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"Healthy York" and "Healthy Adams," a pair of community coalitions in York and Adams Counties in south central Pennsylvania, used AHRQ's Health Literacy Universal Precautions Toolkit as a core resource in a Health Literacy Learning Collaborative.

Over a six-month period beginning in 2011, the Learning Collaborative used the toolkit in a pilot program during a series of patient empowerment training sessions for health professionals. The six practices participating in the Collaborative collectively serve an estimated 25,000 patients. At the end of this developmental period, the work completed in the pilot program was incorporated into the curriculum of a much larger Patient-Centered Medical Home Collaborative (PCMH) and Enduring Learning Forum (ELF) Collaborative. Under the banner of this large-scale quality improvement program, information from the toolkit was adopted by 37 primary care practices, thereby helping to potentially improve the health literacy of about 187,000 patients.

Christine Amy, project director of Aligning Forces for Quality–South Central Pennsylvania (AF4Q–SCPA), a regional health improvement organization, says, "The ÂÜÀòÊÓƵtoolkit has been indispensable in the community's efforts to improve communication between health professionals and patients." Amy is also employed by WellSpan Health, a nonprofit, community-based health care system serving the York and Adams County region. WellSpan Health participated actively in the project.

The Health Literacy Learning Collaborative was born out of a research effort. To gauge the extent to which people were receiving and absorbing useful information about the quality of their health care, AF4Q–SCPA conducted telephone surveys of local consumers. Two annual surveys were conducted, reaching 500 individuals with the chronic illnesses of heart failure, coronary artery disease, or diabetes. The first survey asked participants how they felt about their own encounters with health information. They were asked whether they needed help reading medical literature or forms and whether they ever left medical visits feeling they did not know what they needed to do. The second survey, conducted the following year, asked them about their fears and expectations of health care and tested them on measures of "patient activation."

The first survey indicated that 43 percent of heart failure patients, 30 percent of coronary artery disease patients, and 26 percent of diabetes patients had literacy limitations. The second survey, conducted the following year, found persistent gaps in clinician-patient communication. A more recent health assessment conducted in Adams and York Counties concluded that in the general population, about 17 percent of York County respondents and 15 percent of Adams County respondents had limited health literacy.

Armed with research and a clear call to action, two county-specific task forces were formed. They issued a series of recommendations to their respective communities, calling for efforts to integrate literacy initiatives into all aspects of health management, concerted efforts to develop "plain language" materials, and a campaign to empower patients to be active participants in their care.

To reach the provider community, AF4Q–SCPA created a Health Literacy Learning Collaborative, recruiting participants from five area primary care practices. It engaged the services of Daren Dewalt, M.D., M.P.H., of the University of North Carolina, the developer of AHRQ's Health Literacy Universal Precautions Toolkit, to help implement the program. Participants were guided in the process of assessing their practices' health literacy needs, setting goals, and implementing three of the toolkit modules. They were asked to implement the Teach-Back Method (Tool 5, pages 28-30), the Brown Bag Medication Review (Tool 8, pages 37-40), and a third tool of their choosing.

Dewalt and his team offered frequent coaching sessions and monthly technical assistance calls during the six-month Learning Collaborative. At the conclusion of the collaborative, participating practices reported that both clinicians and patients appreciated the new tools. Gettysburg Adult Medicine, one of the participating practices, reported a dramatic decrease in the number of phone calls from patients seeking clarification after their medical visits.

A comprehensive patient empowerment campaign was launched as part of the expanded PCMH/ELF initiative. Six patient education sessions were made available, including one on medications. As part of this last session, patients were provided with green medication reminder bags to encourage them to bring their medications with them to their medical appointments. The bags were distributed to individuals in the community with the slogan imprinted "It's your health—take charge!" on the bags.

Amy says, "The incorporation of the health literacy program into the PCMH/ELF Collaborative is a significant step forward, signifying that health literacy training and practice are important aspects of quality improvement." The National Committee on Quality Assurance sponsors the PCMH accreditation program as a way to transform primary care by enabling patients to establish long-term partnerships with physicians.

Amy notes that the projects are shifting from the providers' to the patients' perspectives, and from medical practices to the community. Beginning in 2014, the PCMH/ELF Collaborative formed a Patient-Centered Medical Neighborhood Collaborative, which involves primary care practices, specialty practices, and hospitals in quality improvement activities in the community.

AF4Q–SCPA is funded by the Robert Wood Johnson Foundation through "Aligning Forces for Quality," an initiative in 16 communities nationwide to improve the quality of health care by engaging the entire community in the process—health care providers, health insurers, employers, and patients. WellSpan Health is the recipient of the Foundation grant for south central Pennsylvania.

To learn more about the toolkit, visit ÂÜÀòÊÓƵHealth Literacy Universal Precautions Toolkit.