Health Literacy Perspective of a Hospital Clinician and Educator Health Literacy Workshop Sydney, November 2014 Professor Imogen Mitchell Senior Staff Specialist, Intensive Care, The Canberra Hospital Deputy Dean, ANU Medical School

Immediate Challenge 60% Adult Australians have a low health literacy Patients remember and understand less than half of what clinicians explain to them

Immediate Challenges Health literacy not an immediately approachable term for hospital clinicians Many traditions embedded for over a century, if not longer paternalistic viewdoctor knows best (no need to question) language of mysteryallows supremacy (too intimidating to engage with) time jealousopen conversations deemed not as important assumptionspatient/families will undertake instructions delivered Many variables affect health literacy particularly in hospitals acutely unwelljust want someone to sort something out deliriousthe illness creates confusion emotional shocknot in any frame of mind to take something in

Health Literacy Clinicians need to deliver an outcome where information is provided in such a way that the information is: Understood Applied to enable decision making and action Medical educators describe a learning outcome where a concept is: Understood Applied to make decisions and act to ensure patients are safe Can a similar approach be taken?

Approach to Teaching and Learning Gap Analysis What are the differences between what the student understands and what you would like them to understand Set Learning Outcomes Describe what it is you want your students to do by the end of their time Spiral curriculum Start with simple concepts and build upon them prior knowledge not assumed, language not assumed, repetition Questions and Reflection Allow students to apply concepts and understand how they arrived at their answer

Approach to Health Literacy Gap Analysis What does your patient understand so far? What gaps need to be filled? Set Learning Outcomes What is it that needs to happen? Help patient arrive at a decision? Correct medication to be taken? Understand the implications of a diagnosis? Spiral curriculum Use language that can be understood, allow time, chunk information into small, manageable sound bytes building upon their pre-existing knowledge Questions and Reflection Check for understanding using teach back

AMC Graduate Outcome Elicit patients’ questions and their views, concerns and preferences, promote rapport, and ensure patients’ full understanding of their problem(s). Involve patients in decision making and planning their treatment, including communicating risk and benefit of management options Provide information to patients, family/carers where relevant, to enable them to make a fully informed choice among various diagnostic, therapeutic and management options.

The ANU Medical School Year 1 and 2: Clinical Skills: Doctor-Patient Communication Calgary Cambridge Guide to the Medical Interview Initiating the session Gathering information Providing structure Building relationship Explanation and planning Closing the session

Calgary Cambridge Guide to the Medical Interview Gathering information Exploration of problems Additional skills for understanding the patient’s perspective Actively determines and appropriately explores: Patients ideas (i.e. beliefs re cause) Patients concerns (i.e. worries) regarding each problem Patients expectations (i.e., goals, what help the patient had expected for each problem) Effects: how each problem affects the patients life Encourages patient to express feelings

ANU Medical School Year 3 and 4: Professionalism and Leadership Learning Outcome: “You will demonstrate excellent communication skills that are patient centred, and enable patients and carers to understand their health problems and share decision making around their health care choices ; support the maintenance of a patient’s privacy and dignity; recognise the impact of your own values and your professional status in engaging with patients, carers and colleagues”

Teach Back* Asking patients to repeat in their own words what they need to know or do, in a non-shaming way. 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. *Iowa Health System Literacy Collaborative

Teach Back Examples Ask patients to demonstrate understanding, using their own words : “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?” “What will you tell your husband about the changes we made to your blood pressure medicines today?” Creates an opportunity for dialogue in which the clinician gives information, then asks the patient to respond and confirm understanding before adding any new information.

Teach Back: Using it Well Responsibility is with the clinician Use a caring tone of voice and attitude Use plain language Ask patient to explain using their own words ( not yes/no) Use for all important patient education, specific to the condition Document use of and response to teach-back

Improving Health Literacy Engage clinicians At an early stage, provide understanding of health literacy and its critical importance Provide data that supports its importance particularly in terms of current status of communication, better outcomes with better communication Embed health literacy into every day activities and change the language Continually provide the linkage between health literacy activities and better outcomes for the patient Remind them continuously “ No decision about me without me ”

15