How to Understand and Implement Health Literacy

Transcription

1 How to Understand and Implement Health Literacy Presented by: Dr. Nickell M. Dixon HEALTH DISPARITIES REDUCTION/ MINORITY HEALTH SECTION OFFICE OF HEALTH POLICY AND INNOVATION

2 Objectives List barriers to good communication in public health Provide an example for each barrier List techniques to improve health communication. Define plain language Describe communication strategies you can apply in your daily work 2

3 OUTLINE What is literacy Health literacy framework Identifying and Assessing Health Literacy Who is responsible for improving health literacy What can you do Strategic Planning Patient/Physician communication Patient Centered Approach Follow Up 3

4 WHAT IS HEALTH LITERACY? 4

5 Consider Patricia Olsen, the 42-year-old woman who was asked if she had taken her antibiotic premedication and responded: Patient: Yes well actually, No, I didn t. Tell me again why I m supposed to take that medication. Dental Hygienist: Pat, when I saw you last year you told me that you had had an artificial heart valve placed in your heart. Do you remember our discussion about that? Patient: I remember my doctor telling me about my heart valve but I also remember her saying that I don t have to worry about it. Dental Hygienist: I know; and, most of the time that s true. However, the mouth is a warm and moist environment and many germs live and grow in our mouths. When we clean your teeth it s common for some of these germs to get into your bloodstream and travel through your body. Normally, your body s defense mechanisms remove these germs within a short amount of time. However, when a person has an artificial heart valve, like you do, there is a risk that the bacteria might attach themselves to that valve and begin to grow. This can cause an infection around the blood vessel that could become serious. That is why we want you take an antibiotic before you have dental procedures done. That way, if any bacteria do get into your bloodstream, the medication will be waiting there to destroy them before they can attach to your blood vessel and cause a problem. Patient: Now that you say that, I do remember my doctor telling me that I would have to take antibiotics if I ever have surgery. I guess I just didn t think getting my teeth cleaned was such a big deal. Now that you ve explained it to me it makes more sense. Dental Hygienist: Pat, just so that I know I ve explained it clearly to you, would 5 you please tell me why we want you to take antibiotics before your dental appointments?

6 What is Health Literacy? A set of skills that people need to function effectively in the health care environment Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Source: Berkman et al (2011). Health literacy interventions and outcomes: an updated systematic review, pg. ES1. 1 Institute of Medicine 6

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8 Why is it important? Better health outcomes health-related decisions should be based on clear and correct understanding of relevant health information and services. People who have low literacy are most likely not health literate. People with limited health literacy may not be able to navigate the health care system and to find the right resources. Over 70 millions adults in our country with limited health literacy cannot fully benefit from medical care and the health care system. 8 (Howard, Gazmararian, & Parker, The impact of low health literacy on medical costs of medicare managed care enrollees, 2005)

9 Health Literacy in the U.S. 77 million adults have basic or below health literacy skills Source: The Health Literacy of American Adults. Results from the 2003 National Assessment of Adult Literacy. National Center for Education Statistics (2006). 9

10 Health Literacy by Racial Group 10

11 Economic Impact It is estimated that limited health literacy costs the U.S. health care system between $50 and $73 billion per year Source: American Medical Association Foundation (2009). Health literacy and patient safety: manual for clinicians, pg

12 Health Literacy and Healthcare Costs Annual Healthcare Costs of Medicaid Enrollees (<3 rd -grade reading level) (>4 th -grade reading level) Source: Weiss, et al (2004). J Am Board Fam Pract. 12

13 Increased Healthcare Costs Annual health costs for individuals with low health literacy skills are four times higher than for people with higher skills. (Howard, Gazmararian, & Parker, The impact of low health literacy on medical costs of medicare managed care enrollees, 2005) 13

14 Pop Quiz Health Literacy develops over a lifetime? True False 14

15 Pop Quiz 1. Health Literacy develops over a lifetime? True False 15

16 HEALTH LITERACY FRAMEWORK 16

17 (Squiers et al, 2012) 22

18 MODERATORS 18

19 Health Literacy and Health Disparities There is a strong correlation between health literacy and health disparities. o Health disparities: Differences in health that occur by gender, race or ethnicity, income or education, disability, living in a rural locality, or sexual orientation. HHS reports that the cultural and linguistic differences among patients directly impact their health literacy levels, which, in turn, contributes to an increased prevalence of health disparities among minorities. 19

20 Health Literacy and Health Disparities Studies show that when controlling for health literacy, racial and ethnic disparities in health care quality and outcomes often disappear. 20

21 Elderly High-Risk Groups Minorities Limited English Proficiency (LEP) patients Low income Homeless Prisoners Persons with limited education Learning Disabled (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011) 26 21

22 MEDIATORS 22

23 Individuals with Low Health Literacy Literacy 23

24 Poor compliance with medical treatment Often appear to be noncompliant with medical treatment. may miss appointments forget to take medications fail to follow self-treatment regimens Brown, M. T., & Bussell, J. K. (2011). Medication Adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), doi: /mcp

25 POOR HEALTH OUTCOMES 25

26 Poor Health Outcomes Poor literacy skills often result in poor health outcomes for individuals. Diabetes Hypertension Cancer Fail to seek preventive care and are at more than double the risk for hospitalization Report poorer health status than people with better literacy skills. Adult patients with low health literacy in primary care clinics were less able to describe how they would take 5 medications and had a greater probability of misunderstanding instructions on 1 or more labels. Higher all cause mortality 26

27 IDENTIFYING AND ASSESSING HEALTH LITERACY 27

28 POSSIBLE SIGNS OF LOW HEALTH LITERACY Your patients may frequently say: Your patients behavior may include: I forgot my glasses My eyes are tired I ll take this home for my family to read What does this say? I don t understand this Not getting their prescriptions filled, or not taking their medications as prescribed Consistently arriving late to appointments Returning forms without completing them Requiring several calls between appointments to clarify instructions 28

29 Testing for Health Literacy There are several test that can be used to measure Health Literacy in patients: Test of Functional Health Literacy in Adults (TOFHLA) Newest Vital Sign (NVS) The Short Assessment of Health Literacy-Spanish and English (SAHL-S & E) Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) Short Assessment of Health Literacy for Adults Spanish(SAHLSA-50) 29

30 Oral Health Literacy Questions 1) How often do you have somebody help you read hospital materials? 2) How confident are you filling out medical forms by yourself? 3) How often do you have problems learning about your medical condition because of difficulty understanding written information? 30

31 PATIENT/PHYSICIAN COMMUNICATION 31

32 Patient-physician relationship Patients most common complaint is the lack of information provided by physicians Majority of malpractice suits arise from communication errors; not incompetence 32 Silverman, Kurtz and Draper: Skills for communicating with patients 2005

33 The Seven Learning Styles 1. Visual (spatial):you prefer using pictures, images, and spatial understanding. 2. Aural (auditory-musical): You prefer using sound and music. 3. Verbal (linguistic): You prefer using words, both in speech and writing. 4. Physical (kinesthetic): You prefer using your body, hands and sense of touch. 5. Logical (mathematical): You prefer using logic, reasoning and systems. 6. Social (interpersonal): You prefer to learn in groups or with other people. 7. Solitary (intrapersonal): You prefer to work alone and use self-study.

34 Plain Language Medical Hypertension Insomnia Benign Hazardous Disorder Option Routinely Adverse Plain Language High blood pressure Can t sleep NOT cancer Dangerous Problem Choice Often Bad 34

35 Instead of saying Periodontal disease, you might say: The gum tissue and jaw bone surrounds and supports the teeth, just like the foundation of a house surrounds and supports our homes. If we don t take care of problems in the foundation of the home, it doesn t matter how good the condition of the home might be, a weak foundation won t be able to support it. The same is true of your gum tissue, no matter how healthy your teeth are, if the gum tissue and bone that support your teeth aren t healthy, you might still lose your teeth. 35

36 Tips to Identify a Patient s Preferred Language Ask the patient for their preferred spoken and written language. Display a poster of common languages spoken by patients Ask them to point to their language of preference. Make available and encourage patients to carry I speak. or Language ID cards. Many phone interpreter companies provide language posters and cards at no charge. 36

37 Interpreter Individuals who are not trained to be an interpreter make more clinically significant mistakes. Unacceptable language assistance: Untrained/Uncertified clinicians or staff The patient s family and friends Minor children 37

38 Trained health care interpreters can reduce liability, help ensure appropriate utilization, and increase client adherence and satisfaction with services. Trained interpreters help to assure effective communication between the client and provider, support effective use of time during the clinical encounter, and improve outcomes.

39 Services for Non-English Speaking or Residents 39

40 Don t Assume If the information is critical, make sure you or someone in your office reviews the information with your patient and/or the patient s caregiver. When reviewing a handout: Circle or highlight the most important points as you talk about them. Personalize the material by adding the patient s name, medicines, and/or specific care instructions. Use teach-back to confirm understanding. Emphasize the importance of the material by referring to it during follow up phone calls, s, and future office visits. You may need to give the material to the patient more than once. 40

41 Fry Method 1. Randomly select three 100-word segments of your writing. 2. Count the number of syllables in each 100- word block and calculate the average. 3. Count the number of sentences in each 100- word block and calculate the average. 4. Plot the point on the graph (see below) where the numbers from steps 2 and 3 intersect.

42 Are you pregnant? Do you get health coverage from an Iowa program? If you do, your baby will also be covered. Coverage will last until the end of the month of your baby s first birthday. The baby must live with you in Iowa. Grade 3, according to Fry s Readability Graph

43 Health Literacy and Culture The Institute of Medicine has called for the need to view health literacy in the context of language and culture. 43

44 Consider Culture, Customs, and Beliefs Tool Religion, culture, beliefs, and ethnic customs can influence how patients understand health concepts how they take care of their health how they make decisions related to their health 44

45 Cultural, Beliefs and Concepts (989)

46 Teach Back Method Studies have shown that percent of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect. One of the easiest ways to close the gap of communication between clinician and patient is to employ the teach-back method, also known as the show-me method or closing the loop. Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Patient understanding is confirmed when they explain it back to you. It can also help the clinic staff members identify explanations and communication strategies that are most commonly understood by patients 46

47 Teach-Back Use the Teach-Back or Show Me method to ensure patients understand the information you give 47

48 Use Teach Back Method when discussing brushing teeth, flossing etc. Dental Hygienist: Let s review the most effective way to floss your teeth. I ll have you watch me floss your teeth first and then, just to make certain that I ve explained this clearly, I ll have you demonstrate the technique back for me. 48

49 WHO IS RESPONSIBLE FOR IMPROVING HEALTH LITERACY? 49

50 Who is responsible for improving health literacy? Public health professionals, health care providers, and the health care and public health systems have primary responsibility. Health literacy has direct impact on the three pillars of medical and health services provision: Increased quality Improved patient/consumer experience and patient outcomes Reduced costs 50

51 Making Changes The Institute of Medicine stated in order to address the challenge of health literacy requires system-level changes for both health professionals and organizations. Systems change include using the universal health literacy precaution methods which include: Form changes, Sending forms before appointments, No heavy use of patient portal, better communication with patients, Uses of decision aids to help with patient understanding (Easton, Entwistle, & Williams, 2013; Weiss, 2014) 51

52 NIDCR Work Group on Functional Health Literacy (2004) The National Institute of Dental and Craniofacial Research (NIDCR) convened a Working Group on Functional Oral Health Literacy in January The workgroup used existing health literacy knowledge from the medical field to begin building an understanding of oral health literacy. The workgroup was interested in the ways in which the issue of health literacy affected the adoption of effective disease prevention methods, patient adherence to treatment regimens, and ultimately, improved oral health status. In addition, the potential impact of oral health literacy on clinical research was also acknowledged. 52

53 The ADA s House of Delegates meeting in 2006 The delegates adopted the following six oral health literacy-related resolutions: Res. 14H-2006: The ADA recognizes that limited oral health literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease. Res. 16H-2006: Directed the ADA s Council on Access, Prevention and Inter-professional Relations (CAPIR) to work with the Council on Government Affairs and other appropriate ADA agencies to develop and implement an advocacy strategy, based on the 2006 School Health Policies and Programs Study (SHPPS) data, to increase the number of school districts requiring oral health education for K-12 students. Res. 17H-2006: Authorized the ADA President to appoint a three-year National Oral Health Literacy Advisory Committee (NOHLAC) of 12 national health literacy experts from dentistry, public health, literacy and other advocacy organizations. Res. 18H-2006: Directed the CAPIR to design and execute a comprehensive oral health literacy awareness and education strategy targeting the entire dental team. The NOHLAC is will provide recommendations for this plan. Res. 19H-2006: Instructed CDEL and other appropriate ADA agencies to encourage the development of undergraduate, graduate and continuing education programs to train dentists and allied dental team members to effectively communicate with patients with limited literacy skills. Res. 23H-2006: Requested ADA agencies to develop guidelines for the creation of educational products to meet the needs of patients with limited literacy skills, including 53 the involvement of targeted audiences in materials development.

54 WHAT CAN YOU DO? 54

55 Dental practice-related malpractice statistics for the years : The National Practitioner Data Bank Public Use File (NPDB) Summary Report: 34,691 malpractice reports regarding dentist 137 malpractice reports regarding dental residents 17 malpractice reports regarding dental hygienists 19 malpractice reports regarding denturists 8 malpractice reports regarding dental assistants The reasons for these Patient-Clinician Related Malpractice Lawsuits were categorized as follows: Inadequate explanation of diagnoses Inadequate explanation of treatment Patient feels ignored Clinician fails to understand the perspective of patient Clinician discounts or devalues views of patients or relatives Patient feels rushed 55

56 CLAS Enhanced in April 2013 Focuses on health equity For use by both health care and health service organizations CLAS Standards Eliminate Health/care Inequities Improve Quality of Services Advance Health Equity

57 CLAS CLAS standards require health care providers to: Provide free language assistance to individuals who are not proficient in English Notify individuals in their preferred language, verbally and in writing, of the availability of language assistance Establish competence of individuals who provide language assistance rather than using untrained interpreters minors Provide easy-to-read handouts and posters in common languages other than English

58 Include Health Literacy in Staff Training and Orientation Training staff will increase awareness of the need for addressing health literacy and improve their skills for communicating with the public. Include information on health literacy in staff orientation. Make a presentation on health literacy at your next staff meeting. Circulate relevant research and reports on health literacy to colleagues. Post and share health literacy resources. 58

59 A Health Literate Healthcare Organization 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes populations served in the design, implementation, and evaluation of health information and services. 5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. 7. Provides easy access to health information and services and navigation assistance. 8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. 9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines. 10. Communicates clearly what health plans cover and what individuals will have to pay for services. Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. How Can Health Care Organizations Become More Health Literate: Workshop Summary. Washington (DC): National Academies Press (US); 2012 Jul 18. 2, Attributes of a Health Literate Health Care Organization. Available from: 59

60 Has leadership that makes health literacy integral to its mission, structure, and operations. Is health literacy apart of your mission? How does health literacy impact the structure of your office? What operations are in place to address health literacy in your office? Does your office leadership have training in health literacy? 60

61 Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. Are patients with low health literacy giving extra time in appointments? What evaluations measures are in place to assess health literacy in your office? How is information delivered to patients? How are medication instructions written? 61

62 Prepares the workforce to be health literate and monitors progress. Are there trainings in place for staff to stay abreast on health literacy yearly? Have all physicians and nurses take CME and CNE offered on health literacy and cultural competency? Are behavior changes toward being better with low health literate patients on the staff performance evaluation? 62

63 Includes populations served in the design, implementation, and evaluation of health information and services. * Are there audits on medical records to determine all languages of patients in the office? * Are patients literacy/health literacy levels tested? * Is there a survey that asks the patients to grade how the office is doing on various areas of health literacy? 63

64 Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. * How do patients get linked to non-medical support? * Are their less than five steps in getting a patient a referral? * How has the staff taking time to understand the diverse cultures, religions and sexual backgrounds of your patients? * Have you used an interpreter service for all clients who are ESL even if family member interprets? 64

65 Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact * Have written materials in patients spoken language? * Use the Teach Back method with all patients? * How does your physician or office encourage patients to ask questions? 65

66 Provides easy access to health information and services and navigation assistance. * Do you have patient navigators in place? * Are patients who do not have computer access able to get their results and questions easy? 66

67 Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. * Are patient materials tested for readability and understandability? * Is all information giving to patients on a 5 th grade reading level? * Are there any usage of decision aids to help with decision making between the patient and physician? 67

68 Addresses health literacy in high-risk situations, including care transitions and communications about medicines. * Are there measures to help those with low health literacy lessen injuries due to medication and or treatment adherence? 68

69 Communicates clearly what health plans cover and what individuals will have to pay for services. * Does the staff have a cheat sheet for patients to understand their insurance plan before seeing the physician? * Is the physician knowledgeable of health plans and order treatment accordingly as not to increase fees to the patient? * Are all services and fees are written down for the patient and explained thoroughly for the client to agree or 69 disagree with.?

70 STRATEGIC PLANNING 70

71 Your Strategic Plan is to plan the best way to implement the Health Literacy Universal Precautions rules, the toolkit is here to help with the implementation. 71

72 Use Health Literacy Universal Precautions Toolkit Agency for Healthcare Research and Quality created the Universal Precaution Health Literacy Toolkit Because limited health literacy is common and is hard to recognize, experts recommend using health literacy universal precautions. Practices should assume that all patients and caregivers may have difficulty comprehending health information and should communicate in ways that anyone can understand. Health literacy universal precautions are aimed at: simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized8 making the office environment and health care system easier to navigate supporting patients efforts to improve their health 72

73 Steps to Implementing Universal Precaution 1. Raise Awareness 2. Form a Group 3. Bring Team Members together 4. Create a Health Literacy Improvement Plan 73

74 PATIENT CENTERED APPROACH 74

75 Patient Advocacy Part of health literacy is getting the patient to become better advocates for their health. This usually takes skill building of the patient. Most hospitals, health departments, and clinics used community health workers, health educators, volunteers and other staff to spend some time with patients to help build these skills including: Asking physician questions Shared decision making Medication Awareness Numeracy 75

76 Ask Me 3 Ask Me 3 is a patient education program designed to improve communication between patients and health care providers, encourage patients to become active members of their health care team, and promote improved health outcomes. The program encourages patients to ask their health care providers three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this?

77 Don t Ask, Don t Tell Not revealing information due to the patient not asking about it does not work in the medical community especially for those who aren t health literate Those with low health literacy sometimes do not know what to ask or how to ask a question Example of this are immunizations and testing. It is the physician's jobs to stress the importance of immunization and treatment options 77

78 Decision Making Not all patients agree on the same way of making decision about their health. Some believe : The doctors should make all their decisions The doctor and patient should make the decision together The patient should make the decision with their families The patient should make the decision alone The patient will not make any decision. 78

79 Use Decision Aids in every situation Patient decision aids are tools that help people become involved in decision making. making explicit the decision that needs to be made providing information about the options and outcomes clarifying personal values Complement, rather than replace Help those with low literacy make better decisions and lessen decisional regret while also gaining knowledge There are numerous decisions aids already in existence 79

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81 Shared Decision Making Shared decision making (SDM) has been defined as: an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences 81 Implementing shared decision making in the NHS. Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R BMJ Oct 14; 341():c5146.

82 6 steps to SDM 1) Invite Patient to participate 2) Present Options 3) Provide information on benefits and risks 4) Assist patients in evaluating options based on their goals and concerns 5) Facilitate deliberation and decision making 6) Assist with implementation 82

83 NUMERACY AND MEDICATION 83

84 What is Numeracy? Numeracy is the type of math skills needed to function in everyday life, in the home, workplace, and community (Withnall 1995). When applied to health behaviors, it describes the degree to which individuals have the capacity to access, process, interpret, and act on graphical and probabilistic health information. As a cognitive and functional skill, low numeracy correlates with poor outcomes in the management of chronic diseases; Numeracy is therefore an essential component of patients' capacity to adhere to medication regimens. 84

85 Numeracy In particular, people differ in numeracy. Among uninsured adults, we estimated that: 28.8 percent are at a Below Basic level of numeracy 33.4 percent are at a Basic level 29.3 percent are at an Intermediate level 8.6 percent are at a Proficient level of numeric literacy Adult Numeracy Below basic Basic Intermediate Profecieint 85

86 Numeracy Numeracy skills are needed to : select a health plan choose treatments understand medication instructions include education-based skills and emergent decision-based abilities We estimate that the skills needed to make many complex, informed health decisions (e.g., management of chronic diseases) require a Proficient level of numeric literacy, given how numeric information is often provided. 86

87 CREATE A CHEAT SHEET FOR NUMERACY Create a cheat sheet to help those with low numeracy understand basic measurements they will use when taking medication. IE. difference between MG and MM and cup vs ounces. Maybe your clinic would want to create this and give it out to your patients. 87

88 Summary of Recommendations for Presenting Numerical Concepts Recommendation Use the fewest and simplest mathematical constructs Remove nonessential information Order information from most to least important or along a discernible hierarchy Use several formats for presentation, e.g., verbal, quantitative, visual Consider using constructive framing or anecdotes Present benefits and risks, loss and gains, negative and positive Realize positive is more likely to be chosen Consider the best time frame for presenting risk When using graphs, use most appropriate format and explain it to the patient When applicable, show full denominator or full range of scale and explain both the numerator and denominator Tailor information to the patient Make communication interactive Reinforce important messages with repeat instruction Confirm comprehension 88

89 FOLLOW UP 89

90 Follow Up With Patients Follow-up is the act of making contact with a patient or caregiver at a later, specified date to check on the patient s progress since his or her last appointment. Appropriate follow-up can help you to identify misunderstandings and answer questions, or make further assessments and adjust treatments. Choose the ways your office will follow up. Phone. Secure . Texting. Postal mail. Automated calling system Note Patient Portal isn't an option

91 Summary Understanding and implementing Health Literacy is beneficial for the patient, the healthcare community and economically the nation. Health Literacy changes start with understanding the patient, training staff, updating materials, and continuing education amongst health care workers. Decisions aids are a great tool to help those with low literacy. 91

92 Health Literacy Communication Checklist Plain Language Proper Use of Interpreters Making Patient Materials readable for a 4 th grade level Consider Culture of the Patient Use teach Back Method Tell even IF they don t ASK Use Decision Aids Medication Brown Bag Follow up with patients ( less Patient Portal) 92

93 Questions & Comments Dr. NICKELL M. DIXON, DrPH, MPH HEALTH EQUITY INITIATIVE COORDINATOR HEALTH DISPARITIES REDUCTION AND MINORITY HEALTH SECTION PHONE: FAX: CAPITOL VIEW BLDG., 7th Floor 201 TOWNSEND STREET LANSING, MI