1. Speaker: Judith Singletary, PhD
Implementing Health Literacy Universal Precautions: Helping All Patients Better Understand
Speaker: Judith Singletary, PhD
April 19th 2017
This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

2. Judith Singletary, PhD Presenter Head Shot & Brief Bio
Judith Singletary, PhD is a senior health communications strategist with more than 25 years of social marketing and communications experience, largely with health and health-related social issues that affect underserved communities and communities of color. A medical sociologist specializing in social determinants of health and social inequalities, she has extensive experience advising on strategic communications, partnership development, stakeholder outreach, and market research on some of the nation’s most pressing issues, including:
Diabetes
Access to care
Oral health;
Cardiovascular disease;
Infant mortality,
Health insurance and social determinants of health.

3. Today’s Learning Objectives
Identify hidden barriers to health literacy
Understand the impact low health literacy on care
Provide evidence-based strategies and tools to promote better understanding among all patients.
Speaker Notes:
For today’s meeting:
We will go over the MACRA legislation and the two pathways within the MACRA Quality Payment Programs. How you as a provider can prepare for these alternative payment programs under MACRA with TCPI, or The Transforming Clinical Practice Initiative.
We will provide an overview of the Transforming Clinical Practice Initiative and discuss the two key components to TCPI – Support and Alignment Networks (SAN) and the Practice Transforming Networks. The TCPI is critical as it ushers in a new era of practice that shifts its focus from “volume” to “value” and what does this new payment system mean.
We will discuss the criteria for TCPI participation and the benefits to doing so.
If time allows, we will take the opportunity to address your questions.

4. What is Health Literacy?
The capacity to:
Obtain, process, understand basic health information and services
Make appropriate health care decisions (act on information)
Access/navigate health care system

5. Using the Universal Precautions Approach
Structuring the delivery of care as if everyone may have limited health literacy
You cannot tell by looking
Higher literacy skills ≠ understanding
Anxiety can reduce ability to manage health information
Everyone benefits from clear communications
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

6. What We Know…
Low health literacy is associated with numerous adverse health related outcomes
National assessment of health literacy skills of US adults
Assessed both reading and math skills
Focused on health-related materials and tasks
36% of adults were identified as having serious limitations in health literacy skills
Early strategies rushed to rewrite health materials at a simpler level or user graphic redesign principles to enhance visual clarity
Incomplete understanding of the cause
Many factors impact health literacy
Evidence suggests that measures of literacy and health literacy strongly correlate with tests of cognitive function (Wolf et al., 2009)

7. What we know…
Older adults more likely to report lower levels of health literacy than their younger counterparts (Kahana et al, 2011)
Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter (Schillinger et al., 2003)
It is important that all health professionals possess adequate awareness, knowledge, skills and attitudes regarding patients with low health literacy
Health professionals often lack these attributes; deficits tend to differ by profession

8. Red Flags for Low Literacy
Frequently missed appointments
Incomplete registration forms
Non-compliance with medication
Unable to name medications, explain purpose or dosing
Identifies pills by looking at them, not reading label
Unable to give coherent, sequential history
Ask fewer questions
Lack of follow-through on tests or referral
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

9. Mismatched Communication
Clinician Process Giving Information
Patient Process Understanding, remembering and acting on
information
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

10. …And the process is becoming more complex
of confusion
continuum
Patient’s
Pre-visit
Scheduling the
appointment
Visit reason, obtain
records, directions
In office, PP
Registration, new
forms, insurance
Problem, health
status, history
See Clinician
Med list, sources
of care
With Clinician
Adjust/Add med, new
Tests or referrals
See Educator
Pamphlets, charts,
videos
Checkout
New tests, samples,
instructions
Schedule f/u,
referrals, insurance,
billing
*The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

11. Patient Safety: Medication Errors
Research study with 395 primary care patients in 3 states (Davis et al, 2006)
“How would you take this medicine?”
46% with low or moderate literacy did not understand the instructions on one or more labels.
38% with adequate literacy missed at least 1 label.

12. Patient Safety: Medication Errors
In the same study, patients were given a pill bottle and asked to demonstrate how many pills they would take out if the label read:
“Take Two Tablets by Mouth Twice Daily”
35% with low literacy took out the right amount of pills
63% with marginal literacy took out the right amount of pills
80% with adequate literacy took out the right amount of pills

13. Lessons Learned From Patients
Results from interviews and focus groups with hundreds of patients
Tell me what’s wrong (briefly and succinctly)
What I need to do and why
Emphasize benefits for me
With medications – “…break it down for me”:
What is it for
Exactly how to take it
Why I need to take it (benefits)
What to expect

14. Strategies to Improve Patient Understanding
Based on health literacy, patient research and Universal Precautions approach
Agency for Healthcare Research and Quality (AHRQ) recommends healthcare providers
Focus on “need-to-know” & “need-to-do”
Use Teach-Back-Method
Demonstrate or draw pictures
Use clearly written education materials

15. Focus on “Need to know” & “Need to do”
What do patients need to know and/or do…?
When they leave the exam room
When they check out
What do they need to know about?
Taking medicines
Self-care
Referrals and follow-ups
Filling out forms
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

16. Teach-Back Method
Ensures agreement and understanding about the care plan
Essential to engaging patient and family in care and achieving adherence
“I want to make sure I explained it correctly. Can you tell me in your words how you understand our plan to…?”
Some evidence that use of teach-back is associated with better diabetes control

17. Teach-Back Method Explain Assess Clarify Understanding
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

18. Teach-Back Method Confirm Patient and Family/Caregiver Understanding
“Tell me what you’ve understood about our discussion”
“I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine?”
Avoid yes or no questions
“Do you understand?
“Do you have any questions?”

19. Using Visuals to Improve Understanding and Recall
Patient studies find:
Pictures/demonstrations are most helpful to patients with low literacy and visual learners
Most health drawings are too complicated
Physician drawings are often very good (not too complex)
Patients say “show me” & “I can do it
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

20. Universal Precautions - Tips for Clinicians
With all patient and families
Use plain language
Limit information (3 – 5 key points)
Be specific and concrete, not general
Demonstrate, draw pictures, use models
Repeat/summarize
Teach-Back and confirm understanding
Be positive, hopeful and empowering
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition

21. …Tips for Clinicians Patient studies reveal 20 commonly used but complicated words
Screening
Community resources
Dermatologist
Monitor
Immunizations
Cardiovascular
Contraception
Referral
Hypertension
Eligible
Oral
Arthritis
Diabetes
Diet
Hygiene
Prevention
Mental health
Annually
Depression
Respiratory problems
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd ed.

22. …Tips for Clinicians Examples of Plain Language
Annually Yearly or every year
Arthritis Pain in joints
Cardiovascular Having to do with the heart
Dermatologist Skin doctor
Diabetes Elevated sugar in the blood
Hypertension High blood pressure
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd ed.

23. Questions?

24. Thank You!
Contact Information:
Judith Singletary, PhD