Health Literacy: Challenges and Solutions

1. Health Literacy: Challenges and Solutions Presented by: Barbara Meyer Lucas, M.D., MHSA The Michigan State Medical Society Foundation American Medical Association Foundation & American Medical Association 10/03

2. Overview of Presentation: • Definition of Health Literacy • Implications of Poor Health Literacy • Why Is Health Literacy a Challenge? • What Solutions Can We Offer?

3. Definition: 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.” Simplified: Health Literacy is the ability to: ----Read, ----Understand, and ----Act On health care information.

4. 17% 32% Level 4 Level 5 - 3% Level 3 Level 1 21% - InadequateLiteracy Level 2 27% - Marginal Literacy 1993 National Adult Literacy Surveyn=26,000, scored on 5 levels

5. Implications of Poor Health Literacy: 48% of the U.S. Population Are at Risk For: • Inadequate health knowledge and poorer health outcomes • Inappropriate hospitalizations and greater health costs • Increased medical errors

6. Low literate diabetic patients less likelyto know correct management…. Know symptoms of low blood sugar (hypoglycemia) Know correct action for hypoglycemic symptoms Percent Williams, et al. Arch Int Med 1998

7. Poor health outcomes for diabetic patients…… • Diabetic patients with low health literacy have poorer glycemic control than patients with adequate literacy. (Schillinger D, et al. JAMA. 2002.) • Diabetic children (ages 5-17) had poorer glycemic control if their parents had lower literacy skills. (Ross LA, et al. Diabetic Med. 2001.)

8. Patients with low literacy more likely to be hospitalized % Baker, Parker, Williams, et al. JGIM 1999

9. Linkage to Patient Safety: Sentinel Events • Communication Issues are the Leading Root Cause of Sentinel Events, all Categories, 1995-2002 • Communication Issues Implicated as a Root Cause in 56% of Medication Errors

10. Root Causes of Sentinel Events(all Categories, 1995-2002: Source: JCAHO)

11. Root Causes of Medication Errors(all Categories, 1995-2002: Source: JCAHO)

12. Research also shows that: • Literacy is a predictor of health status • It is a stronger predictor than age, income, employment status, education level, or racial and ethnic group

13. Why is Literacy Particularly Challenging In The Healthcare Setting?

14. Contributing Factors: • Cultural Issues • Increasingly complex health system • Growing self-care requirements • More medications, tests, procedures • Aging Population • Increased reliance on printed handouts for patient instruction

15. 4 - 6 weeks bed rest in hospital 650 3 weeks in hospital 2 hours a day of diabetic education classes 2-4 days in hospital (M&R Guidelines) 10,000 + outpatient 0-3 hours diabetic education classes written materials internet telemedicine A More Complex Health Care System: 35 Years Ago Today Treatment of Acute Myocardial Infarction Available Prescription Drugs Treatment of new onset diabetes

16. An Aging Population:Inadequate health literacy increases with age: % Gazmararian, et al. JAMA 1999

17. Increased Reliance on Written Handouts : • As a sincere attempt to improve patient education • To increase office efficiency by using ancillary staff • To comply with mandates from accrediting agencies

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19. Solutions: What can we do to help? • Understand the problem • Identify the barriers faced by both patients and clinicians • Identify and implement strategies to enhance health literacy • Advocate for system change

20. Video: The patient’s voice... • This video was made by the AMA in 2003 • You will see real patients and real physicians talking about literacy issues

21. Two specific goals to enhance health literacy… • Create a shame-free environmentwith improved patient assessment • Improve interpersonal communication with patients

22. Goal #1: Creating a “Shame-Free” Environment 4 Key Strategies for Healthcare Organizations: 1. Adopt an attitude of Helpfulness 2. Convey a safe, non-judgmental environment 3. Be alert for low literacy “red flags” 4. Engage your entire staff

23. 1. Adopt an Attitude of Helpfulness • Attitude of helpfulness, caring and respect by all staff • Easy-to-follow instructions for appointments, check-in, referrals and tests • Assistance provided confidentially • All patients treated as if they are your parents

24. 2. Create a Safe, Non-judgmental Environment • Provide privacy for all discussions • Sit down at patient’s level to talk! • Ask patients how they want information communicated to them • Take the patient’s concern seriously • Ask and listen before you advise • Give the patient time to respond • Be positive, hopeful, empowering

25. Be alert to clues of low Health Literacy • Be alert for “red flags” • Use the “social history” to assess literacy • Use “medication reviews” to identify and address problems

26. Red Flags:Patients may seek to protect themselves by…. • Not completing registration forms • Walking out of the waiting room • Making excuses • Pretending they can read • Becoming angry, demanding • Clowning around, using humor • Being quiet, passive • “Detouring”, letting doctor miss the concern

27. Red Flags:Patient Communication • Unable to name medications, or explain purpose or timing of administration • Difficulty explaining medical concerns • Has no questions

28. Red Flags:Lack of follow-through • Frequently missed appointments • Skipped tests and referrals • Non-compliant with meds • Seeking help only when illness is advanced

29. Use the “social history” to ask: • Ask about education, reading, learning styles – be non-judgmental. • Use this discussion to open a space for the patient to talk about literacy issues. • “How comfortable are you with the way you read?”

30. Use a “Brown Bag Visit” to identify problems: Conducting a Medication Review: • Ask patients to bring in all their medications • Ask them to name and explain the purpose of each one • Discuss exactly how and when they take each one • Use this discussion to identify areas of confusion and to answer questions

31. 4. Engage the entire staff(what is it like being a patient in your setting?) • What forms will you be given? • Will you be offered confidential assistance? • Are check-in personnel friendly? • Were you given easy-to-follow instructions? • First impressions? Non-verbal communication of staff?

32. All staff need to be involved in….. • Understanding the problem of health literacy • Identifying possible barriers in your setting • Developing, implementing, and assessing effective strategies for improvement • Conducting on-going follow-up and evaluation

33. Goal # 2: Improving Communications with Patients 2 Key Strategies for Individual Healthcare Providers: 1. Improving Face-to Face Communication Skills 2. Improving Written Patient Education Materials

34. Failure to communicate Doctor:“Your foot infection is so severe that we will not be able to treat it locally.” Patient:“I hope I don’t have to travel far, doctor. I’m afraid of flying.”

35. Strategy #1: Enhancing face-to-face communications with patients: 1. Conduct patient-centered visits 2. Explain things clearly in plain language 3. Focus on key messages and repeat 4. Use a “teach back” or “show me” technique to check for understanding

36. 1. Conduct patient-centered visits • Sit down, and engage in a dialogue with the patient • Encourage patients to have a family member accompany them • Welcome questions • Understand and address the patient’s concerns. • Listen more and speak less

37. 2. Explain things clearly using plain language. • Slow down the pace of your speech • Use analogies • “Arthritis is like a creaky hinge on a door.” • Use plain, non-medical language • “Pain killer” instead of “analgesic”

38. 3. Focus on key messages and repeat. • Limit information by focusing on 1-3 key messages per visit • Review each point and repeat several times • Have other staff reinforce key messages.

39. Patients Should Leave Your Office Knowing 3 Things: • What is my main problem? • What do I need to do about it? • Why is it important that I follow these instructions?

40. Exercise : What’s the Key Message? Type II DM diagnosed at today’s visit: • Sugar level in blood is high • How the body controls blood glucose • Self-management of diabetes medications • Start medicine to lower sugar • Potential complications of diabetes • Testing the blood sugar level • Proper diet

41. 4. Use “teach back” or “show me” techniques. • Ask patient to demonstrate understanding • “What will you tell your spouse about your condition?” • “I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.” • Do not ask, “Do you understand?”

42. Strategy # 2: Developing patient-friendly written educational materials: • Focus only on key points • Show or draw only simple pictures ---Minimize info about anatomy and physiology • Be sensitive to cultural preferences. • Emphasize what the patient should do

43. Guidelines for creatingpatient-friendly written materials: • Simple words (1-2 syllables) • Short sentences (4-6 words) • Short paragraphs (2-3 sentences) • No medical jargon • Headings and bullets • Lots of white space.

44. In Summary: • Health Literacy is the ability to read, understand, and act on health care information. • 48% of the U.S. population have inadequate or marginal literacy skills

45. In Summary: Poor Health Literacy places patients at high risk for: --Poor compliance with care plans --Poorer health outcomes --Inappropriate hospitalizations --Medical errors

46. In Summary: • Literacy in the healthcare setting is particularly challenging due to: ---patient discomfort/embarrassment ---complexity of healthcare today ---aging populations/cultural issues ---time constraints that increase our reliance on handouts

47. In Summary: What can we do to help? • Strategies for change include: 1. On a System Level: ---Work toward creating shame-free healthcare environments 2. At the Individual Provider Level: --- Improve communications Face to face with patients Simplified written handouts

48. In Summary: What can we do to help? • For Training at Your Sites: Contact: The Michigan State Medical Society Dept. of Educational Programs Health Literacy Grant Team (517) 337-1351