Addressing the Health Literacy Needs of an Elderly Patient Population

1. Addressing the Health Literacy Needs of an Elderly Patient Population LifeLong Medical Care Health Literacy for Elders Project Paula De Leon Molinsky, MPH Rahima Jan Gates, PhD Lyn Paleo, MPA—Consultant For more information contact Paula D. Molinsky at pdmolinsky@netscape.net Funded by Archstone Foundation

2. Background • LifeLong Medical Care Inc. (LMC) operates six community health centers in Berkeley, CA • The Health Literacy for Elders Project targeted LMC’s three Over 60 Health Centers • In 1999 the Over 60 Health Centers provide medical, social, and mental health services to 3,158 geriatric patients • 83% were low income • 74% were non-White

3. Premises for Project Design • Studies suggest that health literacy skills greatly impact health care outcomes • Health literacy skills decrease with increasing age and decreasing income • Racial minority groups are more greatly impacted by low health literacy skills than are non-minorities • Over 60 Health Center patients may be at risk because of age, race/ethnicity and income status • Even patients with adequate health literacy skills appreciate easy to use health care information

4. Purpose of Project Develop organizational protocol to ensure that patients are able to read, understand and act on their health care information so that they are able to participate as fully as possible in their health care

5. Project Goals • Increase the awareness & understanding of the health literacy needs of the Over 60 patient population • Assist clients in maximizing the benefits of their healthcare visits • Enhance provider-patient communication • Increase awareness in the health care community of literacy issues and related negative health outcomes

6. Project Provided • Assessment of health literacy and other communication needs of patients • Developed and implemented Patient Advocate role with the primary purpose of reviewing health care information • Health literacy workshop for staff & providers • Newsletters addressing information on health literacy, resources and updates on project • Assessment of patient education materials for cultural and literacy demand appropriateness and recommendations for replacements for materials if needed • Collaboration with other community organizations

7. Needs Assessment • Random sample of 137 Over 60 Health Centers patients • 30% were White, 58% African American, 4% Latino • Average level of education was 12.8 years; range of 6 – 21 years • Range of ages was 60 to 96 years; mean of 74.3 • Of the 115 who shared income information, 64% had incomes of no more than 120% PL; 10% were above 200% PL Respondents interviewed following medical appointment; received $5 for participating

8. Needs Assessment • Instruments • Short Test of Functional Health Literacy in Adults (STOFHLA) a standardized assessment tool • Score of inadequate indicates unable to read & interpret health texts; marginal indicates has difficulty reading & interpreting health texts; adequate indicates can read & interpret most health texts • administered to 120 of the assessment participants • Project developed questionnaire assessing • Patient satisfaction • Patient perspective of communication with provider during that day’s health care encounter • Knowledge of his/her prescriptive medicine

9. STOFHLA Results

10. STOFHLA Scores & Ethnicity

11. STOFHLA Scores & Educational Levels

12. STOFHLA Scores & Age

13. Other Findings • Regarding STOFHLA • Age, education & language spoken as a child accounted for 34% of the variation in scores • 17 needs assessment participants declined to do the test; nine individuals scored zero • Only 36% of participants were able to complete the test in the time allotted by the tool • Regarding Other Questions on Survey • All Over 60 patients receive a reminder call & are asked to bring all meds to appointment to review with provider; only 36% of survey participants had done so, of these 79% had reviewed meds with provider but 20% still did not know whether or not meds might have side effects • 85% of participants stated their provider was very easy to understand; 45% felt they did not need more time for discussing their health care; 49% received some type of written materials during their health care visit

14. Implications of Findings • Because of the strong association between health literacy and the immutable characteristics of age, ethnicity and educational level, interventions should focus on providers’ verbal and written patient health care information • STOFHLA scores suggest that verbal communication is an essential source of health care information for many of this patient population • Techniques for checking patients’ understanding of information should be developed & routinely used

15. Project Evaluation • Instruments • Pre and post intervention surveys for staff & providers assessing knowledge and behaviors • Post intervention interviews of key informant providers and staff • Post intervention interviews of select group of patients who participated in pre intervention survey

16. Providers/Staff Evaluation of Usefulness of Project Components

17. Lessons Learned from Interviews Poor Health Literacy Skills Impact: • Patient Participation • I know why I’m taking [the medications]. I’m taking them because the doctors say to take them, that’s why. –Patient • …it really does relegate the patient to a passive role in their healthcare which then interferes with all the things that you want them to have an active role in. -Provider • Compliance • I think it has an impact on the motivation for [patients] to comply with their medications. It makes it harder for them to be clear about side effects -Provider • Access • I said cancel them then. So she did, so she screwed me and I screwed myself, I messed up - Patient who accidentally cancelled his coverage. • Healthcare Outcomes • “Oh, you know,” he said, “I thought I would get better.” And he didn’t. Well, he ended up having a pneumothorax –Provider regarding patient who did not understand the significance of his symptoms

18. Recommendations • Recommendations are based on the implementation experience of the Health Literacy for Elders Project, the rationale and suggestions that emerged from the patient and providers/staff interviews and studies of health literacy. • Seek funding to support, prioritize and maintain a health literacy/health education unit • Encourage participation of providers in developing and implementing a practical and systematic check to assess patients’ understanding of and ability to act on their health care information and referral to support services if indicated • Recognize & accommodate the impact that change in routine has on patients and their ability for self-care

19. Recommendations Continued • Discuss the possibility, advantages and disadvantages of incorporating a health literacy assessment into the new patient intake and continuing patient profile • Consider the feasibility of obtaining grant funds to staff a health literacy cross disciplinary team consisting of a supervising physician, patient advocate, nurse case manager and medical assistant • Explore the possibility of having medical assistants assume responsibility for identifying and distributing health education materials to patients after their healthcare visits • Support provider-purposed efforts to incorporate Health Literacy standards into the indicators of performance of the Health Plan Employer Data and Information Set (HEDIS)