Practical Strategies for Advancing Pharmacy Health Literacy in the Ambulatory Care Setting

1. Practical Strategies for Advancing Pharmacy Health Literacy in the Ambulatory Care Setting Anna Dutton, PharmD, BCACP Taylor Hermiller, PharmD Megan Lyons, PharmD, BCACP

2. Objectives • Define health literacy and compare various screening tools available • Identify risk factors and describe negative outcomes associated with low health literacy • Describe methods to communicate with and motivate patients • Review extent of health literacy problem within Health Care Systems and discuss strategies for improvement

3. Defining and Assessing Low Health Literacy Taylor Hermiller, PharmD

4. Definition • Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

5. Prevalence • Nearly 9 out of 10 adults have difficulty using everyday health information available in health care facilities • Approximately 90 million adults lack needed literacy skills to effectively use US health system Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

6. National Assessment of Adult Literacy Performance Levels Level 4: Proficient 12% Level 3: Intermediate 53% • Analyze and integrate information • Multi-step math problems • Simple math • Inferences Level 2: Basic 22% • Find facts in denser text • Find/apply data to solve simple math problems • Simple text • Routine Tasks Level 1: Below Basic 14% Kutner, M., et al. National Center for Education Statistics. 2006.

7. Health Literacy Domains Fundamental Reading/writing Numeracy Arithmetic Health Literacy Scientific Body organs Medical tests Mathematical concepts Cultural Religious/social beliefs Value systems Civic Applying health information to make public policy decisions Zarcadoolas C., et al. Health Promotion International. 2005; 20 (2): 195-203.

8. Risk Factors • Age > 65 years old • Less than high school education • Low income • English as a second language • Immigrants Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

9. Negative Clinical Outcomes • Increased difficulty interpreting labels and health messages • Decreased adherence • Decreased utilization of preventative care services • Negative disease outcomes • Greater use of emergency care • More hospitalizations • Higher mortality rates among elderly National Institutes of Health. 2018. Berkman ND, et al. Ann Intern Med. 2011;155:97–107 Agency for Health Care Research and Quality (AHRQ). 2011.

10. Negative Clinical Outcomes • Baker, 2002 • More likely to be hospitalized • More likely to have negative disease outcomes • Bennett, 2008 • Lower likelihood of: • Receiving the flu shot • Taking medicines correctly • Understanding medical labels and instructions • Nielson-Bohlman, 2004 • Lower health status • Less likely to use preventative care Baker, 2007 - Higher mortality rates within a Medicare managed care setting • Schillinger, 2002 • Worse glycemic control in patients with DM • Higher rates of retinopathy National Institutes of Health. 2018. Schillinger D, et al. Journal of the American Medical Association. 2002;288(4):475-482. Bennett IM, et al.Annals of Family Medicine, 2009, May-Jun;7(3):204-11. Baker DW, et al. American journal of public health.2002; 92(8), 1278-1283. Baker DW, et al. Archives of internal medicine. 2007; 167(14), 1503-1509.

11. Negative Cost Outcomes Inpatient spending increases by $993 for patients with limited health literacy Howard, 2004 Annual cost of low health literacy to the U.S. economy is $106 billion to $238 billion Vernon, 2007 Howard DH, et al. Journal of General Internal Medicine, 2006, Aug;21(8):857-61. Vernon JA, et al.Low health literacy: Implications for national health policy. 2007.

12. Screening Tools: Rapid Estimate of Adult Literacy in Medicine (REALM) • Adults pronounce 66 common words related to anatomy or illnesses • One point for every word pronounced correctly • Shorter versions available (REALM-R: 8 items and REALM-SF: 7 items) • Only available in English • Validated in the United States Davis T., et al. Rapid Estimate of Adult Literacy in Medicine (REALM). 1993. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

13. Screening Tools: REALM • 0-18 words (3rd grade and below):Not able to read easy materials, need repeated oral instructions, materials composed primarily of illustrations, audio, or videotapes • 19-44 words (4th to 6th grade): Need easy materials, not able to read prescription labels • 45-60 words (7th & 8th grade): Struggle with most patient education materials and will not be offended by low literacy materials • 61-66 words (High school): Able to read most patient-education materials Davis, T, et al. Rapid Estimate of Adult Literacy in Medicine (REALM). 1993.

14. Screening Tools: Test of Functional Health Literacy in Adults (TOFHLA) • 50 reading and 17 numeracy items involving common medical situations • Assesses numeracy and reading comprehension • Shorter version (s-TOFHLA) uses 36 reading questions • Results categorized into inadequate, marginal, or adequate levels of health literacy • Available in multiple other languages • Validated in the United States North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

15. Screening Tools: TOFHLA Parker RM, et al. J Gen Intern Med 1995; 537-41.

16. Screening Tools: Newest Vital Sign (NVS) • Six questions regarding interpretation of a standard nutrition label • Assesses both numeracy and comprehension • Includes arithmetic calculations • Validated in English and Spanish • Has been tested in primary care settings Weiss BD, et al. Ann Fam Med. 2005;3(6):514-22. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

17. Screening Tools: NVS Q: If you eat the entire container, how many calories will you eat? Weiss BD, et al. Ann Fam Med. 2005;3(6):514-22.

18. Screening Tools: Single Item Literacy Screener (SILS) • Single item • “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” • Response scale is from 1 (never) to 5 (all of the time) • Responses > 2: high risk of low health literacy • Developed initially and validated in VA clinics but also tested in primary care Morris NS, et al. BMC Fam Pract 2006;7:21. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

19. Screening Tools: Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA-50) • Reading 50 words; choice between two distractors is used to indicate understanding • Tests pronunciation and comprehension • Based on REALM but not a Spanish translation of REALM • Score between 0-37 indicates inadequate health literacy • Validated in the United States Lee, SY, et al. Health Serv Res. 2006; 41(4 Pt 1):1392-412. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004.

20. Screening Tools: SAHLSA-50 Lee, SY, et al. Health Serv Res. 2006; 41(4 Pt 1):1392-412.

21. Comparing Assessment Tools

22. Comparing Assessment Tools

23. Communicating with Low Health Literate Patients Anna Dutton, PharmD, BCACP

24. Patient-Centered Communication • Establish a connection • Create rapport • Prioritize patient concerns • Plan the visit • Explore and integrate patient’s perspective • Ask and acknowledge • Affirm and incorporate Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools. Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. .

25. Patient-Centered Communication • Demonstrate interest and empathy • Acknowledge emotions • Respond appropriately • Collaborate and educate • Involve patient in decision-making • Propose plan • Assess baseline knowledge of plan • Discuss patient’s level of agreement • Provide education and verify understanding • Complete visit Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools. Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. .

26. Patient-Centered Communication • Communicate with finesse • Maintain rapport • Effective question style • Verbal expression • Appropriate language for patient’s health literacy • Non-verbal expression • Confidence and professionalism • Organization • Special considerations Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools. Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. .

27. Incorporating Health Beliefs: Health Belief Model

28. Incorporating Health Beliefs: Health Belief Model Whale Conley CE, Olson AD, Howard JS, et al. Use of an Adaption to the Health Belief Model to Influence Rehabilitation Adherence in Athletic Training. ATSHC 2018;10:10-19.

29. Identifying Patients with Low Health Literacy AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/tool3a/index.html. Accessed July 21, 2018.

30. Universal Precautions Approach • Structuring the delivery of care as if everyone may have limited health literacy • Higher literacy skills ≠ understanding • Anxiety can reduce ability to manage health information • Everyone benefits from clear communications • Focus on “need to know” and “need to do” • Checking out and follow up • Self-care and taking medications AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/tool3a/index.html. Accessed July 21, 2018.

31. Using Plain Language • Anxiety • Dose • Hazardous • Medication • Outcome • Preventable • Respiratory • Worry, fear • Amount, number of times • Not safe, dangerous, risky • Medicine • Result • Can keep from happening • Breathing, related to the lungs CDC. Everyday Words for Public Health Communication. May 2016.

32. Teach Back Method Schillinger D, Piette J, Grumback K, et al. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med 2003;163:83-90.

33. Confirm Patient Understanding “Tell me what you’ve understood.” “I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine?” “Do you understand?” “Do you have any questions?” AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/tool3a/index.html. Accessed July 21, 2018.

34. Interacting with Low Health Literate Patients AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/tool3a/index.html. Accessed July 21, 2018.

35. Healthy People 2020 • HC/HIT-1 Improve the health literacy of the population • HC/HIT-1.1 Increase the proportion of persons who report their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health condition. • HC/HIT-1.2 Increase the proportion of persons who report their health care provider always asked them to describe how they will follow the instructions. • HC/HIT-1.3 Increase the proportion of persons who report their health care providers’ office always offered help in filling out a form. US DHHS. Healthy People 2020. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology/objectives. Accessed July 21, 2018.

36. Healthy People 2020 • HC/HIT-2 Increase the proportion of persons who report that their health care providers have satisfactory communication skills • HC/HIT-2.1 Increase the proportion of persons who report that their health care providers always listened carefully to them. • HC/HIT-2.2 Increase the proportion of persons who report that their health care providers always explained things so they could understand them. • HC/HIT-2.3 Increase the proportion of persons who report that their health care providers always showed respect for what they had to say. • HC/HIT-2.4 Increase the proportion of persons who report that their health care providers always spent enough time with them. US DHHS. Healthy People 2020. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology/objectives. Accessed July 21, 2018.

37. Health Communication CAN • Increase knowledge and awareness • Influence perceptions, beliefs, and attitudes • Prompt action • Demonstrate or illustrate healthy skills • Reinforce knowledge, attitudes, or behavior • Show benefit of behavior change • Increase demand or support for health services • Refute myths and misconceptions US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004.

38. Health Communication CANNOT • Compensate for inadequate health care or access to health care services • Produce sustained change in complex health behaviors without the support of a larger program for change • Be equally effective in addressing all issues or relaying all messages • Complexity of the topic or suggested behavior change • Preconceptions about the topic or message sender • Controversial nature of the topic US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004.

39. Health Communication with Other Strategies CAN • Cause sustained change in which: • Individuals adopt and maintain new health behaviors • Organization adopts and maintains a new policy direction • Overcome barriers/systemic problems, such as insufficient access to care US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004.

40. Health Literacy and the Health Care System Megan Lyons, PharmD, BCACP

41. Patient Demands https://ncphn.org.au/archives/programs/health-literacy. Accessed July 20, 2018.

42. Health Care Outcomes and Resource Use • Reported lower health status • Less likely to use preventive care • More likely to be hospitalized and experience poor disease outcomes • Experienced higher mortality rates • Less likely to comply with treatment and self-care • More medication or treatment errors • Lacked the skills needed to navigate the health care system • Responsible for higher inpatient costs and overall health care spending by Medicare and Medicaid Healthwise. HealthLiteracy-Not All Patient Education is Created Equal. Available at https://www.healthwise.org/blog/health-literacy-and-patient-education.aspx. Accessed July 18, 2018. Wisconsin Literacy. Improving the Health Literacy of Hospitals. October 2010.

43. Patient Skills CDC. Health Literacy. Available at https://www.cdc.gov/healthliteracy/planact/steps/index.html. Accessed July 10, 2018.

44. Provider Skills CDC. Health Literacy. Available at https://www.cdc.gov/healthliteracy/planact/steps/index.html. Accessed July 10, 2018.

45. Patient Case • 69 yo Black malewith PMH sig for Afib, DM2, ESRD on hemodialysis, HFpEF, and CAD s/p stents. • Pt referred to Pharmacy Anticoagulation clinic for warfarin management and Pharmacotherapy clinic for medication compliance • Pt is originally from Africa, speaks French

46. Patient Case 3/30/18: Presents for follow up with pharmacy clinics 1/9/18: Admitted: influenza and NSTEMI 1/22/18: Presents to ED; diagnosed with UTI • Complex medication regimen • Multiple chronic disease states • Frequent health care system use • Multiple appointments • Emergency department use • Hospital admissions • Dialysis • Financial barriers • Insurance terminated • Paperwork required for reinstatement • Cost of healthcare • Cultural/language barriers 1/24/18: Presents for follow up with pharmacy clinics 1/17/18: Presents for follow up with pharmacy clinics

47. Patient Case 7/11/18: Presents for follow up with pharmacy clinics 6/28/18: Returns to UCMC, PCP visit • Complex medication regimen • Multiple chronic disease states • Frequent health care system use • Multiple appointments • Emergency department use • Hospital admissions • Dialysis • Financial barriers • Insurance terminated • Paperwork required for reinstatement • Cost of healthcare • Cultural/language barriers • Financial barriers • Transportation • Food insecurity • Support • Limited family support 7/3/18: Re-establishes with pharmacy clinics 7/24/18: Presents for follow up with pharmacy clinics

48. National Action Plan • Everyone has the right to health information that helps them make informed decisions • Health services should be delivered in ways that are understandable and beneficial to health, longevity, and quality of life. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.

49. Goals: National Action Plan • Develop and disseminate health and safety information that is accurate, accessible, and actionable • Promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services • Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.

50. Goals: National Action Plan • Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community • Build partnerships, develop guidance, and change policies • Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy • Increase the dissemination and use of evidence-based health literacy practices and interventions U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.