Actions to Improve Health Literacy HHQI RN Project Coordinator: Misty Kevech, RN, MS, COS-C, CCP, CPTM This material was prepared by Quality Insights, the Medicare Quality Innovation Network Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW WV HH MMD 102816
Objectives After this webinar the learner will be able to: Identify 3 red flags that indicate health literacy issues Explain how to check written patient materials for readability levels Describe 1 method to assess patient s understanding of patient education/instructions
Health Literacy Definition Health literacy is the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. (Patient Protection and Affordable Care Act, 2010)
Health Literacy Statistics 88% of U.S. adults 36% of U.S. adults 65 years and older Have literacy issues Have limited health literacy More likely to only have basic health literacy skills USDHHS & NN/LM
Did You Know? 80% of patients will forget what their provider says Nearly 50% of what patients remember is recalled incorrectly 42% of the patients could not understand directions for taking medications on an empty stomach 43% of the patients did not understand the rights and responsibilities section of a Medicaid application 60% of the patients did not understand a standard informed consent form Health Resources and Services Administration, 2009
Health Literacy Red Flags Frequently missed appointments Incomplete registration forms Non adherence with medications Unable to name medications or explain purpose of dosing Identifies pills by looking at them, not reading label Unable to give coherent, sequential history Asks fewer questions Lack of follow through on tests or referrals AHRQ
Health Literacy Topics Health Literacy Measurement Navigation Verbal Communication Written Communication Evaluation
Measurement Tools Short Assessment of Health Literacy Spanish and English (SAHL S&E) 18 test terms Rapid Estimates of Adult Literacy in Medicine Short Form (REALM SF) 7 test terms Excellent agreement with the 66 instrument (AHRQ) Behavior Exercise Menopause Rectal Antibiotics Anemia Jaundice TOTAL SCORE
Measurement Tools (cont.) The Newest Vital Sign: A Health Literacy Assessment Tool for Patient Care and Research (Pfizer) Ask patient to answer 6 questions about a nutritional label English & Spanish label Or assume each patient has health literacy issues until proven differently
Navigation Barriers Office location or directions Automated phone systems Process changes Health history paperwork Insurance, assistance, or advance care planning paperwork/processes Transportation
Navigation Tips & Resources Walk through your facility and processes with a health literacy lens Modify barriers Educate staff to understand the barriers Provide as much patient information for other providers (e.g., ED summary, brief update for PCP visit) Resources Navigating the Health Care Systems Synopses Physician office and Home Health Admission encounters Patient Health Record
Personal Health Record English & Spanish
Medical Appointment Reminders Phone call or simple post card reminders Evaluate your auto messaging scripts, talking speed, time for patient responses Doctor Appointment Reminder My Questions for this Visit (AHRQ)
Verbal Communication Barriers Clinician monolog Talking speed Too many topics at once Medical jargon Information is often forgotten quickly
Medical Jargon Activity Diagnosis Immunization Diabetes Recognize Annually Eliminate Medication Examine
Verbal Communication Tips & Resources Cover the most important information or actions first Limit to 3 5 key points Use plain language More details with written communication Engage the patient/family into discussion Utilize the OARS Model Use teach back or other tool to check if message was accurately understood
OARS Model HHQI University Basics of Chronic Disease Management course
Teach-Back
Teach-Back in Action https://www.youtube.com/watch?v=bdheev0m62y. HHQI Underserved Population BPIP (pp. 44 46, 66, 72) Tools IHI Open School Short: What is Teach Back? (Institute for Healthcare Improvement)
Other Health Literacy Strategies Chunk Check Chunk Ask Tell Ask IHI Open School Short: What is Ask, Tell, Ask? Ask Me 3 (National Patient Safety Foundation) What is my main problem? What do I need to do (about the problem)? Why is it important for me to do this?
Written Communication Barriers Too much information Paragraphs and multiple pages Not focused Reading level is high Medical jargon or scientific words Patients are overwhelmed or lose interest Confusing information
Confusing Information I authorize to release to the medical records of. I authorize (patient or representative s name) to release to the medical records of (name of the patient) to. (name of person or office)
Written Communication Tips Provide the most important information first Limit the number of messages (3 4 per document) Needs to know and do One message at a time Short long lists (3 7 items) with bullets State actions the patient needs to do Use solid nouns and active voice Focus on the positive vs. negative Tell the patient what they will gain from understanding and using the materials CDC, 2009
Written Communication Tips (cont.) Choose your words carefully Keep it short Use conversational style Show respect and value (don t preach) Offer small, practical steps Provide examples Limit medical jargon or scientific language Be consistent with words Avoid unnecessary abbreviations or acronyms Limit use of statistics (use words like half ) Limit use of symbols CDC, 2009
Health Literacy Readability 5 th 6 th grade level typically Common 1 2 syllable words if possible Font size (12 14 points) Font style S Serif fonts are best Times New Roman, # ±, Garamond, Georgia Bullets instead of sentences if possible Bold type to emphasize words or phrases Limit italics or underlining Avoid ALL CAPS CDC, 2009
Health Literacy Readability (cont.) Dark letters on light colored paper Appropriate punctuation Subtitles or headers if using a lot of text Boxes or sections White space Meaningful pictures/images Culturally appropriate CDC, 2009
Reading Level Activity
Show Me How Many Pills You Would Take in 1 Day John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill AHRQ Slide by Terry Davis
Rates of Correct Understanding vs. Demonstration Take Two Tablets by Mouth Twice Daily 71 84 63 89 80 35 AHRQ Davis TC, et al. Annals Int Med 2006
Readability Assessments Formulas calculate score of reading or grade levels Key areas are syllables, length of sentences Many score by U.S. school grades Numerous free key tools for assessing reading level Flesch Kincaid Grade Level (U.S. school grade levels) Flesch Kincaid Reading Ease Simple Measures of Gobbledygook (SMOG) Index
Flesch-Kincaid Microsoft Word option Must initially set the feature Click on File tab Locate Word Options button Click on Proofing Check the option for Show readability statistics & click OK To check scoring, run Spell Check and at the end a report will be provided
Flesch-Kincaid (cont.) Reading Ease 90 100 : Very Easy 80 89 : Easy 70 79 : Fairly Easy 60 69 : Standard 50 59 : Fairly Difficult 30 49 : Difficult 0 29 : Very Confusing Grade Level Aim for 5 th 6 th grade
SMOG SMOG Conversion Table Free online tools Drop plain text or file into the tool and auto calculate
Written Communication Resources AHRQ. (2015). Health literacy: Hidden barriers and practical strategies. AHRQ. (2015). Health literacy universal precautions toolkit. Second edition. CDC. (2016). Health Literacy website CDC. (2009). Simply Put A guide for creating easyto understand materials HHQI. (2013). Underserved Populations Best Practice Intervention Package. (pp.31 36; 38 53, 64 68) Nursing/Therapy Track (pp. 69 74 in BPIP) USDHHS. Quick Guide to Health Literacy.
Appropriate Translations