IHS Pharmacy QUAD

Handout to accompany the Health Literacy Poster

Compiled by: CDR Christopher Lamer, PharmD, MHS, BCPS, CDE

................................................................................................Health Literacy ! 2

..........................................................................Health Literacy in Pharmacy ! 2

..................................................................................Health Communications Website! 2

..........................................................................................................................Ask Me 3! 3

..........................................................................................Teach-back and Show & Tell! 4

........................................................................................................Prescription Labels! 4

........................................................................AHRQ Pharmacy Health Literacy Tools! 5

........................................................Documenting Patient Education Codes! 5

...........................................................................Medication Patient Education Codes! 7

.............................................................................Assessing Health Literacy ! 9

....................................................................................................Universal Precautions! 9

....................................................................................................................Other Tools! 10

...........................................................................Barriers to Learning Health Factors! 13

............................................................................Patient Wellness Handout! 16

....................................................................................Update Default PWH for a Site! 17

......................................................................................................Asthma Action Plan! 17

....................................................................................................Create/Modify PWHs! 19

.................................................................................................................PWH Reports! 23

.................................................................................................Patient Goals ! 24

.......................................................Ultra-Brief Personal Action Planning* (UB-PAP)! 24

..................................................................Tips to Promote Health Literacy ! 25

.......................................................................................................Use Simpler Words! 25

.............................................................................Tips for creating patient handouts! 27

........................................................................................Health Literacy White Paper! 28

Health Literacy in PharmacyHealth literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand and act on basic health information and services needed to make appropriate decisions. It encompasses the skills required to read and understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms. It is the ability to participate in self-management activities, make informed choices in their health, and to negotiate complex health care systems. Patients with low health literacy often skip important preventive measures, (such as mammograms, Pap smears, and flu shots), have less knowledge on effectively managing chronic diseases, have poorer health outcomes, and utilize more healthcare dollars and resources.

Pharmacists are the most accessible health care professional and have the opportunity to improve patient’s knowledge and abilities to make well-informed health decisions. IHS pharmacists are pioneers in improving patient care and safety. Many of the practices and standards that have been in place for years are being adopted and taught in mainstream. This article provides an overview and some ideas of how pharmacists can play a vital role in assessing and improving health literacy.

IHS Health Communications Websitehttp://www.ihs.gov/healthcommunicationsIt is a challenge for providers to translate their years of expertise into a language that can be understood by each patient. Your patients face different health problems, come from unique backgrounds, and possess unique communication skills. So, how do you determine how you communicate with your patients? Not only communicate, but how do you talk to your patients about their health? How do you break the information down to a level your patient can understand enough to apply it to their lives and hopefully experience a positive outcome? Do you have a plan?Within Indian Health Service, we are developing better tools and practices to help you communicate effectively with your patients and their families. We have several communication resources to assist you and your patients:

• Tools to assess your patient’s health literacy • Ask Me 3 • Teach-back method to ensure patient understanding • Patient education handouts • A checklist for reader-friendly print materials • Tips for plain language communication

Learn more about the IHS Health Communication initiatives and health literacy resources and tools because the health of your patient depends on it.

Ask Me 3The Ask Me 3 program from the Partnership for Clear Health Communication (http://askme3.org) is a tool that creates awareness and reinforces principles of clear health communication. It encourages the ptient to ask three questions that should improve communication between health care providers and patients. All health care providers should make their patients aware of three key questions to ask any health provider. The questions are:

1. What is my main problem?2. What do I need to do? 3. Why is it important for me to do this?

Pharmacists should be able to provide patients with this information at each encounter and should encourage patients to ask these questions when meeting with other health care providers as well. More information on Ask Me 3 program can be found at http://www.npsf.org/askme3. The IHS health literacy workgroup is developing American Indian designed handouts for patients on Ask Me 3 that will be available in the near future.

Teach-back and Show & TellAs described in standard two of the IHS standard of practice, all patients who present to an IHS pharmacy or who receive discharge medications receive patient education/counseling on their medication therapy in a private consultation or hospital room. During the patient education/counseling the pharmacist should verify that the patient understands the purpose, proper use, and expected outcomes of their drug therapy. The pharmacist determines patient understanding through patient feedback utilizing the "show and tell" or "teach-back" method. These methods utilize specific open-ended questions to enable the pharmacist to ensure patients have an understanding of their treatment plan.

1. What did the doctor tell you the medicine is for?2. How did the doctor tell you to take the medication?3. What did the doctor tell you to expect?4. Just to make sure I didn’t forget anything, please tell me how you are going to use this

medication?

This process was innovated by the IHS pharmacy program in the late 1980s and is uniformly taught throughout pharmacy schools today. In addition to counseling on medication using the teach-back method, pharmacists should also use the “show-and-tell” method for quickly reviewing refills with patients.

1. What do you take this medication for?2. How do you take it?3. What problems are you having?

Prescription LabelsPrescription labels are designed to provide the patient with an easy-to-understand method to verify the medications being prescribed, the instructions in simple language, as well as the reason for taking the medication. Prescription labels should also identify the indication or purpose for which the medications are being used. Many medications are also accompanied by auxiliary labels which provide patients with additional prompts on appropriate methods to use when taking their medications such as taking with food or water. Auxillary labels with multiple steps, higher reading difficulty, or confusing icons may be misinterpretted by nearly 92% of patients. Clear and easy to understand prescription labels will assist the patient in actively participating in the treatment plan, acheiving expected outcomes, and reducing the risk of adverse events. For patients who have difficulty or are unable to read English, the IHS pharmacy program developed pictograph labels that help explain the instructions for the appropriate use of their medications using pictures. Images of who in the family is supposed to take the medication, what time of day to take it in relation to the sun, and how many to take at each time are on the label.

AHRQ Pharmacy Health Literacy Tools• Is Our Pharmacy Meeting Patients’ Needs? Pharmacy Health Literacy Assessment Tool

User’s Guide: This tool is designed to measure the “health literacy friendliness” of pharmacies from perspectives of objective auditors, pharmacy staff, and patients. Available at: http://www.ahrq.gov/qual/pharmlit/index.html

• How to Create a Pill Card: This guide was designed to help users create an easy-to-use "pill card" for patients, parents, or anyone who has a hard time keeping track of their medicines. Available at: http://www.ahrq.gov/qual/pillcard/pillcard.htm

• Strategies to Improve Communication Between Pharmacy Staff and Patients: This training program is designed to introduce pharmacists to the problem of low health literacy in patient populations, to identify the implications of this problem for the delivery of health care services, and to explain how to improve communication with patients who may have limited health literacy skills. Available at: http://www.ahrq.gov/qual/pharmlit/pharmtrain.htm

• Automated Telephone Reminders: A Tool to Help Refill Medicines On Time: This easy-to-understand telephone script is for pharmacies wishing to use automated refill reminder calls to patients to remind them to refill their prescriptions and allow patients to order the refill on the phone. Available at: http://www.ahrq.gov/qual/callscript.htm

Documenting Patient Education Codes5 Steps in Documenting Patient Education

1. Topic (Diagnosis or condition) can be documented as:• Patient education code mnemonic (ex: DM for diabetes)• ICD9 or CPT code (ex: 250.01 for diabetes)

2. Subtopic - there are 14 generic subtopics that can be added to any topic Anatomy & Physiology Complications Disease Process Equipment Exercise Follow-up Home Management Lifestyle Adaptations Literature Medications Medical Nutrition Therapy (Reg. Dietitian use only) Nutrition Prevention Procedures Safety Hygiene Tests Treatment

3. Level of understandingThe patient’s understanding of the education:d) Good - Verbalizes understanding, verbalizes decision or desire to change (plan of action

indicated), or is able to return demonstration correctlye) Fair - Verbalizes need for more education, undecided about making a decision or a

change, or return demonstration indicates a need for further teaching

f) Poor - Does not verbalize understanding, refuses to make a decision or needed changes, or unable to return demonstration

g) Group - Education provided in group and unable to evaluate individual responsesh) Refused - Refuses or declines patient education

4. Provider - who you are

5. Time - how much time the education took in minutes

As an example, an education code may be recorded as: M-I-F-CCL-4 minutes

Optionally you can add a free text comment about the education encounter. For example, if you wanted to document that the patient’s brother, (a proxy), picked up their medications and received education/counseling on the medication, it can be documented as:

M-PRX-G-CCL-5 minutes - brother Bob picked up meds

Patient education can be documented in the Electronic Health Record

Medication Patient Education Codes

M-DI DRUG INTERACTION OUTCOME: The patient/family will have an awareness of potential drug, food, or alcohol interactions associated with the prescribed medications. STANDARDS: 1. Explain the potentially serious adverse effects of the specific interactions with other drugs (including OTC medications and traditional or herbal medicines). 2. Specifically discuss adverse effects of this medication when combined with specific foods. 3. Emphasize the importance of informing the provider (e.g., physician, pharmacist, nurse) of any drug interaction(s) that have occurred in the past. 4. Inform the patient of the procedure to follow in the event of a drug interaction.

M-FU FOLLOW-UP OUTCOME: The patient will understand the importance of follow-up in the medication treatment plan. STANDARDS: 1. Discuss the individual’s responsibility in the management of medication therapy. 2. Review the treatment plan with the patient, emphasizing the need for keeping appointments, fully participating with medication therapy, returning for appropriate follow-up, lab tests, and appointments. 3. Discuss the importance of informing all healthcare providers of medications taken, including prescription, over-the-counter, herbal, supplements, and traditional medicine (medication reconciliation). 4. Discuss the importance of follow up of medication therapy to assess adverse drug effects, safety, and efficacy of the prescribed medications. 5. Assist the patient in obtaining a follow-up appointment as necessary.

M-I INFORMATION OUTCOME: The patient/family will demonstrate knowledge of the use and benefits of the medications in the treatment plan. STANDARDS: 1. Give the name of the drug and show the drug to patient where applicable.2. Briefly review the mechanism of action of the drug and the reason for taking it, emphasizing the importance of full participation with medication regimen. 3. Review the directions for use, duration of therapy, proper storage, and handling of medications. 4. Discuss the probable side-effects or toxicities of medication. Review the course of action to take if toxicity occurs. 5. Emphasize the importance of informing the provider prior to initiating any new medications.

M-L LITERATURE OUTCOME: The patient/family will receive literature about the medication(s) prescribed. STANDARDS: 1. Provide the patient/family with literature on the prescribed medication(s). 2. Discuss the content of the literature.

M-MB MEDICATION BOX TEACHING OUTCOME: The patient/family will be able to fill and use a medication box correctly. STANDARDS: 1. Explain the benefits of using medication boxes. 2. Demonstrate to the patient/family how to fill the box while verbalizing the thought processes involved. 3. Discuss the importance of reading medication labels carefully. 4. Discuss non-child resistant boxes and proper storage as appropriate. 5. Instruct the patient/family on mechanisms to overcome barriers to proper use of medication boxes. 6. Demonstrate and participate in return demonstration of opening and filling the medication box and showing the provider the correct slot for next dosage time.

M-MDI METERED-DOSE INHALERS OUTCOME: The patient will be able to demonstrate correct technique for use of MDIs and understand their role in the management of pulmonary disease.STANDARDS: 1. Instruct and demonstrate steps for standard or alternate use procedure for metered- dose inhalers and ways to clean and store the unit properly. 2. Review the importance of using consistent inhalation technique.

M-MR MEDICATION RECONCILIATION OUTCOME: The patient/family will receive and review a printed medication profile. STANDARDS: 1. Emphasize the importance of maintaining an accurate and updated medication profile. 2. Provide the patient/family with a copy of the patient’s medication profile. 3. Discuss the content of the medication profile with the patient/family. Emphasize that the profile should consist of all medications including prescription, over-the- counter medications, herbals, traditional, and medications dispensed at a non-IHS pharmacy. 4. Emphasize the need to provide a copy of the complete medication profile at every medical visit.

M-NEB NEBULIZER OUTCOME: The patient will be able to demonstrate effective use of the nebulizer device, to discuss the proper care and cleaning of the system, and to describe its place in the care plan. STANDARDS: 1. Describe the proper use of the nebulizer including the preparation of the inhalation mixture, inhalation technique, and care of equipment. 2. Discuss the nebulizer treatment as it relates to the medication regimen.

M-PRX MEDICATION DISPENSATION TO PROXY OUTCOME: The person to whom the medication is dispensed will understand information about the medication and will develop a plan to assure proper medication use. PROXY – Defined as a person who is picking up the patient’s medications when: (a) the patient is not present and (b) the proxy was not present during the patient visit. If the patient or family member is picking up the medication, or if the person picking up the medication was present during the patient’s visit (e.g., family member), use the M-I code. STANDARDS: 1. The proxy will receive information on proper administration of the medications dispensed. 2. The proxy will understand that they are responsible for conveying the education to the patient when picking up the patient’s medications. 3. The proxy will understand the responsibility for delivering the patient’s medications. The pharmacy is no longer responsible for the medications once they leave the pharmacy.

Assessing Health LiteracyUniversal PrecautionsThe National Assessment of Adult Literacy (NAAL) shows that only 12 percent of adults have proficient health literacy. Although low health literacy may affect anyone, people who are most likely to experience low health literacy are older adults, racial and ethnic minorities, people with less than a high school degree or GED certificate, people with low income levels, non-native speakers of English, and people with compromised health status. It is our responsibility, as pharmacists, to ensure that health information and services can be understood and used by all the patients we serve.

Although the NAAL identifies characteristics of patients who are most likely to have low health literacy, anyone can have low health literacy. It is not uncommon for someone with a PHD to have a poor understanding of how the health care system works. Rather than guess or assume that a patient has adequate or low health literacy skills, it is best to apply universal precautions and use clear communications with all patients.

Other Tools for assessing Health LiteracyMost people need some help in understanding health care information. Low health literacy can affect people of any socioeconomic status, education level, race, age, or gender. There are many tools that can be used to assess health literacy and the IHS is currently evaluating three (see Appendix A):

1. The Rapid Estimate of Adult Literacy in Medicine (REALM-R) that assesses the patient’s ability to read and say medical terms. The REALM-R takes about 5-10 minutes to administer and is considered the “gold standard” for this project since this test has been validated among American Indian and Alaska Native (AI/AN) populations.

2. The Brief Questionnaire that asks the patients a series of 16 ordinal questions pertaining to their ability to manage health related information.

3. The Newest Vital Sign that uses an ice cream nutrition label and a series of six questions to assess the ability to process information and numbers.

1. REALM-R

2. Brief Assessment Questions:

1. How often are appointment slips written in a way that is easy to read and understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

2. How often are medical forms written in a way that is easy to read and understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

3. How often are medication labels written in a way that is easy to read and understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

4. How often are patient educational materials written in a way that is easy to read and understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

5. How often are hospital or clinic signs difficult to understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

6. How often are appointment slips difficult to understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

7. How often are medical forms difficult to understand and fill out? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

8. How often are directions on medication bottles difficult to understand? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

9. How often do you have difficulty understanding written information your health care provider (like a doctor, nurse, nurse practitioner) gives you? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

10.How often do you have problems getting to your clinic appointments at the right time because of difficulty understanding written instructions? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

11.How often do you have problems completing medical forms because of difficulty understanding the instructions? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

12.How often do you have problems learning about your medical condition because of difficulty understanding written information? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never 13.How often are you unsure on how to take your medication(s) correctly because of problems understanding written instructions on the bottle label? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

14.How confident are you filling out medical forms by yourself? (1) Extremely (2) Quite a bit (3) Somewhat (4) A little bit (5) Not at all

15.How confident do you feel you are able to follow the instructions on the label of a medication bottle? (1) Extremely (2) Quite a bit (3) Somewhat (4) A little bit (5) Not at all

16.How often do you have someone (like a family member, friend, hospital/clinic worker, or caregiver) help you read hospital materials? (1) Always (2) Often (3) Sometimes (4) Occasionally (5) Never

3. Newest Vital Sign

A practical method for assessing health literacy is to look for signs or actions that may indicate that the patient is having difficulty with the health care system such as:

• Filling out intake forms incompletely • Misspelling many words• Identifying medications by looking at the tablet or capsule rather than reading the label• Handing written materials to a relative or other person accompanying the patient• Providing excuses about reading forms saying, “I will read this at home," or "I can't read this

now; I forgot my glasses"• Aloofness or withdrawal during physician/provider explanations• Frequently misses appointments, including appointments for specialty consultations or additional

laboratory tests• Frequent errors in medications or self-care instructions, and is consequently considered

"noncompliant."

Barriers to Learning Health FactorsHEALTH FACTOR DEFINITION ASSESSMENTNo Barriers (NONE) The patient has no apparent

barriers to learningVisually Impaired (VISI)

The patient has difficulty seeing even with best corrected vision. The difficulty can be compensated with the use of other measures, devices, or both to improve vision (large print, better lighting, magnifying glasses).

The patient may divert the eyes, squint, or state his or her difficulty seeing.

Blind (BLND) The patient is blind and cannot compensate with low vision devices.

The patient may divert the eyes, wear sunglasses inside, state his or her inability to see, or is diagnosed with blindness (best corrected vision is ≤ 20/200 or ≤20 degrees of visual field in the better eye).

Hard of Hearing (HEAR)

The patient has a problem hearing that can be compensated with increased volume or hearing devices.

The patient may not respond to questions initially and may ask for things to be repeated, may speak loudly, bend ear or lean toward the speaker, or wear a hearing device.

Deaf (DEAF) The patient is deaf and CANNOT compensate with increased volume or hearing devices.

The patient may not respond to questions, may look intently at your lips as you speak, may motion to communicate by writing, may use sign language to indicate deafness, or may have a diagnosis of deafness.

HEALTH FACTOR DEFINITION ASSESSMENTDoes Not Read English (DNRE)

The patient is unable to read English.

Ask the patient or the patient’s family about his or her ability to read English. The patient may be embarrassed to admit he or she cannot read English or may make excuses such as “I forgot my glasses.” This is a sensitive subject and must be treated accordingly. Stress “English” in this evaluation and acknowledge that the patient’s primary language may be unwritten. Another technique is to have the patient read a sentence that could be interpreted in different ways and ask the patient how he or she interprets the sentence. If the patient is unable, state that reading English can be hard for people who learned another language first and ask if this applies to him or her.

Speaks English as a second language (ESLA)

The patient’s primary language is not English.

The patient speaks English fluently, but may have minor barriers due to differences in primary language.

Interpreter needed (INTN)

The patient does not readily understand spoken English.

The patient may verbalize the need for an interpreter, answer questions inappropriately, or answer or nod “yes” to all questions. These actions could also imply hearing difficulty and may require further assessment.

FineMotorSkills Deficit (FIMS)

The patient has fine motor skills impairment which can interfere with tasks requiring manual dexterity.

The patient may have difficulty or lack the physical control to direct or manage body movement, such as paralysis, arthritis, amputation, unable to handle testing supplies (for example checking blood sugars or measuring medications).

Dementia (DEMN) The patient may have difficulty learning because of impaired thought processes.

The patient may answer questions inappropriately, behave inappropriately, or display symptoms of confusion or forgetfulness. The patient may have a documented diagnosis of dementia.

HEALTH FACTOR DEFINITION ASSESSMENTValues or Beliefs (VALU)

The patient has values or beliefs that may impact learning; this may also include traditional Native American/Alaska Native values or beliefs that may impact the medical or clinical aspects of heath care.

The patient may comment or be asked about values or beliefs in relation to health information or medical or clinical aspects of health care.

Stressors (STRS) The patient’s ability to learn is limited due to social stressors from current personal difficulties or ongoing mental or behavioral health issues.

The patient may appear distraught, avoid eye contact, or show anger. The stressors may be acute or ongoing, as in the case of conflict, mental disorders, disease, death, alcohol or substance abuse, or domestic violence. Social stressors are external while emotional stressors are internal.

Low Health Literacy (LOHL)

The patient does not demonstrate the ability to obtain, process, and understand basic health information.

Assessment is made by a low score on a health literacy screening tool or observation.

Cognitive Impairment (COGI)

The patient demonstrates cognitive impairment

The patient may be unable to give return demonstration, fails to understand simple information despite multiple attempts to teach, or has a diagnosis of cognitive impairment.

Patient Wellness HandoutThe Patient Wellness Handout (PWH) is a tool that provides patients with access to some of the information in their medical record. Information, education, and the delivery of preventive services improve patient health and facilitate communication between healthcare providers and patients. This results in improved patient outcomes.

The PWH is installed as a menu item under the Health Summary Maintenance Menu. To access the PWH menu, you must have two things: (1) the RPMS keys to access the PWH and (2) the PWH must be added to your RPMS menu. If you cannot find the PWH or if you are unsure if you have access to the PWH, talk to your RPMS site manager or computer operations department.

To quickly find the PWH, try typing: “^patient wellness”

************************************* ** IHS Health Summary ** ** Health Summary Maintenance Menu ** ************************************* IHS PCC Suite Version 2.0

CIHA HOSPITAL

PWH Generate a Patient Wellness Handout DEF Update Default PWH for a Site AAP Print Asthma Action Plan MPWT Create/Modify Patient Wellness Type TPWH Number of PWHs Given to Patients Report

There are a couple of options in the PWH:• PWH is used to print a PWH - this option is not reviewed in this document• DEF is used to designate a default PWH that prints when the option is selected• AAP isn’t really part of the PWH, but it enables you to create, print, and save an asthma action

plan• MPWT is the menu option that is used to create or edit a PWH• TPWH enables you to run many different kinds of reports on the number of PWHs printed

Update Default PWH for a SiteSelect Patient Wellness Handout Menu Option: DEF Update Default PWH for a Site

This option is used to set the default Patient Wellness Handoutfor a site.

Select PCC MASTER CONTROL SITE: TEST HOSPITAL// <ENTER> IHS TEST 01 NC DEFAULT PAT WELLNESS HANDOUT: ADULT REGULAR// ?? <ENTER> Choose from: ADULT REGULAR CHRIS'S WELLNESS HANDOUT MEDICATION RECONCILIATION DEFAULT PAT WELLNESS HANDOUT: ADULT REGULAR// ADULT <ENTER> ADULT REGULAR

Asthma Action PlanAn asthma action plan is recommended for all patients with asthma, especially those with moderate to severe persistent asthma. It is recommended that the asthma action plan be reviewed and updated at least yearly. Before printing the asthma action plan, you will need to know what the instructions are for patients when they are in the red or yellow zones.

Select Patient Wellness Handout Menu Option: AAP<ENTER> Print Asthma Action Plan

*** Print ASTHMA ACTION PLAN ***

This option will produce an Asthma Action Plan thatcan be given to the patient.

Select patient: DEMO,PATIENT <ENTER> <CWAD> M 03-22-1947 XXX-XX-0003 CI 1

Please enter the RED ZONE Plan for this patient, including medication name(s)and instructions. If you don't enter anything, a blank line will be printed on the form so that you can write in the medication name.

Enter Patient's Red Zone instructions: Take 2 puffs of albuterol inhaler every 5 minutes. Take one prednisone 40mg tablet. Call the Emergency Room.

Please enter the YELLOW ZONE Plan for this patient, including medication name(s)and instructions. If you don't enter anything, a blank line will be printed on the form so that you can write in the medication name.

Enter Patient's Yellow Zone instructions: Take 2 puffs of albuterol inhaler every 5 minutes. Check peak flow in 15 minutes. If you are not in the green zone, call the Emergency Department.

Select one of the following:

P PRINT Output B BROWSE Output on Screen

Do you wish to: P// <ENTER> RINT OutputDEVICE: HOME//<ENTER> VT Right Margin: 80//

TEST HOSPITAL Today's Date: Jan 26, 2010Patient Name: DEMO,PATIENT Birth Date: Mar 22, 1947 Age: 62_______________________________________________________________________________My Doctor: Doctor Smith Phone number: 555-867-5309 Address: 1 Main Street Cherokee, NC 28734My Pharmacy: Test Pharmacy Phone number: 555-867-5309My Contact person: Demo Phone number: 555-555-1234_______________________________________________________________________________

Asthma Triggers DUST MITES Documented on Sep 30, 2008 AIR POLLUTANTS Documented on Sep 30, 2008 TOBACCO SMOKE Documented on Sep 30, 2006

ASTHMA ACTION PLAN

Do your peak flow today. What is your number? What Zone are you in? 0-224 RED ZONE [0-49% of Best Peak Flow] 225-359 YELLOW ZONE [50-79% of Best Peak Flow] 360-450 GREEN ZONE [80-100% of Best Peak Flow]

TEST HOSPITAL Today's Date: Jan 26, 2010Patient Name: DEMO,PATIENT Birth Date: Mar 22, 1947 Age: 62

Your Personal Best Peak Flow: 450 liters/minute on Oct 16, 2009

Follow these steps to control your asthma.*******************************************************************************

RED ZONE [49-0%] - Need Medical Help!! Peak Flow less than 226 liters/minute ORYou are coughing, short of breath, and wheezing.You have trouble walking or talking.Your rescue medicine doesn't work.

Take 2 puffs of albuterol inhaler every 5 minutes. Take one prednisone 40mg tablet. Call the Emergency Room.

Ask someone to bring you to the Emergency Room, call 911, or call your doctor.*******************************************************************************

YELLOW ZONE [50-79%]- Asthma is Getting Worse Peak Flow is 225-359 liters/minute liters/minute ORYou are coughing or wheezing.You are waking at night from your asthma.You have some trouble doing usual activities.

Take 2 puffs of albuterol inhaler every 5 minutes. Check peak flow in 15 minutes. If you are not in the green zone, call the Emergency Department.

Keep taking your green zone medications. Check your peak flow readings every few hours.

CALL YOUR DOCTOR or care provider IF:1. You are in your yellow zone for more than 24-48 hours.2. OR You need to use your reliever medication more than every 4 hours.3. OR Your symptoms are getting worse.*******************************************************************************

GREEN ZONE [100-80%] - You Are Doing Well Peak Flow is 360-450 liters/minute ORYou have no coughing, wheezing, or chest tightness during the day or night.You sleep through the night without coughing, wheezing, or chest tightness.You can do usual activities.

Take your long-term control medication every day.

Active Controller MedicationsFluticasone MDI Two puffs every 12 hours to prevent asthma symptoms

Active Reliever MedicationsAlbuterol MDI Two (2) puffs every six (6) hours as needed for breathing

Create/Modify PWHsWith version 2 of the PWH you can create a handout the same way you can create different health summaries by adding or removing different components.

Select Patient Wellness Handout Menu Option: MPWT <ENTER> Create/Modify Patient Wellness Type

This option will allow you to create a new or modify an existingPatient Wellness Handout type.

Select HEALTH SUMMARY PWH TYPE NAME: TEST <ENTER> Are you adding 'TEST' as a new HEALTH SUMMARY PWH TYPE (the 5TH)? No// Y <ENTER> (Yes)NAME: TEST// <ENTER>LOCK: <ENTER>

Patient Wellness Handout: TEST STRUCTURE: Order Component

Enter ?? for more actions

MS Modify Structure PH Print HandoutDH Display Handout Q QuitSelect Action:+// MS <ENTER> Modify Structure You can add a new component by entering a new order number andcomponent name. To remove a component from this PWH type select thecomponent by name or order and then enter an '@'.

Select SUMMARY ORDER: 10 <ENTER> Are you adding '10' as a new STRUCTURE (the 1ST for this HEALTH SUMMARY PWH TYPE)? No// Y <ENTER> (Yes) STRUCTURE COMPONENT NAME: MEDICATIONS <ENTER> COMPONENT NAME: MEDICATIONS// <ENTER>

Select SUMMARY ORDER: 20 <ENTER> Are you adding '20' as a new STRUCTURE (the 2ND for this HEALTH SUMMARY PWH TYPE)? No// Y <ENTER> (Yes) STRUCTURE COMPONENT NAME: ?? <ENTER> This shows you all of the available components

This field specifies a component to appear on the health summary, in the order indicated by the SUMMARY ORDER field. A component must be specified for the entry in the STRUCTURE multiple to be created, and components are chosen from those present in the HEALTH SUMMARY COMPONENT file. Entering a question mark "?" will produce a list of the available components. Choose from: ACTIVITY LEVEL ALLERGIES ASK ME THREE QUESTIONS BLOOD PRESSURE CANCER SCREENING CHOLESTEROL DIABETES CARE HEIGHT/WEIGHT/BMI HIV SCREENING IMMUNIZATIONS DUE IMMUNIZATIONS RECEIVED MEDICATIONS PATIENT GOALS QUALITY OF CARE TRANSPARENCY REPORT CARD STRUCTURE COMPONENT NAME: ASK ME THREE QUESTIONS <ENTER> COMPONENT NAME: ASK ME THREE QUESTIONS// <ENTER>

Select SUMMARY ORDER: 30 <ENTER> Are you adding '30' as a new STRUCTURE (the 3RD for this HEALTH SUMMARY PWH TYPE)? No// Y <ENTER> (Yes)

Select SEQUENCE: 10 <ENTER>

Are you adding '10' as a new SEQUENCE (the 1ST for this STRUCTURE)? No// Y <ENTER> (Yes) SEQUENCE TRANSPARENCY QA MEASURE: ?? <ENTER> Choose from: ASTHMA MEDICATION STATUS DIABETES AND BP CONTROL DIABETES AND GLYCEMIC (A1c) CONTROL DIABETES AND LDL CONTROL FLU SHOT (INFLUENZA) VACCINE SEQUENCE TRANSPARENCY QA MEASURE: ASTHMA MEDICATION STATUS <ENTER> TRANSPARENCY QA MEASURE: ASTHMA MEDICATION STATUS // <ENTER> Select SEQUENCE:

Patient Wellness Handout: TEST STRUCTURE: Order Component 10 MEDICATIONS 20 ASK ME THREE QUESTIONS 30 QUALITY OF CARE TRANSPARENCY REPORT CARD Measures: 10 ASTHMA MEDICATION STATUS

MS Modify Structure PH Print HandoutDH Display Handout Q Quit

Select Action:+// MS Modify Structure

You can add a new component by entering a new order number andcomponent name. To remove a component from this PWH type select thecomponent by name or order and then enter an '@'.

If you add something but want to remove it, you can delete components from the PWH

Select SUMMARY ORDER: 30// 30 <ENTER> QUALITY OF CARE TRANSPARENCY REPORT CARD SUMMARY ORDER: 30// @ <ENTER> SURE YOU WANT TO DELETE THE ENTIRE '30' SUMMARY ORDER? Y <ENTER> (Yes)

Patient Wellness Handout: CHRIS'S SECOND TEST STRUCTURE: Order Component 10 MEDICATIONS 20 ASK ME THREE QUESTIONS

MS Modify Structure PH Print HandoutDH Display Handout Q Quit

From this menu, you can generate a sample PWH to see how it will look

Select Action:+// DH <ENTER> Display Handout Select PATIENT NAME: DEMO,PATIENT <ENTER>

Patient Wellness Handout: TEST <ENTER> My Wellness Handout Report Date: Jan 26, 2010 Page: 1 ------------------------------------------------------------------------------

********** CONFIDENTIAL PATIENT INFORMATION [CCL] Jan 26, 2010 **********

DEMO,PATIENT HRN: 1 CHEROKEE INDIAN HOSPITAL 1 MAIN STREET CHEROKEE, NC 28719 CHEROKEE, NORTH CAROLINA 28719 DOCTOR SMITH 555-555-1234 555-867-5309

Thank you for choosing TEST HOSPITAL. This handout is a new way for you and your doctor to look at your health.

______________________________________________________________________

MEDICATIONS - This is a list of medications and other items you are taking including non-prescription medications, herbal, dietary, and traditional supplements. Please let us know if this list is not complete.

1. AMOXICILLIN 250MG/5ML SUSP (150ML) Directions: TAKE 1 TEASPOONFUL BY MOUTH THREE (3) TIMES A DAY FOR TEN DAYS

2. ARTIFICIAL TEARS (PVA) 15ML Rx#: 2787163 Refills left: 11 Directions: INSTILL 1 DROP INTO AFFECTED EYE(S) FOUR TIMES A DAY IF NEEDED

3. ASPIRIN= 325MG *EC* TAB Rx#: 2847683 Refills left: 11 Directions: TAKE ONE (1) TABLET DAILY; GETS FROM PHARMACYMART

4. CALCIUM ACETATE 667MG GELCAPS Rx#: 2847605 Refills left: 11 Directions: TAKE ONE (1) CAPSULE BY MOUTH THREE TIMES A DAY

5. PHENYTOIN= 100MG CAP Rx#: 2847606 Refills left: 3 Directions: TAKE ONE (1) CAPSULE BY MOUTH THREE TIMES A DAY [CLINIC]

==========

Your prescription for these medications has expired. You need to talk with your prescriber to get a new prescription for these medications.

6. ALBUTEROL NEB SOLN 0.083% (3ML) U/D Rx#: 2847600 Refills left: 0 Directions: USE 1 AMPULE INHL NOW Last date filled: USE 1 AMPULE INHL NOW Expired on: JAN 14,2010

______________________________________________________________________ ASK ME 3 - Every time you talk with a doctor, nurse, pharmacist, or other health care worker, use the Ask Me 3 questions to better understand your health. Make sure you know the answers to these three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this?

PWH Reports

The PWHs that are printed can be tracked and evaluated using the PWH tally report. You can also see when patients got a PWH by adding a component to the health summary - the health summary will show what type of PWH the patient received and the date they received it.

Select Patient Wellness Handout Menu Option: TPWH <ENTER> Number of PWHs Given to Patients Report

This report will tally the number of Patient Wellness Handouts given topatients. The user will be able to tally based on handout type, locationdate the handout was generated and user/provider who generated the handout.Optionally, the user can produce a list of patients receiving the handout.

Enter beginning Date of Patient Wellness Handout: T-180 <ENTER> (JUL 30, 2009)

Enter ending date of Patient Wellness Handout: T <ENTER> (JAN 26, 2010)

Do you wish to run the report for a particular patient handout? N//<ENTER> NO

Do you wish to run the report for a particular location? N//<ENTER> NO

Do you wish to run the report for a particular provider/user? N//<ENTER> O

Do you want a list of patients? N// YES <ENTER>

Select one of the following:

N Name of Patient P Provider/User L Location T Type of Handout D Date Handout Generated

How do you want the list sorted: N// Type of Handout <ENTER>

Select one of the following:

P PRINT Output B BROWSE Output on Screen

Do you wish to: P// <ENTER> RINT OutputDEVICE: HOME// <ENTER> VT Right Margin: 80// <ENTER>

********** CONFIDENTIAL PATIENT INFORMATION [CCL] Jan 26, 2010 ********** PATIENT WELLNESS HANDOUT TALLY Date Range: Jul 30, 2009 - Jan 26, 2010Handout Types Selected: AllLocations Selected: AllProviders/Users Selected: All--------------------------------------------------------------------LOCATION #-------------------------------------------------------------------- TEST HOSPITAL 2000 ADULT REGULAR 1879 LAST NAME, FIRST A 204 LAST NAME, FIRST B 38 LAST NAME, FIRST C 6

Patient Wellness Handout Report Date: Jan 26, 2010 Page: 11------------------------------------------------------------------------------:HRN Patient Name Date Type Provider Loc-------------------------------------------------------------------------------

1 DEMO,PATIENT 01/26/10 TEST LAMER,CHRISTOP CI1235 LAST, FIRST 01/26/10 ADULT REGULAR LAST, FIRST CI1235 LAST, FIRST 07/30/09 ADULT REGULAR LAST, FIRST CI

Enter RETURN to continue or '^' to exit: ^ <ENTER>

********** CONFIDENTIAL PATIENT INFORMATION [CCL] Jan 26, 2010 **********

Patient GoalsUltra-Brief Personal Action Planning* (UB-PAP)The Ultra-Brief Personal Action Plan has 5 core elements:1. The plan must be truly patient-centered, that is what the patient himself/herself actually wants to do, not what the doctor told him/her to do.2. The plan must be behaviorally specific – that is very concrete and specific about what, when, where, how long, etc.3. The patient should re-state the complete plan (i.e. “commitment statement”). 4. The plan should be associated with a level of confidence (on a 1 to 10 scale) of 7 or greater. If the confidence level is <7, the clinician and patient should begin problem-solving on strategies tomodify the plan. 5. There should be a specific date and mechanism for follow-up (or accountability).Ultra-Brief Personal Action Planning is structured around 3 core questions:1. ___ Elicit patient preferences/desires for behavior change“Is there anything you would like to do for your health over the next few days (weeks) before I see you again?”___ What? ___ Where? ___ When? ___ How often? ___ Elicit commitment statement (e.g. “I will walk for 20 minutes, in myneighborhood, every Monday, Wednesday and Friday before dinner”)2. ___ Check confidence level“That sounds like a great plan. But changing behavior and sticking with a plan is actually very hard for most of us. If you consider a confidence scale of 1 to 10, where ‘10’ means you are very confident you will carry out the plan and ‘1’ means you are not at all confident, about how confident are you?”If confidence level <7, problem solve solutions

“That’s great that you feel a confidence level of 5. That’s a lot higher than 1. I wonder if there are some ways we could modify the plan so you might get to a confidence level of 7 or more. Perhaps you could choose a less ambitious goal, ask for help from a friend or family member, or think of something else that might help you feel more confident about carrying out the plan”?3. ___ Arrange follow-up “Great, so let’s make a date for our next appointment, so we can check on how you’re doing with your plan.”*Ultra-Brief Personal Action Planning, © Steven Cole, MD, Professor of Psychiatry, Stony Brook University. May be reproduced, not-for-profit, for clinical or education purposes. Steven.cole@stonybrook.edu (unpublished document, 2008).

Tips to Promote Health LiteracyUse Simpler WordsInstead of….. Use…..Abdominal Stomach

Accommodations Places to stay

Accurate Correct

Acquire Get, buy, pick up

Additional More

Applying To apply

Appropriate Correct, right for you, right

Approximately About

Area Spot, place, section

Circulation Blood flow, way it moves through

Component Part, piece

Consult Ask, talk to, check with

Contains Has

Deficiency Lack

Diagnosing To find out

Discussion Talk with you

Edema Swelling, holding fluid

Elevate Raise, lift

Eligible Can get, can apply for

Equivalent Equal

Evaluate Check

Examination Exam or test

Excessive More than expected, lots

Facilitate Help, assist

Factor Reason, cause

Flatulence Gas, passing gas

Flexible Able to bend

Frequently Often

Health care professional Doctor, nurse, dietitian or therapist

Illustrations Pictures, drawings

Implement Do, follow

Inability Not able

Intermittent Now and then

Interventions Things you can do

Lower extremity Leg

Maintain Keep

Majority Most

Medication Drug, medicine

Modify Change

Necessary Needed

Notify Call, tell

Nutrition Diet, food and fluids, how you eat

Obtain Get

Objective Goal, aim

Optimal Best

Option Choice

Oral Cavity Mouth

Particular Certain

Perspective View

Pharmacy Drug store

Physician or surgeon Doctor

Possibility Chance

Prescribed Ordered

Procedure for How to

Provide Give, supply

Purchase Buy

Radiology X-ray

Recommendations What your ??? told you to do, things to try

Registration Sign in

Regulate Control

Reimburse Pay or pay back

Requirement Need

Securely So it doesn’t come off, so it is safe, tight

Selection Choice

Similar Like, same as

Subsequent Next, future

Substituted Used in place of, instead of

Sufficient Enough

Temporary Short term use, for awhile

Termination End or finish

Understand Know, can you tell me about…

Upper extremity Arm

Urination Passing urine, passing water, going to the bathroom

Utilize or utilization Use

Other points to keep in mind:• Pay attention to local customs and phrasing. • Watch cultural variations in word choices.

Tips for creating patient handoutsOne out of five American adults reads at the fifth grade level or below, and the average American reads at the eighth to ninth grade level, yet most health care materials are written above the tenth grade level. The IHS health literacy workgroup recommends that all patient materials be written at a sixth grade level or below. Some simple recommendations for writing documents are:

1. Write in Plain Language2. Use Simple Vocabulary3. Utilize Abbreviations that may be utilized consistently in the health care setting 4. Refrain from using authoritative and legal language5. Refrain from using colloquialisms, slang or jargon6. Write in the active voice 7. Write in Simple Sentences8. Include information on where patients can obtain additional information or assistance within the

written material.9. Use at least a 12 point font (14 is even better)10. Limit bulleted lists instead of long paragraphes (but limit them to 5-6 bullets)

11. Use tools to assess reading level of the document. Documents developed for patients should be written at a 6th grade or lower reading level. You can assess reading level with Microsoft Word by selecting “tools” in the menubar, then “options,” then “spelling & grammar,” then ‘show readability statistics.”

All written materials should be reviewed with the patient during the time of the encounter.

Health Literacy White PaperIndian Health Service:

White Paper on Health Literacy

Health Literacy has come to the forefront as a major public health issue. The problem of low

health literacy has been addressed by many institutions: Institute of Medicine (IOM), Department of

Health and Human Services (DHHS), including Indian Health Service (IHS), and American Medical

Association (AMA). In 2004, IOM released a report that approximately 90 million people, almost half of

the United States (US) population, have inadequate health literacy skills (1). Indian Health Service

recognizes that many of their American Indian and Alaska Native (AI/AN) patients are included in these

statistics. While low health literacy affects people from all facets of life, it is disproportionately

burdensome on vulnerable populations, such as AI/AN people and their elders. Persons with limited

health literacy skills make greater use of services designed to treat complications of disease and less use

of services designed to prevent complications. The primary purpose of this paper is to focus the issue of

health literacy on the AI/AN population.

90 million people, almost half of the US population, have inadequate health literacy skills.

What is Health Literacy?

Health literacy is the degree to which individuals have the capacity to obtain, process, and

understand basic health information and services needed to make appropriate health decisions (2).

Health literacy should not be confused with literacy; in fact, health literacy depends on many variables

and is not necessarily related to years of education or general reading ability. Health literacy requires the

patient to be able to follow instructions, analyze the given information, and make well-informed

decisions in health situations. This includes, but is not limited to, reading prescription labels, properly

taking prescription medication, and filling out medical forms. Navigating the health care system is

difficult and the demands on patients are steadily increasing (3). Everyday, patients are expected to

describe their symptoms accurately, weigh the risks and benefits of various procedures, interpret test

results, and understand spoken and written medical advice about treatment directions. For people with

low health literacy this can make seeking health care overwhelming.

Health literacy requires the patient to be able to listen to instructions, analyze the given information, and make well informed decisions in health situations.

The pervasiveness of the problem

Health literacy statistics

Being able to read does not necessarily mean one will be health literate. However, the lack of

basic literacy skills does mean that patients almost certainly will have difficulty reading and

understanding basic health information. In fact, among 12th grade students, 80% of American Indians

scored below proficient in reading compared to 58% of whites (4). A study by Williams et al found that

of the 2,659 patients surveyed, 41.6% were unable to comprehend directions for taking medication on an

empty stomach and 59.5% could not understand a standard informed consent document. Additionally,

out of 1,892 English-speaking patients, 35.1% were found to have inadequate or marginally functional

health literacy.

How to determine health literacy

There are numerous methods developed to test the literacy skills of patients. One of the most

popular tests is the Rapid Estimate of Adult Literacy in Medicine (REALM) (8). REALM tests the

patient’s ability to pronounce 66 common medical words and lay terms for body parts and illnesses and

can be administered in less than two minutes. Other tests include the Newest Vital Sign (NVS) or Test of

Functional Health Literacy (TOFHLA). However, the administration of tests often times is not the best

way to evaluate patients in a medical setting as it may discourage patients from seeking needed medical

treatment.

41.6% of people surveyed were unable to comprehend directions for taking medication on an empty stomach.

Many studies have been done to determine less direct ways of evaluating a patient’s literacy

skills (3,6,7). Other methods used to identify patients with low health literacy skills include:

• Hand brochure to patient upside down and see if he or she correctly aligns the page in order to

read it.

• Ask the patient if the print on the brochure is clear enough to read.

• Determine if the patient registration form or others forms are filled out completely and correctly.

• Notice if the patient gives excuses when asked to read something (e.g., forgot reading glasses,

has a headache).

• Observe if the patient gives medical brochures or materials to person accompanying them

• Verify the patient can describe how to take medications.

Health literacy can be identified by health care providers using standard tests or simple observation methods.

Impact on the health care system

Health and cost implications

Much research has been done on the correlation between health literacy and health outcomes. A

release by DHHS stated that literacy skills are directly related to use of health care services such as

mammography and cancer screenings (9). Furthermore, inadequate literacy is significantly associated

with increased risk of hospitalization and overall worse health status, due to lack of understanding the

disease process and necessary prevention measures. Increased medical costs are also associated with low

health literacy, as people with low health literacy have been found to be hospitalized 40-50% more often

than those with adequate health literacy. A study by the National Academy on Aging Society estimated

additional health care expenditures in 1998 as a result of low health literacy skills are about $73 billion

(9).

Health care costs for those with low health literacy are four times higher than those with adequate health literacy. Implications for American Indian and Alaska Native people

Health literacy is closely linked to poverty (11). “According to the 1990 census, the median

household income in 1989 for AI/ANs residing in current Reservation States was $19,897, compared

with $30,056 for the US all races population. During this period, 31.6% of AI/ANs lived below the

poverty level, in contrast with 13.1% for the US all races population (22).” These poverty rates have

substantial health effects on the AI/AN population. In his address entitled “Literacy and Wellness,” Dr.

Charles W. Grim, former Director of the Indian Health Service, stated that AI/ANs tend to have higher

chronic disease rates than the rest of the nation. For diabetes alone, the rate among AI/ANs is 420%

higher (13). Patients with diabetes and poor health literacy “are nearly twice as likely to have poorly

controlled blood sugar and serious long term complications.” This may be because people with low

health literacy skills tend to have less knowledge of their disease and less of an understanding for

effective self-management skills than patients with higher health literacy skills (14). As of December

2006, the Director of IHS identified several key initiatives that could all be greatly impacted by

increased health literacy: chronic disease management, behavioral health, and health promotion/disease

prevention. AI/ANs are at increased risk for health complications due to poor health literacy.

There are many methods to improve patient’s health literacy and there has been little research to

show which method is preferred, especially in the AI/AN community. It is suggested to a) consider

cultural diversity, b) improve patient-provider communication, c) use appropriate written materials, and

d) include health literacy in strategic planning.

Cultural diversity

There is a large gap in cultural understanding between patients and health care providers. In

order to improve minority health, it is important for medical professionals to understand that cultural

beliefs play an important role in health care (16). For example, a Native American receiving radiation

for cancer asks his doctor if he can use the tribal sweat lodge to purify himself. But his Anglo physician

recommends against it. The man foregoes the sweat lodge, but feels depressed and spiritually deprived

(which could) possibly affect his overall health and recovery (17). Failure to take into account how a

person’s culture will influence their actions may severely compromise communication and ultimately the

effectiveness of the care provider’s message. Some believe that providing information in a culturally

relevant context will make the message more persuasive, while others believe it will simply make the

information more interesting for the patient (18). Either way, if the information is not relevant to the

patient, it is unlikely to be taken into consideration by the patient.

Making health information culturally relevant to the patient will make it more likely to be truly considered by the patient.

Communication

Improving communication between patients and health care providers is one of the best ways to

combat low health literacy. Recently, the National Resource Center on Native American Aging held a

seminar with health professionals and Native Elders to discuss how to improve health literacy and

communication. A 2004 report from the National Resource Center on Native American Aging provides a

summary of strategies for health care professionals to improve communication with their patient (19).

Their advice is as follows:

From the health care professionals:

• Plan what to say in logical order one step at a time

• Define health care terms and explain acronyms

• Verify understanding: rephrase message and have the patient explain instructions back to you

(teach-back method)

• Adjust to patient needs

• Encourage participation

• Pay attention to non-verbal communication: What is the patient not saying?

From the Elders:

• Provide more time and allow for interaction

• Help Elders to form questions: What would you want to know if you were in their shoes?

• Be positive. Native healers are positive and supportive that a remedy will work. Often, non-

Native providers indicate that a remedy should be tried and if it does not work, then the

patient can return and try something else.

• Define anatomy using patient-friendly terms.

• Deal with biases, e.g., fear of doctors, denial, anger, etc.

• Be attentive to non-verbal communication (e.g., silences, gestures). Eye contact may be

considered rude.

Using simple language and the teach-back method, as well as addressing the patients’ fears and needs will help to improve the patients’ understanding and compliance of instructions.

Appropriate written materials

Written materials can be a good supplement to oral communications with a patient.

Unfortunately most materials are often written three to four grade levels above the reading level of most

patients. The National Resource Center on Native American Aging (2009) provides guidelines for

creating effective written materials:

• use simple language

• use pictures to explain how to do a procedure

• use short sentences and one message per sentence

• explain why things should be done

• use mostly lower case letters

• include plenty of white space (blank space surrounding the text)

In addition, written materials should “recognize the healing systems, practices, and food preferences or

diet restrictions unique to minority groups (21).”

Improving the readability of written materials and improved oral communication between patients and health care providers will lead to improved health literacy.

Indian Health Service strategic plans

Indian Health Service has incorporated many strategies to improve health literacy among its AI/

AN population. In 1995, IHS began the Patient Education Protocols and Codes Project (PEPC) which

provides training to IHS staff on educating AI/AN patients. As a result of this project, educational

encounters have increased from 452,000 in 2001 to 2,202,279 in 2008 (RPMS report).

In 2005, the IHS Health Communications Workgroup began working to integrate the Healthy

People 2010 objectives. These objectives for its AI/AN population include:

• Increasing internet access

• Improving health literacy

• Increasing patient-provider communication

Other health literacy endeavors: The Partnership for Clear Health Communication

The Partnership for Clear Health Communication (PCHC) is a coalition of national organizations

working together to promote awareness of low health literacy and its effect on health outcomes. PCHC

has developed many useful resources which are available for free from their website: www.askme3.org.

These resources, including posters, brochures, and power point presentations, are intended to deliver

information to patients, as well as medical education and practice management tools for health care

professionals.

Ask Me 3 is a campaign by PCHC to promote patient-initiated communication by encouraging

patients to ask questions. Ask Me 3 has a downloadable worksheet available from their website that

offers tips for improved communication. With permission from the PCHC, IHS modified the Ask Me 3

materials to incorporate AI/AN community images. These are available from: www.ihs.gov/

nonmedicalprograms/healthed. The premise is based on three key questions that every patient should

ask when visiting their health care provider:

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Ask Me 3 initiative delivers information to patients, as well as medical education and practice management tools for all people interested in health literacy.

Conclusion

Using available demographic and socioeconomic data, IHS recognizes that low health literacy is

disproportionately burdensome on AI/AN people and their elders. Since low health literacy also

adversely affects the health care system, IHS is working to address this problem by providing hospital

staff and patients with a variety of tools and resources to improve healthcare communications. Health

care workers are encouraged to a) consider cultural diversity, b) improve health communication, c) use

appropriate written materials, d) include health literacy in strategic planning, and e) utilize national

campaigns to promote health literacy activities. Patients are provided education and support to make

appropriate health decisions and promote self-care management skills. IHS is working on a national and

local level to increase patient-centered activities and provide transparent service to our patients by

improving health literacy.

References

1. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End Confusion.

Institute of Medicine. Washington, DC: The National Academies Press; 2004, p 345.

2. HHS, National Institutes of Health, National Library of Medicine (NLM). In: Selden, C.R.; Zorn,

M.; Ratzan, S.; et al.; eds. Health Literacy, January 1990 Through 1999. NLM Pub. No. CBM

2000-1. Bethesda, MD: NLM, February 2000, vi.

3. McCray A. Promoting Health Literacy. Journal of Medical Information Association

2005;12:152-163

4. 2003 Nation’s Report card. From the National Center for Education Statistics. http://nces.ed.gov/

NATIONSREPORTCARD. Retrieved on May 22, 2009.

5. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at

two public hospitals. JAMA. 1995;274(21):1677–82.

6. Ask Me Three. Partnership for Clear Health Communication. http://www.askme3.org. Retrieved on

May 22, 2009.

7. Identifying and assisting low-literacy patients with medication use: a survey of community

pharmacies. Annals of Pharmacotherapy 2005; 39:1441-5

8. Murphy PW et al. Rapid Estimate of Adult Literacy in Medicine (REALM): a quick reading test for

patients. Journal of Reading 1993;37(2) 124-130

9. US Department of Health and Human Services. Health communication. In: Healthy People 2010,

second edition. With understanding and improving health and objectives for improving health.

(chapter 11). Washington, DC: US Government Printing Office, 2000.

10. Baker DW, Parker RM, Williams MV, Clark WS. “Health literacy and the risk of hospital

admission.” J Gen Intern Med. 1998; 13: 791-98.

11. Centers for Health Care Strategies. http://www.chcs.org/publications3960/publications.htm.

Retrieved on May 22, 2009.

12. National Conference of State Legislators. http://www.ncsl.org/print/pubs/slmag/

2003/03slapr_sts.pdf. Retrieved on may 22, 2009.

13. “Literacy and Wellness” an address by Charles W. Grim, D.D.S., M.H.S.A. Assistant Surgeon

General Director, Indian Health Service. From the conference “Promoting Wellness in American

Indian Communities: Addressing Health Disparities and Health Literacy”. http://www.ihs.gov/

PublicInfo/PublicAffairs/Director/2003_Statements/FINAL_Literacy_Oct_2003.pdf. Retrieved

on May 22, 2009.

14. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma

knowledge and self-care. Chest. 1998; 114:1008-1015

15. Betancourt, J.R. et al. (2002) Cultural Competence in Health Care: Emerging Frameworks &

Practical Approaches. The Commonwealth Fund.

16. Health communication and cultural diversity. Centers for health care strategies fact sheet, http://

www.chcs.org. Retrieved on May 22, 2009.

17. “Providing Culturally Sensitive Health Care”. National Women’s health Report. http://

www.healthywomen.org/healthreport/october2004/pg3.html.. Retrieved on May 22, 2009.

18. Kreuter MW, Steger-May K, Bobra S, et al. Sociocultural characteristics and responses to cancer

education materials among African American women. Cancer Control. 2003 Sep Oct; 10(5

Suppl):69–80.

19. Health Literacy Review: Promoting wellness in Native American communities. Addressing Health

Disparities and Health Literacy Communicating with clients. National Resource Center on

Native American Aging. http://ruralhealth.und.edu/projects/nrcnaa/pdf/health_literacy.pdf.

Retrieved on May 22, 2009.

20. Schaafsma E, Raynor T, and de Jong-van den Berg L. Assessing medication information by ethnic

minorities: barriers and possible solutions. Pharm World Sci 2003;25(5): 185-190

21. Wilson F, Racine E, Tekeili V, and Williams B. “Literacy, Readability and Cultural Barriers: Critical

Factors to Consider when Educating Older African Americans”. Journal of Clinical Nursing

2003;12: 275-282

22. Trends in Indian Health, 2000-2001. Rockville, MD: Indian Health Service, 2000.