Help Your Clients Understand: A Dual Role for the Social Worker

1. Help Your Clients Understand: A Dual Role for the Social Worker Summer Institute on Aging June 10, 2010 Nancy Daugherty Program Coordinator WV Geriatric Education Center (WVGEC)

2. Your Guide to Medicaid “The Medicaid Pharmacy Program does have a Preferred Drug List (PDL). Your doctor and pharmacist have copies of this list. If the drug that is prescribed for you is not on the list, a prior approval will be required. In most cases, the drug prescribed or a substitute (approved by your doctor) from the list, can be given to you while you are in the pharmacy. If not, a three-day emergency supply of your prescription is always available to you. You should never leave the pharmacy without some of your medicine. As soon as the approval is given, you will be able to get the rest of your prescription.”

3. Learning Objectives • Describe the prevalence of low and limited health literacy (LHL) in the general population and the impact of LHL on important health outcomes. • Communicate effectively with all clients, including those with LHL. • Coach your clients about strategies for using the skills they do possess to interact more effectively with their other health providers and “the system”.

4. What Do We Mean: “Health Literacy”? The ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment.

5. What Do We Mean: “Health Literacy”? Many factors contribute: General literacy-the ability to read, write, and understand written text and numbers; Amount of experience in the health care system; Complexity of information being presented; Cultural factors; How material is communicated.

6. National Assessment-Adult Literacy 2003 • Four levels defined: • Proficient:fully developed skills, can read and understand virtually all text and numerical info • Intermediate: can deal with “most” of info in health care settings, including ability to calculate BMI • Basic: most have difficulty understanding typical patient handouts or filling in health insurance applications • Below basic: may be able to identify the date of a medical appointment from a hospital appointment slip given them

7. Question #1 • What % of US adult population functions at only basic or below-basic levels of health literacy? • 10-15% • 20-25% • 35-40% • 50-55% • > 60%

8. National Assessment-Adult Literacy 2003 Survey results: Proficient- 12% Intermediate- 53% Basic- 22% Below-basic- 14% (12% women, 16% men)

9. National Assessment-Adult Literacy 2003 Adults 65+ Survey results: Proficient- 3% (0.5) Intermediate - 38% (1.3) Basic - 30% (0.8) Below basic – 29% (1.4) Note: People with lower HL levels tended to get health information from the radio and television, instead of print materials, friends and family, or health professionals

10. Question 2 • Do you accurately identify which of your patients have limited health literacy? • Yes, all of the time • Yes, most of the time • Yes, some of the time • Very infrequently • Only if someone tells me the patient is having a problem

11. Video • AMA Foundation • Health literacy and patient safety: Help Patients Understand 2007-2009 • Online courses: • http://www.hrsa.gov/healthliteracytraining.htm • http://www.medscape.com/viewprogram/8603_pnt • http://www.nynj-phtc.org“Health Literacy and Public Health”

12. Patients with limited literacy skills: 26%: did not understand when their next appointment was scheduled 42%: did not understand instructions to “take medication on an empty stomach” 78%: misinterpret warnings on prescription labels 86%: could not understand rights and responsibilities section of a Medicaid application

13. LHL a strong predictor of poor health • Health knowledge deficits • Pts. less likely to know how to use inhaler • Pts. w/ DM less likely to know sxs. of hypoglycemia • Pts. w/ HTN less likely to know wt.loss, exercise lower BP • Mothers less likely to know how to read thermometer • Less likely to understand direct-to-consumer TV ads • Less healthy behaviors • More smoking, including during pregnancy • More exposure to violence • Less breastfeeding • Less access to routine children’s health care

14. Increased Costs of LHL • Annual health care costs of Medicaid enrollees • $2,891 All enrollees • $10,688 Enrollees with limited literacy Weiss BD, Palmer R. “Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population” J Am Board Family Pract. 2004;17:44-47

15. Risk Factors for LHL • Age greater than 65 • Low income • Unemployed • Did not finish high school • Minority ethnic group (Hispanic, African American) • Recent immigrant to US who does not speak English • Born in US but English is second language

16. Behaviors and responses that may indicate LHL • Behaviors • Patient registration forms that are incomplete or inaccurate • Frequently missed appointments • Noncompliance with medication regimens • Lack of follow-through w/ laboratory or imaging tests, referrals • Patients say they are taking their medications, but labs or physiological parameters do not change as expected • Responses to receiving written information • “I forgot my glasses. I’ll read this when I get home.” • I forgot my glasses. Can you read this to me?” • Let me bring this home so I can discuss it with my children.” • Responses to questions about medication regimens • Unable to name medications or explain what medication are for • Unable to explain timing of medication administration

17. Non-disclosure of limited literacy 85%: Co-workers 75%: Health care providers 68%: Spouses 62%: Friends 52%: Children Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. “Shame and health literacy: the unspoken connection” Patient Educ Couns. 1996; 27:33-39

18. Question 3 • How common do you think LHL is in your practice setting(s)? • Extremely common • Very common • Common • Uncommon • Very uncommon

19. Question 4 • Are you confident that you communicate effectively with patients who have limited health literacy? • Yes, all of the time • Yes, most of the time • Yes, some of the time • Very infrequently • It seems as if I am never successful

20. Evidence based strategy for communicating with LHL patients and/or families • Use plain language • Slow down, Create a shame free environment, Encourage questions, Make relevant to patient • Nonmedical language, terms, e.g. pain killer for analgesic, skin infection for cellulitis • Limit the amount of information • Really no more than 3-5 points per encounter • Learn to prioritize • “Teach back”

21. “Teach Back” Technique • Do not ask a patient, “Do you understand?” • Instead, ask patients to explain or demonstrate how they will undertake a recommended treatment or intervention • If the patient does not explain correctly (using their own words), assume that YOU have not provided adequate teaching. Re-teach the information using alternative approaches • Remember, patients have different learning styles

22. Role Play • 81 yo man, lives with his wife, cognitively intact, first myocardial infarction, followed by LAD stenting. New prescriptions: • Toprol XL 25 mg daily • Altace 2.5 mg daily • HCTZ 12.5 mg daily • Plavix 75 mg daily • ASA 81 mg daily • Lipitor 80 mg daily • Ambien 10 mg qhs • NTG 1/150 SL prn chest pain

23. Role Play (cont.) Low cholesterol diet Cardiac rehabilitation outpatient referral Needs to have stitches out in 10 days Follow up appointment with PCP in 2 weeks. Follow up appointment with cardiology in 4 weeks. No driving until cleared by cardiology (but the patient is the only driver in the family) Off work until cleared by cardiology (but does not have sick day benefit)

24. Role Play (cont.) So how could we narrow this down and limit the key concepts when you work with this client? What are the “between the lines” issues here that need to be addressed to keep patient safe and from returning to hospital unnecessarily?

25. How Would You Coach Your Team? Same case, but this time use it as an example for coaching your colleagues, the care team, about discharge teaching and instructions? What would your key points be? How many?

26. How Can You Help Clients with LHL? They may not understand how to access the system. They may not understand that they need to access the system. They may not understand what the doctors and nurses tell them, or what they need to do for themselves. They may not feel comfortable asking questions when they go to see the doctor. They may not be able to remember their questions when they get there, or the answers given.

27. How You Can Help (cont.) Is there someone who can go with the client and help them communicate with the system (two pairs of ears and eyes often better than one pair)? Can someone help them write their questions down and devise a system to make sure they take with them? ALWAYS take all of their medicine, including over the counter with them (MUCH better than lists, especially for folks with LHL)

28. Role Play You run into Mrs. Jones’ daughter in the parking lot. She tells you that her mother has become very forgetful, isn’t eating well or taking care of herself well. You don’t have anything with you (since you just came from Zumba class) What could you do for Mrs. Jones’ daughter, and how would you know that she understood?

29. Summary • Low health literacy is so VERY common that it makes sense to use effective verbal communication strategies with every patient and/or family • Use: • Plain language • Limit the amount of information to 3-5 points • Teach back

30. WVGEC Faculty Development in Health Literacy 3 cohorts so far Lead Instructor, Charlotte Nath, RN, MSN, CDE, EdD with over 10 years practice and teaching experience in the field Train the trainer model – effective communication and how to teach it Follow up projects and evaluation as part of secondary and tertiary outcomes for HRSA grant Change clinical outcomes through improved communication

31. Health Literacy: More Information • Contact WVGEC @ wvgec@hsc.wvu.edu • Phone: 304-347-1208 or 304-347-1295 • Mark A. Newbrough, MD, Director @ mnewbrough@hsc.wvu.edu • Nancy Daugherty, WVGEC Program Coordinator @ ndaugherty@hsc.wvu.edu