Deborah Slawson, PhD, RD, LDN East Tennessee State University College of Public Health Conference on Practical Strategies in Medication Adherence June 2012

Presentation Themes  Health Literacy: partnering with patients to ensure understanding  Cultural Competency: interacting effectively with people from diverse cultures  For Your Tool Kit: essentials to help your patients get the most out of medication & diet regimes

 “The degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”  Print literacy  Numeracy  Oral literacy ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

2006 Institute of Medicine Report, Preventing Medication Errors Each year: 1.5 million adverse drug events in U.S. 33% of these are in outpatient settings Poor patient understanding and unintentional misuse of Rx drugs (specifically poor understanding of drug labeling) is a root cause of med errors, poor adherence and poor health outcomes. Ref in Davis TC, et al. JGIM 2008; 24(1): Health Literacy – Prescribing and Medication Management NC Program on Health Literacy Betsy Bryant Shilliday, PharmD, CDE, CPP Ref in Davis TC, et al. JGIM 2008; 24(1):57-62.

Health Literacy: an essential first step American Medical Association

 One in three English-speaking adults in the United States are limited in health literacy.  Low health literacy is associated with: ◦ More emergency room visits ◦ More use of inpatient care ◦ Among older adults:  Poorer health status  Higher risk of death ◦ Poor ability to interpret health messages ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

 Social support, patient self-efficacy, and stigma may impact the relationship between health literacy and health outcomes.  Health literacy has been shown to mediate the effect of key characteristics on health outcomes: ◦ Education level ◦ Race ◦ Income ◦ Urbanicity ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

National Assessment of Adult Literacy, 2003

Achieving clarity is an art…  Present essential information by itself  Present the most important points first  Use direct, plain wording  Lower reading level text  Use pictures & videos where appropriate ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

 Tips and tools to enhance your practice  How to enhance: ◦ Spoken communication ◦ Written communication ◦ Patient self-management ◦ Engaging your community AHRQ Pub. No EF, April 2010 AHRQ Pub. No EF, April 2010

 Limit to 3-5 key points  Plain, non-medical language  Watch your pace  Encourage participation – ask open-ended questions  Use graphics: draw pictures, use 3-D models  Use Teach-Back AHRQ Pub. No EF, April 2010

NC Program on Health Literacy

 LEARN: ◦ What did you learn?  CONCERN: ◦ We covered several important topics. What may have confused or concerned you?  DO: ◦ What are you going to do now as a result of what we talked about?

 Ask patients to bring in medications and supplements as well as herbal remedies and OTC’s  Consider providing a special bag for meds  Ask open-ended questions  Clarify med instructions; i.e. teach-back  Bill for medication review (ICD-9 V58.69) AHRQ Pub. No EF, April 2010

 Well-designed printed materials must be used thoughtfully ◦ Front desk personnel should be trained in literacy awareness:  Understand that low literacy is common  Work with patients to ensure understanding in a sensitive manner ◦ Review materials fully with patients ◦ Ask patients to Teach Back what was discussed ◦ Review and reinforce key points

Clear Doc Index  Short sentences  Few multi-syllable words  Avoid medical jargon: a “positive” test is not always good!  Use white space & chunk information in sections  Add graphics  Bulleted lists  Bold key terms  Clear, concise formatting eases understanding AHRQ Pub. No EF, April 2010

 Medication adherence tips ◦ Ask patients how they remember to take their meds. ◦ Use non-judgmental verbiage. “Most people forget to take their pills sometimes. When was the last time you forgot to take medicine?” ◦ Give precise instructions ◦ Provide a pill chart with times and details ◦ Will generics will look different? Use pictures to inform patients. AHRQ Pub. No EF, April 2010

Cultural Competency Awareness of patients’ ethnic, cultural and religious backgrounds leads to greater understanding and clearer communication.

 One approach = CLAS standards ◦ Standards that define cultural competency in health care delivery and practice  Source of CLAS standards ◦ Developed by US Department of Health and Human Services, Office of Minority Health ◦ Derived from analysis of current practice and policy on cultural competence ◦ Shaped by input of health providers, advocates, policymakers, researchers, and consumers

 Consists of 14 standards in 3 themes ◦ Culturally Competent Care (standards 1-3) ◦ Language Access Services (standards 4-7) ◦ Organizational Supports for Cultural Competence (standards 8-14) DHHS Office of Minority Health Center for Linguistic and Cultural Competency in Health Care

Sample standards “Health care organizations should…” 1ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. 7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. CULTURALLY & LINGUISTICALLY APPROPRIATE SERVICES (CLAS)

 Health beliefs and customs  Ethnic customs  Religious beliefs  Dietary customs  Interpersonal relations  Culture Clues Tip Sheets Culture Clues AHRQ Pub. No EF, April 2010

 “I am not familiar with your cultures and beliefs. Can you teach me what I might need to know so I can better treat you?”  “What do you call your illness? What do you think caused your illness? How do you think it should be treated?”  “Do any traditional healers advise you about your health?” AHRQ Pub. No EF, April 2010

She believes that entering the hospital will kill her, and opts for traditional therapies. Her family physician desperately wants to work with the patient to manage her diabetes better. But how? Cultural Fact Some American Indian cultures, the Navajo for example, believe that mentioning an illness will cause the illness. A Physician’s Practical Guide to Culturally Competent Care DHHS Office of Minority Health Center for Linguistic and Cultural Competency in Health Care

 Practices participating in Medicare/Medicaid are legally required to provide equal access to services for patients who do not speak or understand English well. AHRQ Pub. No EF, April 2010

 Use an “I speak” card:  Use an interpreter: ◦ American Translators Association American Translators Association AHRQ Pub. No EF, April 2010

 Don’t rely on children of patients, family members, patient’s friends  Assure patient that all staff are bound by confidentiality  Speak directly to the patient  ALL communications must be interpreted  Avoid jargon, slang, metaphors  Debrief with interpreter: additional cultural considerations? Ethnomed.org, 2005

“Ensuring that people understand health care information is critical to a high-quality, safe health care system. Improving health literacy will be a major step in the nation's efforts to enhance health care quality and safety."