1. Health Literacy: Helping Patients Understand Their Care Community Health Integrated Partnership Webinar Nancy Weber Jacqueline Hill Ray & Associates, LLC

2. Our Agenda  Understanding health literacy  Assessing health literacy  Employing health literacy techniques  Enhancing the patient-friendliness of your clinic  Wrap-up

3. Understanding Health Literacy

4. Basic Health Literacy Is…  The ability to read, understand, and act on medical information.  It is also:  Cultural competency  Plain language  Patient-friendly written materials

5. Cultural Competency  Ability of professionals to work across cultures  Appropriately recognizing these factors can produce positive health outcomes:  Contributes to health literacy by improving communication and building trust  Attitudes  Language Preferences  Cultural Beliefs  Values  Traditions

6. Prevalence of Limited Health Literacy  Affects 1/3 of American adults  More common among patients who:  Are older  Are of minority background  Have less education  Have low income/are unemployed Source: Kutner, Greenberg, Jin & Paulsen. 2006. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. US Department of Education.

7. Prevalence of Limited Health Literacy Source: Weiss. 2007. Health literacy and patient safety: Help patients understand. Manual for clinicians, 2 nd edition. American Medical Association Foundation.

8. Consequences of Limited Health Literacy  Patients with low health literacy may have difficulty with the following:  Understanding medication directions  Completing medical forms  Managing chronic conditions  Understanding consent forms

9. Consequences of Limited Health Literacy  Low literacy is associated with the following:  Higher health care costs  Poorer health status  Higher probability of hospitalizations  Less health knowledge Source: Weiss & Palmer. 2004. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. Journal of American Board of Family Practice, 17, 44-47.

10. Patient Coping Strategies  Patients having problems with reading and understanding health information may cope in the following ways:  Bring someone who can read with them  Watch and copy others’ actions  Tell you they can’t read or forgot their glasses  They will NOT ask for help from staff

11. Patient Abilities  Patient forms and instructions are typically written above the average adult reading level  Adults with adequate literacy skills are generally unable to read and understand similar materials with unfamiliar vocabulary and concepts  Compromised health decreases patients’ ability to understand and act on health information

12. Why Is Health Literacy Important?  The more health literate patients are, the more likely they are to:  Navigate the healthcare system, including locating providers/services and completing forms  Share personal and health information with providers  Engage in self-care and disease management techniques  Adopt health promoting behaviors, such as exercising and healthy eating  Act on health-related news and announcements

13. Why Is Health Literacy Important?  More health literate patients are likely to have:  Improved health outcomes  Reduced health care costs  Better quality of care  Higher satisfaction  Providers of health literate patients are likely to have:  Decreased stress and frustration  Improved job satisfaction

14. Assessing Health Literacy

15. Red Flag Behaviors  Incomplete or inaccurate patient registration form  Frequently missed appointments  Medication regimen noncompliance  Lack of follow-up with tests & referrals  Patient reported taking medications, but physical indicators do not improve

16. Red Flag Responses  “I forgot my glasses, I’ll read this when I get home.”  “I forgot my glasses, can you read this to me?”  “Let me take this home to discuss with my family.”  Unable to name medications  Unable to explain medication purpose  Unable to explain medication administration regimen/schedule

17. Health Literacy Assessment Strategies  Social history  What is the best way for you to learn new things?  How happy are you with the way you read?  How often do you need to have someone help you read instructions or complete medical forms?

18. Health Literacy Assessment Strategies  Brown bag medication review  Ask patients to bring all medications (Rx, OTC, herbs, vitamins) to clinical visit  During visit, ask patients to name each medication, its purpose, and describe how it is taken

19. Health Literacy Assessment Strategies Source: caglecartoons.com

20. Health Literacy Assessment Strategies  Rapid Estimate of Adult Literacy in Medicine (REALM)  Word recognition test to identify patients at risk for limited health literacy skills  Ask patient to pronounce the following words: Source: Bass, Wilson & Griffith. 2003. A shortened instrument for literacy screening. Journal of General Internal Medicine, 18(12), 1036-38.  Fat  Flu  Pill  Osteoporosis  Allergic  Jaundice  Anemia  Fatigue  Directed  Colitis  Constipation

21. Consider This…  During a medication review, Nurse Practitioner Welden asks Ms. Diaz, who has hypertension and coronary artery disease, to explain the name of each pill, its purpose, and how it should be taken. She is on Lipitor, Lisinopril, topral, Plavix and a diuretic.  What responses would you expect when conducting medication reviews with patients who have limited health literacy?  Inability to state the medication’s purpose  Inability to describe when to take the medicine  Inability to explain importance of medication

22. Employing Health Literacy Techniques

23. It’s Not What You Say…  It’s how you say it  Importance of tone and body language Source: Mehrabian, 1981.

24. Behaviors to Improve Understanding  Slow down  Use plain, non-medical language  Show or draw pictures  Limit amount of information provided and repeat it  Use the “teach-back” technique  Create a shame-free environment by encouraging questions (e.g., “ask me three”)

25. Behaviors to Improve Understanding  Use orienting statements  Encourage patients to ask questions or probe to find out if they have unaddressed concerns  Ask patients to explain their understanding of the medical problem and treatment  Sit rather than stand  Listen rather than speak

26. Plain Language  Technique for making written and oral information easier to understand  Break down complex information  Organize information so that most important points come first Source: Bliss by Harry Bliss, 5/9/09.

27.  Explaining concepts to patients without medical terms can be challenging.  Sometimes pictures, analogies, and models help. Plain Language  COPD  Cardiologist  Asthma  Monitor  Arthritis  Hypoglycemia  Anti-inflammatory  Cholesterol

28. Teach Back Method  Have patients explain/demonstrate how they will perform their treatment or take their medication.  If patients do not answer correctly, state that you YOU have not explained something correctly.  Restate instructions in a different way and check for comprehension.

29. Ask Me 3  What is my main problem?  What do I need to do (about the problem)?  Why is it important to do this?

30. Enhancing the Patient-Friendliness of Your Clinic

31. Patient-Friendly Practice  Clear signage and directions  Plain language written materials  Consent forms  Health history questionnaire  Patient education materials  Alternative non-written materials

32. Patient-Friendly Written Materials  Benefit all patients  Basic principles  Depth and detail of content  Complexity of text  Format of material  User testing Source: Environmental Protection Agency, 2006.

33. Patient-Friendly Non-Written Materials  Graphic illustrations  Pictures  Pictograms  Models  Computer modalities  Static and interactive internet websites

34. Remember…  Assess for literacy  Social history  Medication review  Improve understanding and compliance  Make practice patient friendly  Use plain language  Draw a picture  Have patient “teach back” instructions  Ensure patients can “Ask me 3”

35. RAY & ASSOCIATES, LLC Nancy Weber nancy@rayllcmail.com Jacqueline Hill jacqueline@rayllcmail.com Community Health Integrated Partnership (CHIP) Peggy Oehlmann poehlmann@chipmd.org