Improving Patient-Provider Communication: Needs & Strategies

1. Improving Patient-Provider Communication: Needs & Strategies The Ethics of Effective Communication in Healthcare Conference October 7, 2011 Diane L. Smith, Ph.D., OTR/L, FAOTA Chair & Assistant Professor University of Missouri Department of Occupational Therapy Stan Hudson Associate Director University of Missouri Center for Health Policy

2. Objectives • Participants will be able to: • Understand the concepts of health literacy and plain language • Importance to healthcare and the patients we serve • Relationship to quality assurance for vulnerable populations • Learn techniques to evaluate professional/patient interaction to determine health literacy level • Learn how to develop interventions to improve patient understanding of information provided

3. “Be careful about reading health books. You may die of a misprint.” Mark Twain

4. Common Definition Health literacy is the degree to which people have the capacity to: • Obtain, process, and understand basic health information and services • Make appropriate healthcare decisions (act on information) • Access/ navigate healthcare system Derived from the definition of health literacy in the Institute of Medicine, A Prescription to End Confusion.

5. MO high school dropout rate is 25%. U.S. rate is 30%. EPE Research Center (2008). “Cities in Crisis”

6. Health Literacy Levels Are 4 to 7 Grades Below the Highest Grade Completed

7. -- George Bernard Shaw • Over three quarters of physicians (77%) believed patients knew their diagnosis; however, when asked, only slightly over half (57%) of patients actually did (P.001). • Nearly all physicians (98%) stated that they at least sometimes discussed their patients’ fears and anxieties, compared with 54% of patients who said their physicians never did this (P=.001). The Problem With Communication Is the Illusion That It Has Occurred 7 Olson DP & Windish DM, Arch Intern Med. 2010;170(15):1302-1307

8. The Health Literacy Gap Complexity & Demands of Health and the Healthcare System Individual Skills & Abilities

9. Patient-Centered Care Gaps Solutions must provide adequate support to address all gaps!

10. Common Definition - Revisited Health literacy also includes the degree to which the system provides adequate support to empower people to have the capacity to: • Obtain, process, and understand basic health information and services • Make appropriate healthcare decisions (act on information) • Access/ navigate healthcare system Derived from the definition of health literacy in the Institute of Medicine, A Prescription to End Confusion.

11. “non-compliant” patients/families?or “in-effective communications”?

12. What makes it complicated? • The vocabulary and concepts in medicine • Patients & providers from different cultures • Health care is disjointed • Competing sources of health information • Media, Internet • Patients often see numerous doctors and professionals who can provide the patient with conflicting and even contradictory information Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004

13. MO HealthNet Application Eligibility App

14. Application for TARP Capital Purchase Program - Bank bailout

15. Making the case - the moral imperativeEdmund D. Pellegrino, MD • The nature of illness itself makes medicine a special kind of human activity.  The sick person is uniquely dependent, vulnerable, and exploitable. • It is this fundamental vulnerability of the patient and the need for trust in the healing relationship that constitutes the moral imperative for the physician to serve the patient with the patient's best interest in mind.

16. Second, the physician's knowledge is not proprietary. It is acquired through the privilege of a medical education. Society sanctions certain invasions of privacy……… • The physician's knowledge therefore is not private property. Nor is it intended primarily for personal gain, prestige, or power. Rather, the profession holds medical knowledge in trust for the good of the sick.

17. By accepting the privilege of medical education, physicians enter into a covenant to use their medical knowledge for the benefit of society.  • Moreover, this covenant is acknowledged publicly when the physician takes an oath. The oath . . . is a public promise--a "profession"--that the new physician understands the gravity of his or her calling, promises to be competent, and promises to use that competence in the interests of the sick.

18. It is these 3 aspects--the nature of illness, the nonproprietary character of medical education, and the oath of fidelity to the patients' interests--that define medicine as a moral community and determine the ethical obligations of the individual physician and the profession as a whole. Edmund Pellegrino

19. It is a professional obligation to obtain an authentic understanding of the patients that we serve

20. Health Literacy – the patient experience

21. Health literacy test? TOFHLA (22 minutes) S-TOFHLA (12 minutes) REALM NVS (Newest Vital Sign) Short screening questions How often do you have problems learning about your medical condition because of difficulty understanding written information How often do you have someone help you read hospital materials How confident are you filling out hospital forms by yourself

22. Newest Vital Sign Label

23. Health Literacy Is Dynamic • Health literacy demands can change over time and differ by setting and circumstance • Age (young adult vs senior citizens) • Life event (birth of a child, stress at home) • Medical condition (new diagnosis, chronic illness) • Health literacy is highly contextual and reflects both sides of the interaction. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004

24. Dosing Instructions? • Numerous ways to get it wrong • Abbreviation not in dosage instructions • Use of uncommon measures (drams, cc) • Dssp?

25. Universal Precautions A communication strategy which assumes that all health care encounters are at risk for communication errors, and aims to minimize risk for everyone (DeWalt et al, 2010)

26. Universal Communication Principles • Everyone benefits from clear information. • Many patients are at risk of misunderstanding, but it is hard to identify them. • Testing general reading levels does not ensure patient understanding in the clinical setting. Adapted from: Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. AMA, 2007

27. Health literacy is a stronger predictor of health status than age, income, employment status, education level, or racial and ethnic group Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999

28. Health Literacy Health Outcomes Health Literacy Affects Health Outcomes Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. he National Academies Press; 2004

29. Health Care Costs • Individuals with limited health literacy skills make greater use of services designed to treat complications of disease and less use of services designed to prevent complications • Patients with limited health literacy skills have greater rates of hospitalization and use of emergency services – higher costs Scott TL et al. Med Care. 2002;40:395–404 Baker DW et al. J Gen Intern Med. 1998;13:791–798 Baker DW et al. Am J Public Health. 2002;92:1278–1283. Gordon MM et al. Rheumatology. 2002;41:750–754 Howard DH et al. Am J Med. 2005;118:371–377.

30. Health Literacy Costs • Those with low health literacy have over four times higher average annual health care costs – $13,000 compared to only $3,000 for those with higher literacy levels (AMA Foundation “Health Literacy A Manual for Clinicians” ) • Nationally is estimated to cost $238 billion annually - just over 10% of total US health care expenditures (Vernon, et al. Low health literacy: implications for national health policy, 2007)

31. “ An Example: Medication Errors “How would you take this medicine?” 395 primary care patients in 3 states • 46% did not understand instructions ≥ 1 labels • 38% with adequate literacy missed at least 1 label Davis TC , et al. Annals Int Med 2006

32. “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 Slide by Terry Davis

33. Reading vs. Comprehension In a study of adults with literacy below the 6th grade level: • 71% correctly read the instruction to “take two tablets by mouth twice daily” • Only 35% could demonstrate the number of pills to actually take (Davis et al, 2006)

34. Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth Twice Daily” 89 84 80 71 63 35 Davis TC , et al. Annals Int Med 2006

35. Communication is the Foundation of Patient-Centered Care • Engage in a dialogue with the patient • Make scripts interactive (Listen more and speak less) • Encourage questions and support • Understand and address the patient’s concerns • Ensure that the patient understands their diagnosis and treatment options/plan American Medical Association Foundation & American Medical Association

36. Benefits of Addressing Health Literacy • Key element to providing patient-centered medical care • Compliance with new standards • Culturally & Linguistically Appropriate Standards (CLAS) – released by HHS • Joint Commission Accreditation 2012 • Preparation for payment reform (ACOs, pay for performance, medical home, etc.)

37. Use Plain Language • Screening • Mental Health 20 complicated and commonly used words • Dermatologist • Annually • Immunization • Depression • Contraception • Respiratory problems • Hypertension • Community Resources • Monitor • Oral • Cardiovascular • Diabetes • Referral • Diet • Eligible • Hygiene • Arthritis • Prevention

38. Provide Explanations in Common Language • Most patients do not take anatomy in school and have little exposure to medical terms • Use familiar, common, & everyday language. If possible, use the patient’s own words/vocabulary. • Use analogies that are relatable to the patient.

39. Patient Recall of Health Information Is Poor • Patients/Parents forget 40%–80% of what their doctor tells them as soon as they leave the office and nearly 50% of what they do remember is recalled incorrectly • The more information provided, the less a patient/parent is able to recall Kessels RP. J R Soc Med. 2003;96:219–222

40. Focus on “Need-to-know” & “Need-to-do” What do patients need to know/do…? • When they leave the exam room/check out • When they get home • What do they need to know about? • Taking medicines • Self-care • Referrals and follow-ups • Filling out forms

41. Teach-back is… • Asking patients to repeat in their own words what they need to know or do, in a non-shaming way. • NOT a test of the patient, but of how well you explained a concept. • A chance to check for understanding and, if necessary, re-teach the information.

42. Teach-Back: Closing the Loop Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003

43. Teach-back Examples Ask patients to demonstrate understanding, using their own words: • “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?” • “What will you tell your husband about the changes we made to your blood pressure medicines today?” • “We’ve gone over a lot of information, a lot of things you can do to get more exercise in your day. In your own words, please review what we talked about. How will you make it work at home?”

44. Teach-back is Evidence-Based • “Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on the strength of scientific evidence.” • AHRQ, 2001 Report, Making Health Care Safer • “Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.” Schillinger, Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”

45. ‘Teach-back’ Improves Outcomes Diabetic Patients with Low Literacy Audio taped visits – 74 patients, 38 physicians • Patients recalled < 50% of new concepts • Physicians assessed recall 13% of time • When physicians used “teach back” the patient was more likely to have HbA1c levels below the mean • Visits that assessed recall were not longer Schillinger, D. Archives of Internal Med, 2003

46. Teach-back – Additional Points • Do not ask yes/no questions like: • “Do you understand?” • “Do you have any questions?” • For more than one concept: • “Chunk and Check” • Teach the 2-3 main points for the first concept & check for understanding using teach-back… • Then go to the next concept

47. Teach-back – Using it Well:Elements of Competence • Ethical responsibility is on the provider. • Use a caring tone of voice & attitude. • Use Plain Language. • Ask patient to explain using their own words (not yes/no). • Use for all important patient education, specific to the condition. • Document use of & response to teach-back.

48. Health Literacy Strategies Always try to: • Use plain language and analogies • Slow down and break down into short statements. • Focus on the 2 or 3 most important need to know and start with these. • Check for understanding using teach-back.

50. Acknowledgements Many slides were adapted from materials developed by: • Karen Edison, MD • Andrew Pleasant, PhD • Darren DeWalt, MD, MPH • Terry Davis, PhD • Mary Ann Abrams, MD MPH