1 Developing a Health Literacy Universal Precautions Toolkit DeWalt DA, Hawk V, Broucksou K, Hink A, Brach C, Callahan LF AHRQ Annual Meeting 2009

2 Project in Process Rationale Process Prototype Feasibility

3 Rationale Low health literacy is common We do not have good strategies for knowing who is struggling with health information Health literacy universal precautions is – structuring the delivery of care in the practice as if every patient may have limited health literacy

4 Process Identify and review tools Identify gaps Develop plan for toolkit organization Create implementation guidance Test individual tools Create “toolkit” as unified approach Pilot test toolkit in practices

5 Tool identification and review Searched the internet via Google (health literacy, health communication, health education materials) Directed inquiries: Advisory Board, Health Literacy List Serve, primary care practices in PBRN Conducted conference calls with practices in NC and across the country with a reputation for working on health literacy universal precautions

6 Tool Review Catalogued tools – Training for clinicians and staff – System changes in practices – Use of educational media – Connections with community organizations Made assessment of how tool could be used in primary care – Ease of use – Documented experience or research on tool – Format (book, internet, video, etc) Avoided creating a catalog of patient education materials

7 Results Number Total number of tool candidates identified219 Total number tool candidates by category* Category 1 -Health literacy training110 Category 2 -System changes63 Category 3 -Educational media79 Category 4 -Community links18 Category 5 -Other25 Target Audience* Patients57 Providers & Staff163 Other45 * Some tools are classified in more than 1 category and target more than one audience.

8 Gaps to Fill Practice assessment for primary care Individual tools (form templates for practices, patient follow-up procedures, etc.) Implementation guidance

9 Implementation Guidance How do we take an idea and get it implemented reliably and sustainably in practice? Steps for implementation Frame in the Model for Improvement (PDSA) Examples of how others have done it Ways to track progress

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13 Test Individual Tools Each “tool” or “implementation guidance” was tested in 2-4 practices Practices reviewed the tool and attempted implementation on a small scale Reviewed feedback by conference call Received feedback from Advisory Board

14 Create Prototype Toolkit Developed the framework for the toolkit – Introduction – Getting Started Form a team Assess your practice Raising awareness in your practice Built in tutorial for Model for Improvement Added examples of practices doing this work

15 Toolkit Organization Introduction and getting started Assessment of practice Four Key Changes – Effective Oral Communication E.g. teach back method – Effective Written Communication E.g., forms, education materials – Self-Management and Empowerment E.g., action plans, encouraging questions – Supportive Systems E.g., community resources, supportive systems

16 Final List of Tools Getting Started – Forming a team – Assessing your practice – Raising awareness Effective Oral Communication – Communicating Clearly with patients – Using the teach back method – Following-up with patients – Improving telephone communication – Using the brown bag review – Addressing language differences – Knowing your patients: understanding differences Effective Written Communication – Designing easy to understand forms – Using effective health education – Making your practice easy to navigate – Creating a welcoming front desk Self-Management and empowerment – Encouraging questions – Action plans – Improving medication adherence – Obtaining patient feedback Supportive systems – Providing support for patients – Getting patients the medications they need – Using health resources in your community – Using Literacy Resources in your community

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18 Feasibility Testing in Process 8 practices (pediatrics, family medicine, internal medicine) Each practice performs an assessment Each practice chooses 5 tools to try to implement in 3 months Follow-up phone calls to be completed end of September

19 What are we learning? Practices start from very different levels – Health literacy expertise – Practice change expertise Need to grab the attention of practices – Video helps – Get entire practice involved (not just clinicians) – Assessment results helpful Practices want – “real life” examples – Quick start guide Volume of tools is a bit overwhelming Must be easy to navigate the toolkit

20 Conclusion Conducted a thorough search for tools Juxtaposed toolkit with chronic care model/medical home Designed from perspective of making incremental changes Overwhelming for some practices Requires close attention and hard work, just like any reliable practice change

21 Acknowledgements Authors – Darren DeWalt, MD, MPH – Leigh Callahan, PhD – Victoria Hawk, RD, MPH – Kimberly Broucksou, MSW, MPA – Ashley Hink, MPH – Rima Rudd, ScD – Cindy Brach, MPP Advisory Panel – Michael Barr, MD, MBA – Toni Cordell – Gail Neilsen, RTR, BSHCA, SAHRA – Michael Paasche-Orlow, MD, MPH – Ed Wagner, MD, MPH North Carolina Network Consortium