Page 1 Strategies to Improve Communication Between Pharmacy Staff & Patients What About You??? Vona Broughton, CHES Kevin McCarthy, RPh Content partially developed by Sunil Kripalani, MD, MSc and Kara L. Jacobson, MPH, CHES Overview 1. Define health literacy 2. Describe the health care experiences of lowliteracy patients 3. Discuss health literacy and medication use 4. Review techniques to improve communication with low-literacy patients 5. Discuss the economic impact of low health literacy Definition Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. U.S. Department of Health and Human Services. Healthy People 2010
Page 2 Skills Needed for Health Literacy Health Literacy in America: Results from the NAAL Evaluating information for credibility and quality Analyzing relative risks and benefits Calculating dosages Interpreting Test results Locating health information 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Kutner et al 2006 12% 53% Proficient: Define medical term from complex document, Calculate share of employee s health insurance costs Intermediate: Determine healthy weight from BMI chart, Interpret prescription and over-the-counter drug labels 22% Basic: Understand simple patient education handout 14% Below Basic: Circle date on appointment slip, Understand simple pamphlet about pre-test instructions High Risk Groups Kirsch et al 1993 Elderly Minorities Immigrants Poor Homeless Prisoners Persons with limited education Functional Literacy of High Risk Populations Group Low Literacy (%) All 50 Elderly ( 65) 81 Racial/Ethnic group: White 41 Black 77 Hispanic 78 Education level: 0-8 yrs 96 9-12 yrs 81 HS/GED 55 Immigrants: 0-8 yrs prior educ 91 Weiss 2005. Adapted from Table 2-1. 9+ yrs prior educ 71
Page 3 Overview 1. Define health literacy 2. Describe the health care experiences of lowliteracy patients 3. Discuss health literacy and medication use 4. Review techniques to improve communication with low-literacy patients 5. Discuss the economic impact of low health literacy Health Care Experiences Low-literacy patients commonly hide their difficulty Many feel ashamed Avoidant behaviors When do you suspect low literacy? Your experiences? Parikh et al 1995. Weiss 2003. Possible Indicators of Low Health Literacy Excuses: I forgot my glasses. Lots of papers folded up in purse/pocket Lack of follow-through with tests/appts. Seldom ask questions Questions are basic in nature Difficulty explaining medical concerns or how to take meds Universal Precautions Can t tell by looking Communicate clearly with everyone Confirm understanding with everyone Weiss 2003. Katz et al 2007.
Page 4 Overview 1. Define health literacy 2. Describe the health care experiences of lowliteracy patients 3. Discuss health literacy and medication use 4. Review techniques to improve communication with low-literacy patients 5. Discuss the economic impact of low health literacy Low Literacy and Medication Use Ability to identify their own medications 12-18 x greater odds Understanding of how to take medications Take med every 6 hrs 52% correct Take med on empty stomach 46% correct Understanding of drug mechanisms and side effects Warfarin works by thinning blood 70% correct Bleeding/bruising most common SE 49% correct Misinterpretation of common warning labels 3-4 x more likely to misinterpret Kripalani et al 2006. Gazmararian et al 1999. Fang et al 2006. Davis et al 2006. Misinterpretation of Warning Labels Don't take food Chew pill and crush before swallowing Chew it up so it will dissolve. Don t swallow whole or you might choke Don't leave medicine in the sun Don't drink and drive Don t drink alcohol. It s poison, and it ll kill you If allergic to dairy, don't take medicine Don t eat for 1 hour after taking medicine Stats to Show Understanding Simple, familiar-- 1 st grade level 84% More complex-- 10 th - 12 th grade level 59% Unfamiliar, multi-step 10 th -13 th grade level 8% Don t take when wet. Don t need water Don t drink hot water Use extreme caution in how you take it Medicine will make you feel dizzy Take only if you need it Davis et al 2006. Adapted from Table 3. Davis et al 2006. Adapted from Table 3.
Page 5 Health Literacy and Medication Use Understanding of numerical information If your blood test result for warfarin is just right when it is between 2.0 and 3.0, which of the following results would be just right? 29% correct Medication adherence Adverse drug events (?) Health care costs Some Challenges in Trying to Improve Things Increasingly complex health system Greater self-care requirements More medications for chronic conditions Formulary and manufacturer changes Medication reconciliation Most patient instructions are written Low-literacy pts have trouble understanding Verbal instructions Often complex Delivered rapidly Easy to forget in stressful situation Fang et al 2006. Gazmararian et al 2006. Howard et al 2005. Overview 1. Define health literacy 2. Describe the health care experiences of lowliteracy patients 3. Discuss health literacy and medication use 4. Review techniques to improve communication with low-literacy patients 5. Discuss the economic impact of low health literacy Recommended Strategies to Improve Communication 1. Explain things clearly in plain language 2. Focus on key messages and repeat 3. Use a teach back or show me technique to check understanding 4. Effectively solicit questions 5. Use patient-friendly educational materials to enhance interaction Weiss 2003. Kripalani and Weiss 2006.
Page 6 1. Explain It Clearly in Plain Language Slow down the pace of your speech Use plain, non-medical language Blood pressure pill instead of antihypertensive Pay attention to patient s own terms and use them back Avoid vague terms Take 1 hour before you eat breakfast instead of Take on an empty stomach Using Plain Language: What could we say instead of Adverse reaction Hypoglycemia PRN Topical Suppository Side effect Low sugar When you need it On skin Pill that goes in your bottom/behind 2. Focus on Key Messages and Repeat 3. Check Understanding Using Teach-Back Limit information Focus on 1-3 key points Develop short explanations for common medical conditions and side effects Discuss specific behaviors rather than general concepts What the patient needs to do Review each point at the end Schillinger et al 2003
Page 7 Teach Back Scripts I want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, what would you say? Let s review the main side effects of this new medicine. What are the 2 things that I asked you to watch out for? Show me how you would use this inhaler. 4. Effectively Solicit Questions Don t say: Do you have any questions? Any questions? Instead say: What questions do you have? 5. Patient-Friendly Materials Appropriate Content Plain Language (K.I.S.S.) Layout Illustrations
Page 8 Overview 1. Define health literacy 2. Describe the health care experiences of lowliteracy patients 3. Discuss health literacy and medication use 4. Review techniques to improve communication with low-literacy patients 5. Discuss the economic impact of low health literacy Low Health Literacy = Use of More Health Care Services People with low health literacy had 6% more hospital visits Fewer doctor visits, more hospital resources Economic Impact of Low Health Literacy $73 billion extra in 1998 dollars Medicare pays 39 % FICA pays additional expenditure THE JOINT COMMISSION REPORTS 65% of Sentinel Events 90% of Root Cause Analyses Patient Safety Goal effective January 1, 2006 facilities must implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions
Page 9 Reasons for Communication Break Down Different communication styles High level of activity Frequent interruptions No standardization in organizing essential information S-BAR MODEL S- Situation B- Background A- Assessment R- Recommendation Loss of information SBAR Example (Listen carefully to this example) PQRSTU MODEL OF SYMPTOM ANALYSIS P- Precipitating, Palliating, Previous Tx of Therapy Q- Quality R- Radiation S- Severity T- Temporal U- YOU!
Page 10 Help me make sure I ve explained things clearly Help me make sure I ve explained things clearly so far How do you know if a patient has low health literacy? Name at least 2 techniques to improve communication with low-literacy patients. Help me make sure I ve explained things clearly so far Provide an example of the teach-back. Wrap Up Adopt Universal Precautions Implement Strategies to Improve Communication, e.g., Plain Language Focus on Key Messages Teach Back
Page 11 Health Literacy Organizations and Programs Health Literacy. American Medical Society Foundation. http://www.ama-assn.org/ama/pub/category/8115.html Health Literacy Center, University of New England http://www.une.edu/hlit/ Health Literacy Consulting http://www.healthliteracy.com/ What questions do you have? National Institute for Literacy http://www.nifl.gov/ World Education, Health and Literacy Initiative http://www.worlded.org/ References Notes 1. Davis TC, Wolf MS, Bass, PF III, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S, Parker RM. Low Literacy Impairs Comprehension of Prescription Drug Warning Labels. Journal of General Internal Medicine. 2006;21(8):847 851. 2. Fang MC, Machtinger EL, Wang F, Schillinger D. Health Literacy and Anticoagulation-related Outcomes Among Patients Taking Warfarin. Journal of General Internal Medicine. 2006;21(8):841-846. 3. Freidland RB. Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy. Washington, DC: National Academy on an Aging Society; 1998. 4. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP. Health Literacy Among Medicare Enrollees in a Managed Care Organization. JAMA. 1999;281:545-551. 5. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors Associated with Medication Refill Adherence in Cardiovascularrelated Diseases: A Focus on Health Literacy. Journal of General Internal Medicine. 2006;21(12):1215-C15. 6. Howard DH, Gazmararian J, Parker RM. The Impact of Low Health Literacy on the Medical Costs of Medicare Managed Care Enrollees. The American Journal of Medicine. 2005;118(4):371-377. 7. Katz MG, Jacobson TA, Veledar E, Kripalani S. Patient Literacy and Question-Asking Behavior During the Medical Encounter: A Mixed- Methods Analysis. Journal of General Internal Medicine 2007;22(6):782-786. 8. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education; September 1993. 9. Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson TA. Predictors of Medication Self-management Skill in a Lowliteracy Population. Journal of General Internal Medicine. 2006;21(8):803-900. 10. Kripalani S, Weiss BD. Teaching About Health Literacy and Clear Communication. Journal of General Internal Medicine. 2006;21(8):888-890. 11. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006. 12. National Quality Forum. Safe Practices for Better Healthcare, 2003; Washington, D.C. 13. Parikh N, Parker R, Nurss J. Shame and health literacy: the unspoken connection. Patient Education and Counseling. 1995;25:109 199. 14. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K; Castro C, Bindman AB. Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 2003;163:83-90. 15. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report No. 43 from the Agency for Healthcare Research and Quality. AHRQ Publication No. 01-E058; 2001. 16. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000. 17. Weiss, BD. Epidemiology of Low Health Literacy. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. AMA Press; 2005:19. 18. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003.