1. Geriatric Intern Rotation: Health Literacy Workshop Seema S. Limaye, MD Section of Geriatrics and Palliative Medicine University of Chicago

2. Acknowledgements Sincere thanks to the Stanford Geriatric Education Center for granting me the privilege of re-producing, incorporating, and disseminating geriatric health literacy materials developed for use as part of the Stanford Faculty Development Program in Health Literacy and Geriatric Education. Stanford Geriatric Education Center Faculty Development Program in Health Literacy and Ethnogeriatrics Curriculum. Stanford CA: Stanford Geriatric Education Center, Stanford University. 2009.

3. Goals Health Literacy Workshop: Health Literacy Workshop: 1. Understand the impact of low health literacy on our geriatric patients 2. Develop communication skills to improve patients’ understanding of their medical issues. 3. Develop and utilize effective patient HO materials.

4. Part I:

5. Take two tablets by mouth twice daily…

6. Understand - “Take Two Tablets by Mouth Twice Daily” Davis T., Wolf M.S., Bass, P.T., et. al. (2006) Literacy and Misunderstanding Prescription Drug Labels, Annals of Internal Medicine. 145, 887-894. Stanford Geriatric Education Center Stanford Geriatric Education Center

7. Functional Health Literacy Measure of person's capacity to function in the health care setting as determined by literacy and numeracy Measure of person's capacity to function in the health care setting as determined by literacy and numeracy Literacy: comprehension of written health care materials Literacy: comprehension of written health care materials Numeracy: ability to understand and act on numerical health care instructions Numeracy: ability to understand and act on numerical health care instructions

8. US Census Bureau 2000 : Projected Population Growth of Elderly 7 Whites Blacks, American Indian/Alaska Natives, Asian and Pacific Islander, Hispanic/Latino 84% 36% 64% 16% 2000 2050 U.S. Census. www.census.gov. www.census.gov

9. National Health Disparities Report Many racial/ethnic groups as well as poor and less educated patients report: Many racial/ethnic groups as well as poor and less educated patients report: Poor communication with their physicians Poor communication with their physicians More problems with some aspects of the patient- provider relationships More problems with some aspects of the patient- provider relationships Greater difficulty accessing healthcare information, including information on prescription drugs Greater difficulty accessing healthcare information, including information on prescription drugs National Healthcare Services AHRQ, 2004 AHRQ National Health Care Disparities Report 2003, AHRQ Publication, July 2003

10. What the Levels Mean Stanford Geriatric Education Center

11. What the Levels Mean Stanford Geriatric Education Center

12. US Literacy Profile - NAAL 2005 Result: 36% of US population have Basic or Below Basic literacy skills Stanford Geriatric Education Center

13. Millions of Americans have “Below Basic” Literacy Stanford Geriatric Education Center

14. Low Health Literacy Outcomes People with low health literacy: People with low health literacy: Use screening/preventive services less Use screening/preventive services less Present for care with later stages of disease Present for care with later stages of disease Are more likely to be hospitalized Are more likely to be hospitalized Have poorer understanding of treatment and their own health Have poorer understanding of treatment and their own health Adhere less to medical regimens Adhere less to medical regimens Have increased health care costs Have increased health care costs Die earlier Die earlier Schwartzberg, VanGeest, & Wang, 2004. Sudore, et al, 2006.

15. Importance of Enhanced Communication with Geriatric Patients High-risk patients! High-risk patients! Cognitive impairment Cognitive impairment Impaired sensorium Impaired sensorium Low functional health literacy Low functional health literacy Complicated medical history with multiple, chronic medical problems and complex medical regimens. Complicated medical history with multiple, chronic medical problems and complex medical regimens.

16. Identifying Low Literacy Patients Highest risk groups Highest risk groups Did not complete high school, minority, elderly Did not complete high school, minority, elderly Frequent missed appointments Frequent missed appointments Do not know names of medicines Do not know names of medicines “I forgot my glasses” “I forgot my glasses” Always comes with someone else -“surrogate reader” Always comes with someone else -“surrogate reader” Eyes wandering over page, very slow to finish, sounding out words, look confused Eyes wandering over page, very slow to finish, sounding out words, look confused Mimic behaviors Mimic behaviors Stanford Geriatric Education Center

17. First Step: Bringing Up the Topic “What things do you like to read?” “What things do you like to read?” “We need help fixing the information we give to people, what do you think we could make better?” “We need help fixing the information we give to people, what do you think we could make better?” “How far did you go in school?” “How far did you go in school?” Ask patient to read prescription bottle. Ask patient to read prescription bottle. BIGGEST BARRIER: SHAME! Stanford Geriatric Education Center

18. Before Patients Leave … These questions should be answered: What health problems do I have? What health problems do I have? Why is that important to me? Why is that important to me? What should I do about them? What should I do about them? Where do I go for any tests, medicine, and appointments that I need next? Where do I go for any tests, medicine, and appointments that I need next? How should I take my medicine? How should I take my medicine? Any other instructions necessary? Any other instructions necessary? Who to call with questions? Who to call with questions? Stanford Geriatric Education Center

19. Workshop—Part II Teach-back Method

20. Teach-back Method Technique to improve communication and confirm understanding, esp among individuals with limited literacy skills Technique to improve communication and confirm understanding, esp among individuals with limited literacy skills Involves individuals to recall or explain in their own words what has been discussed. Involves individuals to recall or explain in their own words what has been discussed. Eg: “I always ask my patients to repeat things back to me to make sure I explained things clearly. I’d like you to tell me how you’re going to take the new medicine we discussed today.” Eg: “I always ask my patients to repeat things back to me to make sure I explained things clearly. I’d like you to tell me how you’re going to take the new medicine we discussed today.” Stanford Geriatric Education Center

21. Copyright © 2009 Wolters Kluwer.3 Figure 1 Closing the loop: physician communication with diabetic patients who have low health literacy Schillinger D; Piette J; Grumbach K; Wang F; Wilson C; Daher C; Leong-Grotz K; Castro C; Bindman AB Archives of Internal Medicine. 163(1):83-90, 2003 Jan 13.

22. Teach-back method Preferred method to confirm understanding of consent information Preferred method to confirm understanding of consent information Use is advocated by National Quality Forum and AHRQ Use is advocated by National Quality Forum and AHRQ

23. Teach-back Cards 3 cards to complete during rotation 3 cards to complete during rotation Remind your attending that they’ll need to directly supervise you and sign-off on the card Remind your attending that they’ll need to directly supervise you and sign-off on the card

24. Workshop—Part II Direct-observation checklist  Explain things clearly and use plain language  Emphasize 1 to 3 key points during visit and repeat ideas throughout visit  Effectively encourage patients to ask questions—use an open-ended approach  Use teach-back method to confirm patient understanding (use demonstration of skill, if needed)  Write down important information for patient Kripalani and Weiss, 2006.

25. Workshop—Part III Task: Analyze patient education materials: 40 min Task: Analyze patient education materials: 40 min Tools to analyze material and provide HO Tools to analyze material and provide HO Homework: revise the actual patient discharge handout material and bring it back to class Homework: revise the actual patient discharge handout material and bring it back to class

26. U.S. Health Literacy Mandates Plain language laws Plain language laws Joint Commission of Accreditation of Health Organizations (JC aka JCAHO) - hospitals must assure and document patient understanding of health care instructions Joint Commission of Accreditation of Health Organizations (JC aka JCAHO) - hospitals must assure and document patient understanding of health care instructions Increase in health literacy funding initiatives (NCI, CDC, AHCPR, others) Increase in health literacy funding initiatives (NCI, CDC, AHCPR, others) Increase in health literacy related research Increase in health literacy related research Adult Basic Education (ABE) classes Adult Basic Education (ABE) classes Increased emphasis on non-print media Increased emphasis on non-print media Doak, Doak, & Root, 2001

27. Plain Language Laws Legislation requires use of plain language in all consumer documents (varies by state, public and private sector agencies/organizations) Legislation requires use of plain language in all consumer documents (varies by state, public and private sector agencies/organizations) Plain language – not “dumbing down” but assures that Plain language – not “dumbing down” but assures that People find what they need People find what they need Understand what they find Understand what they find Act appropriately Act appropriately www.health.gov/communication/literacy/plainlanguage Stanford Geriatric Education Center

28. Expected Health Literacy Outcomes Desired results from patient education: Desired results from patient education: Reducing health care costs Reducing health care costs Improving patient outcomes Improving patient outcomes Reducing errors Reducing errors Ultimately improving quality of life Ultimately improving quality of life In spite of the mandates, resources, and training, minimum competencies in health literacy skills have been difficult to achieve In spite of the mandates, resources, and training, minimum competencies in health literacy skills have been difficult to achieve Schwartzberg, VanGeest, & Wang, 2004 Stanford Geriatric Education Center

29. Models of Health Care Messages In what ways can health care messages be delivered? In what ways can health care messages be delivered? Oral Oral Written or printed information Written or printed information Visual Visual Technological Technological Stanford Geriatric Education Center

30. Creating Effective Health Care Messages for Older Adults Realistic objectives Realistic objectives Focus on behaviors and skills, less on facts Focus on behaviors and skills, less on facts Establish a context for new information Establish a context for new information Partition/”chunk” complex instructions Partition/”chunk” complex instructions Cultural values/beliefs Cultural values/beliefs Include interactive or experiential activity Include interactive or experiential activity Repeat important information Repeat important information Motivate the learner Motivate the learner Relate to past experience Relate to past experience Write for the patient, not the formula Write for the patient, not the formula Doak, Doak, and Root, 1996 An older learner must understand what to do and feel enabled to take action. Stanford Geriatric Education Center

31. Ethnogeriatric Considerations for Health Information Translated and pilot-tested messages Translated and pilot-tested messages Cultural appropriateness of topic or intervention Cultural appropriateness of topic or intervention Education level and ability to read/write Education level and ability to read/write Individual vs. family orientation Individual vs. family orientation Community support, input, and assistance from key informants or cultural navigators Community support, input, and assistance from key informants or cultural navigators Indigenous /other communication methods Indigenous /other communication methods Stanford Geriatric Education Center

32. Tools for Assessing the Suitability of Health Messages How suitable is the health information? How suitable is the health information? Understandable? Understandable? Acceptable? Acceptable? Helpful? Helpful? Stanford Geriatric Education Center

33. Categories of Assessment Tools Attribute checklists Attribute checklists Readability formulas Readability formulas Suitability of Assessment of Materials (SAM) Suitability of Assessment of Materials (SAM) Stanford Geriatric Education Center

34. Attribute Checklists Simple and quick method of assessing appropriateness of health messages Simple and quick method of assessing appropriateness of health messages Assessment categories: Assessment categories: Organization Organization Writing style Writing style Appearance Appearance Appeal Appeal What would be important for older adults from different cultures? Area Health Education Center, Biddeford, Maine Stanford Geriatric Education Center

35. Readability Formulas Assess reading difficulty based on Assess reading difficulty based on Word difficulty (number of syllables) Word difficulty (number of syllables) Length of sentences Length of sentences Not suitable for tables, charts, word lists Not suitable for tables, charts, word lists Many different formulas exist Many different formulas exist Micrsoft Word Program Micrsoft Word Program Simple Measure of Gobbledygook (SMOG) Simple Measure of Gobbledygook (SMOG) Many are available in different languages Many are available in different languages Stanford Geriatric Education Center

36. SMOG Demonstration http://www.harrymclaughlin.com/SMOG.htm Stanford Geriatric Education Center

37. Suitability of Assessment of Materials (SAM) Used for printed materials, illustrations, videos and audio taped instructions Used for printed materials, illustrations, videos and audio taped instructions Validated with different ethnic populations and different medical specialities Validated with different ethnic populations and different medical specialities Indicates need for supplemental instructions Indicates need for supplemental instructions Doak, Doak, & Root, 1996 Stanford Geriatric Education Center

38. SAM Categories 1. Content 2. Literacy demand 3. Graphics 4. Layout and typography 5. Learning stimulation, motivation 6. Cultural appropriateness Doak, Doak, & Root, 1996 Ratings: Superior material; Adequate material; Not suitable Stanford Geriatric Education Center

39. Task: Use the SAM Choose a patient HO material you frequently use or one you think may be useful Choose a patient HO material you frequently use or one you think may be useful Put the HO to the test! Put the HO to the test! Score the HO Score the HO Improve the HO Improve the HO

40. ASSIGNMENTS DUE At our next meeting: At our next meeting: SAM evaluation and revision of your chosen HO SAM evaluation and revision of your chosen HO 3 completed Direct observation cards 3 completed Direct observation cards