Health Communications within the IHS: Health Literacy and Health Education

1. Health Communications within the IHS: Health Literacy and Health Education Mary Wachacha Chris Lamer IHS Health Education Program January 2012

2. In an effort to improve our interaction with our patients, the IHS Health Education Program has developed the infrastructure for education; and, in partnership with OIT, several new enhancements have been developed in RPMS that permit the documentation of education in RPMS. This presentation is to create greater awareness of those enhancements and tools.

3. Health Communication plays a vital role in improving patient care. 1. Health communications includes: oral and written communications, patient-provider communications, accessing the internet 2. Health communication must integrate services to meet: barriers to learning, learning preferences, and readiness to learn.

4. Health literacy is important in patient care. 1. Low literacy is linked to poor health outcomes: higher hospitalization rates higher use of Emergency Rooms less frequent use of preventive services. 2. AI/AN populations are more vulnerable because, they are: elderly, less than a high school or GED certificate, low incomes, non-Native speakers of English, compromised health status, lack access to services and resources.

5. IHS information systems, such as RPMS/EHR, can be used to document communications. Patient Education Protocols and Codes (PEPC) Patient Wellness Handout Health Factors Electronic Health Record (EHR) Personal Health Record iCare

6. Health Communications from Healthy People 2020 • Effective use of communication and technology by health care and public health professionals can bring about an age of patient- and public-centered health information and services. By strategically combining health IT tools and effective health communication processes, there is the potential to: • Improve health care quality and safety. • Increase the efficiency of health care and public health service delivery. • Improve the public health information infrastructure. • Support care in the community and at home. • Facilitate clinical and consumer decision-making. • Build health skills and knowledge.

7. Health Communications is a partnership meant to provide many ways to interact with patients. We may interact with patients by: • Internet Access/computer use • Understanding the impact of a patient’s health literacy level • Improving the patient-provider communications – making sure the patient understands the information • Presenting written materials in Plain Language • Providing education • Documentation

8. Examples of Health Communication by Providers Providing Education (PEPC) Documentation in the Medical Record (RPMS/EHR) Ensure that patient can read posters, Handouts. (Health Literacy) Answering Questions About their Health (Ask Me 3) Providing Patient Handouts (www.ihs.gov) Providers Helping patient to get Online Health Information (Internet Access) Helping patients find their Way in our Facilities (Wayfinding) Cell phone, Text Messaging Computers (PHR) Health Providers Talking to Patients (Teach Back, Motivational Interviewing)

9. Each person’s health is also determined by: Increase awareness and understanding of the determinants of health, disease, and disability and the role we play as health care providers. Physical Environment 5% Social Environment 15% Health Services 10% Biology & Genetics 30% Our patients Individual Behavior 40%

10. Forms of Health Communications

11. Internet Access Increase our AI/AN clients use of the Internet (blending RPMS/EHR and internet access) Electronic Health Record • Patient Wellness Handouts – is your site participating? (2005) • Encryption of emails between provider and the patient (January 2012) • Personal Health Record (Funding) • Medline Plus Info button in RPMS – Available now • Documentation/coding of health/patient education – Available since 1998 • Healthcare industry standards require: • Provide education • Documentation/coding of education • Documentation/coding of educational Needs: • Barriers to learning • Learning Preferences • Readiness to Learn

12. Internet Access Are you aware that Patient Registration is asking: • Do you have an email address: Yes or No? • If yes, where is that email address: Home, work, library, community center/Chapter House? • What is your email address? • Do we have permission to email you generic health information? • What is your cell phone number? All of this information will be used to “connect” with our patients: Text messaging, electronic newsletters, share lab results, Personal Health Record

13. Internet Access: what does that mean? It means receiving health information - not only from a “person” but from: Computers Cell phones Blackberry

14. A coming innovation to increase Internet Access Personal Health Record

15. IHS Personal Health Record (PHR) • A personal health record, or PHR, is an electronic application through which patients can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment. • A patient portal is an internet application that allows patients to access their electronic health records and permits two-way communication between patients and their healthcare providers. • Integrated with Master Patient Index • Real time access to health information

16. Patient Handouts/ Education Family Health History Home Monitoring Secure Database (PHR) Other Health Care System Patient Portal RPMS Personal Health Records

17. Improve Health Literacy • What is Health Literacy? Health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

18. The Most important things to remember about health literacy. • Obtain • Process • Understand • Obtain health information: obtain– talking, give a pamphlet (that they can process/ understand) • Process health information: process – deal with, manage, handle, sort out • Understand health information: understand- “repeat back, show me, tell me”

19. Health Literacy: • Recognizing the role of health literacy and its impact on the patient’s understanding of their health and health care. • Healthy literacy is not just about reading, although most of our patients read at between 6-8th grade reading level. • 4 out of 10 patients will have trouble understanding their health. • Usually they do not ask questions • Because of low health literacy, they do not participate in preventive health because they do not understand why it is important.

20. Patient perspective = Low Health Literacyresults in lack of participation in Preventive Health • Why floss? Lack of Dental sealants, putting soda pop in a bottle • PAP Smears, mammograms, colorectal screening • Fatalism – “I will get diabetes” • “I can’t quit smoking, so why try?” • “I do not drink too much.” • “Why take a baby aspirin?” • “What is hypertension? What does that mean?”

21. Conversely, low understanding/Literacy by providers results in a lack of participation in RPMS documentation by providers • “I educate - I just don’t document!” • Fatalism – “Patient won’t listen.” • I am asking, “Do you smoke? Yes or No? (But this does little to move the patient toward cessation.) • Never heard of Barriers to Learning, Learning Preference, “somebody else must be doing that” • I assume we have data • “Point and click, point and click – this is too cumbersome.” • Health Factors – what’s that?

22. A new electronic Health Literacy Toolkit* * At www.ihs.gov Under Health Communications

23. Improving patient-provider communications • Encourage patients to ask 3 questions: Ask Me 3: • What is my main problem? • What do I need to do about it? • Why is it important for me to do this? • Use of the Patient Wellness Handout • Determining a patient’s level of understanding • Helping a patient to set goals for behavior change • Using Motivational Interviewing • Using the Teach Back Method

24. Written materials: Plain Language – What is that? http://www.ihs.gov/healthcommunications/ • Plain language is communication your patients can understand the first time they read or hear it. Written material is in plain language if your audience can: • Find what they need; • Understand what they find; and • Use what they find to meet their needs. • No one technique defines plain language. Rather, plain language is defined by results-it is easy to read, understand, and use. • Conversely, the provider uses plain language when talking.

25. Example of determining readability using Microsoft Word on the computer: Under “Help” – type Readability and follow the instructions.

26. Flesch Readability Ease Score: The Flesch Reading Ease is the standard test of readability used for documents and forms. It indicates how easy it is to read a given material. The results can be between 0 and 100. The higher the score, the easier it is to understand what you have written. To achieve this score, use shorter sentences and common words. • The results can be interpreted as following: • 0-29 - very confusing & hard to read • 30-49 - difficult to read • 50-59 - fairly difficult • 60-69 - standard : it is better to have a score of 60 or more. Even for business documents, a score of 60 is very achievable and it takes only a few edits to obtain it. • 70-79 - fairly easy • 80-89 - easy • 90-100 - very easy

27. More information on Health Communications can be found at www.ihs.gov

28. You can search for handouts for patients. Most handouts are written at a Flesch Reading Ease score of 60 and above.

29. A sample Patient Education handout at www.ihs.gov using Universal Symbols developed by the Indian Health Service

30. Where does the data come from? From provider documentation

31. You are the key to documentation: If it isn’t documented, it isn’t done!

32. We obtain educationdatafrom our Data Sources: • National Data Warehouse (RPMS) • Outpatient visits • Inpatient discharges • Behavioral Health GUI

33. How is your facility doing in communication? Every Site that Uses RPMS can run theCRS Education Report.Ask your CAC/IT staff to run theCRS Education Report. You can track your communications and patient education through this report.

34. An Important Tool in Data Collection: Health Factors

35. Health Factors: does your patient? Test their sugar? Drink? Smoke? Literacy level? Type of work? Exercise? Have Asthma?

36. What is a Health Factor? • Health Factors describe a component of the patient’s health and wellness not documented elsewhere or as an ICD or CPT code. • Health factors are not visit specific and relate to the patient’s overall health status. (This means you/anyone can assess a person’s health factors at any visit.) • Health factors should be reassessed at least once yearly.

37. Educational Assessments are documented as Health Factors • Healthcare accrediting agencies require the documentation of education. • Included in those requirements, is the requirement that other factors that might impact a patient’s ability to understand their health care – must also be documented. • In the IHS, these are called Educational Assessments. • Learning Preferences • Barriers to Learning • Bottom Line: Regardless of your facility accreditation: Providing education is a part of good patient care.

38. Educational Assessment:Learning Preference (Health Factor) – How do you prefer to learn new information? Assess once a year – document as a Health Factor *Current RPMS data indicates that AI/AN patients prefer to learn by talking with their provider

39. Education AssessmentBarriers to Learning (Health Factor)Assess once a year – assess by observation.

41. Confidence Health Factor • Confidence is used to assess the likeliness that the patient will take an active role in managing their health and well being. • Ask the patient, “How sure are you that you can manage and control most of your health problems?”  No

42. Confidence Health Factor

43. Physical Activity Health Factor • Activity Level: How much exercise do you think you get in a week? • Inactive – No physical activity • Some Activity < 150 minutes 2 ½ hrs • Active – Engages in 150 minutes • Very Active - > 150 minutes Adults: minimum of 30 minutes 5 times per week Children: minimum of 1 hour per day

44. Where to document Health Factors?

45. Documenting Health Factors in the EHR

46. Health Factors – For More Information: • http://www.ihs.gov/RPMS/PackageDocs/bjpc/bjpc0200.05o_aum.pdf

47. Using iCare to improve population health and participation in preventive health.

48. iCare: helps to manage patients • Population display of patients • Create registers of patients (called panels) • View data on: • Groups of patients • GPRA measures • Clinical Reminders • Individual patients

49. Creating Panels (or a listing of your patients • Choose what patients you want in your panel By provider By appointment By RPMS register By QMAN search By visit date By diagnoisis By community By age or gender

50. You will be able to view Panel data