Guest Column

Take the lead in filling your patients’ perception gap’

Low health literacy affects many people

By Mindy Owen, RN, CRRN, CCM
Chair, Commission for Case Manager

A perception gap often exists today between what health care providers say, prescribe and advise, and what patients actually understand and carry out in their self-care. Many factors can influence this gap, including a lack of language comprehension. Yet, even when a patient is well educated, highly conversant, and appears to understand what the health care provider is saying, a perception gap can result.

Adding to that gap is greater fragmentation in care delivery and a lack of coordinated communication. This reflects the rise in complex cases as an increasing number of patients deal with catastrophic and chronic diseases. At the same time, however, they are receiving less acute care than they have in the past, with the average hospital stay down to 4.8 days. In addition, patients are being seen by multiple health care providers with various specialties, which adds to the fragmentation and many times leads to a communication breakdown.

Although it has been a goal of case management to help counter that fragmentation and bridge the perception gap, I do not believe we have achieved that yet.

For one thing, it is difficult for case managers to establish a rapport with a patient and his/her family, to provide education, and effectively communicate during a short hospital stay, when both the patient and family are experiencing a heightened amount of stress.

In addition, a patient also may be working with more than one case manager; for example, an acute care case manager at the hospital, an insurance company case manager, and even a case manager who works in the home health arena. The result is an imperfect communication structure due to the number of health care practitioners, with more than one case manager trying to coordinate care and facilitate the exchange of information.

While communication problems and perception gaps are easier to identify when general literacy (reading, language and overall comprehension) is an issue, the problem becomes masked when a patient is highly literate — but his or her health literacy is impaired. Health literacy includes understanding a chronic illness and how it impacts a person’s life, plus treatment and self-care requirements. The risk with highly literate patients with low health literacy is that although they appear to understand, they may not follow through with treatment or they may not be astute about watching for signs and symptoms.

In fact, a highly literate/low health literacy patient may be the most risky situation because it is easy to assume that the person has comprehended instructions for medication, self-care, diet restrictions, and so forth. However, there may be gaps in that patient’s perception due to what he/she heard (vs. what was actually said), and even judgments and opinions about taking medication — from whether it really needs to be taken to taking it more or less frequently than prescribed. Stress, anxiety, and other emotional causes also can affect comprehension and widen the perception gap.

The perception gap is particularly problematic with medication, given the statistics on prescriptions: One-third of the prescriptions written are not filled by the patient, and of the remaining two-thirds, half are taken inappropriately or not at all. When a patient does not fully or adequately understand treatment, he or she may arbitrarily stop taking a medication, believing that it’s "not doing anything; I don’t feel any different" or taking it more or less frequently than prescribed. This highlights the need to address the perception gap as part of an overall drive to improve patient safety, whether in an acute-care setting, as outpatients, or administering self-care under a doctor’s advisement.

For the case manager, the first responsibility is to recognize that a perception gap may exist with every patient, including those who appear highly literate and capable of comprehending information and instructions given by a health care provider. The next step is to assess the patient’s ability to communicate with health care providers. In other words, does the patient exhibit sufficient literacy and health literacy to comprehend the practitioners’ instructions? Does the patient comprehend his or her disease state and the recommended interventions? Are there language or cultural issues? (As an example, a diabetic patient I worked with did not follow through with self-administering his insulin shots because he expected his wife to do this for him. Until this factor became known, he was not receiving the prescribed dosage in a timely manner.)

Fortunately, there are tools for case managers to assess patients and their level of communication and interaction with health care practitioners. These tools, which mostly track medication adherence, also provide case managers with the means to track patients using specific data measures. By utilizing these tools, case managers can gauge improvements in patient adherence, which also reflects their level of communication with providers.

In every setting and practice venue, and in specialties from pediatrics to geriatrics, case managers can help bridge the perception gap that affects patients and impedes the quality of the care they receive.

With more fragmentation among health care providers, shorter hospital stays, and an increase in the number and variety of care providers whom a patient may see, case managers fill a vital role. Case managers can assess patients’ ability to comprehend what health care providers are telling them, and act as a conduit of information about a particular disease or health state, care, and treatment.

The first step to closing the perception gap is to recognize that it exists, and then to implement a specific plan aimed at identifying patients’ communication needs and providing the education and support they require.

[Mindy Owen, RN, CRRN, CCM, is chair of the Commission for Case Manager Certification (CCMC). She also is principal of Phoenix HealthCare Assoc. LLC, a Coral Springs, FL-based consulting firm specializing in case management, disease management, and managed care development and education.]