Alacare Home Health & Hospice Social Work Supervisor Non-compliance, Poor Outcomes and Acute Hospitalizations… Is it Low Health Literacy? Kim Riggs, LGSW Alacare Home Health & Hospice Social Work Supervisor Proprietary property of Alacare. Copying or distribution by others is prohibited

What is Health Literacy?

Health Literacy: The degree to which an individual is able to obtain, process and understand the health information and services needed to make appropriate health decisions and to follow instructions for treatment.

Low Health Literacy Impairment in an individual’s ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and to following instructions for treatment. Does one even have to be impaired in order to have difficulty understanding his or her own healthcare? Absolutely not. Follow up instructions are often glossed over, spoken of in terms that a lay person does not understand, or completely ignored. Sometimes as healthcare professionals we assume that others have knowledge that they do not possess.

The Scope of Low Health Literacy Statistics from the US Dept. of Health and Human Services and the National Patient Safety Foundation More than 75 million Americans have limited health literacy, making it difficult for them to understand and use basic health information. Literacy skills are a stronger predictor of an individuals health status than age, income, employment status, education level, or racial/ethic group. 1 out of 5 American adults reads at the 5th grade level or below, and the average American reads at the 8th or 9th grade level, yet most health care materials are written above the 10th grade level. While we understand our role in delivering the proper health information in the proper way, the scope of the actual health literacy program is overwhelming. It is the single most prevalent predictor of health status.

Scope (Continued) A disproportionate number of minorities and immigrants are estimated to have literacy problems: 50% of Hispanics 40% of Blacks 33% of Asians While ethnic minority groups are disproportionately affected by low health literacy, the majority of those with low health literacy skills in the US are white, native-born Americans (who represent the largest segment of the population) More than 66% of US adults age 60 and over have either inadequate or marginal literacy skills. The aged population in the US is growing by leaps and bounds and 66% of those have marginal literacy skills!

The Impact of Low Health Literacy In 2011 the US Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) reviewed the literature from more than 100 new studies from 2004 to 2011 on health literacy. The following conclusions were drawn: What is the impact of Low Health Literacy?

Impact (continued) Low health literacy in older Americans is linked to poorer health status and a higher risk of death. Low health literacy in adults of all ages is linked to more frequent use of hospital emergency rooms and inpatient care. Low health literacy is linked to a lower likelihood of utilizing preventative services such as mammograms, flu shots, and routine physician appointments. Individuals with low health literacy have a greater likelihood of taking medications incorrectly compared with adults with higher health literacy. Poor health and even death, increased hospitalization which increases all of our healthcare costs, less use of preventative medical strategies resulting in more illness, higher likelihood of medication imcompliance leading to further medical issues

The Cost of Low Health Literacy A limited ability to read and understand health care information translates into poor health outcomes and higher economic costs – with Estimates between $50 to $73 billion every year. This is largely due to medications errors, excess hospitalization, longer hospital stays and a greater use of Emergency Departments. One study indicated that the average annual costs for all Medicaid enrollees in California was $3000 per enrollee. For enrollees with limited literacy skills, the average annual cost per enrollee skyrocketed to $13,000. Obviously, all of these issues lead to higher cost on our state and federally funded programs, which ultimately costs all of us more money.

Health Literacy Challenges Red Flags for Low Health Literacy Frequent hospitalizations Non-compliance with medications, blood sugar monitoring, sliding scales, etc. Missed appointments Difficulty understanding health coverage plans (Part D or Medigap) Difficulty understanding premiums, copays and deductibles Difficulty performing return demonstrations. Failure to follow through on instructions for wound care. Unable to state diagnoses. Unable to state name and purpose of medications Unable to give coherent, sequential history Asks few questions And the list goes on!

Red Flags (continued) Unable to accurately report currently utilized resources/services Difficulty understanding concepts related to advance directives Difficulty understanding hospice philosophy What can we do as health care providers to help in these situations?

Strategies and Interventions Responding to Low Health Literacy

An Alternative Definition of Health Literacy that Healthcare Providers Need to Consider: A healthcare provider’s ability to explain, write, and share health care information so that their clients can truly understand and get the health care they need. What is our responsibility in this process? Do we truly want our patients to be successful? Keep in mind that healthcare in general is being judged more and more by its outcomes and compensation is also beginning to be based on outcomes.

Strategies and Interventions Progress can be achieved with a multi-level intervention plan. What can we do? Individuals/Patients/Caregivers – One on One interventions Health Care Providers/Agencies– Awareness, Staff training, written materials and products Macro Level – Policy/legislation, research, funding, education There are many layers to affecting a change in the healthcare literacy, outcomes for patients, and healthcare costs.

Strategies/Tips/Interventions Oral Communication Written Communication Self-Management and Empowerment “Teach Back”

Strategies/Tips/Interventions Tools to Improve Oral Communication Tips for Communicating Clearly The Teach-Back Method Follow-up with Patients Telephone Considerations How to Address Language Differences Culture and Other Considerations We will go over each of these strategies in detail:

Strategies/Tips/Interventions Tips for Communicating Clearly Warm Greeting: Greet patients with a smile and a welcoming attitude. Eye Contact: Make appropriate eye contact throughout the interaction Plain Language: Use common words when speaking to patients. Avoid the use of jargon. Take note of what words they use (i.e. to describe illness or identify resources) and use the words they use. See Handout

Strategies/Tips/Interventions Tips for Communicating Clearly (Cont.) Slow Down: Speak clearly and at a moderate pace. Limit Content: Prioritize what needs to be discussed and limit information to 3 to 5 key points. Repeat Key Points: Be specific and concrete in your conversation and repeat key points. Make a List: Write down key points, instructions, plan of action. We are both auditory and visual learners. More will be understood if we provide both avenues of learning to our patients.

Strategies/Tips/Interventions Tips for Communicating Clearly (Cont.) Patient Participation: Encourage patients to ask questions and be involved in the conversation during visits and to be proactive in their health care. Encourage to ask questions of you, their physicians, nurses, therapists, etc. Ask them: What questions do you still have? Avoid asking: Do you have any questions? Teach Back: Confirm patients understand what they need to know and do by asking them to “teach back”. Ask open ended questions which require thought on the patient's part to answer.

Strategies/Tips/Interventions The Teach Back Method Is asking patients to repeat in their own words what they need to know or do, in a non-shaming way. Is not a test of the patient, but of how well you explained a concept A chance to check for understanding and, if necessary, re-teach the information. Explain to the patinet that you want to make sure that you explained everything correctly.

Strategies/Tips/Interventions Asking for a Teach-Back I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did? Can you please tell me what you are going to ask when you see the doctor? We’ve gone over a lot of information today. In your own words, please review what we’ve talked about So, how do you ask for the Teach Back? Find a way that is comfortable for you.

Strategies/Tips/Interventions Teach-Back Tips Rephrase if a patient is not able to repeat the information accurately. Ask the patient to teach the information back again using their own words, until you are comfortable they really understand it. If they still do not understand, consider other strategies. Do NOT ask yes/no questions like: Do you understand? Do you have any questions? For more than one concept use “chunk and check” Teach the 2-3 main points for the first concept & check for understanding using teach-back. Then go to the next concept.

Strategies/Tips/Interventions Follow Up with Patients – allows reassessment of understanding/ability. Schedule follow-up visits where possible and appropriate Follow-up with phone calls Verify follow-through on referrals. Discuss issues from previous visits. Review previous visit contact notes. Reinforce knowledge and action plans. Document follow-up One strategy may be to go ahead and make follow up appointments for them and give them the appointment information on a summary with all other instructions. If they need to reschedule they may do so.

Strategies/Tips/Interventions Telephone Considerations Use Teach-Back method to assess client’s ability to understand information provided by phone. Schedule face to face contact where client is unable to demonstrate accurate teach-back. Supplement phone call with written information via mail. Telephone interventions and instructions are most appropriate for clients with proficient health literacy.

Strategies/Tips/Interventions Addressing Language Differences Broken English – Use Teach Back Interpreter Services – AIDB, Optimal Phone Interpreters. Concerns with family/friends interpreting Sometimes family and friends are trying to protect the patient or may not understand the instructions or information themselves.

Strategies/Tips/Interventions Culture and Other Considerations Culture Clues: Web site from the University of Washington that offers insight into the health care preferences and perceptions of patients from 10 different cultures and special needs groups . Also covers end of life issues. http://depts.washington.edu/pfes/CultureClues.htm

Strategies/Tips/Interventions Culture and Other Considerations (con’t) Health Beliefs and Customs: Some patients have different beliefs about the causes of and treatment for specific diseases. Some may also have misconceptions or fears with regard to the medical community. Ethnic Customs: Customs like fasting at particular times or the treatment of women by men are things that clinicians need to be aware of. Religious Beliefs: Practices based on religious beliefs such as refusing blood transfusions can be very important in treatment decisions. Dietary Customs: Could have significant effects on patient’s ability and willingness to adhere to plan of care. Interpersonal Customs: Eye contact and touch customs vary.

Strategies/Tips/Interventions Culture and Other Considerations (cont) Learn about your patient’s health beliefs and cultural practices. Read/research ASK the patient or caregiver I’m not familiar with your cultures and beliefs. Can you teach me what I might need to know? What do you call your illness? What do you think caused your illness? How do you think it should be treated? Avoid Stereotyping

Strategies/Tips/Interventions Written Communication 1 out of 5 American adults reads at the 5th grade level or below, and the average American reads at the 8th to 9th grade level, yet most health care materials are written above the 10th grade level. Prescription drug warning pamphlets VA pension application Discharge instructions

Strategies/Tips/Interventions Written Communication (cont.) Make use of written information when instructing patients. Print – no cursive writing Make it look easy to read Use bullets Leave space between points Limit information to a few key points Write short, simple sentences Avoid jargon Use step by step instructions 1, 2, 3,

Strategies/Tips/Interventions Assist with understanding written materials from MD or other health care professionals. Assess each patient’s ability and willingness to complete forms and applications. Provide appropriate level of assistance based on patient abilities. Identify individuals in patient’s internal resource system who can assist with forms/applications. Ask patient to show you forms and information provided by physicians and nurses. Ask patient to teach you about what is on the forms/information to assess level of understanding Review written information for jargon, and redefine words for patient.

Strategies/Tips/Interventions Self Management and Empowerment Identify personal strengths and work to instill confidence in those strenghts. Create an environment that encourages patients to ask questions and get involved with their care. Encourage patients to write down their questions prior to nurse/therapist/md visits. Assist patient in formulating relevant questions. Encourage patients to take medications to md appointments. Emphasize importance of patient agreement with and participation in their plan of care.

Strategies/Tips/Interventions Self Management and Empowerment (cont) Use Teach-Back technique Request feedback on services from patients Identify areas of confusion and provide clarification. Empower clients to utilize internal resources. Empower clients to utilize personal strengths. Teach self advocacy and assertiveness skills Remind patients of their right to self determination Provide positive reinforcement

Strategies/Tips/Interventions General Ideas Pill Boxes Medication Bags Medication logs/diaries Family/Friend present for interactions Alert other medical professionals to low health literacy

Be Creative Be Flexible Be Patient As Teachers: Be Creative Be Flexible Be Patient

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