Advancing Clear Health Communication to Positively

Impact Health Outcomes

Presentation Sections

The Problem: Low Health Literacy – Scope and Impact

Finding a Solution

– The Partnership for Clear Health Communication

– Ask Me 3

How to Become Involved: Solutions into Action

The Problem:Low Health Literacy

Scope and Impact

Do You Know Which Critical Public Health Issue…

Impacts nearly one in every three people living in the United States

Can hit any population segment, regardless of age, race, education or income

Costs the healthcare system as much as $58 billion a year

Can’t be diagnosed by any new medical technology and is not visible to the eye

Answer:Low Health Literacy

The Issue: Low Health Literacy

What is health literacy?

– The ability to read, understand and act on health information

How Big Is the Problem?

Approximately 40 to 44 Million Adults in the US Are

Functionally Illiterate1

Approximately 50 Million Are Marginally Illiterate1

Average Reading Skills of Adults in the US Are Between the 8th and 9th Grade Levels2

More Than 90 Million People in the US Have Difficulty Reading

Sources:1 Kirsch et al., “A First Look at the Results of the National Adult Literacy Survey” Nat’l Center for Education Statistics, 19932 Stedman L, Kaestle C. Literacy and Reading Performance in the US From 1880 to Present. In: Kaestle C, Editor.

Literacy in the US: Readers and Reading Since 1880. New Haven (CT): Yale University Press; 1991. P. 75–128

Cannot Perform Basic Reading

Tasks Required to Function in Society

Have Trouble Reading Maps and

Completing Standard Forms

Reading Levels & Skills

Reading Skills

18

32

50

0

10

20

30

40

50

60

1 2 3

Reading Grade Level

% o

f U

S P

op

ula

tio

n

Functional Competency

23

2831

15

3

0

5

10

15

20

25

30

35

1 2 3 4 5

Levels

% i

n L

evel

0-5 6-9 10-16+

How Does Low Health Literacy Affect Your Practice?

Chances are high that some of your patients are among the 90 million who have low health literacy

You may not know that patients with poor health literacy skills are in your care:– They use well-practiced coping mechanisms that

effectively mask their problem– They are often ashamed to admit they have difficulty

understanding information and instructions

Defining the Problem Scope

Coping Mechanisms for Patients With Low Literacy

98%Bring Someone Who Can Read

Watch and Copy Others’ Actions

Ask for Help From Medical Staff

Ask Other Patients

90%

80%

88%

Source: Parikh et al., 1996

Who Is at Risk for Low Health Literacy?

Anyone in the US – regardless of age, race, education, income or social class – can be at risk for low health literacy

– Ethnic minority groups are disproportionately affected by low health literacy

– The majority of people with low literacy skills in the US are white, native-born Americans

– Older patients, recent immigrants, people with chronic diseases and those with low socioeconomic status are especially vulnerable to low health literacy

Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System

The Largest Study Conducted to Date on Health Literacy Found That…

Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82

33% Were unable to read basic health care materials

42% Could not comprehend directions for taking medication on an empty stomach

26% Were unable to understand information on an appointment slip

43% Did not understand the rights and responsibilities section of a Medicaid application

60% Did not understand a standard informed consent

Low Health Literacy Negatively Impacts Health Outcomes

Adults with low health literacy:

– Are often less likely to comply with prescribed treatment and self-care regimens1

– Make more medication or treatment errors1

– Fail to seek preventive care1

– Are at a higher risk for hospitalization than people with adequate literacy skills2

– Remain in hospital nearly 2 days longer3

– Lack the skills needed to negotiate the health care system1

People with low health literacy AND diabetes:

– Were found to be less likely to have effective glycemic control4

– Were more likely to report vision problems caused by their diabetes4

1 Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 19992 Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798.

3 Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993.

4 Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB. Association of Health Literacy With Diabetes Outcomes. JAMA. July 24/31 2002 (288) No 4.

Low Health Literacy Impacts Resource Utilization

Adults with low literacy:

– Averaged 6% more hospital visits1*

– Stayed in the hospital nearly 2 days longer than adults with higher literacy skills1*

– Had fewer doctor visits, but used significantly more hospital resources2

– Had annual health care costs 4 times higher than those with higher health literacy3

•Among adults who stayed overnight in a hospital

1Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993.

2Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798.

3Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 1999.

Implications of Low Health Literacy

Poor Health Outcomes

Under-utilization of preventive services

Over-utilization of health services

Unnecessary health care expenditures

Limited effectiveness of treatment

Needless patient suffering

Higher patient dissatisfaction

Higher provider frustration

You Can’t Tell By Looking

Finding a Solution

Solutions: Focus on Care Providers and Materials

SKILLED READERS POOR READERS MANAGING THE PROBLEMS

Interpret meaning

Read with fluency

Get help for uncommon words

Grasp the context

Persistent reader

Take words literally

Read slowly, miss meaning

Skip over the word

Miss the context

Tire quickly

Explain the meaning

Use common words, examples

Use examples, review

Tell context first, use visuals

Short segments, easy layout

Differences between good and poor readers…

and how you can manage problems

But just 41% of those patients say they have

received this kind of assistance

17% of patients report trouble understanding

Rx Information

The Patient-Provider Relationship

70% of physicians say they provide patients

with additional resources to help them understand

their medications

75% of physicians report patients have trouble

understanding Rx information

There Is a Disconnect Between Patient and Provider: Bridging the Information Gap Will Help Improve Health Literacy

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

Why is this?

Short-term memory has very limited capacity and short storage time

Most people can store 7 or fewer independent items at one time

This memory lasts less than 1 minute

Short-term memory

Long-term memory Long-term memory lasts for days and years

Long-term memory has no practical capacity limits

To move into long-term memory, use association and interaction

Getting Into Long-term Memory

• Gain the patient’s attention

• Present no more than seven items at a time

• Get to the point

Short-term memory

Long-term memory

•Associate new information with what patient already knows

•Involve the patient in interaction with the information

•Repeat or review

Written Communication

87% report reading Rx information Yet only 34% believe others read this same information

What Do We Do?

Develop Written Materials at 6th Grade or Below, Where 160MM Can Understand and Act

Written

Making Health Information Understandable

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

50% of adults read at below 8th grade reading levels

20% of adults read at below 5th grade reading levels

40% of seniors read at below 5th grade reading levels

Consumer healthcare materials written at 10th grade or above, where only 50MM can understand and act

What You Need to Know About Low Blood Sugar

Treat low blood sugar quickly. If you have signs of low blood sugar, eat or drink something that has sugar in it. Some things you can eat are hard candy, sugar-sweetened soda, orange juice, or a glass of milk. Special tablets or gel made of glucose (a form of sugar) can be used to treat low blood sugar. You can buy these in a drug store. Always have some of these items handy at home or with you when you go out in case your blood sugar drops too low. After treating a low blood sugar reaction, eat a small snack like half a sandwich, a glass of milk, or some crackers if your next meal is more than 30 minutes away.

Source: The National Institute of Diabetes and Digestive and Kidney Diseases

Example of Health Communication That May Not Reach a Broad Consumer Audience

70 150

Blood Sugar Is Too Low if It Is Under 70

Blood Sugar Is Too High if It Is Over 240

Good Range

TooHigh

TooLow

9th Grade Reading Level

Example of Clear Health Communication – That Reaches a Broad Consumer Audience

Common visual used to explain concept

Uses action captions that clarify the point of the visual

Creates interaction with the reader

Verbal Communication

Patients experience shame around the issue

Only 14% of patients say they feel awkward admitting they don’t understand; yet 79% feel others don’t understand

Providers experience time challenges

Providers interrupt patients 30 seconds after they start speaking; if not interrupted, patients will speak less than two minutes

Communicate Effectively

What Can We Do?

Up to 80% of Patients Forget What Their Doctor Tells Them As Soon As They Leave the Doctor’s Office – AND

Nearly 50% of What They Do Remember is Recalled Incorrectly

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

Reaching the Solution

In the Office - Best Opportunity for Immediate Impact

1. Tell patients that instruction is aimed at solving/managing their health problem. Ask what they know, then outline topics you plan to cover.

2. Get to the point quickly. Low literacy skills = short attention span.

3. Ask patients to solve a problem with the new information. Ask them to tell or show you how they will use the information just learned.

Limited Education Objectives (example)

Objectives (for patient) “Must Include” Topics Interactive Questions

1. Understand what hypertension is

2. Follows medication regimen

What is hypertension & what is patient’s BP?

Dangers of hypertension

Taking medicine can control hypertension

Must take medication every day even if you feel okay

What is HBP?

What is your blood pressure?

What are some dangers to you from HBP?

How can you lower your blood pressure?

What about taking medication on days you feel okay?

Choosing the Right Words

Concept words describe a general idea or abstract framework (i.e. eat a ‘variety’ of foods; keep your glucose level within a ‘normal range’) = often misunderstood

Category words describe groups of things; people with low literacy skills have trouble understanding categories

Value judgment words (i.e. ‘excessive’ bleeding; exercise ‘regularly’); need to be specific

Use examples of common ideas to explain uncommon words

Use visuals/pictures to emphasize or clarify

Guidelines for Health Education

Reaching the Solution

1. Set realistic objectives. Use a planning sheet to write down key points.

2. To change health behaviors, focus on behaviors and skills. Emphasize skills, rather than facts.

3. Present context first (before giving new information). State the use for new information before presenting it; relate it to context of patients’ lives.

4. Partition complex instructions. Break instruction into easy-to-understand parts. Provide opportunities for small successes.

5. Make it interactive. Consider including an interaction after each key topic. The patient must: write, tell, show, demonstrate, select or solve a problem.

Clear Health Communication – We Can All Be a Part of the Solution

Even if you are not in a position to directly answer the three questions, keep clear health communicationin mind and in your dialogue when communicating with patients

Many people have trouble understanding medical terms. Often, these terms are better understood when explained with common words, an example or visual interpretation

Clear Health Communication in Action

Benign Harmless

Chronic Happens again and again; does not end

Cardiac Heart

Edema Swelling; build up of fluid

Fatigue Tired

Screening Test

Intake What you eat or drink

Generic Not a brand name

Adverse events Side effects

Consider Using This One Instead

Instead of Using This Word

Start by Decreasing the Use of Medical Jargon

Finding a Solution

The Partnership’s First Solution

Addresses awareness and education

Creates a Call to Action for patients and providers

Is designed to promote clear communication between patients and providers to improve health outcomes

Was developed with health literacy experts, then tested and validated

Ask Me 3

Use of Ask Me 3 resulted in reduction in 30 day readmission rates for heart failure pts. (7.2% to 2.5%)

Patient surveys indicated a statistically significant improvement in perceived ability of nursing staff (p = .001)

Ask Me 3 does not add time to patient visits

Use of Ask Me 3 resulted in reduced call-backs and missed appointments

Over 1 million providers use the Ask Me 3 program

Ask Me 3 - For Patients

Patients Should Not Be Anxious About Asking Their Health Care Provider Questions!

Health information can be confusing at times

Everyone wants help with health information

Asking questions helps patients understand how to prevent or manage illness

ProviderPatient

All they can about their condition/medication

Why this advice/treatment is important for good health

Steps to take to prevent a condition or keep it under control

Ask Me 3 - For Providers

Health Care Providers Want Patients to Know:

Ask Me 3 – Creates Shared Responsibility for Clear Health Communication

Patient Provider

De-stigmatize andReduce Embarrassmentof Low Health Literacy

RecognizePatient Coping Mechanisms

Provides a consistent approach to patient-provider dialogue Allows patients to get information they need to manage their health Time-efficient for providers to reinforce healthcare instructions

What Is Ask Me 3

Promotes three simple, but essential, questions and answers for every healthcare interaction:

Why Is It Important for Me

to Do This?

Context

What Do I Need to Do?

Treatment

What Is My Main Problem?

Diagnosis

Ask Me 3 – For Patients

Element: Poster

Description: – Stimulates curiosity

about Ask Me 3– Informs patients and staff

about the program

Implementation (hang poster):– In waiting areas– In exam rooms– On the ceiling, above

the exam table– On a door– In a staff break room– Hang anywhere where provider-

patient interaction takes place – Anywhere patients might see it!

Ask Me 3 – For Patients

Element: Patient brochure

Description: – Educates patients about

the Ask Me 3

– Motivates patients to ask their healthcare provider questions

Implementation:– Display in waiting

rooms/registration area

– Distribute to patients upon arrival/sign-in

– Distribute with any paperwork

– Distribute during events or with mailings to patients

Ask Me 3 – For Providers

Element: Provider brochure

Description:– Explains the scope and impact

of low health literacy

– Offers communication tips

– Emphasizes how effective communication can positively impact patient health outcomes

Implementation: – Distribute to all staff interacting

with patients through staff meetings or mailings

– Conduct departmental in-service training on Health Literacy and Clear Health Communication

Ask Me 3 – For Providers

www.AskMe3.org:

– Has everything you need to start acting/implementing

– Materials can be downloaded/ordered from this website

– Other health literacy tools available on the site:

• Bibliography on health literacy

• List of literacy resources

• White paper on health literacy

• Links to other relevant websites

• Cultural competence primer

What Can You Do?

Six steps to improving patient understanding

1. Limit the amount of information provided at each visit

2. Slow down

3. Avoid medical jargon

4. Use pictures or models to explain important concepts

5. Assure understanding with the “show-me” technique

6. Encourage patients to ask questions

What Else Can You Do?

When making an appointment, provide people with simple options and clear facts

Appointment InstructionsAlso see: Urgent Care (if you are too sick to wait for an appointment)

Making a medical appointment for the first time, it is straightforward: You call 555-2222 and make a appointment at XYZ Health Services just like you would at any doctor's office.

You can request a specific clinician if you have someone in mind, or you can explain your need or problem to the appointment counselor, and he or she will schedule you with an appropriate clinician at the earliest possible date. At your first appointment you will receive a medical record card -- often referred to as your "gold card" -- which you will keep and use as your XYZ Health Services identification. 

If you are unsure about whether you should make an appointment, you may call the Advice Nurse at 666-7777. Also, in advance of your first appointment, be sure to read "How to Make the Most of Your XYZ Visit."

Please call 643-7177 to make an appointment in the Specialty Clinics, including Allergy & Travel. Specialty appointments require a referral.

You may also drop by the Appointment Office to make a medical appointment. The Appointment Office is located on the first floor in Room 1111. You may also make an appointment in the Specialty Clinics by going to the Specialty Clinic reception desk, located behind the elevators on the first floor. If you need to cancel an appointment, please call our 24-hour cancellation line at 643-7033. Please note that you will be billed for a broken appointment fee if you do not show up for your appointment and have not called to cancel it.

Your Name

Your Appointment DateTimePlace

Our Telephone Number:Do not eat or drink for 6 hours before the day and time on this card.

People Have Difficulty Making Appointments

What Else Can You Do?

Phone answered by a tape recording. Speaking quickly, the caller is offered numerous options and alternatives

Speak slowly and clearly Provide an easy way to

connect with a live person Provide options in

other languages

People Have Trouble Understanding Phone Recordings

What Else Can You Do?

Ambulatory Entrance

Hospital XYZ

Some people become confused about whether this entry was intended for ambulances or for patients

Ambulatory Entrance

The use of visuals clarify the message

Contrast in color makes it easy to read

Try to be consistent when hanging signs

People Have Trouble Reading Signs

What Else Can You Do?

To make maps easier to follow: Match the color in the map with the

paint color on walls or floors Match the names in the map to the

names on the signs Use 14 point font size or larger

Maps are usually hard to follow: Too complicated Codes are hard to understand Names and directions not always match Small fonts

People Have Trouble Understanding Maps

How Can Enhanced Communication With Your Patients Benefit Your Practice?

Patients who understand health care information may:– Be more compliant with instructions and medications– Call back less often– Visit less often– Have fewer hospitalizations– Have better health outcomes– Have increased patient satisfaction

Greater Provider Satisfaction

Help Patients Understand…

The Practical Solution: