Carol M. Mangione, MD, MSPH

Transcription

1 Understanding What Works in Improving Health Literacy Across a State Carol M. Mangione, MD, MSPH Professor of Medicine and Public Health November 30, 2010

2 Outline Prevalence of low literacy and health literacy Health professionals current knowledge and practice around issues of health literacy What should be the core competencies for health professionals? Where does health literacy fit in the curriculum? Results from an informal environmental scan of the UC system HL Curricular Resources Potential road map to rapid infusion of the most promising approaches

3 Health Literacy What percentage of patients understand what we tell them or give them to read? - 52% 1 Definition: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. 2 1 IOM Report Health Literacy: A Prescription to End Confusion Ratzan and Parker, 2000

4 Results from 2003 National Assessment of Adult Literacy Almost 45% of the United States population (or 93 million Americans) have only basic or below basic literacy skills: The NAAL categorizes Below Basic as the ability to perform only the most simple and concrete literacy skills such as: - signing a form - adding amounts on a bank deposit slip - searching in a simple text to find out what a patient is allowed to drink before a medical test. The NAAL only measures adult literacy, that is, the ability to read. Health literacy is much broader, involving the ability to read, understand and act upon health information. Numeracy is also an important component of health literacy.

5 California Estimates of Low Prose Literacy (2003) 23% of 23 million residents lack basic prose literacy levels Nearly 70 percent of the immigrants who have resided in California for ten or fewer years are functionally illiterate. To be functionally illiterate means to be unable to read the label on a medicine bottle, complete a medical history form, or find an intersection on a street map. 1 Statewide estimates of health literacy are not available but are likely to be higher than low literacy levels overall 1

6 Why is Health Literacy Important in Patient Care? More written patient instructions Verbal instructions complex, quickly delivered, and easy to forget amidst stress Complex health system

7 Association between Low Health Literacy and Processes and Outcomes of Care Low HL is associated with - Delays in diagnosis 1 - Poor disease management skills 2 - Higher health care costs 3 1 Bennet CL et al. J Clin Onc 1998;13: Williams MV et al. Acad Emerg Med 1995;2: Weiss BD et al. J Health Care Poor Underserved1994;5:99.

8 Do Low literate adults experience lower quality of care? No N/A Yes 94% of physicians believe that low literate adults experience a lower quality of care

9 Have you received any formal training in health literacy? Yes 89% of physicians have not received any formal training in health literacy. 1 No 1

10 Key Findings from the California Health Literacy Initiative 2003 More knowledge and more research about what and how to train medical professionals are greatly needed. While there are some techniques that are being used by some medical providers, such as the teach-back method and reduction of medical jargon, more techniques should be created and used. Many physicians have received the message that health literacy, as an issue, exists. This message should now be spread to all allied health professionals, including pharmacists, nurses, nurse practitioners, and medical assistants.

11 The Challenge When Considering HL Workforce Needs Most of the literature on health literacy has focused on patient factors When surveyed, health professionals tend to overestimate patients health literacy and lack the skills needed to address low HL in clinical settings. Many best practices for effective communication with low health literacy patients are not routinely used by healthcare practitioners. The evidence base for understanding whether using these improves care is limited to a small number of studies.

12 5 domains based on AMA Recommendations 1 Understandable language Teach back method Patient friendly materials Help understanding Patient friendly environment 1 Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31(Suppl 1):S96 S104.

13 Technique Routine Use of Communication Techniques by Profession 1 MD (N=99) Routine Use % PharmD (N=121) Routine Use % RN (N=87) Routine Use % P-value Asking patients to repeat information (using teach-back technique) <.000 Speaking more slowly n.s. Presenting 2 or 3 concepts at a time and checking for understanding <.020 Asking patients how they will follow instructions at home <.000 Using simple language (avoiding technical jargon) n.s. Reading aloud instructions < Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31(Suppl 1):S96 S104.

14 2004 IOM Report 1 Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy. Professional schools and professional continuing education programs in health and related fields, including medicine, dentistry, pharmacy, social work, anthropology, nursing, public health, and journalism, should incorporate health literacy into their curricula and areas of competence. 1 Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Institute of Medicine of the National Academies, Board on Neuroscience and Behavioral Health,Committee on Health Literacy. Washington, D.C.: The National Academies Press; 2004.

15 ACGME required competency in health communication Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Source:

16 What should be the core competencies for HL training? Although numerous agencies have called for health professional training in HL, few have identified what the core competencies should be. Dr. Cliff Coleman and colleagues from Oregon Health & Science University have a project underway to define what the knowledge, skills, attitudes, and practices should be for health professionals.

17 Health Literacy Competencies The knowledge, skills and attitudes which health professionals need in order to address low health literacy among consumers of health care and health information Practices are the regular application of knowledge, skills, and attitudes in clinical settings. Project currently underway using expert panel Delphi Methods to define these. Source: Cliff Coleman,MD, MPH in an address to Conference on Competencies and Resources to address Health Literacy. St. Louis, MO, 2010

18 Teach Back Asking patients to recall and restate what they have heard during the informed consent process was identified in 2001 as one of the 11 top patient safety practices by AHRQ Source: Making Health Care Safer. 2001,

19 Teach Back Interactive Communication Loop New Concept: Health Information, Advice, or Change in Management Clinician Assesses Patient Recall and Comprehension Clinician Explains New Concept Patient Recalls & Comprehends Clinician Clarifies and Tailors Explanation Adherence Clinician Reassesses Patient Recall and Comprehension Source: Schillinger, D. et al. Arch Intern Med 2003;163: Copyright restrictions may apply.

20 HL Training in U.S. Schools for Health Professionals Limited data available Anecdotally inadequate training Available data suggest that health professionals have limited awareness and skills Repeated calls to improve training and curricula Curricula proliferating - 70% of medical schools require some HL training but the content and effectiveness are unknown Source: C. Coleman, Conference Proceedings 10/10

21 Informal Survey of Health Literacy Curriculum for Health Professionals in training in the UC System An request was sent to the 5 UC SOM Deans of Education, the Deans of the pharmacy school, 2 nursing schools, and 2 schools of public health requesting descriptions of their curriculum to prepare health professionals to work with patients with low health literacy

22 Schools Sampled Each UC campus engaged in training health care professionals was contacted with the following text: Dear Dr. : We are preparing a presentation on health literacy training for health care providersacrossuc campuses for an upcoming IOM conference. Would yoube able todirect me to curriculaatuc that specifically educates health care providers in teaching and/or promoting patient health literacy? Schools Contacted: SON - UC, Davis - UCI Pharmacy - UCSF SOM - UC, Davis - UCI - UCLA - UCSD - UCSF Public Health - UCLA - UC, Berkeley

23 University of California Health Literacy Training Campus UC Berkeley Public Health UC Davis Medicine UC Davis Nursing UC Irvine Medicine UC Irvine Nursing UCLA Medicine Response No specific curriculum on health literacy, this topic is included in various courses. Sessions taught for Joint Medical Program students (Berkeley and UCSF) and for the public health students in Public Health Interventions class as well as in sessions for other professors' courses. Health literacy is embedded in the three year Doctoring course. New school entering class is Masters and PhD level Training, as of yet, no specific curricula developed. Through the Reynolds grant several sessions in the curriculum touch on health literacy. Health Literacy is taught throughout the curriculum in both our Adult Health Care course and Community-Based Health Care course to our undergraduate nursing students. It is also taught in the Human Behavior and Mental Health courses at the graduate level. Session held early in the third year curriculum on health literacy and introduced teach back as a technique to verify patient understanding. Low Literacy guidelines and scenarios developed as teaching resources. Design & Technology unit developing an online module based on presentation by Dr. Fernandez (UCSF).

24 University of California Health Literacy Contacts Response Table Continued Campus UCLA School of Public Health UCSD Medicine UCSF Medicine UCSF Pharmacy Response Many courses in the Community Health Sciences and Health Services Departments describe the prevalence of low health literacy and the implications for communication and care delivery. Additionally, all MPH program participants are required to do field work in underserved communities where they witness the impact of low health literacyfirst hand. Included in Clinical Foundations Sequence that all students takeduring the pre-clerkship years, and highlighted particularly regarding issues of adherence to therapy and cultural competency. Developed interactive presentation on common medical scenarios, possible clinical outcomes, and practical skills for students touse if encountering similar situations. Integrated into online training in helath disparities Response pending

25 Where is the fit in the health professional curriculum? Long tradition of formal training in health communication for nurses, doctors, and pharmacists Structure of this training in health professional schools has traditionally has assumed a high level of both prose and numeric literacy and has not covered specific competencies such as teach back and speaking without using medical jargon. Often nested in the part of the curriculum that covers health care disparities. It is challenging to estimate the number of hours in the curriculum devoted to the acquisition of the needed communication skills to be effective with patients who have low health literacy

26 Competencies For example, UCSD s SOM website identifies communication as a skill that needed to be acquired during training: - Communicate effectively with patients, families, colleagues and other health care professionals. - But does not explicitly say which skills might be needed to provide excellent, safe care to persons with low health literacy.

27 UCLA DGSOM Session on teach back in Doctoring 3 for 3rd year students. Following a didactic sessions, students have a chance to role play the skill in 3 cases 3rd year students also complete an online health disparities module that devotes some time to health literacy. In the second year Doctoring 2: We address it although not in a specific module, but a consideration in each case.

28 Unanswered Questions How much curriculum is enough to achieve competence when communicating with patients who have low health literacy? Given the high rates of low HL in our state, should demonstration of competence be a requirement for all health professionals?

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30 Health Literacy Toolkit Over 28,000 distributed 56-page Manual for Clinicians Video Documentary Patient Education Materials Buttons for Office Staff CME credit Free online AMA Bookstore Source: Dr. Joanne D. Schwartzberg, AMA

31 Train-the-Trainer Curriculum Module 1 Overview Module 2 Creating a Shame-Free Environment Module 3 Enhancing Patient Interaction & Communication PowerPoint slides, participant guides, evaluations, reporting forms, & faculty instructions Over 30,000 physicians and other health professionals reached in training sessions. Source: Dr. Joanne D. Schwartzberg, AMA

32 38 Teams Trained Alleghany County Medical Society Ambulatory Pediatric Association American Academy of Neurology American Academy of Pediatrics American Academy of Pediatrics -Illinois Chapter American Lung Association of Ohio Arkansas Medical Society Canadian Public Health Association Care Alliance Health Center Cleveland Department of Public Health Cuyahoga County Board of Health Department of Defense Center for Education and Research in Patient Safety Diabetes Association of Greater Cleveland Fairview, Lakewood and Lutheran Hospitals Free Medical Clinic of Greater Cleveland Georgia Academy of Family Physicians Health Insight Illinois State Medical Society Intermountain Healthcare Iowa Medical Society Massachusetts Medical Society Medical Society of the State of New York Michigan State Medical Society National Medical Association National Patient Safety Foundation Neighborhood Family Practice Oregon Medical Association Philadelphia County Medical Society Society of Teachers of Family Medicine St. Vincent Charity Hospital Texas Medical Association University Hospitals - Rainbow Babies & Children's Hospital University of Pittsburgh Medical Center Family Practice Residency Program University of Utah Utah Department of Health Utah Medical Association VA Salt Lake City Health Care System Virginia Medical Society

33 Degree of Practice Change Reported Area of Practice % Increased % No Change % Decreased Asking patients to repeat back instructions 72.8% 27.2% 0% Presenting 2 or 3 concepts at a time and checking for understanding 64.2% 29.6% 6.2% Using simple language (avoiding technical jargon) 80.0% 20.0% 0% Reading instructions to patients 47.4% 50.0% 2.6% Speaking more slowly 70.4% 29.6% 0% Conducting follow-up calls to check understanding and compliance 30.3% 69.7% 0% Arranging for patients to have help with office forms 31.1% 68.9% 0% Quality of care you provide 71.4% 28.6% 0%

34 AHRQ Health Literacy Universal Precautions Toolkit Universal precautions refers to taking specific actions that minimize risk for everyone when it is unclear which patients may be affected. For example, health care workers take universal precautions when they minimize the risk of blood borne disease by using gloves and proper disposal techniques. Health literacy universal precautions are needed because providers don't always know which patients have limited health literacy. Source: Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF, April Rockville, MD: Agency for Healthcare Research and Quality.

35 AHRQ Health Literacy Universal Precautions Toolkit Designed to help adult and pediatric practices ensure that systems are in place to promote better understanding by all patients. The toolkit is divided into manageable chunks so that its implementation can fit into the busy day of a practice. It contains the following: - Quick Start Guide - Path to Improvement (6 steps to take to implement the toolkit) Tools (2-5 pages each). - Appendices (over 25 resources such as sample forms, PowerPoint presentations, and worksheets). Although designed for practices, could be integrated into health professional curricula. Source: Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF, April Rockville, MD: Agency for Healthcare Research and Quality.

36 CDC s Health Literacy for Public Health Professionals Online Training The purpose of this training is to educate public health professionals about limited health literacy and their role in addressing it in a public health context. This is a web-based course and can be accessed 24/7 by any computer with Internet access. 1.5 to 2 hours to complete. Trainees can earn a variety of continuing education credits. Source:

37 HL Curricula for Health Professional Students IOM Round Table on Health Literacy 3 - Medical Student Curriculum at University of Chicago - Pritzker School of Medicine

38 Summary Curricula exist for practicing health professionals and dissemination is underway Integration of the content of these programs into existing modules on health communication or health disparities in undergraduate curriculum may be most feasible Reinforcing health literacy knowledge and skills in postdoctoral training needs to be addressed - ACGME may have leverage Consensus on required competencies and assessments to see if these are met would enhance communication training for health professionals As is the case for much of medical education, we may never know how much is enough, but especially in California a stronger focus on HL in health professional training and the impact of this training on health care quality and safety is needed.