Information for Health Insurers and Health Care Commissioners

A Brief introduction to approaches that increase health literacy and patient activation for people with long term health conditions

 1.1    Background

The scale of growth in multimorbidity and an ageing population requires health and social care systems to scale up approaches to supporting people to effectively manage their health and wellbeing.

Key to this is addressing the prevalence of low health literacy in the population and the associated health inequalities.

The prevalence of low (i.e. a level that has a negative impact o a persons health) health literacy was highlighted in the 2011 European health literacy survey of eight European Member States: Austria, Bulgaria, Germany (North Rhine-Westphalia), Greece,Ireland, the Netherlands, Poland and Spain . Although the prevalence of low

health literacy varied considerably across Member States, when taken together,the health literacy of 47.6% of the adult population was below the recommended level. In all, 12.4% of the adult population had thelowest level of health literacy and would thus be expected to experience severe difficulties[1]

There is a direct correlation between low health literacy and poor health outcomes and increased costs[2]

There is increasing evidence that services based on a health literacy and person centred methodology is the foundation for improving outcomes and managing the demand associated with increasing prevalence of multiple long term conditions in the population.

This requires a whole systems transformation to achieve the cultural and behavioural changes needed to improve health literacy.  It also requires a local understanding of the needs and assets within communities that can support people to stay well and reduce reliance on clinical services for issues that are driven by social factors

1.1      LOGIC MODEL

Improving outcomes for people with multi morbidity and dual; mental health diagnosis is a major challenge for commissioners and raises important questions about the organisation of services

Approaches such as population health management combined with a focus on improving health literacy are currently gaining traction as effective ways of improving health outcomes and reducing unwarranted use of services and reducing costs.

In insurance based health care systems with capitated budgets this allows for effective targeting of resources at those at most at risk of moving to high complex patients.

The core logic model for improving health literacy for people with long term health conditions has a number of key steps. Each has its own evidence  based methodology.


Proactive identification of people who are likely to have low knowledge, skills and confidence within the population

Prioritise people with low health literacy

Support needs identified(bio-psychosocial)

Access to support to improve health literacy

Leading to reduced unwarranted costs, improved health and well being outcomes, improved health literacy


Proactive identification of people who are likely to have low health literacy within the population through:

  • Routine review of hospital discharge and admissions
  • Risk stratification and segmentation
  • Review of priority groups of people
  • Review of local data and demographics and the wider determinants of health
  • Tacit knowledge of primary care clinicians of their patients
  • Use of tools to measure people’s health literacy/ knowledge, skills and confidence via an appropriate tool, such as the EU HLQ, Patient Activation Measurement (PAM), long-term condition patient-reported impact measure (PRIM) or self-efficacy scales, for all people with long-term conditions.

Prioritise people with low activation and poorly controlled clinical markers. Ensure more time given to people with low health literacy. People with High health literacy move to open access

Support needs (biopsychosocial)  identified through:

  • Personalised care and support planning tailored to level of complexity carried out by appropriate roles –e.g. health coaches, healthcare assistants, link workers, health trainers, general practice nurses, District Nurses, specialist nurses or GPs, depending on the person’s level of activation and complexity. May also include use of shared decision making tools
  • All staff trained in basic health coaching/personalised care skills with increasing training and supervision depending on roles

Access to support-Refer (via single gateway) to:

  • Quality assured, evidence-based health coaching or structured group coaching course
  • Quality assured, evidence-based self-management education approaches (face-to-face and virtual), which include disease-specific, generic and online self-management courses
  • Peer support and community activities (Social Prescribing)

Why care planning is key as a commissioning model

The year of care programme in the UK  provides a effective model to enable an understanding of the different components that are needed to enable the described process.

The Diabetes Year of Care (YoC) programme aimed to firstly demonstrate how personalised care planning can be delivered as routine care for people with LTCs, using diabetes as the exemplar, and also to ensure that the services that people need to support the actions they want to take to improve their health and wellbeing are available through commissioning.

The Year of Care Programme developed the ‘Year of Care House’ which provides a structured framework for commissioners.

Figure 4: Year of Care House 

Five key elements of an integrated LTC Year of Care service have been defined.

1 Co-ordinated care

2 Patients engaged in decisions about their care

3 Supported self-management

4 Prevention, early diagnosis and intervention

5 Emotional, psychological and practical support


The Year of Care house provides a useful model to help understand where these different components are needed and in what order they may need to be implemented. It also ensures that ensuring that attitudes, skills and infrastructure are all addressed together leading to culture and system change (Diabetes Year of Care Pilot Programme).

It is essential to understand that just commissioning one component without regard to the whole will not produce significant changes and outcomes.

For example just commissioning consultation skills or shared decision making without also ensuring that people have access to services that enable them to develop confidence and knowledge will lead to an imbalance. Likewise just commissioning static care plans or patient skills programmes without the work on culture change among teams will lead to people feeling that their needs are not being met.


Want to know more?

Our team at CEmPaC and our network have many years of experience in implementing these approaches. CONTACT US  if you would like further information or support


[1]Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G et al. Health

literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015;25(6):1053–8.


[2]Eichler K, Wieser S, Brugger U. The costs of limited health literacy: a systematic

review. Int J Public Health. 2009;54(5):313–24.