1. Challenges to Creating Effective Health Literacy Curriculum Donna M. Roberts, MD University of Louisville Department of Family and Geriatric Medicine Amanda Allmon, MD and Sarah Swofford, MD University of Missouri Department of Family and Community Medicine

2. Disclosures NONE

3. Learning Objectives Define the current state of health literacy curricula in US medical schools Compare methods used to teach health literacy at two institutions Practice the teach-back method in pairs

4. Need for Health Literacy Education The Institute of Medicine defines health literacy (HL) as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. ~36% of Americans have low HL

5. Need for Health Literacy Education Individuals with low HL –Less likely to use preventive services –More likely to visit ER and hospitals –Poor knowledge and control of their chronic conditions such as asthma and DM –Elderly patients with low HL have higher mortality and report poor health status

6. Need for Health Literacy Education Physicians often overestimate patients’ literacy levels Even when presented with information about patients’ literacy levels, physicians are not equipped with necessary skills to communicate effectively

7. Need for Health Literacy Education The Institute of Medicine and American Medical Association have recommended that medical schools develop health literacy curriculum. LCME requires communication skills as a core requirement for medical training.

8. Need for Health Literacy Education University of Michigan –Examined medical students’ recognition of HL in a single embedded curricular activity Majority of medical students 61.5% (n=161) recognized HL as a barrier to optimal health outcomes However, 66.8% (n=175) failed to identify the manner in which HL serves as a social determinate of health

9. Current State of Health Literacy Curricula in US Medical Schools Curricula developed varies widely in design and evaluation methods. Many challenges in the implementation of effective and efficient curricula

10. Health Literacy Teaching in US Medical Schools 2010 Published in Family Medicine 2012, Oregon Health & Science University –Web-based survey of 133 US allopathic schools, 61 institutions participated –72.1% reported HL required curriculum –Median time spent teaching HL was 3 hours –Most of teaching occurred in first 2 years

11. Health Literacy Teaching in US Medical Schools 2010 Of schools with required HL curriculum –84.1% used lecture/didactic format –56.8% used encounters with SPs –45.5% used workshop/role playing formats Less used techniques included: Assigned readings (31.8%) Video (31.2%) Experience with adult low HL patients (25%) Online training (6.8%)

12. Health Literacy Teaching in US Medical Schools 2010 Were unable to determine how much time is spent on each HL topic and the quality of instruction Unsure of which teaching techniques are most effective since evaluative outcome data is limited

13. Major Questions facing Medical Schools about HL Training What are the most effective means of teaching HL? When should medical students be taught these skills? Can teaching students about HL improve patient outcomes?

14. Current State of Health Literacy Curriculum Less than 50% of IM residency programs provided any formal teaching on HL Less than 25% of IM residents reported being confident in HL knowledge or skills HL primarily taught in IM residencies via –Didactics 75% –Clinical observation 42% –Role-playing 25%

15. Current State of Health Literacy Curriculum HL dimensions residency programs focused on: –Use of teach-back technique (100%) –Prevalence of low HL (83%) –Association between low HL and patient outcomes (83%) –Use of plain language (83%)

16. University of Missouri-Columbia 2010- began Next Level of Excellence strategic planning initiative for curriculum Involved students, faculty, administrators, program directors and patients Reviewed key characteristics and assessed gaps in curriculum Comprehensive lit review, SWOT analysis, lots of discussions to achieve consensus Internally funded

17. University of Missouri-Columbia Mind the Gap: 3 areas emerged with work groups assigned to develop longitudinal approach to each topic: 1-Culturally effective care/Health Literacy* 2-Population Health 3-Professional Formation *chose to initially focus on Health Literacy Speaking in plain language; Teach back; Universal precautions

18. University of Missouri-Columbia Health Literacy is embedded throughout the first 2 years –Modeled by faculty in live interviews for PBL cases –SPs; course objectives FM and IM took lead among clerkships FM M3 Clerkship –Teach back technique/use of plain language role played in several seminars (DM2/hyperlipidemia, HTN) –Interactive seminar focused on working with an interpreter –Videotape examples developed locally and found –One pager of prompts given to each student –Monitored in PLOG- required to document use with 2 pts

19. The University of Louisville Program Identified the need for HL education in the medical school curriculum Funded by HRSA grant 2008-2011

20. The University of Louisville Program Year One –Hired full time project coordinator –Worked with Standardized Patient Clinic to train SP’s to portray limited health literacy –Developed didactic and small group presentations for faculty, residents, and students –Trained faculty in use of asynchronous learning methods

21. The University of Louisville Program Year Two –All third year students during Family Medicine Clerkship –Day One: Pre-test, didactic presentation, faculty demonstration of teach-back with standardized patients, faculty-facilitated small group work with standardized patients

22. The University of Louisville Program Year Two –During six-week clerkship: Students respond through the Blackboard electronic course management system to three forums posted by faculty based on required readings –End of clerkship: SP assessment of teach- back method, Post-Test

23. The University of Louisville Program Assessment of the Curriculum –Written evaluation of sessions at the end of day one –Pre and Post-test scores –School of Medicine Online Course Evaluation contained questions about the curriculum –Follow-up survey near time of students’ graduation

24. The University of Louisville Program Year Three –Funding reduced –Reduced the number of SP’s used during orientation from three to one –Faculty less receptive to use of Blackboard asynchronous learning –Reflective paper required at end of clerkship to replace Blackboard forums

25. The University of Louisville Program After the funding –Less faculty release time –No funding for independent SP sessions –Project coordinator transitioned to another position within the department and replacement not hired

26. The University of Louisville Program After the funding –Clerkship faculty modified the curriculum Emphasis on recognition of Red Flags Universal Precautions: CLEAR cards Students practice teach-back in pairs –SP sessions still include limited health literacy and requirement for use of teach-back –No pre- or post-tests

27. Red Flags of Limited HL Forms are incomplete Asks staff or family for help with forms Frequently missed appointments Noncompliance with medical regimen Lack of follow-through with labs, imaging tests, referrals Postpones decision making Patients say they are taking their meds but labs or physiological parameters do not change

28. Universal Precautions: Keep it CLEAR CCreate a shame-free environment LListen actively EEncourage, use teach-back AAvoid medical jargon RReinforce with visual and written materials Adopted from Weiss 2007, AMA

29. The Teach-Back Method Teach-back –Do not ask a patient, “Do you understand?” –Instead, ask patients to explain their diagnosis or how they will undertake a recommended treatment or intervention This is not a test for the patient, but rather a check of how well you explained the concept.

30. The Teach-Back Method Sample Lead-Ins “Would you tell me what you need to do so I can be sure I didn’t leave anything out.” “I want to be sure that I did a good job explaining your blood pressure medications, because this can be confusing. Can you tell me what changes we decided to make? ” “We’ve covered several things and I want to make sure I explained them well. In your own words, can you tell me what you need to do to take care of your diabetes?” Clear Health Communication Initiative http://www.pfizerhealthliteracy.com /

31. Teach-Back Practice Divide into groups of two Each group will receive two packets One of you will be the physician and one the patient. Do not look at the other paper. Begin at the point described on your paper Then change positions and use second set of papers

32. Teach-Back Method What went well? What was difficult about the process?

33. Discussion

34. Please evaluate this session at: stfm.org/sessionevaluation