PTP 783 1

1. Review learning theories 2. Discuss a framework in which learning can occur in Geriatric PT practice. 3. Discuss how health literacy impacts Geriatric PT practice. 4. Identify strategies to address assessing health literacy in verbal and written communications. 2

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“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Healthy People

5 Population >65 Non-English Speaking Medications Prescribed Specialists Hospital Stay Length Time spent with Patients Reimburse- ment More Self Management in the Home

The complexity of the healthcare system exacerbates literacy vulnerabilities Payment structures Testing Appointments & Referrals 6

“Every system is perfectly designed to get the results it gets” “The definition of insanity is continuing to do the same thing over and over again and expecting a different result” −Albert Einstein 7

8 “As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve. Health care professionals do not recognize that patients do not understand the health information we are trying to communicate. We must close the gap between what health care professionals know and what the rest of America understands.” Dr. Richard Carmona, U.S. Surgeon General

 General literacy  Experience with health care system  Complexity of information  Cultural and language factors: ◦ ESL ◦ Cultural experience  How information is communicated  Aging and disease/treatment factors 9

 Fills out intake forms incompletely  Misspelling many words  Leaves the clinic before completing forms  Gets angry about forms  Identifies medication by looking at pill rather than reading the label 10 Weiss BD. Health literacy: a manual for clinicians. 2003

n = 19,714 ● Most up to date portrait of literacy in U.S. ● Scored on 4 levels ● Levels 1 and 2 cannot: ◦ Use a bus schedule or bar graph ◦Explain the difference in two types of employee benefits ◦Write a simple letter explaining an error on a bill 11 National Center for Educational Statistics, U.S. Department of Education

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Outcomes Associated with Health Literacy Health Outcomes/Health Services General health status Hospitalization Prostate cancer stage Depression Asthma Diabetes control HIV control Mammography Pap smear Pneumococcal immunization Influenza immunization STD screening Behaviors Only Substance abuse Breastfeeding Behavioral problems Adherence to medication Smoking Knowledge Only Birth control knowledge Cervical cancer screening Emergency department instructions Asthma knowledge Hypertension knowledge DeWalt, et al. JGIM 2004;19:

 90 million Americans have trouble understanding & acting on health information  Unfamiliar/complex text most difficult to read  3 billion Rx written a year  Pharmacist/physician time is limited  Elderly fill 30 Rx/year, see 8 physicians, on average 16 Medication error: most common medical mistake

“How would you take this medicine?” 46% did not understand instructions ≥ 1 labels 38% with adequate literacy missed at least 1 label 395 primary care patients in 3 states Davis TC, et al. Annals Int Med 2006, slide by T Davis 17

18 John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill Slide by Terry Davis

Davis TC, et al. Annals Int Med

 People with low literacy have 30-70% increased risk of hospitalization  RR = 1.29 ( ) Medicare Managed Care  RR = 1.69 ( ) Urban Public Hospital 20 *Adjusted for age, gender, socioeconomic status, health status, and regular source of care. Baker et al. AJPH :1278. Baker et al. JGIM :791.

21 Sudore et al. JGIM 2006; 21: Health, Aging, and Body Composition Study

Simple Familiar Wording Understood by Most Patients 84% (1 st grade.) Slide by Terry Davis 22

More Complex Message Limited Comprehension 59% (10 th -12 th grade. Slide by Terry Davis 23

Unfamiliar Multi-step Instructions Rarely Understood 8% (12 th -13 th grade) Slide by Terry Davis 24

Comprehension Increased with Patient Literacy Level In multivariate analysis only literacy and age predicted comprehension. Patients with low literacy (< 6th gd.) 3x more likely to incorrectly interpret warning labels. 9 79%86%88% † 35%66%78% * 8%64%82% * 8%18%23% * 0%6%15% * * p<.0001, † p<.05 Davis et al. JGIM 2006; 21:847– % with a correct response

 Rapid Estimate of Adult Literacy in Medicine (REALM)  Test of Functional Health Literacy in Adults (TOFHLA)  The Newest Vital Sign (NVS): ◦ recently developed and tested 26

 Word recognition and pronunciation  Read aloud a list of 66 medical words  Takes 2-3 minutes to administer  Highly correlated with other standard tests of reading ability ( )  Does not test comprehension  Not available in other languages 27

fat flu pill dose eye stress smear nerves germs meals disease cancer caffeine attack kidney hormones herpes seizure bowel asthma rectal incest fatigue pelvic jaundice infection exercise behavior prescription notify gallbladder calories depression miscarriage pregnancy arthritis nutrition menopause appendix abnormal syphilis hemorrhoids nausea directed allergic menstrual testicle colitis emergency medication occupation sexually alcoholism irritation constipation gonorrhea inflammatory diabetes hepatitis antibiotics diagnosis potassium anemia obesity osteoporosis impetigo REALM Prevention & Patient Education Project Terry Davis, PhD P.O. Box Shreveport, LA

 17 numeracy items  50 reading comprehension items  Tests ability to read and understand several health care related items  Takes minutes to administer  Best for research purposes  Well correlated with REALM and WRAT (Wide Range Achievement Test)  Available in Spanish 29

Doxycycline 100 MG Take medication on empty stomach one hour before or two hours after a meal unless otherwise directed by your doctor. If you eat lunch at 12:00 noon, and you want to take this medicine before lunch, what time should you take it? 30 Available from: Peppercorn Books & Press Inc. (

Your doctor has sent you to have a _________ X-ray. a. stomach b. diabetes c. stitches d. germs You must have an ________ stomach when you come in. a. asthma b. empty c. incest d. anemia 31 Available from: Peppercorn Books & Press Inc. (

 High correlation between first two reading comprehension passages and entire assessment (including numeracy items)  Administer only the first two reading comprehension passages  Takes 5-7 minutes 32

33 REALMTOFHLA Word recognitionCloze method 2-3 minutes5-7 minutes Grade levels Inadequate/marginal/ adequate English onlyEnglish and Spanish

 Patients are given a nutrition label  6 questions are verbally administered  Assesses literacy and numeracy  Takes 3 minutes  Validated against the TOFHLA  Available in English and Spanish 34 Weiss et al., Ann Fam Med; 3(6) 2005

35 If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Weiss et al., Ann Fam Med; 3(6) 2005 Available at Pfizer Clear Communication Initiative: m/physicians-providers/newest- vital-sign.html

36 REALMNVS Word recognitionProblem-solving 2-3 minutes3 minutes Grade levelsNumber correct (1-6) English onlyEnglish and Spanish

 If just for screening, the REALM is likely the best choice ◦ Easiest to explain to patients ◦ Fastest ◦ Reasonably accurate  For research purposes, REALM is good, but may consider other instruments depending on goal of research 37

 Sensitive topic  Patients go to great lengths to hide problems  May offend some  Inappropriate labeling 38

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 Raise awareness among providers  Develop easier to read materials ◦ Including your brochures- readability assessment  Improve communication skills  Practice-redesign  Literacy training / adult education 40

 Good health information is hard to come by  Most written at too high of a reading level  Few health care systems have comprehensively integrated educational materials in their overall care plans 41

 Teach-back method  Patient centered learning ◦ What is required of them to learn  Survival skills ◦ What pt. needs to know in order to get through session. ◦ 3-5 things that are need to know  Ask Me 3 ◦ Three questions about topic  Therapeutic alliance  Repetition/reinforcement 42

Understanding Clarify Assess Explain 43 Teach-back

 Speaking or writing in every day language  Limit & organize the information ◦ Get the message quickly and clearly ◦ Makes sense  Focus on behaviors & be realistic  Use carefully phrased words as there is a tendency to take words literally  3-5 ‘need to know’ points 44

 Frame the message: tell them what you are going to tell them before you do.  Give specific examples and real world examples.  Use analogies for key points.  Use repetition, rephrasing and interactivity  Verify understanding with teach-back technique. 45

 Every MS Office product has this capability  Your brochures will be tested for readability  Other resources: see the BB shell 46

Chew et al in 2004: Used 16 health literacy screen questions on a 5 pt Likert scale followed by S-TOFHLA (n=322) 3 questions were effective: 1.How often do you have someone help you read hospital materials? 2.How confident are you filling out medical forms by yourself? 3.How often do you have problems learning about your medical conditions because of difficulty understanding written information? Wallace followed up in 2006 identifying just the second question above was most accurate with detecting limited health literacy skills (83.3% sensitivity). -more accurate than a screen of demographicS 47

 Should we measure literacy and target interventions or should we institute “universal precautions”?  When low health literacy is identified, what do we do?  Is it enough to recognize that many patients have this problem? 48

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 What do you call your problem? What name does it have?  What do you think caused your problem?  Why do you think it started when it did?  What does your sickness do to you? How does it work?  How severe is it? Will it have a short or long course?  What do you fear most about your disorder?  What are the chief problems that your sickness has caused for you?  What kind of treatment do you think you should receive?  What are the most important results you hope to receive from the treatment? 50 Dr. Arthur Kleinman, Patients and Healers in the Context of Culture. The Regents of the University of California. 1981