Health literacy review case studies

The following videos provide you with insights from the people working in the health organisations that piloted the review guide.

Here is what they had to say. You’ll notice that all organisations had senior leaders who mandated the work from the start.

Counties Manukau – lifelong engagement with oral health services

Counties Manukau Health reviewed oral health services and were concerned about life-long consumer engagement with services. They describe the reasons they undertook a review this video.

Geraint Martin (Chief Executive Officer, CMDHB):

We’re now moving into an area where people need to be spending time looking after themselves on a continual basis. We’re talking the management of diabetes, the management of rural health, for example, and that means to say that people need to understand not just what to do, but why it’s important for them to do it. So healthy literacy is, I think, an incredibly important component to the design of modern health care.

Margie Apa (Director Strategic Development, CMDHB):

We decided to carry out a health literacy review because we saw it as a really important part of being a patient- and whānau-centred organisation.

Oral health was a really neat opportunity to test it as one of our first services.

The services are free to young people up until 18 and often we know that when young people transition from under 18 to being adults and actually having to look after their own teeth without the sort of school services available, it’s very difficult to get young people engaged in services so it was a really great opportunity to test it with a potentially challenging population group.

Benedict Hefford (Director Primary Health and Community Services, CMDHB):

The way that we communicate, making sure that our messages are simple and clear, sending letters that people can actually read and understand, giving information in different formats, all of those kinds of things actually add to health literacy.

So with the providers through this review we’ve identified some really tangible practical ways that we can improve some of those things and give our workforce, you know, better tools and techniques as well.

Dr Siniva Sinclair (Public Health Physician, CMDHB):

Doing the process of the review really helped us think about all the 6 dimensions of health literacy and we realised that the best way for our organisation to use this is to take a service by service approach, looking at each service across all the 6 dimensions rather than, for instance, trying to look at 1 dimension across the whole organisation.

Dr John Falkiner (Managing Director, Mighty Mouth Dental):

What I quickly appreciated was the potential for our service to be less than satisfactory in health literacy terms. Our patient demographic ranges over all socioeconomic groups, multiple ethnicities and widely divergent patient groups, all with their unique requirements in terms of communication.

Margie Apa:

The health literacy reviews were incredibly valuable for us as an organisation. We got lots of insights about ourselves, our services and our health professionals, and how we work. Probably one of the most critical insights was how we work across the health care system.

But we also actually learned that oral health messages and health literacy isn’t just about a young person and seeing the dentist and that contact. Actually, oral health messages need to be part of their general health care experience, whether they’re seeing their GP or, particularly for children, they’re seeing Well Child nurses or Plunket nurses as well, and when they’re unwell in hospital, oral health has got to be a critical part of all those experiences so that when a young person or a child or a parent is hearing those messages from their GP, their Well Child nurse, their dentist or even if they’re in hospital for specialist care that’s impacting on their oral health, that the messages are the same, they’re clear and they’re concise, and we’re all playing our part in reinforcing those messages.

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Capital & Coast DHB – non-attendance at children’s outpatient clinics

Capital & Coast DHB reviewed a service issue – non-attendance at children’s outpatient clinics. This was an issue they were already investigating and the review contributed a health literacy perspective. What CCDHB found is described in this video.

Mal Joyce (Operations Manager, Children’s Health, CCDHB):

Well, for children’s services initially, it was related to the high incidences of DNA in our children’s population and they were persistent and it was particularly high for Pacific and Māori children.

So when we became interested in this whole notion of health literacy and had a look at some of the literature, one of the things that we discovered was that 56% of adult New Zealanders do not have sufficient health literacy to make simple health care decisions, so then we thought ‘well, what does that mean for their children and what does it mean for the whole family?’ so got really interested in the idea of making a difference for children and families in our environment.

Cheryl Goodyer (Manager, Capability, Māori Health Development Group, CCDHB):

We were able to take an organisational approach. We believe it was everybody’s responsibility so we were keen to look at the layers that were outlined in the guide, and looked at what we did and how we did it better in regards to our communication interaction with our patients.

Darlene Natoli (Team Leader, Patient Administration Service, CCDHB):

Part of our role in patient administration is we book what we call a first specialist appointment for all paediatrics, all services within the DHB, but specifically for paediatrics.

We found that giving good clear communication was going to be a benefit for children and parents as they often don’t understand what paediatrics means, or – we use a lot of terminology like FSAs, DNA, so it was making sure that the communication was clear and easy for them to follow.

Mal Joyce:

We found out that families were unsure about why they were actually referred to our service, and we found out that often referrals were very unclear from GPs.

We found out also that families didn’t realise the consequence of them not turning up to an appointment. They didn’t actually have any sense that it would cost the organisation anything, or it may actually even waylay the time that it took to see us.

So what we’ve instigated is a programme called ABC which is Ask Bill Check and that is all about eliciting the understanding of families in relation to the particular reason that they’re in hospital for.

Chris Lowry (Chief Operating Officer, CCDHB):

I think as an organisation we had an appreciation of the fact that we don’t make things easy for patients to access our services and we also know that understanding or lack of understanding of what is wrong with you can lead to patients making uninformed decisions and not necessarily therefore taking the course of action that they should.

So this presented an opportunity to underpin some work we were already doing and adding another depth to the work that we were doing to improve access for our patients.

We know that our population is quite diverse and we had been doing quite a bit of work with our Māori Health Directorate, looking at how we could improve disparities and inequalities. And some of the work that we have been doing has clearly demonstrated that at a global level we have improved services and access to services for patients, but when you look at it from either a Māori or Pacific point of view, that those inequalities and disparities still exist.

We already had a big piece of work occurring in relation to our Did Not Attend rates and for a number of years had been looking at lot of strategies to reduce that level of Did Not Attend.

Where we had got to was we needed to take a wider organisational view to identify some of the systemic issues, or what might be some of the underlying systemic issues. So we thought that it was a really good opportunity to bring that in and increase the breadth of our focus on the DNA project and look at it from another viewpoint really, to address some of those underlying issues, which you know intuitively, but until we did the review, we actually then had the facts that supported what we had thought intuitively.

The work that was completed confirmed some of the issues that we thought we had an understanding of, but it really highlighted for us that you think as an organisation which is large and complex, and as health professionals, we are doing the best we can for our patients and that’s certainly the intention behind everything that we do.

However, the different language that we used, whether it be in primary care to the patient, primary care to secondary care, or once the patient comes into our secondary care services between secondary care service providers and the patients, the language is quite different, and we’re also not very good at checking for understanding.

So it gave us an opportunity to really look at the services that we do provide, how we provide, what information we provide to patients before they come into the hospital, how easy it is to navigate through our physical facilities, and also then what to do after an appointment and how to access or go on to access other services that they may need.

I can see that some of the findings from the review will help steer the organisation as to where we now want to focus our efforts going forward.

If you look at the environment that we do try to provide at Capital & Coast District Health Board for patients who use our services, it is an environment that is supportive and provides the right services to the right patients at the right time, and I think this will help inform where we might need to develop our navigation services for example. In the past we’ve put in navigation roles because there’s been a perceived need. I think we’ll now be able to really focus those positions and look beyond them as to what we need to do from an organisational point of view around staff education in general, around health literacy.

We have all sorts of patients accessing all of our services and there are inherent issues with health literacy, I believe, across the board, and if we can apply even half of the learnings from this review to the rest of, you know, how we deliver our services, then we’ll be making a huge impact on health literacy overall, and therefore access to services, and therefore patient outcomes is the ultimate goal.

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Northland DHB – diabetes services in primary care

Northland DHB worked with Te Tai Tokerau Primary Healthcare Organisation to review diabetes services in primary care. The quality of diabetes care is of great importance in the North because of the growing numbers of consumers with diabetes. The reasons for Northland’s review are described in this video.

Rose Lightfoot (Chief Executive Officer, Te Tai Tokerau PHO):

The district health board decided to get involved in the health literacy review as a way of improving outcomes for people with long-term conditions and diabetes was chosen because it’s such a burden of disease in the Northland population.

Health literacy is definitely about the systems and processes of health professionals and health service providers, the service itself. It’s not about patients as their responsibility. It’s about the way we configure and deliver the services to patients that is critical and that is what we’ve learnt from being part of this project.

Lauren Demblon (Practice Manager, Kerikeri Medical Centre):

The benefits for us were that we had identified within our strategic planning that communication with our patients was key and so an opportunity to be involved in health literacy research was very much aligned to what we were wanting to do.

Dr Chris Read (Clinical Leader, GP, Kerikeri Medical Centre):

We were interested because we just saw it as being a very, kind of obvious but novel way of looking at improving patient care. Because we took part in this review, which was really useful in itself, it made you start to think about other aspects of the care in the team. It made us think about the whole way we communicate and give people reminders of what they’re taking, and it’s given us some simple ideas that we know we can improve with, with our medication record and just in terms of the information and the various forms we give to the patient.

The obvious areas are patients with diabetes because we spend a lot of time and effort in educating the patient as well as prescribing various drugs, and so we’re giving the patients a huge amount of information. It’s our responsibility – I think that’s the change that we’ve realised – it’s our responsibility to think about this in all aspects of what we do.

John Wigglesworth (Chief Executive Officer, Hokianga Health):

Now with the review that’s occurred and we’ve just undertaken, there’s been an opportunity for us to check how well we’re doing on that journey. We’ve had reviews of the actual consultation process and we’ve had feedback on how that communication is occurring so for us it’s just continuous quality improvement. How do we continue to enhance that in the future?

Dr Norma Nehren (Medical Director, Te Hiku Hauora):

As doctors we’re always trained to find out where the patient is and then work with them to help them create their own strategies for addressing a problem they might have. But there are 2 key things to that I think that are important, and that were important to us as we went through the health literacy review and we were able to improve on as we went through that process.

The first thing that a patient needs to do to work on their problems that they have, to develop their goals and their strategies, is to learn about the problem at the beginning. Once they have that understanding they fly, and if they can engage and create their own self-management goal they’re usually much more successful.

To make that happen, so that – to ensure that the patient can create their self-management goals, to ensure that they have the health literacy, the knowledge that they need about their condition – the team, the doctor, the nurse, the health care assistants and even the administrative team all need to be on the same page, and we all need to improve our knowledge about how to present that information.

Rose Lightfoot:

This whole process has pointed out some areas that we can do, certainly that we can improve on. I guess what have we learnt about it? We’ve learnt to just pull the system apart, have a really good look at it. We’ve been given some excellent tools to do that, but we know we’re at the very beginning of what is a very long journey because it has implications for all the services that we provide so this is the start of something quite big.

The process of being involved in the health literacy pilot programme that we’ve just completed is going to be very valuable in terms of informing the way we implement the diabetes care improvement programme, so the next step for us will be introducing the learnings that we’ve had with health literacy into those individual practice plans at the pace that the practices are ready to do that.

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