1. Health Literacy Teaching Tools for Medical Educators 101 Tracey Smith, DNP, PHCNS-BC, MS Hope Cherry, BS Southern Illinois University School of Medicine

2. Disclosures I have nothing to disclose.

3. 30-39% have below basic health literacy skills

4. What is Health Literacy? Ability to –Obtain –Process –Understand basic health information and services needed to make appropriate health decisions –Navigate the healthcare system

5. 9 out of 10 Struggle Four performance levels: Below Basic, Basic, Intermediate, and Proficient Three domains of literacy: –Prose, Document, Numeracy –The majority of adults (53 percent) have Intermediate health literacy. About 22 percent have Basic and 14 percent have below basic health literacy.

6. Examples of Health Literacy Performance Levels Proficient: Find the information needed to define a medical term by searching a complex document Intermediate: Determine a healthy weight range for a person of a specified height, based on a graph that relates height and weight to body mass index (BMI) Basic: Give 2 reasons a person with no symptoms should be tested for a disease after reading a pamphlet Below basic: Circling date of an appointment on a hospital admission slip

7. Age Gender Language Income level Ethnicity

8. BUT IT IS NOT BECAUSE OF DISINTEREST OR INABILITY TO LEARN

9. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes, Am J Health Behav 2007. Sep-Oct;31 Suppl 1:S19-26.

10. Objectives 1. Discuss the educational content areas for teaching about health literacy and clear communication 2. Discuss methods for teaching about health literacy and clear communication 3. Discuss how to incorporate application of health literacy skills into a crowded curriculum 4. Identify gaps in medical students’ training around health literacy and begin to identify practical means for filling those gaps

11. Objectives 1 & 2 Coleman, C., Hudson, S., & Maine, L. (2013). Health literacy practices and educational competencies for health professionals: a consensus study, Journal of Health Communication: International Perspectives, 18:sup1, 82-102, DOI: 10.1080/10810730.2013.829538 (See handout #1)

12. Knowledge- 24 items –Of those we will cover 6 that were rated very important or important by 95% of those on the expert panel

13. Know which kinds of words, phrases, or concepts may be jargon to patients –PlainTrain-Plain Language Network http://www.plainlanguagenetwork.org/plaintrain/ –Health Literacy Consulting: Acronyms http://www.healthliteracy.com/article.asp?PageID =7279http://www.healthliteracy.com/article.asp?PageID =7279

14. Know the rationale for and mechanics of using a teach back or show me technique to assess patient understanding –Always Use Teach-Back! Toolkit http://www.teachbacktraining.org/

15. 95% Know the basic literacy skill domains and gives examples of health care related demands put on patients for each domain, including difficulties between the ability to read and reading comprehension –The Centre for Literacy http://www.centreforliteracy.qc.ca/health_literacy

16. 95% Know that adults with low literacy tend to experience shame, and hide their lack of skills from health care professionals –Parikh NS 1, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996 Jan;27(1):33-9.Parikh NSParker RMNurss JRBaker DW Williams MVPatient Educ Couns.

17. Recognize “red flag” behaviors which may suggest a patient has low health literacy –Weiss, B. Health literacy and patient safety: Help patients understand. Manual for Clinicians, AMA 2007. http://med.fsu.edu/userFiles/file/ahec_health_clinicians_manual.pdf –Quick Guide to Health Literacy: Fact Sheet http://www.health.gov/communication/literacy/quickguide/factsliteracy.htm 95%

19. Know examples of the direct relationship between health literacy and –Knowledge about one’s chronic disease(s) and medications –Adherence to medications and treatment plans –Receipt of preventive health services –Health outcomes or risk of harm –Quick Guide to Health Literacy: Fact Sheet http://www.health.gov/communication/literacy/quickguide/factsliteracy.htm

20. Objectives 1. Discuss the educational content areas for teaching about health literacy and clear communication 2. Discuss methods for teaching about health literacy and clear communication 3. Discuss how to incorporate application of health literacy skills into a crowded curriculum 4. Identify gaps in medical students’ training around health literacy and begin to identify practical means for filling those gaps

21. Objectives 1 & 2 Coleman, C., Hudson, S., & Maine, L. (2013). Health literacy practices and educational competencies for health professionals: a consensus study, Journal of Health Communication: International Perspectives, 18:sup1, 82-102, DOI: 10.1080/10810730.2013.829538

22. Skills –27 skills Of these we will discuss the 7 skills that were identified as very important or important by > 95% of the expert panel

23. Demonstrate ability to use verbal and non- verbal listening techniques when speaking with patients

24. Demonstrate effective use of a teach back or show me technique for assessing patient’s understanding –Teach Back Method-UNC Toolkit http://www.nchealthliteracy.org/toolkit/tool5.pdf

25. Demonstrate ability to orally communicate accurately and effectively in patients’ preferred language, using medical interpreter services –AAMC Models of effective Cross-Cultural Communication at https://www.aamc.org/download/54338/data/culturalcomped.pdf –Physician’s Practical Guide to Cultural Competency at and submit the completion certificate https://www.thinkculturalhealth.hhs.gov/Content/ContinuingEd.asp

26. Demonstrate ability to write or rewrite unambiguous medication instructions –PRISM Toolkit: Group Health Research Institute https://www.grouphealthresearch.org/about- us/capabilities/research-communications/prism/https://www.grouphealthresearch.org/about- us/capabilities/research-communications/prism/

27. Demonstrate ability to use examples or analogies to improve patients’ comprehension – List of Medical Analogies: Altoona Family Physicians Residency http://www.altoonafp.org/analogies.htm – Health Literacy Consulting: Analogies http://www.healthliteracy.com/article.asp?PageID=3771

28. 94% Skills Demonstrate ability to use common familiar lay terms, phrases, and concepts, and appropriately define unavoidable jargon and avoid using acronyms in oral and written communication with patients

29. 94% Skills Demonstrate ability to recognize, avoid and/or constructively correct the use of medical jargon, as used by others in oral and written communication with patients –CDC Clear Communication Index http://www.cdc.gov/ccindex/index.html –Suitability Assessment of Materials (SAM) Tool http://aspiruslibrary.org/literacy/sam.pdf

30. Resources for Health Literacy Knowledge & Skills Health Literacy Universal Precautions Toolkit –http://www.ahrq.gov/professionals/quality-patient- safety/quality-resources/tools/literacy- toolkit/healthliteracytoolkit.pdfhttp://www.ahrq.gov/professionals/quality-patient- safety/quality-resources/tools/literacy- toolkit/healthliteracytoolkit.pdf Newest Vital Sign –http://www.pfizerhealthliteracy.comhttp://www.pfizerhealthliteracy.com Cultural Competence Online –http://www.c-comp.org/guide/resources/HelpPatients.aspxhttp://www.c-comp.org/guide/resources/HelpPatients.aspx Health Literacy PubMed Search –http://www.nlm.nih.gov/services/queries/health_literacy.htmlhttp://www.nlm.nih.gov/services/queries/health_literacy.html

31. Objectives 1. Discuss the educational content areas for teaching about health literacy and clear communication 2. Discuss methods for teaching about health literacy and clear communication 3. Discuss how to incorporate application of health literacy skills into a crowded curriculum 4. Identify gaps in medical students’ training around health literacy and begin to identify practical means for filling those gaps

32. Health Literacy Teaching in US Medical Schools, 2010 61 schools responded 44 schools reported health literacy in curriculum Average of 3 hours spent teaching about health literacy Majority of teaching was in first 2 years Looked at methods of teaching, topics taught, and methods of evaluation Coleman CA, Appy S. Health Literacy Teaching in US Medical Schools. Fam Med 2012; 44(7): 504-507

33. Methods of Teaching Coleman CA, Appy S. Health Literacy Teaching in US Medical Schools. Fam Med 2010; 44(7): 504-507

34. Topics taught Coleman CA, Appy S. Health Literacy Teaching in US Medical Schools. Fam Med 2010; 44(7): 504-507

35. Methods of Evaluation Coleman CA, Appy S. Health Literacy Teaching in US Medical Schools. Fam Med 2010; 44(7): 504-507

36. Examples of published articles on Health Literacy Medical School Curricula Roberts, D. et al. (2012) A replicable model of a health literacy curriculum for a third-year clerkship. Teaching and Learning in Medicine, 24(3), 200- 210. DOI: 10.1090/104001334.2012.692261 Kripalani, S. Weiss, BD. (2006) Teaching About Health Literacy and Clear Communication. J Gen Intern Med, 21:888-890. Hess, J. Whelan, JS. (2009) Making health literacy real: adult literacy and medical students teach each other. J Med Libr Assoc, 97(3).

37. Examples of other searchable information on Health Literacy Medical School Curricula Health Literacy Curriculum for Medical Students (PowerPoint)- University of Chicago-Pritzker School of Medicine –http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthL iteracy/14HarperHealthLiteracyinmedicalschoolcurriculaONLINEversion. pdfhttp://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthL iteracy/14HarperHealthLiteracyinmedicalschoolcurriculaONLINEversion. pdf Health Literacy Seminar (Course Description)-Tuft University School of Medicine –http://www.advancinghealthliteracy.com/curricula/tufts.pdfhttp://www.advancinghealthliteracy.com/curricula/tufts.pdf Health Literacy Course (Course Description)-Mount Sinai School of Medicine –http://www.advancinghealthliteracy.com/curricula/zarcadoolas.pdfhttp://www.advancinghealthliteracy.com/curricula/zarcadoolas.pdf Teaching Medical Students About Health Literacy (Poster)-Oregon Health and Science University –https://www.iha4health.org/wp-content/uploads/2014/06/Long-Term- Effects-of-a-Health-Literacy-Curriculum-for-Medical-Students.pdfhttps://www.iha4health.org/wp-content/uploads/2014/06/Long-Term- Effects-of-a-Health-Literacy-Curriculum-for-Medical-Students.pdf

38. SIU School of Medicine Health Literacy Curriculum Longitudinal (Y1-Y4) Not always labeled as health literacy Address all knowledge and skill recommendations by the expert panel Recent LCME site visit allowed us to better trace health literacy within the curriculum

39. SIU SOM Y1 Often not labelled as health literacy but communication skills are taught regularly and assessed by Standardized Patient encounters. Address knowledge concepts #15, 18 and 19 regularly and skill concepts #1, 2, 8, 9, and 13

40. SIU SOM Y2 Again not frequently labelled as health literacy but regularly assessed during Standardized Patient encounters except in Y2 we assess teachback skill to a higher level than Y1 and at the end of the year introduce the topic of shared decision making into didactic and OSCEs. 3.5 hour health literacy session: introduces all knowledge aspects except for #24 and skill concepts #19,20,25, and 26 –AMA video –Didactic (Fast facts, teachback/chunk/check) –Inhaler demonstration –Practice (The Newest Vital Sign; Speaking Plainly; Teach-back role play; Creating Easy to Understand Materials)

41. SIU SOM Y3 Again not frequently labelled as health literacy but regularly assessed during Standardized Patient encounters. All knowledge and skill concepts are incorporated except for knowledge #24 and skills #20 and 25. Health Literacy Curriculum in the FCM Clerkship –Flipped Classroom (video recording- in class discussion and practice) –Assignment (example in following slide) –SP testing Health Literacy Curriculum in the IM Clerkship –Medication Reconciliation –SP testing –Didactic on Patient Safety

42. COPC/Health Literacy Assignment Objectives: 1. To enhance understanding of the COPC process 2. To enhance knowledge about geographic specific risk factors 3. Improve understanding of assessment of literacy levels of educational materials 4. To improve skills in developing individualized prescriptions for health Instructions: Use IPLAN or another information site to identify the top five causes of mortality in the County where you are completing your clerkship. For one of the five common causes, identify how and if the community is addressing the risk factor. Then locate two examples of educational material for the common cause selected and assess the literacy level and consider methods to decrease the reading level of the material (You must use an official tool to complete this assignment such as the Fry Formula, SMOG, etc). Complete a “Prescription for Health” for a patient that you saw with your preceptor using one of the top five causes of mortality for that County. Assignment (all due Monday, week 5 except as noted below): 1) Submit a list of the 5 top causes of mortality identified 2) Describe how the community is addressing the mortality cause selected 3) Provide a copy of the two examples of educational materials located (bring with you to Wednesday of Week 6) 4) Discuss your assessment of the literacy level of those educational materials 5) Describe your suggestions for decreasing the literacy level of these materials 6) Submit a copy of the “Prescription for Health” completed (bring with you to Wednesday of Week 6)

43. Assignment Example

44. Assignment Example Continued

45. SIU SOM Y4 –Electives in Family Community Medicine, Internal Medicine, and Medical Humanities have topics ranging from patient education, web-based toolkits, cultural competence, patient safety, and enhancing communication that incorporate health literacy knowledge, skills, and attitude components

46. Objectives 1. Discuss the educational content areas for teaching about health literacy and clear communication 2. Discuss methods for teaching about health literacy and clear communication 3. Discuss how to incorporate application of health literacy skills into a crowded curriculum 4. Identify gaps in medical students’ training around health literacy and begin to identify practical means for filling those gaps

47. Gaps/Concerns Education Privilege Time in the curriculum Time in the encounter Knowledge of educators Lack of modeling in encounters

48. More Resources  California Health Literacy Initiative  http://cahealthliteracy.org/resource_center.html http://cahealthliteracy.org/resource_center.html  National Patient Safety Initiative, Ask Me 3  http://www.npsf.org/?page=askme3&terms=%22ask+and+3%22 http://www.npsf.org/?page=askme3&terms=%22ask+and+3%22  Plain Language.gov  http://www.plainlanguage.gov/whyPL/benefits/ http://www.plainlanguage.gov/whyPL/benefits/  Health Literacy Out Loud  http://www.healthliteracyoutloud.com http://www.healthliteracyoutloud.com  Teaching Patients with Low Literacy Skills by Cecilia Doak, Leonard Doak and Jan Root: Institute for Healthcare Advancement  NIH Senior Health  http://nihseniorhealth.gov/index.html http://nihseniorhealth.gov/index.html

49. References 1. Brach C, Dreyer B, Schyve P, et al. Attributes of a health literate organization. Institute of Medicine of the National Academies Discussion Paper. January 2012. 2. Brach C, Keller D, Hernandez L, et al. Ten attributes of health literate health care organizations. Institute of Medicine of the National Academies Discussion Paper. June 2012. 3. CDC Clear Communication Index at http://www.cdc.gov/healthcommunication/pdf/clearcommunicationindex/fillableformmay2013.pdf http://www.cdc.gov/healthcommunication/pdf/clearcommunicationindex/fillableformmay2013.pdf 4. Coyle, D. The talent code. Arrow books.2009. 5. Friedland RB. Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy. Washington,DC:National Academy on an Aging Society;1998 6. Fry graph can be found at: http://www.readabilityformulas.com/free-fry-graph-test.phphttp://www.readabilityformulas.com/free-fry-graph-test.php 7. Improve health literacy at www.health.gov/communications/literacy/www.health.gov/communications/literacy/ 8.Koh HK, Baur C, Brach C, et al. Toward a systems approach to health literacy research. Journal of Health Communication 2013 Jan: 18(1): 1-5. 9.Koh HK, Berwick, DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can held the nation move beyond the cycle of costly ‘crisis care.’ Health Affairs 2012 April: 31 (2): 434-443.

50. 10. Koh HK, Brach C, Harris LM, et al. A proposed ‘health literate care model’ would constitute a systems approach to improving patients’ engagement in care. Health Affairs 2013 Feb: 32(2): 357- 367. 11.Paasche-Orlow, M. Caring for patients with limited health literacy, JAMA, Sept 2011, 1122-1129. 12. Palmer, J. Cycle of Crisis Care Presentation. CDC. 13. Parnell T, McCulloch, E, Mieres J, Edwards, F. Health literacy as an essential component to achieving excellent patient outcomes. Institute of Medicine 2014 Jan. 14. Suitability of Assessment (SAM) at http://aspiruslibrary.org/literacy/SAM.pdfhttp://aspiruslibrary.org/literacy/SAM.pdf 15. The Health Literacy Universal Precautions Toolkit at http://www.cdc.gov/healthcommunication/pdf/clearcommunicationindex/fillableformmay2013.pdf http://www.cdc.gov/healthcommunication/pdf/clearcommunicationindex/fillableformmay2013.pdf 16. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy- toolkit/healthliteracytoolkit.pdf http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy- toolkit/healthliteracytoolkit.pdf 17. Weidmer BA, Brach, C, Hays RD. Development and evaluation of CAHPS survey items assessing how well healthcare providers address health literacy. Medical Care 2012 Sep; 50 (9 Supp 2): S3- S11. 18.Weiss BD, Palmer R. J Am Board Family Prac, 2004; 17: 44-47 Health Literacy: A Manual for Clinicians. AMA/AMA Foundation 2007