each
E0240                Bath/Shower Chair, With or Without wheels, Any size
E0241                Bath Tub Wall Rail, Each
E0242                Bath Tub Rail, Floor Base
E0243                Toilet Rail
E0244                Raised Toilet Seat
E0245                Tub Stool or Bench
E0246                Transfer Tub Rail Attachment
E0274                Over-Bed Table
E0315                Bed Accessory: Board, Table, or Support Device, any type

The day of knee replacement surgery is mostly a day to recover from your procedure. But it is not just about rest. Depending on the time of day of your surgery, you may be asked to sit in a chair or on the side of the bed.

Patients will begin simple activities including ankle pumps, leg lifts, and heel slides. It is important for patients to take sufficient pain medication to allow them to participate in their rehabilitation exercises

Some doctors will place you into a motion machine, called a CPM. The benefit of a CPM has not been clearly proven, and some surgeons choose not to use the device. Thanks to the rapidly evolving sophistication of knee braces, you have improved chances of successfully protecting, rehabilitating, and supporting these vulnerable joints.  DJO Inc,  the U.S. leader in orthopedic rehabilitation devices and a preferred supplier of TherFit, creates knee braces (and other orthopedic gear) that address pressing medical needs and are also a little lighter, more comfortable, and stylish than in the past.

During your hospitalization, you will meet with physical and occupational therapists. The physical therapist will work on mobility, strengthening, and walking. The occupational therapist will work with you on preparing for tasks such as washing, dressing, and other daily activities

Therapy progresses at a different pace for each patient. Factors that will affect the rate of your progression include your strength before surgery, body weight, and ability to manage painful symptoms. The type and extent of surgery can also affect your ability to participate in physical therapy.

Patients are usually discharged 3 to 5 days after knee replacement surgery. It is important that discharged patients be able to safely get in their homes and perform regular activities, such as getting to the bathroom and preparing food

If patients are not progressing to the point that they can safely return to their home environment, in-patient rehabilitation may be recommended. This allows for further work with the therapists and 24-hour support services

Patients who return home will have home services arranged as necessary. This may include a visiting therapist and/or nurse.

Walking:

Most patients take their first steps after surgery with the aid of a walker. Patients with good balance and a strong upper body may opt to use crutches. Transitioning to a cane depends on two factors. First, restrictions from your surgeon -- not all surgeons allow full weight to be placed on the leg in the early weeks after surgery. Second, your ability to regain strength

•    Usual time to return: 2 to 4 weeks with a cane; 4 to 6 weeks unassisted

Stairs:

Many patients have to navigate stairs in order to enter or get through their homes. Therefore, your therapist will work with you to get up and down steps using crutches or a walker. 

•    Usual time to return: 1 week with crutch/walker; 4 to 6 weeks unassisted

Return to driving depends on a number of factors, including the side of your operation and the type of vehicle you have (standard or automatic). Patients need to be able to safely and quickly operate the gas and brake pedals. Under no circumstances should patients drive when taking narcotic pain medications.

•    Usual time to return: 4 to 6 weeks

Return to work depends on the activity that you have to do at your job. Patients who work in a seated position, with limited walking, can plan on returning about 4-6 weeks from the time of surgery.

Patients who are more active at work may need more time until they can return to full duties. Laborers should consider their work obligations before undergoing knee replacement. For example, patients may not be able to return to activities such as heavy lifting after knee replacement.

From the article:

1. Provider Consolidation

In the coming year, hospitals and care providers will need to coordinate patient care to promote long-term wellness, while delivering quality care in a cost-effective manner. This requires much more focus on the patient over time and across delivery organizations, as opposed to the more common historic view that has looked primarily at specific episodes of care delivered by a specific provider.  Some industry analysts have predicted the number of independent organizations could decrease by two-thirds over the next 10 years.

2. Industry Repricing

Under healthcare reform, hospitals must survive on what Medicare pays them, which currently only covers about 87 percent of the actual cost of care and is declining. Many experts and industry analysts predict the overall impact of healthcare reform will result in a 20 to 30 percent reduction in the average hospital's cost structure.

3. Supply Chain Centralization

The supply chain represents the second largest and fastest growing operating expense for most hospitals. The challenge in reining in supply chain costs is that most hospitals have historically focused their efforts on lowering the price they pay for products, which is only part of the cost. They've not yet fully explored ways to reduce direct and indirect costs--things like error-ridden manual processes, discrepant data, logistics and inventory carrying costs, to name just a few. Gartner Research says supply chain represents 40 to 45 percent of hospital or healthcare system operating expense and these organizations can reduce those costs by 5 to 15 percent if they better analyze, plan and control the purchase and use of goods and services.

Hospitals are increasingly relying on supply chain leaders to work cross-functionally with teams around their organizations to reduce costs. This in turn is resulting in consolidation of what have historically been multiple, separate supply chains within a single organization. This consolidation can result in business process automation for lower costs, more extensive contract management and product standardization and the return of clinical time to patient care instead of supply ordering and management.

Healthcare suppliers and their vendors will need to focus more on bottom-line growth in 2012, which can be achieved through better operational performance. It also requires a focus on quality patient care as a means to reduce costs. According to Dale Locklair, vice president Supply Chain and Construction, McLeod Health, "When I focus on quality, I can reduce costs. The reverse is not necessarily true."

5. Improving Trust

Lack of trust between hospitals and suppliers has historically hampered the industry's ability to lower the cost of doing business and, in turn, the cost of healthcare. Both hospitals and suppliers are having more difficulty growing revenue. With lower reimbursements a certainty, hospitals are hard-pressed to pay more for products, unless they can be proven to lower hospital-acquired infections, readmissions and other factors influencing reimbursement levels. The bridge to this relationship is the supply chain.

Gartner Research has noted that SG&A costs for healthcare suppliers are nearly twice those of companies in other industries recognized as having highly efficient supply chains.

Copyright (C) 2012 PR Newswire. All rights reserved

Point by point, let’s briefly examine the claims.  

Provider Consolidation. Highlights the need to provide a better continuity of care.  TherFit has held this view for a long time, and continues to develop the Continuum of Care matrix.  This section also talks about the fact that health care providers who do not evolve face the prospect of disappearing.

Industry Re-Pricing.  No surprise here, reimbursement is declining quickly.  If your practice had to face the 20~30% decline in reimbursement (income), would you survive?  TherFit provides a way of replacing that soon to be lost income.

Supply Chain Centralization.  While the article specifically mentions the supply chain costs for hospitals, the same reality affects all providers.  There has never been a greater need to efficiently deliver the required products, in order to insure good health outcomes.  TherFit works with the best vendors in the world to deliver quality products, quickly, safely and inexpensively to your patients.  You, as the health care professional help insure better health outcomes, largely by relying on the streamlined TherFit delivery system and aggregated buying power.

Quality Focus for Cost Reduction.  The article says it best.  Bottom line growth through better operational performance.  Such performance is not limited to delivery of products to patient.  It also refers to delivering your professional services more efficiently.  Stay tuned, TherFit is working on protocols to help make delivery of health cares services in the clinical/non-clinical setting more efficient.  Better health outcomes as a result of better follow-through after the office visit.

Improving Trust.  TherFit seeks a trusted relationship with all our clinical and non-clinical partners.  We are your advocate directly back to the manufacturers.  By reducing the number of layers between Point of Manufacture and Point of Consumption, we reduce costs.  We share revenue with our health care providers.  We seek constantly for other revenue sharing opportunities.  And like it says in the article, the Supply Chain is the bridge that gets us across the chasm.

What are you waiting for?  Get setup today, start using the system as fast as possible.  Realize the benefits and work with us to get progressively more efficient over time.  We exist to help organizations of all sizes become more efficient, survive the tough economic conditions, and thrive is an ever more competitive environment.

The anti-kickback and Stark laws were put into place because there were clinicians taking advantage of the “trusted agent” relationship they had with their patient/customer. The AMA discourages retailing by its members. Most clinicians are taught to hold askance the idea of selling something to a patient for profit, and the peer pressure against retailing is strong. The potential vulnerability of a consumer in the clinician/patient relationship is clear to everyone. The opportunities for over-charging for products, for selling customers things they don’t need, and for a clinician promoting something in which they have a vested financial interest are all very real issues for the clinician to consider. The opportunities for irresponsible behavior that reflects poorly on the greater community of care-providers are all too apparent to even the casual observer.

All of the negative aspects of retailing by clinicians are important to consider. And, in the world we lived in a few years ago, it was much easier to not have to really wrestle with the decision. As every clinician knows because of the painful experiences of the past few years, though – combined with what is clear is coming down the road – puts the independent clinician back into taking a look at issues that used to be easily brushed aside. The industry, market, and environment have changed dramatically, and the world looks much different today.

CNN has posted multiple articles in recent weeks about the financial risks and turmoil that surround clinicians today. While it used to be that the general public would see a clinical degree as a “ticket to ride” into endless prosperity, the destination of that ticket today is more troublesome. To remain financially viable, clinicians are doing all sorts of things they could not have imagined 5 – 10 years ago, often just so they can provide the level of care they think their patients deserve.

In the world in which we operate today, it seems like there are three main reasons for clinicians to investigate the ethics and the viability of retailing for profit:

1. Extending the level of care. How much time to you get with your patient today as opposed to 10 years ago? How do you know they will do what you have suggested they do to improve their health? How do you know they are getting the best solutions to assist them? In a time when our expectation is that some procedure or pill is going to let us all be healthy until we are 100, how do we help our customers – patients – meet their objectives? One way is to provide them access to the products, equipment and supplies you believe will be of benefit to them. The most sure way to do that is if they purchase those from you.

2. Liability. The dreaded “L” word is there every time you turn around. If your reading of the upcoming regulations included in the health care legislation includes that you are going to be held more liable for your patients outcomes than you are at present, and if you see your patient for less quality time and then they go do whatever they want, liability for their health has to be a major concern. If you have a retailing capability, you can now offer your patients the product you believe they need, and if they choose to not take your recommendation, that is now in their records and should help to mitigate potential liability (Note: we are not attorneys, and this should not be construed as legal advice).

3. Profit. At the end of the day, practicing medicine to help others is all well and good, but it is profit that keeps the doors open. Keeping those doors open is more and more difficult to do for many clinicians. The average US citizen spent $360 out of their own pockets for the products available on a TherFit eStore. Multiply that number by your patient count. If your profits from retailing to your patients / customers were only 10% of that number, would that help keep your doors open?

The past “stigma” of retailing – now that a viable, legal and profitable model exists through TherFit – could be the difference between remaining independent and working for a large organization. Serving your customers the way you want to serve them. Or giving you a little more time to meet with each patient. There is a choice to make, because now a viable option exists. We’re looking forward to supporting your clinical and business objectives in a way that works well with how you like to practice.  Open a TherFit eStore today!

Promoting your eStore at your place of business with the ability to take that order right there after you have made the recommendation of a product is key to having higher retail conversions.   Of course, to get take these orders in person requires a good technology implementation plan for your business. 

Implementing computers, tablets, digital picture frames, televisions and other technology will give you the ability to have a retailing kiosk at your location as well as a great way to market your business.  Over the next few weeks, TherFit will be rolling out training tutorials to set up your different technology devices to maximize your customer purchase at your location as well as ways you can the devices to follow up on recommendations, get more Facebook and Twitter followers, market you services, etc. 

TherFit specializes in helping healthcare and wellness business build a healthy new revenue stream by retailing products to their customers or patients.  We assist in setting up internal technology, marketing and processes which will lead to higher retail revenues and more community awareness.  When signing up for an eStore, we provide our eStore owners with a implementation recommendation plan based on their specific business and assist those businesses in integrating those ideas into their daily routines.  The plan includes how to involve your personnel, how to implement your specific technology, marketing programs that can be integrated as well as the financial projections of your TherFit eStore. If you have not already filled out the information form about your business, do so now by clicking here.  Once we received this information, we will provide you with a 5 page implementation report on how to have the most successful eStore for your business.  If you have already submitted a report, you should expect to receive this report from your eStore Success manager soon.

1. Promote your Facebook and Twitter accounts in your place of business: Lets face it. Your patient is not going home to seek out your Facebook or Twitter account to follow what is going on. However, knowing that it is common for patients to wait once they have arrived at your location is the perfect opportunity to pick up those news fans and followers. You could have those out of date magazines sitting there for them to read or you can take advantage of the fact that most people pass time on their mobile devices nowadays. This by far is the best time to market your social media sites to your patients or customers. Doing a good job of promoting your sites in clinic will increase the opportunity that they will follow or like your Facebook or Twitter acount while they are sitting there waiting to see you. Chances are, they have a mobile device in their hand and they are already logged into Facebook and Twitter and it would be really easy for them to visit your page or profiles and become a fan!

2. Use QR codes: Another great way to peak your patient's interest enough to visit your social media sites are the use of QR codes. QR codes are scannable media that can be scanned by mobile applications on most smart phones. You can place QR codes anywhere.  Once the QR code is scanned, it will link to the website that you have determined for the code. They have no need to type anything into their browser on their phone, just scan and it links directly to your Facebook page or Twitter account. Chances are, once they land on these pages, you will pick up a new fan!

3. Use digital slides to advertise: Digital slides are easy to set up and display on different types of technology. A digital slide is a marketing image that can be displayed as a screensaver on a computer, in digital picture frames, on tablets, and other technology. Digital slides are the best way to advertise the many different services, products, or social media sites of your business. Again, give patients something to view while they are waiting to see you or while they are receiving treatment. QR codes, interesting facts, events, specialties, are just a few of the things that can be advertised on these slides.

4. Use technology in the clinic: Americans love their technology. Show them you love technology as well. Set up your television with marketing messages in the waiting room, strategically place digital picture frames with slides throughout your location, use a computer or tablet as a marketing tool in the clinic. Technology is the best way to present your customers with information about your business and will give you the best opportunity to pick up new fans!

5. Capture email addresses: you see hundreds of patients per month. One of the easiest ways to stay in contact with your patients or customers is to get their email addresses. Once you received their email address, you can add them to your email newsletter program which can also drive more traffic to your social media sites. You can also search for your patients on Twitter via their email address and automatically follow them. This is a great way to engage your customers whenever they have left the clinic!

The TherFit team can assist you in implementing marketing and technology into your location to increase your social media awareness. Not only can TherFit assist you in marketing your healthcare or wellness business but can also provide your business with a new way to bring in additional revenue. Therfit offers a free retailing program for health and wellness professionals to recommend and retail healthcare products to your patients. For more information, please visit www.therfit.com

Those who will be using these medical products should be consulted prior to making
the decision of which ones to buy. The medical professional who is using the equipment
acquired will have his or her own preferences concerning various brands, sizes, and
materials. In order to help him give the patients the best possible treatment, he should
be supplied with products with which he is comfortable working. In doing so, the
physician will be more efficient and effective, and the patients can be better treated for
the condition that they are seeing the physician for.

Specialists will have particular needs that are not common to other practitioners. A
Physical Therapist will not need the same types of medical products as a Chiropractor
will. If you are looking for smaller pieces of equipment which are intended for use
directly on the patients, such as Thera Bands or Braces, will you send the patient to a
third party retailer or will you medically retail these items to the patient?

If you are looking for larger medical products, you will need to ask how much space
you have in your facility. The dimensions of larger, durable goods such as beds, carts ,
and cabinetry are included with the product literature and should be taken into account.
It will be useless to purchase a set of massage beds to furnish a business only to find
that they are too large to allow for any movement in the rooms. Carefully measuring
your space will prevents mishaps such as this when you are purchasing your larger
durable goods.

When you are buying medical products, make sure that you plan ahead and consult
with those using the products for their recommendations and preferences. You will need
to provide them with the highest quality of products in order to enable them to do their
job to the best of their ability. If you are directly retailing to patients make sure to explain
to the patients that not all medical equipment and supplies are manufactured to the
same standards. Quality of equipment and supplies can affect how well and how fast a
patient will heal. 

Whether you are a hospital administrator, a massage therapist, a PCP or an athletic trainer, you are faced with the decision about retailing products to your patients and customers. The issues, of course, are many and varied, including:

• Did I really go through all of that education and training to get involved with selling products to my customers / patients?
• Is it ethical for me to profit from product recommendations I make?
• I have heard stories of price-gouging – how do I protect my reputation?
• I can barely keep up with all of the new protocols, tools, drugs, etc. How am I supposed to know about products as well?

You probably have a few questions to add to the list. You have probably discussed this to some extent with your peers and people you respect. Let me share a story with you.
My wife’s best friend’s needed to have surgery. Her husband is a radiologist in a big medical system. A day or so after coming home, she was in a lot of pain and called my wife asking her to go get her some products she needed to alleviate the discomfort (this was before TherFit’s eStore was “live”). My wife, of course, had no idea of where to go, and neither did her friend.

This is a common situation that happens countless times each and every day. U.S. citizens spent over $100 billion out of pocket in 2009 buying products that are carried in the TherFit eStore, and then think about how many people never bought what they needed because they didn’t know where to get it or that a solution was even available. This is a reflection of our care model today, in that individuals have increased responsibility for their health, but they lack the tools or guidance they need to effectively do so. We don’t get the level of care we really need, because it doesn’t extend into the “real world” in which consumers must operate day in, and day out.

With a TherFit eStore, the surgeon could have provided the option to purchase the products prior to the surgery, helping our friend be fully prepared. The hospital could have provided the same option during check-in. No one did, because no one could. Now, you can. She would have appreciated it, and probably taken advantage of the extension of care on her behalf.

Almost 9% of all health care costs in 2009 were out-of-pocket expenses. Your customers and patients are already spending over $1,000 each per year on their direct health care costs not affiliate with health insurance. They could greatly benefit from your guidance. Guiding their health care purchases through a retailing web site is a great way to extend the level of care you provide to help them get exactly the product solutions they need to improve their health.

For now, the answer to the question of “should I retail?” is open for discussion. By 2014, when so many health care laws change and you become directly liable for the quality of care you provide, the question becomes “when” instead of “if”. Might it make sense to get in front of the curve and learn how to optimize both your patient’s experience with buying products from you even while you are doing the same thing with your retailing practices?

TherFit has constructed a tool that you can customize to your needs, that meets legal requirements for clinicians, and that takes care of all of the “hassle-related” issues commonly associated with retailing. Check out www.therfit.com to learn how to get started now.

What was not covered as well was the impact on the consumer in paying for health care.  And, even as the big players are getting more involved and more aggressive in the care model, the consumer is paying more and more cash for their health.  This is a major factor in the health care model, and one that providers overlook at the potential peril to both their bottom line and to the quality of care they provide.

Deloitte tells us that “out-of-pocket consumer expenses for health care in 2009 was $363 billion… these are supplemental to traditional costs for doctors, drugs, hospitals, and insurance coverage.”  Fully $199 billion of that was for products and services not covered by insurance – somewhere around 9% of all health care costs.  When one looks at the products specifically addressed within the TherFit eStore, their market value – for cash-based purchases – is over $100 billion per year.  And this amount grows every year.

• Cash-based purchases of products that are in your TherFit eStore           $108 billion
• Rough population of the United States                                                       307 million
• Average cash purchases per US citizen per year on TF eStore products    $351
• Number of discreet patients you will see in 2012                                       3,000
• Potential sales volume                                                                              $1,053,000
• Your potential profit                                                                                 $150,000

Go ahead, and use your own numbers.  Whatever they are, anything less than these numbers are profits your business is leaving on the table.  Can your business afford that?

Let’s put your clinical hat on for a moment, and ask yourself the following:

• Are my patients looking for a higher degree of care than I can currently provide?
• Am I already suggesting products for my patients to buy?
• How will my patients know what the best solution is for them?  Who will help them make a choice so that whatever they buy will do them the most good?
• If I –as their clinician – have a good understanding of what my patients need, is anyone else in as good of a position as I am to be a great source of products, supplies and equipment for them?  Would anyone else be better?

Of course, we’re excited about the TherFit eStore.  But, we think you should be too.  From our perspective, we think it helps you to extend the level of care you provide to your patients while also profiting from doing so in an honest and professional manner.

So, most will do nothing at all. Others will get the wrong product. And you’re just trying to help your patients and customers get better or achieve their health goals.

Everyone knows – or has personally lived – this story. Options for the patient or customer are few, and the accompanying results from these stories are unclear to everyone.

What we do know is that the story line can change. It is changing. Caregivers, trainers and clinicians can now plug into a tool that helps their customers and patients get exactly what they need, in a timely manner, and at a fair cost. What

So, where has the TherFit eStore been? Well, the technology behind tis unique business opportunity that provides a mechanism for caregivers to profit from the sale of medical-grade products just didn’t exist until lately. In fact, combining this technology to provide you with an eStore may never have been done before in the healthcare, senior care and fitness industries.

But, it’s what the technology facilitates – offering you your own branded eStore – that we’re really excited about.

Will TherFit’s eStore ever rid the world of the distress of patients looking for product solutions? Sadly, no. But, working closely with you – the eStore owner – we’ve decided to reduce some of the confusion and make a small contribution to the health and well-being of the American population. And while we’re at it, to the profitability of those who provide them with training and care.

Let’s take the “Hip Replacement Kit” as an example. AAOS (American Academy of Orthopaedic Surgeons) recently reported that there are a little over 193,000 total hip replacements procedures performed each year in the United States. Almost every one of these patients will be given a strict set of precautions that they must follow as part of their post operative care, and one of those precautions is not to allow the patient to bend the hip angle past a certain point making it impossible for them to lean over. This is where the hip replacement kit becomes a very instrumental part of the patients’ recovery. The hip replacement kit typically consist of the following items: 1. A reacher, 2. A contoured scrub brush, 3. Dressing Stick, 4. Elastic shoe laces, 5. Shoehorn, 6. Leg Lifter, 7. Sock assist. These are all necessary to help the patient abide by the doctor’s orders and stay independent at the same time. This kit is viewed by the doctor as medically necessary, but is not covered by almost all insurances available.

In some cases the patient may be informed by the physician or their staff to purchase this equipment before their surgery. For some people this can be a very stressful purchase because they do not know where to make the purchase. Also keep in mind this is not the only piece of equipment that is needed post operation on a total hip replacement. They will also ask that you purchase a raised toilet seat which is also a non covered benefit with most insurance. The first question the patient or caregiver will have is “Where do I purchase these items?” At that point the physician may point them to a DME provider.

What if the physician could assist that patient or caregiver with purchasing the item right then? If that were the case, the patient and caregiver could make the purchase at the pre-operation appointment. With the TherFit eStore program this is possible. The order could be placed at the appointment and delivered the very next day to the patient’s home. This could alleviate a very stressful situation for the patient and caregiver, knowing the correct item has been purchased and will be delivered to them in a very short time.

This is just one example of durable medical equipment that is typically not covered by insurance. TherFit offers a solution to close the gap between the patient/caregivers and the physician when it comes to purchasing these types of equipment

In 2004, the Institute of Medicine (IOM) published “Health Literacy: A Prescription to End Confusion.” In this publication, the IOM suggested several steps to facilitate the improvement of health literacy in the United States. Some of these suggestions included developing uniform standards for addressing health literacy, supporting health literacy research, incorporating health-related tasks by educators into lesson plans, and offering continuing education in the health fields (IOM, 2004).

In 2007, the S. 2424: National Health Literacy Act of 2007 Bill went into Congress (GovTrack.us, 2007). It was aimed to ensure that all Americans have basic health literacy skills to function effectively as patients and health care consumers. Although this bill never became law, it was read and referred to as the Committee on Health, Education, Labor, and Pension.

That same year, the Joint Commission published a report titled “What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety.” In this report, the Joint Commission made three major recommendations for improving the communication gap between ordinary citizens and the skills required to comprehend health care information. The recommendations were as follows: make effective communication and organization priorities to protect the safety of patients, address patients’ communication needs across the continuum of care, and pursue policy changes that promote improved practitioner-patient communications. The progression of health literacy awareness continued in 2009 when President Barack Obama proclaimed October as National Information Literacy Awareness Month.

Throughout all of this progression, however, no official statements or legislation has been made on the topic of health literacy in the nursing profession. Currently, the American Nurses Association has 69 position statements posted on its website; none of them address health literacy (www.nursingworld.org). Therefore, if nursing professionals wish to see a change in policy or legislation, it is up to each individual nurse and the organization to which he or she belongs to bring about those changes. “Nurses should take a more active role in policymaking to break down health care communication structure and procedure that create barriers to access and understanding of information for vulnerable groups” (Speros, 2005, p. 639). In a recent message, the President of the American Nursing Association, Rebecca Patton (2009), expressed her gratitude to the nurses for their continued effort to improve health care and legislation by supporting the newly passed health care report. She went on to describe a phone call she received from President Barack Obama in which he expressed his gratitude to the work ANA has done in supporting the reform.

This example demonstrates that nurses do have a voice in the health care world. President Patton urged nurses to continue their efforts towards making changes in legislation (Patton, 2009). This legislation should include health literacy; IHS was able to implement policy and cultural changes to their hospitals, and they stand as a positive example of policy change. Likewise, nurses in other health organizations need to strive towards achieving similar goals.

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All of these factors associated with low health literacy are significantly taxing the United States economy. In 1998, low health literacy was estimated to cost the United States economy between $50 billion and $73 billion per year (National Academy of Aging Society, 1998). The economic consequences fall into the following broad categories:
· Poor health outcomes leading to unnecessary repeat visits
· Confusion regarding health information, leading to extra time spent by health care professionals to provide adequate explanations
· More negative health impacts as a result of delays from not seeking earlier treatment when people do not know how to access the health care system

In 2000, almost half of the American population had a chronic condition, which equated to a cost of $510 billion in that year. By 2020, the cost is projected to double, exceeding $1 trillion (Partnership for Solutions, 2003). A large contributing factor to these costs is the percentage of hospital readmissions. People with low health literacy skills, for example, are 52% more likely to be hospitalized (Baker, Parker, & Williams, 1998). According to an Agency for Healthcare Research and Quality study, up to 19% of all readmissions to the hospital within six months of discharge were preventable. With a cost of $7,400 per readmission, the total preventable cost for these incidents would be $729 million dollars per year (Klein, 2008).

As suggested by the National Academy of Aging Society (1998), all citizens of the United States pay the price of low health literacy. Of the $50 billion plus cost of limited health literacy, 39% is paid by workers through FICA taxes, 17% by employers, 16% paid out-of-pocket by patients, 14% by Medicaid, and the remaining 14% by other public and private agencies.

Patients are expected to teach themselves regarding their illnesses, medications, diet, and treatments, with minimal information, feedback, and practice. There has been a change in health care delivery over the past 35 years: now patients go home earlier, have complex home care, and use community-based services with ultimately less contact with their physician. This arrangement further complicates the treatment and management of chronic illness (Horner et al., 2000).
The change in health care delivery has also put a strain on nurses who educate patients. Nurses have inadequate time to provide the education required patients, yet they are expected to provide enough education for patients to go home and care for themselves safely. According to Bastable (2008), the following factors have made nursing rely on printed educational materials more than ever: early discharge, lower reimbursement rates for hospitalization, more emphasis being placed on the community for after-hospital care, greater demands on nursing time, complex technological treatments, and the assumption that printed materials are adequate for patient instruction. All these factors place a heavier burden on the patient and their families to receive adequate health care education. It also places significant burden on nurses as they attempt to provide valuable instruction and more effective communication (Osborne, 1999). The remainder of this paper will outline health literacy management strategies and provide recommendations for educating nurses regarding health literacy issues.

As made evident through the literature review discussed in previous sections, health literacy impacts patient outcomes and the overall subsequent costs to health care providers in addition to its effect on society as a whole (Klein, 2008; Parker et. al., 2003; Horner et al., 2000). The need to bring about a cultural change in communicating with and educating patients as a way of battling limited health literacy is a strong theme repeated throughout this paper. The literature review suggests several different components that can bring about this change: health literacy education in professional schooling curriculum (Cornett, 2009), health literacy education as part of continued learning post-graduation (Lamiani, Furey, 2008), educating patients to navigate the health care system (Cegala, Post, McClure, 2001), changes in policies and legislation, and involvement in research (Mancuso, 2008).

Several components of these approaches concentrate on education; however, they propose two separate themes: educating the patient and educating health professionals. Some research concentrates on addressing the belief that patients need to be trained to understand the technical language of their provider. For example, in a research study published in the Journal of American Geriatric Society (Cegala et al., 2001), patients received an informational booklet three days prior to a doctor’s appointment and a 30-minute face-to-face training session prior to seeing the physician. The study concluded that “communication-skills training for older patients has the potential not only to enhance patients’ participation, but also to improve their health”. (p. 1510)

Other articles focused solely on the point of view that providers need to be trained to communicate better in their current practice. Throughout these articles there is a common agreement that health literacy should be part of initial as well as continuing medical education. The resulting conclusion to include this topic in the health provider curriculum was determined through research conducted by a variety of health care professionals. For example, in the article written by Powell and Kripalani (2005) on health literacy in physician training, the authors stated that while their study suggests that residents naturally develop awareness of literacy during their clinical rotations, it is still highly necessary to offer curricula that include health literacy education. The authors also make suggestions on what topics should be offered as part of health literacy education: awareness of how to recognize low-literate patients; strategies which may enhance understanding and adherence in this population.

Another area where health literacy has been addressed is the rehabilitation therapy field. According to Levasseur and Carrier (2010), in general, health professionals must take appropriate actions to address health literacy. The responsibility is even greater for rehabilitation professionals due their specific competencies. The authors also discuss the importance of avoiding common mistakes made in health education such as the reductionist approach to health literacy and limiting the development of personal competencies in this field.

A nursing research article written by Speros (2005) stated, “Health literacy definitions, means of assessing it, strategies to reach high risk individuals and groups, and interventions that limit the negative effects of inadequate health literacy are topics that are essential to include in nursing curricula” (p. 639).

Several articles addressed both approaches to this topic. The research article by Parker, Wolf, and Kirsch (2008) stated that the public educational system should provide opportunities for future generations to learn skills that would allow them to “interact with health care providers and organizations and engage in health promotion, prevention, and self-care activities” (p. 1274). On the other hand, Parker et al. (2008) suggest that it is equally important to simplify the health care system and reduce the level of difficulty in tasks that are required to be completed by patients. The article also suggested that health care professionals should be prepared to communicate with their patients no matter what their patients health literacy level might be.

Levy and Royne (2009) also proposed a two-pronged approach to the health literacy issue. They proposed that a solution would involve overall literacy level improvement in the general population through schools and other community-based programs. This education would cover topics such as “critical thinking, problem-solving, and analytic ability to educate the groups on a myriad of pertinent health topics” (Levy & Royne, 2009, p. 371). On the other hand, authors recommended a revision of printed and video materials in order to include more simple messages as well as to provide encouragement for health care providers to ensure patient comprehension.

The function of educating patients is significant in changing current health literacy culture and has important long-term effects on health care as well as society (Klein, 2008; Parker, et al., 2003; Horner et al., 2000). Health care professionals attend years of higher education to learn the terminology and functionality of the human body, so it may be illogical to expect patients to share a similar capacity for understanding without having a similar education background. In other professions, it is generally not expected that the customer would understand high level proprietary language specific to that profession. Patients may also be seen as customers, and the service they receive regarding their health is of more importance and is more life-changing than what they receive from those working in many other professions. Therefore, nursing educators have a great power of influence on the discipline of nursing at this time.

This review will concentrate on changing behaviors among health care providers in the nursing profession. If educators can bring about change in the way health literacy is viewed and approached by the nursing professionals, they will affect the policies and attitudes of other health care professionals. Research conducted by the nursing discipline discussed topics of professional school education, post-graduate education, research, and policies and legislation. In the following sections, each one of these topics will be discussed in more detail.

Whew! Now that the rollercoaster ride is over, relax a little, help is on the way. Stay tuned for article 6. ~Mark

With all of the identified at-risk groups, it is no wonder that patients do not understand basic health information. It has been reported that for most American adults, many written health materials such as consent forms, information handouts, and other basic materials are not understood. This may be because consents, discharge instructions, and all other printed educational materials are printed at a higher reading comprehension level than the patients are able to understand (Weiss, Hart, & Pust, 1991). The reality is that 50% of people seeking health care cannot read above the fifth-grade level (Albright et al., 1996), yet most health documentation is written at a 10th to 12th-grade level.

In 1996, in response to some of the literacy issues addressed above, the Joint Commission and the National Committee for Quality Assurance instituted some health literacy guidelines. They specified that health information and consent documents should be written in a way that patients can understand (Weiss, 2003). In fact, health care institutions and providers may be held liable for adverse health outcomes if their patients do not understand important health information (Quirk, 2000).

According to Winslow (2001), the mean reading level of the U. S. population is at or below the eighth-grade level, with many of those reading two to four levels below their completed level of education. In one study, it was determined that the average Medicaid enrollee reads on a fifth-grade reading level (as cited in Bastable, 2008, p. 241). This poses great difficulty for many people because they cannot read and understand simple medical instructions. For example, the directions on an aspirin bottle are written in a format that requires a tenth-grade reading level (as cited in Bastable, 2008, p. 239).

In a study done in 1988, more than half of the patients who reported to the emergency room were unable to read and comprehend discharge instructions and medical documents (Weiss et al., 1991). A study done by the American College of Obstetrics and Gynecology evaluated all of their printed handouts using the SMOG readability test and found that 82% of their materials were written on at least an eleventh-grade level (as cited in Zion & Aiman, 1999). Another study done in multiple cancer-centers found that the informed consent forms for cancer trials were written on a college or graduate level (Morrow, 1980), while the surgical consents were written on the level of professional journals (Grandner, 1980). In a large study on surgical consents, 10% of the nation’s hospitals were asked to present their consents for readability. Results indicated a mean grade level of 12.6 was necessary to read and understand the consents (Hopper, TenHave, Tully, & Hall, 1998). Compounding the problem of inadequate reading level is that about half of all verbal instruction is forgotten immediately (Kessels, 2003). These factors together have been shown to decrease compliance and increase morbidity and misuse of the health care system (Weiss et al., 2005).

With the inability to read and understand health information, patients are unlikely to follow prescribed treatments. When this happens, they are often seen as noncompliant, when in actuality, the patients’ lack of understanding renders them unable to comply (Mayeaux et al., 1996).These patients may also have difficulty giving complete and accurate health histories, which has a major impact on adequate and safe health care, especially when health needs are complex (Hayes, 2000). After all, there is a positive correlation between literacy level and control and management of chronic illness (Williams, Baker, Honig, Lee, & Nowlan, 1998), which helps to account for why complex instructions lead to poor health outcomes. In fact, even those with strong literacy skills may have difficulty understanding health information. For instance, doctors may not know how to fill out their own Medicare forms, teachers may not understand what their doctors told them about a specific test that was done, and accountants may not know when they should have routine health screening tests done (Institute of Medicine, 2004).

Another barrier to health literacy is patients who feel shame and embarrassment about their lack of health understanding. As Parikh et al. (1996) stated, “Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers” (p. 33). Illiterate patients are reluctant to admit they do not understand and deny having questions because they are afraid it will be judged as irrelevant, ignorant, or dumb (Bastable, 2008). Because patients are afraid to admit when they do not understand simple directions or cannot read simple instructions, they try to hide it (Tkack et al., 2008). The sentiment is best expressed by a respondent in a study conducted by Weir (2001), “Self-esteem is intrinsically tied to literacy…I don’t tell anybody or say anything [about my literacy], they might think I am a bad person” (p. 1486). In addition, patients feel intimidated by hospital staff members who may seem angry and frustrated when the patients do not understand medical facility signage or medical forms (Baker, et al., 1996).

It is difficult to know if someone is experiencing shame because patients do not tell their health care providers about their problems.Additionally, not only are their health care providers unaware of their problems, but so are their spouses and family members. In one study, it was found that two-thirds of health-illiterate patients never informed their spouse about their inability to understand health information (Tkack et al., 2008).

The knowledge deficit associated with low health literacy has a significant impact on health outcomes. Patients are not safe if they do not understand and are not able to carry out the instructions of their health care providers. For instance, a diabetic patient who does not understand how to control his or her blood sugar is at risk for significant health consequences. The poor health outcomes, as a result of the poorly controlled diabetes, thus leads to eventual end organ failure and tremendous treatment costs. In another study, diabetic patients with low health literacy showed worse blood sugar control than their health-literate counterparts. Furthermore, poor blood sugar control leads to higher complication rates, including retinopathy, blindness, and cerebrovascular disease (Schillinger et al., 2002). One study showed that 50% of those with low health literacy levels did not know the symptoms of hypoglycemia and/or how to manage them. Even more disconcerting was that only 75% of those with reported adequate health literacy knew and could manage hypoglycemic symptoms (Williams et al., 1998).

Statistically speaking, patients with low health literacy are 69% more likely to have a late stage cancer diagnosis (Bennett et al., 1998) and are four times more likely to be noncompliant with HIV antiretroviral medications (Kalichman, Ramachandran & Catz, 1999). In asthma patients with low health literacy, only 36% understood the use of an inhaler and the importance of seeing a doctor for prevention and maintenance; in contrast, 95% in the health literate population understood its use and importance (Williams et al., 1998).

In a study done by Williams, Barker, Parker, and Nurss (1998), patients with high blood pressure did not understand their role in lowering blood pressure through exercise and losing weight. Some of this misunderstanding can be attributed to health care providers who did not feel that they had the time to properly educate and assure understanding of health information. According to Schillinger et al. (2003), it does not take that much extra time to ensure that patients understand health information. In a study that he and others conducted, health care providers who used the teach-back method of instruction, to ensure their patients understood them, spent only an extra two minutes per patient visit which is a small price to pay for a better patient outcome. Teach-back is a technique during which the patient is asked to repeat back what was heard or to demonstrate the steps that were just explained by the provider.

The above data show that there is an obvious communication breakdown between what health providers are teaching and what patients are learning. In fact, one study showed that 40%–80% of medical information provided to patients is forgotten immediately, while half of the remembered information is incorrect (Kessels, 2003). It is not surprising that patients with low health literacy rates prone to being sicker, have more frequent emergency room visits, are susceptible to more hospitalizations, have less preventive care, are less likely to benefit from disease management programs, and are at increased risk of premature death (U.S. Department of Health and Human Services, 2004). All of these lead to inadequate medical care and increased costs to the health care system (Tkacz et al., 2008).

Stay Tuned! Article 5 deals with Costs, you don’t want to miss it.

Medication Literacy

When it comes to medication in the United States, low health literacy has been linked to an estimated 1.5 million preventable injuries as a result of adverse drug events (Perlow, 2010). To further complicate the medication issue, patients are not being prescribed only one medication for an illness, but several. For instance, a person with hypertension may be prescribed a diuretic, beta-blocker, ace-inhibitor, and potassium. Consequently, this patient would need to be aware of side effects, dosage, when to take the medications, and their interactions with other medications and food.

Health care providers are becoming more aware of how common it is for people to struggle with health literacy issues such as medication administration. Medication information is seldom written for patients with low health literacy, so these patients have difficulty following prescribed drug regimens (Weiss et al., 2005). The following illustration is an example that, unfortunately, is not uncommon among health care patients: “A two-year-old is diagnosed with an ear infection and prescribed an antibiotic. Her mother understands that her child has an ear infection and knows she should take the prescribed medication twice a day. After looking at the label on the bottle and deciding that it does not tell how to take the medicine, she fills a teaspoon and pours the antibiotic into her daughter’s ear” (Parker et al., 2003, p. 150).

In addition to understanding medication instructions, it helps to put the problem in perspective when one can understand the complexity of medications themselves. There has been tremendous advancement in the discovery and use of substances to improve health. Thirty-five years ago, there were only 650 medications available for human consumption. Today, there are over 10,000 individual and combinations of medications available on the market for treatment of numerous ailments (AMAF, 2006). A newly diagnosed diabetic patient 35 years ago would have been hospitalized for several weeks and would have received hours of education, monitoring by professionals, and ability to practice drawing up medication and injecting it prior to going home. Today, that same patient is treated on an outpatient basis and given brochures to read and referrals for training that may be scheduled weeks after diagnosis (AMAF, 2007).

At-Risk Populations

There are certain groups of the population who are more prone to low health literacy. They are those with lower educational levels, certain ethnic groups, the elderly (Gazmararian et al., 1999) and persons with cognitive challenges (Nutbeam, 2000).

According to the U. S. Department of Health and Human Services (2004), low health literacy is also associated with living in the South or Northeast, being female, being incarcerated, and having a low income level. Additionally, Bastable (2008) summarized research regarding people with low reading and comprehension skills to include the following: the impoverished, the elderly, immigrants, racial minorities, high school dropouts, the unemployed, prisoners, inner-city and rural residents, and those with poor health status as a result of chronic health and mental issues.
Nurses who educate patients also need to be aware of the changing, aging demographics of the American population in order to positively impact health literacy. Increasing age is a factor in low health literacy as the “baby boomers” are now entering retirement. According to Bastable (2008), people age 85 years and older are the fastest growing age demographic in the country. People are living longer and the elderly often have poor health literacy skills. Despite the fact that by the year 2000, 64% of those 65 and over had a high school education, most baby boomers are not keeping up with the rapid advances in technology and the advanced information age of present day (Bastable, 2008). (See above graph - Percentage of adults in each health literacy level by age)

The elderly as an at-risk population for low health literacy will continue to increase as this population increases in numbers. In 2000, there were 35 million Americans age 65 and older, with a projected 70 million by 2030 (U.S. Census Bureau, 2002). The elderly, defined as age 65 and older, are one of the fastest growing sectors of the American population. Incidentally, they are also at the greatest risk for having health literacy issues due to declining health, impaired cognition, and inability to properly access health information in today’s rapidly advancing technological world (Weiss, 2003). This inability to understand health information brings great embarrassment to not only the elderly but also to anyone who struggles with navigating and understanding the health care system.

Another barrier for older people is that with increasing age comes deterioration of senses and cognition. According to Kessels (2003), older people have some degree of cognitive slowing and sensory deficits. This is significant because it has been shown that as a person ages, their health literacy declines (Gazmararian et al., 1999). Ultimately, these changes can lead to lack of ability and motivation to learn new things, which the elderly may find frustrating.
In addition to the physiologic changes that occur with age, this group also tends to have more chronic illness and therefore are taking more medications. In fact, 80% of seniors have at least one chronic condition, while 50% have at least two (Centers for Disease Control and Prevention, 2003). As a result, the elderly with chronic conditions see an average of eight different doctors and use 18.5 prescriptions per year (Parker et al., 2003). These medications can further affect their cognitive fluency and speed of processing information (Bastable, 2008) and, therefore, influence their ability to learn. It appears that from these statistics, the population who needs the most care has the least ability to comprehend information and navigate the health care system.

In addition to the elderly, minorities, or non–English speaking Americans, are of increasing concern regarding adequate health literacy. It was projected that by 2010, over half of the nation’s major cities will see non–English speaking adults become the majority population (Robinson, 2000). A higher percentage of these adults translate into more people with low health literacy, as the majority of health education materials are printed in English (Horner, Surratt, & Juliusson, 2000). It has also been noted by Horner et al. (2000) that even if English is understood by an individual, other forms of communication may not be. Examples may include emotional tone, voice inflections and volume, gestures, eye contact, and touch. Misinterpretations from non-verbal communication may also lead to inaccurate interpretation of health information (Bastable, 2008). In addition, cultural barriers and different educational opportunities place non–English speaking adults at higher risk of low health literacy (Parker et al., 2003). This is primarily due to language barriers and a reluctance to seek treatment. As a result of these demographics, nurse educators will see a change in health education material development and marketing. They will also need better communication skills in order to understand and properly interpret patient behaviors.

Article 4 in the series is coming soon! ~Mark

The term health literacy was first used in 1974 in a paper that discussed how the health care system was impacted by health education. There was a strong link between the health care system, the educational system, and mass communication. There was a minimum standard for health education in the public educational system. Low health literacy was blamed on the failure of the educational system to properly teach health issues in the schools (Parker, Ratzan, & Lurie, 2003). The importance of health literacy in the United States was first recognized in the 1990s as a result of an escalating awareness that reading ability and health were strongly linked (AMAF, 2007). During that time, it was noted that low health literacy impacts many aspects of society and health outcomes for patients. This is because the one half of the United States population that is at risk for low health literacy is susceptible to medical misunderstandings. Knowing what prescription bottles advise, accurately carrying out basic health care instructions, filling out applications, and following appointment slip information can prove difficult for many patients (Gazmararian et al., 1999).

To help explain the issues of health literacy and improve health literacy skills, the U. S. Department of Health and Human Services petitioned the help of the U. S. Department of Education and their National Assessment of Adult Literacy (NAAL) to determine current health literacy skills. In addition, the American Medical Association (AMA), Institute of Medicine (IOM), and the Agency for Healthcare Research and Quality (AHRQ) all ascertained that half of the American adult population lacks adequate health literacy skills to function in the current health care environment (as cited in Bastable, 2008).

As a result of the NAAL assessments showing no improvement in literacy scores over a 10-year period, Healthy People 2010 was initiated. The goal of Healthy People 2010 was to improve the literacy skills of those with low or inadequate health literacy (Tkacz, Metzger, & Prucnicki, 2008). It was determined that raising awareness regarding health literacy issues was imperative in order to make a difference in the health outcomes of patients.
All of the agencies previously mentioned have a common goal of being a part of a changing health care environment that optimizes health and well-being while also controlling cost. The United States health care system, along with technology, has changed substantially when compared to past decades. To be considered literate 100 years ago, for example, it required U.S. citizens to be able to read and write their own names. Today, to be able to function appropriately in the health care world, literacy entails the ability to learn new skills, problem-solve, think critically, and apply knowledge to current situations (Weiss, 2003).

The educational system can no longer be blamed for low health literacy of Americans. Moreover, the volume of information and the means to access that information has never been better. The real problem lies in the fact that many Americans have been left behind by the rapid advancement of technology. Many Americans are not computer savvy and have been unable to access the electronic media used to disseminate health information. Therefore, patients have a much greater responsibility for their health in a very complicated health care system, where the gap between actual skills and demand for skills is widening (Parker et al., 2003).

As described above, there are many components of health literacy that have an impact on patients and their health outcomes. Mancuso (2008) described these multidimensional components of health literacy in her concept/dimensional analysis model by stating the following: “The attributes of health literacy are integrated within and preceded by the skills, strategies, and abilities embedded within the competencies needed to attain health literacy. The outcomes of health literacy are dependent upon whether one has achieved adequate or inadequate health literacy and have the potential to influence individuals and society” (Mancuso, 2008, p. 250–251) (See Figure 1). In her model, Mancuso (2008) described the far-reaching implications of health literacy on the individual and society. In order to be health literate, there are many areas of skill and ability (or competence) one must have in order to function within the health care environment. She described six areas of competence: operational, interactive, autonomous, informational, contextual, and cultural.

Figure 1. Manusco’s concept model. This concept model helps clinicians visualize the presence of the many health literacy dimensions that impact patients.

Operational competence is the ability to use techniques that help a person to meet his or her own basic health needs; some of these techniques may include the ability to read, write, speak, understand, and act upon the written and spoken word. Interactive competence is the ability to work with others, such as health care providers, to improve health. Autonomous competency is being self-aware and taking responsibility for one’s own health. Informational competence is the ability to obtain health information, understand it, and apply it appropriately to a specific health situation. Contextual competence is being comfortable in the health care environment and understanding the expectations of health care providers. Finally, cultural competence is the ability to accurately interpret and act on health information based on patterns of communication, actions, beliefs, customs, and the like, which collectively impact understanding.

Mancuso further illustrated the center of the model with certain aspects of health literacy that she described as attributes.

These attributes consist of capacity, comprehension, and communication, and they are used to describe a person’s potential for navigating the health care environment, understanding it, and being able to effectively communicate with their health care provider. These attributes are integrated within the competencies needed to attain adequate health literacy that ultimately impacts the individual and society (Mancuso, 2008). The following subsections describe some examples of those dimensions and competencies outlined by Mancuso as well as their impacts on the patient and society.

Stay tuned, Part 3 is coming up!

Mark Dustin here, it’s my turn to write the blog article this week. Rather than forcing you to hear from me, I thought you might enjoy hearing from someone way smarter. As some of you know my wife recently completed her Masters of Nursing Education degree. Her thesis was on Health Literacy. As a nurse with more than 20 years on the job, she has seen firsthand the impact of poor health literacy on the lives of her patients and their families, and on the medical institutions attempting to provide health care. She has agreed to let me re-use her thesis as a series of blog articles. At the conclusion of this series I’ll produce an article describing how TherFit helps in these challenges. So read along and please feel free to comment.

As part of the foundational work for her thesis she started conducting workshops with different medical groups, her work was well received. Since completing her degree, the college where she graduated has invited her back for Fall Semester to begin teaching classes on, you guessed it, Health Literacy. The goal is to add this missing piece to the educational background of new nursing students. She is also attracting the attention of some large hospital groups in our area to formulate the topic into a workshop format, whereby she will present to existing medical staff. Part of the reason for the attention is the cost of poor health literacy. In 1998, National Academy of Aging Society estimates place the annual wasteful expenditure due to poor health literacy at somewhere between 50 and 73 Billion dollars. The problem is getting worse, and the waste is increasing dramatically. I’m grateful to her for allowing me to re-use her work. Here is the first article in the series:

Health Literacy: Improving Patient Outcomes Through Nursing Education
by
Tracy W. Dustin, BSN, RN

A thesis submitted in partial fulfillment
of the requirement for the degree
of
Master of Science in Nursing Education

Westminster College
Salt Lake City, Utah

December 2010

The topic of health literacy has captured the attention of the public, many disciplines within public health, as well as other health professionals. This state of the science literature review paper presents a summary of background information, recent statistical review, effects on patient outcomes, and other research pertaining to the topic of health literacy. Electronic database searches and journal reviews were conducted to collect this data. Articles reviewed for this paper unanimously agree that the topic of health literacy should be included as a part of all health education curriculums; however, the articles do not provide any suggestions as to the process of implementing this education into academia or clinical settings. This review concentrates on the nursing discipline and shows that there is insufficient education on this topic in nursing schools and in the nursing field as part of continuing education. Suggestions for college curriculum and nursing staff development are outlined in the recommendations portion of this review.

Keywords: health literacy, nursing education, curriculum, continuing education, medication literacy, health outcomes, reading level

I would like to extend my thanks to Jannette Publications, Blackwell Publications, and Commonwealth Fund for granting permission to reference their work.

Health literacy is defined by the U.S. Department of Health and Human Services as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness” (Weiss, 2003, p. 6). According to Parker et al. (2003), people with adequate health literacy seek care earlier, read and understand instructions, understand and carry out what their doctors have advised, are not afraid to ask questions, are able to seek out new information through use of modern technical devices such as the Internet, and are able to read information with a critical eye.

Unfortunately, there is a significant problem with adequate health literacy in the United States, and the ensuing consequences continue to expound. The magnitude of low health literacy is of great concern in this country because it leads to poor health outcomes and significant economic consequences. The cost of excess hospitalizations alone, which is attributed to low health literacy, is estimatedto be between $8 and $12 billion per year (Arozullah et al., 2006).

This state of the science literature review paper was conducted with the purpose of presenting a summary of background information, recent statistical review, effects on patient outcomes, and other research pertaining to the topic of health literacy.

The American Medical Association Foundation (AMAF) reported that health illiteracy affects more than 89 million Americans (American Medical Association, 2010), and is considered a crisis. The National Center for Education Statistics released a study in 1993 and then again in 2005 indicating that approximately 50% of American adults lack basic health literacy skills (Rudd, 2007). Half of the adult population can neither read nor understand basic health information and are therefore unable to properly navigate the health care system. The problem is worsening as technology and health products continue to become more complicated. As health literacy is directly correlated to health status, the United States adult population is experiencing a rise in poor health outcomes, which in turn leads to an astounding increase in health care costs (Von Wagner, Steptoe, Wolf & Wardle, 2009). Many of these costs are attributed to the lack of basic literacy skills.

In order to function within the current health care environment, basic reading and numerical skills are essential (Institute of Medicine, 2004). Most health information is written with a level of complexity that even people with a college education struggle to understand. This is due in large part to the disparity between the reading comprehension levels of most patients as compared to the reading level with which most health care information is published. Medication labels and instructions add to the disparity, thus leading to patients who are unable to adhere to prescribed drug regimens (Tkacz, Metzger, & Pruchnicki, 2008). It is an ongoing challenge that is expected to only worsen.

Over the years, the health care system has changed significantly, having grown increasingly complex and increasingly technical (AMAF, 2006). This consequently leads to a health illiteracy crisis as more and more patients are unable to understand basic health information (Bastable, 2008). As a result, low health literacy skills have been linked by recent studies to undesirable health outcomes and long-term negative health consequences as patients are expected but unable to understand and carry out complicated health instructions (Albright et al., 1996). These outcomes include but are not limited to delayed diagnoses, poor disease management skills, higher health care costs, low medication compliance, and higher risk of hospital readmission (Schwartzberg, Cowett, VanGeest & Wolf, 2007).

The populations that are most at risk of having poor health outcomes are the elderly, the undereducated, those with a low income level, and certain ethnic groups (Gazmararian, Baker, & Williams, 1999).

One of the factors adding to the complexity of health literacy is that adults with low literacy skills do not typically disclose their problems to family members or health care providers. Admitting to health literacy issues brings too much shame and guilt to an already complicated issue (Parikh, Parker, Nurss, Baker, & Williams, 1996). In addition, health care providers are not taking the time to ensure their patients understand information because of imposed time constraints. In actuality, however, it only requires a very slight change in patient teaching practice to make a big difference in patient satisfaction and understanding (AMAF, 2007).

It is imperative that nurse educators help staff and student nurses become aware of health literacy issues. They need to know what constitutes “best practice” with regard to health literacy in order to facilitate better health outcomes for patients. For the medical establishment, teaching about health literacy is not just about saving money; it is about alleviating fear and anxiety amongst patients. It is about making patients feel that they are in charge of their health and are not just simply bystanders. There is a high cost attached to health illiteracy, and health care providers need to be advocates for their patients and for system changes in advancing the issue of health literacy. As described above, “Health literacy is a safety issue, a financial issue, an access issue, a fairness issue, a communications issue, and a time management issue” that ultimately affects how patients are cared for in the United States (AMA, 2006, p. 5).

The purpose of this paper is to suggest methods that will bring awareness of health literacy issues to nursing staff and give them tools to better educate their patients, thus promoting better health outcomes. As health and staff educators, we have the ethical responsibility to provide the proper training to nursing staff regarding health literacy issues, ultimately impacting the safety of patients. In addition to identifying health literacy issues, solutions will also be outlined for properly educating patients so they understand the health information that they receive.

It’s Mark again, pretty shocking reality, right? I had no idea things were so tough until my wife started on this topic. It gets even better so stay tuned for the second in this series…

After more than 14 months of visioning and effort by the TherFit team, www.TherFit.com came to life on Friday, July22, 2011 to support pre-registration of eStore owners for their own retailing web sites. After taking a few moments to savor the achievement, we then realized we had fewer than 1,000 hours before the site is scheduled to go live as a fully-functional, fully-populated site ready to accept and ship consumer orders. Great progress and achievement by an outstanding team – and then back to work.

This is a red letter date for TherFit, one of many more to come. While the initial seeds of a dream were planted back in May of 2010, the dream has grown seemingly by orders of magnitude in the ensuing weeks and months. It continues to expand, which is important. But it is also key to transition dreams into the stepping stones that move us toward achieving the potential wrapped up in TherFit, and we continue to take step after step towards achieving that potential. Just this week, we:

• Finalized our social media marketing plan that goes into effect 06Sep11 to attract thousands of eStore owners
• First published print ad in Advance for Senior Living, to be followed next week by Advance for Physical Therapists
• Initiated discussions to create a strategic marketing alliance with a highly innovative service provider to our target market that will greatly enhance our reach and sales potential
• Reviewed the initial plan for TherFit Logistics, LLC, which will support our supply chain management, project management and installation requirements
• Reached agreement to begin development of a non-profit entity to repurpose used products to those who cannot afford new products for their own needs.
• Held an outstanding working session on moving TherFit Community Health forward into the business modeling phase.
• Celebrated commitments from additional sales team members to support TherFit.
• Made significant introductions that will support reaching our business objectives.

A long-term vision is critical to any business, especially a new one. Laying down one stepping stone after another is what makes that vision reality, and I’m proud of the TherFit team for being able to take these steps while not losing sight of the goal.

From physical therapists using iGoniometer apps on their iPads to fitness professionals planning a personal training schedule via iPhones, health and wellness professionals are adopting technology as a very important tool in the treatment of their consumers. A recent study has shown that 30% of physicians use tablet devices compared to just 5% of U.S. consumers. This same study shows that the trends will increase dramatically over the next few years as more and more health applications are developed and the Cloud continues to grow. Adoption rates are higher in the healthcare industry than most other industries. There is now no reason to invest in a $10,000 software program to make your business more efficient and offer better service for your patients or consumers whenever you can download the latest app for $5.99.

These enormous advances in technology couldn’t come at a better time. The talk of the country for the last couple of years has been, what is going to happen in the healthcare industry? Obamacare has been passed but no one really knows what that means. We do know that patients are going to be more responsible for their own health than ever before. Technology will help fill many of the gaps that patients and consumers have to deal with in the past not knowing exactly what they are suppose to do to take care of their health. Clinicians and wellness professionals can now give patients a “path to run on” by utilizing technology to set up plans for them to take care of their health.

There is still a very large gap that exists in the market that hasn’t been filled but technology advances will be able to close that gap. Patients and consumers are faced with the challenge of recovering from injuries or starting their own personal training programs laid out before them by their clinicians or fitness instructors. One of those challenges, what type of products they need to support their treatment plans. In the past, professionals recommend products to their consumers and then they are on their own to figure out how to choose the right products from the hundreds of thousands of products on the market. This is a very difficult task for consumers as they are usually not educated on products and have a difficult time choosing or locating the right products.

For the first time ever, TherFit will be closing this gap between the patient and the professional. TherFit allows the clinicians to be part of this equipment and supplies selection process by utilizing their technology to find the correct products for the patients and consumers. Professionals can now recommend the products, help the consumer select the correct products in the clinic, and deliver products directly to them without the stress of patients having to do it on their own. Not only will this benefit the patients and consumers but it will allow the professionals to select the best products as part of their treatment and wellness plans. From therapy bands to treadmills, professionals can now offer just about every product that their clients could ever need to recover from injuries, become more independent, lose weight, etc.

TherFit offers complete retailing solutions for clinicians and wellness professionals that consumer will appreciate since product selection in this industry is not an easy task. For more information about the program, visit www.TherFit.com .

Mark here, offering a few thoughts from this week…
OKC was HOT! Figuratively and literally, things are smokin’.
We had a number of great meetings this week; sales structure planning, the features and functionality we need from the software system, all are coming into focus quickly. Will and I spent some time discussing the possible pitfalls, thus positioning ourselves to handle the unexpected. As we discussed, the big hurdle revolves around the ability to assist the eStore owners in making the transition from being a just a care provider, to also being a salesperson. TherFit can be a very successful company acting only as a supply chain partner to eStore owners who are purchasing for their own internal consumption. But we want to be more. Much more. We want to positively impact the lives of patients everywhere. Certainly we want to reach the broader target audience with sales, but in keeping with our corporate mission statement we want to help medical providers offer a better quality of care. Discharge planning worksheets, which embody a measure of accountability, with clear expectations and instructions, and including recommended medical products, will go a long ways to insuring better health outcomes, and also act as a vehicle for selling in an unobtrusive fashion. It can be as simple as a physician writing a prescription.

The technological platform we are assembling will literally save small practices from lingering in obscurity, scraping by, barely able to make payroll, and hoping something catastrophic doesn’t end their practice. We are asking people to alter their behavior, but we are offering ways of being more efficient, and leveraging better practices. Without making radical shifts in current habits. I have been re-reading a classic from Japanese literature. It was a favorite of mine years ago while living in Japan, I re-read it again last week. The book is called Go Rin No Sho, in English it is the Book of Five Rings by Miyamoto Musashi. At first glance it looks like just a martial arts book. In reality it is a treatise on strategy, and self-improvement. Musashi repeatedly states the need for people to continually strive to understand “the nature of the thing”. Basically, constant study and learning in order to be prepared to meet contingent circumstances. Additionally, he makes the point that a true warrior (whether a Samurai, an Artist or a Farmer) must be fully committed to the endeavor, or they should simply stop. Half-hearted effort wins no battles. I am encouraged by the fact that as a fledgling company we are following both principles diligently. What a great week!

As always, be sure to follow our progress on Facebook or Twitter and have a wonderful weekend!

• We want to be entrepreneurial. We want everyone associated with TherFit to have the opportunity to be rewarded in proportion to their contribution to the company.
• We want an accountable organization. Each of us will be accountable for our performance to the rest of the team – starting with Eric and I. If we are going to agree to do something a certain way, then we all do it and will be measured to that commitment.
• The system is the hero. Heroes come along in times of crisis, and they are expensive. We want the system to be the hero of TherFit, not any one of us. If the system is designed correctly and continues to improve, then each of us just needs to do our part to make sure the system is used properly, which makes it powerful.
• We believe in self-selection. Each partner, manager and member of TherFit will determine by their actions their position within the company, or if they belong in the company. No one has a guaranteed position, but we will provide opportunities to earn, retain and grow positions.