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Intersecting Health Literacy with Cultural Competency in Patient Centered Medical Homes

Intersecting Health Literacy with Cultural Competency in Patient Centered Medical Homes. Cara L. Léos, Pharm D, BCPS Network Pharmacist Care Network of East Alabama c ara.leos@eamc.org. CNEA: Who are we?. Care Network of East Alabama, Inc. 1 of 3 pilot programs started Fall 2011

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Intersecting Health Literacy with Cultural Competency in Patient Centered Medical Homes

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  1. Intersecting Health Literacy with Cultural Competency in Patient Centered Medical Homes Cara L. Léos, Pharm D, BCPS Network Pharmacist Care Network of East Alabama cara.leos@eamc.org

  2. CNEA: Who are we? • Care Network of East Alabama, Inc. • 1 of 3 pilot programs started Fall 2011 • Over 36,000 Patient First Medicaid patients in 7 counties • ~16,000 patients ≥ 1 chronic medical condition • ~67% pediatric patients • Over 50 physician/physician practices contracted • Interdisciplinary medical case management • Administrative staff and medical director • Licensed social workers • Registered nurses • Pharm D’s each with 2 years of post-doctoral residency training plus academic experience Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  3. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  4. Non-compliant Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  5. Objectives • Define literacy and health literacy • Discuss TJC call-to-action regarding health literacy • Explore the prevalence of functional illiteracy and health illiteracy • Discuss the economic impact of low health literacy in the US population • Discuss techniques to detect and care for the patient with low health literacy • Explain the use of the REALM-SF • Administration • Scoring and documentation • Communication of findings Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  6. Patient struggles • Understanding of the healthcare system • Ability to navigate large medical centers • Parking • Locating services • Transportation and ability to walk • Affordability of services • Un-insured • Under-insured • Asking questions and perception of “questioning the doctor” • Support system Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  7. Cultural Competency • The ability to incorporate the understanding of a patient’s thoughts, feelings, and beliefs into a care plan • Regional • Religious • Political • Legal • Traditions • “Understanding” or “trust” Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  8. Cross Cultural Challenge: Health Literacy Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  9. Literacy • The ability to use written materials in a functional manner • 2003 National Assessment of Adult Literacy (NAAL) • Below Basic (the most simple and concrete literacy skills) • Signing a form • Adding amounts on a bank deposit slip • Searching simple text to discern what a patient can eat/drink before a medical procedure • Basic (simple and everyday literacy skills) • Using the TV Guide to find the time of a specific program • Comparing ticket prices for 2 events • Finding information in a pamphlet regarding the selection of a jury pool • Findings: 45% of the US population (93M people) have only Basic or Below Basic literacy skills Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  10. Three components of literacy • Prose literacy • Understanding of text in books, magazines, and newspapers • Healthcare: patient education materials (disease state or drug) • 14% below basic; 29% basic level; 44% intermediate level • Document literacy • Understanding of applications, schedules, forms, maps, and tables • Healthcare: Medicaid/Medicare applications, consent forms • 12% below basic; 22% basic level; 53% intermediate level • Quantitative literacy (Numeracy) • Understanding of basic mathematical operations (bank forms) • Healthcare: daily weights, blood glucose, caloric intake, food labels, number of tablets taken at each medication dose • 22% below basic; 33% basic level; 33% intermediate level Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  11. Age Per the National Adult Literacy Survey, 44% of those ≥ 65 yoa are functionally illiterate. • Literacy levels decline in later years • Loss of sight and hearing • Changes in cognition in elderly population • Children/adolescents transition from parental care to self-care • Insurance • RX drugs • Physician visits • Disease state understanding Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  12. Culture Disease state and illness perceptions in a given culture Care of the elderly family member in various cultures Perceptions of male vs. female roles in care of family Formal education in male vs. female family members Children’s responsibilities regarding financial success of the family Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  13. Language • Speaking louder and slower doesn’t help • Use of translators without medical language skills • English as a second language • 2000 US Census report • 1-in-5 US residents speak a foreign language in the home (47M) • Increase of 15M since the 1990 Census • Spanish speakers increased 62% since 1990 Census Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  14. Emotion • Chronic illness can be overwhelming • Depression • Directly relates to activation of the patient For the HCP: • Emotion of the HCP can be misunderstood by patients • Keep conversations on task • Empathize with patients • Echo their sentiments Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  15. Provider struggles • Time and priorities (professional and personal) • Priority determines capacity • Support staff in offices and hospital settings • Costly • Stretched to capacity • Contact with patients outside of scheduled appointments • Telephonic follow-up • “…just have them make an appointment…” • Establishing patient trust and “face” • Inherent trust of medical professionals • Easily violated by miscommunication or perceptions Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  16. Provider expectations of patients Follow written and verbal instructions Use medical equipment appropriately Keep appointments Fill prescriptions regularly Take medications as directed on labels Understand written literature in prescription bags Ask questions and engage in conversation Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  17. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  18. Sources of increased costs Increased medication errors / misadventures Excess hospitalizations Longer hospital stays More ED visits General higher level of chronic illness Results: An excess cost of $73 billion per year to the US healthcare system. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  19. Health Literacy in HF population Peterson PN, et al, Health Literacy and Outcomes Among Patients with Heart Failure, JAMA. 2001;305(16):1695-1701 Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  20. Health Literacy and RX Labels Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  21. Health literacy and hospital admission Baker DW, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees, Am J Public Health. 2002;92:1278-83. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  22. Health literacy and hospital admission Baker DW, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees, Am J Public Health. 2002;92:1278-83. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  23. Other studies… • Relation of lack of knowledge about dietary sodium to hospital readmission in patients with heart failure • Kollipara UK, et al. American Journal of Cardiology. 2008;102:1212-15 • Predictors of medication self-management skill in a low literacy population • Kripalani S, et al. Journal of General Internal Medicine. 2006:21:852-56. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  24. New consensus statements Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  25. Five steps for health care providers to address low health literacy Evangelista LS, et al. Health literacy and the patient with heart failure – Implications for patient care and research: A consensus statement from the Heart Failure Society of America. Journal of Cardiac Failure 2010:16:9-16. Recognize that health literacy is real and may compromise patient care Identify patients at risk for low health literacy Screen patients who are at risk Document learning preferences in patient records Integrate strategies to facilitate health education Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  26. TJC • TJC National Patient Safety Goal • Encourage active involvement of patients & families • Ensuring understanding of care plan • “Universal precautions” approach to all encounters • Clear communications • Plain language • Employ multiple teaching techniques • Use written materials while educating including highlighting, underlining, circling, etc. • Keep it short – no more than 2-3 points per conversation • “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  27. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  28. EAMC Health Literacy Assessments 45% • Used in Telehealth and HF Clinic • 45 patients to date • Low = 7 (16%) • Marginal = 13 (29%) • Adequate = 16 (36%) • Patients w/o documentation = 8 (18%) • Used in-house sporadically to date • To be used in process of determining “high risk” patients • Patient and/or primary care-giver need to be assessed • Takes less than 1 minute to administer Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  29. CNEA Health Literacy Assessments 61% • Used to help screen for level of service needed • Used in 122 currently open patient cases • Patients or caretakers evaluated as appropriate • 44 (36%) found to have “low” health literacy • 31 (25%) found to have “moderate” health literacy • 47 (39%) found to have “adequate” health literacy • Patients and/or caretakers screened as appropriate • Care plan developed • Medication use evaluated and regimens redesigned with MD by pharmacist Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  30. CNEA Health Literacy Assessments Of the 122 patient assessments (open cases): • 14 assessments of caretakers (11%) • 50% found to have low-moderate scores • Scores range from 2-7 • 108 assessments of patients (89%) • 63% found to have low-moderate scores • Scores range from 0-7 • 40 have ≥ 3 ED visits in last 12 months • Range = 3-35 visits • All found to have “low” health literacy (8 = score of zero) • 37/40 in the top quintile of cost in the state Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  31. Tools for Your Practice Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  32. Video • “Help Patients Understand” • American Medical Association (AMA) • Discussion with MD’s and patients • University of Arizona (Tucson, AZ) • Louisiana State University (Shreveport, LA) • Emory University College of Medicine (Atlanta, GA) • AMA (Chicago, IL) • Approximately 21 minutes • http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-video.page Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  33. Screening Tools • The Newest Vital Sign (NVS) • Validated in English and Spanish • Uses a food label to ask 6 questions • Takes ~3 minutes to administer • Available free at http://www.pfizerhealthliteracy.com/physicians-providers/NewestVitalSign.aspx Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  34. Screening Tools • Test of Functional Health Literacy in Adults (TOFHLA) • Validated in English and Spanish • Available in a short form (SF)  7-8 minutes to administer • Requires purchase of a license through Peppercorn Books and Press • Rapid Estimate of Adult Literacy in Medicine (REALM) • Validated in English • Separate tool for Spanish speakers • Available in a short form (SF)  < 1 minute to administer • SF available free from US HHR http://www.ahrq.gov/populations/sahlsatool.htm Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  35. REALM-SF Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  36. REALM-SF • Rapid Estimate of Adult Literacy in Medicine • Validated in English speaking population • Consists of 7 words patient is to read aloud • No need for understanding of the words – just pronunciation • Number of correct pronunciations correlates with a grade equivalency and explanation • 2 forms (patient and administrator) • Patient sheet – green (laminated) • Administrator sheet – white grading form • Short explanation and test administration • Collection of grade level and reading level comfort • Documentation Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  37. Patient use form • 7 words – 5 seconds each • Tell patient to say “skip” or “pass” if it is an unfamiliar word • Check correct words on administrator copy • Menopause • Antibiotics • Exercise • Jaundice • Rectal • Anemia • Behavior • Add up correct number and score at bottom of administrator form Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  38. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  39. Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  40. Low Marginal Adequate Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  41. Other “tip-offs” to low health literacy • The “forgotten glasses” • “poor lighting” • “I’ll read it later…” • Pointing to words as they read • Holding the page close to read • Fail to follow medication instructions • Missed appointments (failure to follow-through) • Incomplete forms • Brown bag test • Social history Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  42. Working with the patient SLOW DOWN! Convey only the most important concepts (1-2 points) Use “living room language” Ask about desired ways to learn – then document this! Involve family members Use visual aides Do not ask…”do you understand?” Employ the teach-back model Avoid closed ended questions Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  43. Steps we’ve taken… Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  44. Staff Training • Health Literacy • Bridges to Poverty • Social issues of patients raised in poverty and those new to poverty • Motivational Interviewing • Continuing training to improve communication • Disease state education • SW and Nursing continuing education programs • Asthma educator training course • Sickle Cell • Diabetes Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  45. Care Plan in Low Health Literacy • Adult patients offered literacy programs • Physician appointments • Case Manager may attend appointments with patient • Transportation arranged for appropriate date/time • Medications • Adherence assessed by review of pharmacy records • Medication regimen re-worked for patient with MD • RX devices arranged for as necessary (spacers, nebulizers, insulin pens, etc) • Patients/caretakers taught to use a pill box and schedule • Disease state education by CM or pharmacists Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  46. Coming Soon… • Medication adherence • Focused adherence measure for pulmonary and cholesterol medications • Contract with commercial product for medication schedule development and accurate medication lists for MD, patient, and acute care facilities • Expansion of disease state education • Full time pharmacist as of September 2012 • Use of free pharmacy clinic • Coordination with ADA Certified Diabetes Center in area • CME for physicians on recent evidence based medicine practices Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  47. What We’ve Learned • Reinforcement of health literacy issues with staff • Recognition of “poor patient behavior” resulting from our actions • Challenge the staff and have them share experiences • Documentation • Defined place in EMR • Problem list? • Communication of information between providers • Screening of assessment by other providers • Coordination with hospitals or home health agencies • TJC mandate – how are they addressing? • Readmission interventions • Clinics and educational experiences offered Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  48. What We’ve Learned • Allowing for an open environment  improved care plans and improved patient care • Reductions in hospitalizations and ED visits • Improved control over chronic diseases • Changes in provider attitudes and approaches • Awareness for MD’s, CRNP’s, community pharmacists • Anecdotal improvements in medication adherence • Data collection ongoing • Improvements expected with new full time pharmacist • Specific measures written to assess compliance and ED utilization (more coming…) Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  49. Patient Cases JR: 7yo AA male with chronic asthma and multiple hospital and ED admissions • Mother: unable to read • Father: moderate health literacy and history of CVAs • Poor drug adherence with asthma medications • Identified by pharmacy claims data / pharmacy records • CM interventions • Regular contact with patient and family checking the use of inhalers • Coordination with school nurse • Thus far: improved drug adherence and improved symptoms Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

  50. Patient Cases EW: 80yo Caucasian male with PMH significant for ischemic cardiomyopathy s/p AICD, T2DM, HTN. • Four hospitalizations and 2 skilled nursing stays in last year • Medication review revealed adherence issues • Glipizide, lisinopril, and long acting nitrate “lost” • Pt had medications in possession ≥ 13 years old • Wife and husband suffering from early stages of dementia • Husband had always “taken care of things” per the wife • Husband’s health lit not assessed; wife “low” • Pill box (self fill) too overwhelming for wife • Arranged for pharmacy services to fill pill box and deliver meds to patient home Going for the Gold • APHCA 2012 Annual Conference and Trade Show September 25 - 27, 2012 • Perdido Beach Resort, Orange Beach

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