Health Literacy: What did that doctor say??May 13, 2009

FacultyMedicine NursingPharmacyEvelyn Kemp Peggy McConnell Charles CollinsForrest Lang Sue Grover Richard Hess

Public Health Social WorkBrian Martin Robin Lennon-Dearing

ObjectivesParticipants will learn the following:Extent of low literacyThose most at riskCorrelates and results of low health literacyClinical red flagsWays of assessing health literacyStrategies for helping patients with low health literacy

Finally, participants will identify quality improvement project goals that address patients health literacy levels.

Agenda for today11 -11:30 Introduction to health literacyVideo followed by groups discussion of what they see in the video and suggestions for changeStrategies for helping patients with limited literacy11:30-12 Practice with standardized pts

Literacy in the US14% of adults cannot read21-23% can read a little but not well enough to: fill out an application read a food label read a simple story 46% of US population have limited health literacy. (Paasche-Orlow, 2005.)

What is HealthLiteracy?Healthy People 2010: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

LiteracyDemographicsLimited health literacy is greatest amongOlder adultsPoorRural Those with limited educationMinoritiesThose with limited English proficiency

Results of limited literacy

12% of general population do not understand when their next appointment is.

Over 19% do not understand instructions to take medication on an empty stomach.http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

Correlates of Low health literacyPoor knowledge of chronic diseases such as HTN, diabetesPoor glycemic controlPoor health outcomesIncreased risk of hospital admissionsLength of hospital stay increased by nearly 2 days

How good are we at detecting low literacy?Clinicians identify only 47% of low literacy patients. (Rogers, 2006)

Clinical Red Flags Indicating Limited Health LiteracyIncorrect or incomplete forms.Frequently missed appointments.Lack of follow through with diagnostic testing or referrals.Medication count, medication refill history, or lab tests inconsistent with patient report.Patient asks no questions.

How we explain things to patients

Video MDI Discussion

StrategiesAssess LiteracyCreate a shame-free environmentAdjust approach to patient needsImprove communication Ask-Tell-Ask

Informal Assessmentof Health LiteracyThe Indian Health Service model uses a series of three questions:What did your prescriber tell you the medication is for?How did your prescriber tell you to take the medication?What did your prescriber tell you to expect?

Conduct a Medication Review:Ask patients to bring in all their medications Ask them to name and explain the purpose of each one Brown Bag Test

Formal Assessmentof Health LiteracySingle Item Literacy Screener (SILS)How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? (Morris, 2006)Sensitivity 54% - Specificity 83%1-Never, 2-Rarely, 3-Sometimes, 4-Often, and 5-AlwaysScore above 2 is considered positive

Creating a Shame-free Environment

Use ubiquity statements, Many people have difficulty understanding medical information. Convey an attitude of helpfulness, caring and respect.Avoid acting impatient or annoyed.Involve the entire staff.Offer to help with paperwork.

Adjustments based on patient needHearingVisionCognition

Strategy: Improve CommunicationSpeak slowly.Use simple, plain nonmedical language.Focus on 1-3 key messages per visit.Ask how the patient learns best. Models, charts, pictures, analogiesInclude a family member or friend.

Strategy: Improve CommunicationBenignHarmlessChronicHappens again and againCardiac HeartEdemaSwelling; build up of fluidFatigueTiredScreeningTestIntakeWhat you eat or drinkGenericNot a brand nameAdverse eventsSide effectsCommon LanguageJargonAvoid Use of Medical Jargon

Strategy: Improve communicationShow or draw pictures. Visual images can improve the patients recall of ideas. Uses captions that clarify the point of the visualUSP Pictograms http://www.usp.org/audiences/consumers/pictograms/

Strategy: Improve communication

Ask-Tell-Ask

ASK pt their understanding of their disorder and treatment.TELL them missed or incorrect information. ASK for a restatement of their understanding of information given in your own words.*Dont ask, Do you understand?

Remember to do with every patient . . . Assess health literacy: How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Ask the patient to restate their understanding of information given in your own words.*Dont ask, Do you understand?

Practice Session - 30 minutes

Video #2 (Explanation of Albuterol)Video #3 (Demonstration of Inhaler)Video #4 (Tell-back)

**Speak slowly. Slow down the pace of your speechUse simple, plain nonmedical language: Pain killer instead of analgesicharmless instead of benign high blood pressure instead of hypertension keep track of instead of monitor Limit the amount of information provided at each visitFocus on 1-3 key messages per visit:Review each point and repeat several times Have other staff reinforce key messagesAsk how the patient learns best. Asking, "How do you learn new things?" will help determine what the best approach is with that particular patient.Some may prefer models, charts, pictures or analogies (arthritis is like a creaky hinge on a door).Ask if they would like a family member or friend present during the visit.

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Medical terminology can be a source of confusion for many patients and/or family members. If medical terms must be used, they should be explained, defined and/or demonstrated.

I Hear You Talking, But I Dont Understand You!http://www.medicalleadership.org/downloads/Medical_Jargon.pdf

**Use patient-friendly materials and visual aidsShow or draw pictures. Visual images can improve the patients recall of ideas. Uses captions that clarify the point of the visual

Successfully communicating medical information to patients with low literacy requires providing appropriately written materials, oral communication, and visual presentation (Doak, et al., 1996). The plan is to generate informational materials that patients will not only understand and act upon, but that they will also save and refer to again and again.

Pictograph or pictograms are simple drawings that represent ideas, and they can help a person grasp, understand, and remember medical information quickly. Road signs are a common example of pictographs.

A library of medication-related pictograms that clinicians can download is available at the USP Pharmacopeia web site, www.usp.org.USP Pictograms http://www.usp.org/audiences/consumers/pictograms/USP Pictograms are standardized graphic images that help convey medication instructions, precautions, and/or warnings to patients and consumers.

Doak, C. C., Doak, L. G., & Root, J. H. (1996). The literacy problem. In Teaching patients with low literacy skills. 2nd ed. Philadelphia: J.B. Lippincott Co.

*An illustrated medication schedule can be a low-literacy patient education tool to promote appropriate use of prescription medications.

Other patient resources: Medication Tracking Pocket Cardhttp://www.rihlp.org/pubs/MM-3254.V4.RIHLP_med_tracking_card.pdf

Family Medical Tree - This resource is from the Rhode Island Health Literacy Project. Listing your family medical history before your visit, makes your appointment less stressful and you do not have to remember so many things. http://www.jeffcohealth.org/healthed/your_family_medical_tree[1].pdf

S. Kripalani, R. Robertson, M.H. Love-Ghaffari, L.E. Henderson, J.P. Praska, A. Strawder, M.G. Katz and T.A. Jacobson, Development of an illustrated schedule as a low-literacy patient education tool, Patient Educ Couns 66 (2007), pp. 368377. Article | PDF (459 K) |

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