1. Health Literacy: What did that doctor say?? May 13, 2009

2. Faculty Medicine NursingPharmacy Evelyn Kemp Peggy McConnell Charles Collins Forrest Lang Sue Grover Richard Hess Public Health Social Work Brian Martin Robin Lennon-Dearing

3. Objectives Participants will learn the following: Extent of low literacy Those most at risk Correlates and results of low health literacy Clinical red flags Ways of assessing health literacy Strategies for helping patients with low health literacy Finally, participants will identify quality improvement project goals that address patients’ health literacy levels.

4. Agenda for today 11 -11:30 Introduction to health literacy Video followed by group’s discussion of what they see in the video and suggestions for change Strategies for helping patients with limited literacy 11:30-12 Practice with standardized pts

7. Literacy in the US 14% of adults cannot read 21-23% can read a little but not well enough to: fill out an application read a food label read a simple story ●46% of US population have limited health literacy. (Paasche-Orlow, 2005.)

8. What is Health Literacy? Healthy People 2010: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

9. Literacy Demographics Limited health literacy is greatest among Older adults Poor Rural Those with limited education Minorities Those with limited English proficiency

10. Results of limited literacy  12% of general population do not understand when their next appointment is.  Over 19% do not understand instructions to “take medication on an empty stomach”. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

11. Correlates of Low health literacy ●Poor knowledge of chronic diseases such as HTN, diabetes ●Poor glycemic control ●Poor health outcomes ●Increased risk of hospital admissions ●Length of hospital stay increased by nearly 2 days

12. How good are we at detecting low literacy? Clinicians identify only 47% of low literacy patients. (Rogers, 2006)

13. Clinical Red Flags Indicating Limited Health Literacy ●Incorrect or incomplete forms. ●Frequently missed appointments. ●Lack of follow through with diagnostic testing or referrals. ●Medication count, medication refill history, or lab tests inconsistent with patient report. ●Patient asks no questions.

14. How we explain things to patients Video MDI Discussion

15. Strategies Assess Literacy Create a shame-free environment Adjust approach to patient needs ●Improve communication Ask-Tell-Ask

16. Informal Assessment of Health Literacy ●The Indian Health Service model uses a series of three questions:  What did your prescriber tell you the medication is for?  How did your prescriber tell you to take the medication?  What did your prescriber tell you to expect? ●Conduct a Medication Review:  Ask patients to bring in all their medications  Ask them to name and explain the purpose of each one – “Brown Bag Test”

17. Formal Assessment of Health Literacy ●Single Item Literacy Screener (SILS)  “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” (Morris, 2006)  Sensitivity 54% - Specificity 83%  1-Never, 2-Rarely, 3-Sometimes, 4-Often, and 5-Always  Score above 2 is considered positive

18. Creating a Shame-free Environment ● Use ubiquity statements, “Many people have difficulty understanding medical information.” Convey an attitude of helpfulness, caring and respect.  Avoid acting impatient or annoyed.  Involve the entire staff. Offer to help with paperwork.

19. Adjustments based on patient need Hearing Vision Cognition

20. Strategy: Improve Communication Speak slowly. Use simple, plain nonmedical language. Focus on 1-3 key messages per visit. Ask how the patient learns best. Models, charts, pictures, analogies Include a family member or friend.

21. Strategy: Improve Communication BenignHarmless ChronicHappens again and again Cardiac Heart EdemaSwelling; build up of fluid FatigueTired ScreeningTest IntakeWhat you eat or drink GenericNot a brand name Adverse eventsSide effects Common LanguageJargon Avoid Use of Medical Jargon

22. Strategy: Improve communication Show or draw pictures. Visual images can improve the patient’s recall of ideas. Uses captions that clarify the point of the visual USP Pictograms http://www.usp.org/audiences/consu mers/pictograms/

23. Strategy: Improve communication

24. Ask-Tell-Ask ASK pt their understanding of their disorder and treatment. TELL them missed or incorrect information. ASK for a restatement of their understanding of information given “in your own words”. *Don’t ask, “Do you understand?”

25. Remember to do with every patient... Assess health literacy: “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Ask the patient to restate their understanding of information given “in your own words”. *Don’t ask, “Do you understand?”

26. Practice Session - 30 minutes

27. Video #2 (Explanation of Albuterol) Video #2 Video #3 (Demonstration of Inhaler) Video #3 Video #4 (Tell-back) Video #4