Advancing Clear Health Communication to Positively Impact Health Outcomes

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Advancing Clear Health Communication to
Positively Impact Health Outcomes
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Presentation Sections

• The Problem Low Health Literacy Scope and
  Impact
• Finding a Solution
• The Partnership for Clear Health Communication
• Ask Me 3
• How to Become Involved Solutions into Action
• For Providers How Does Clear Health
  Communication Affect Your Practice
• Tips for Enhancing Patient Provider
  Communication

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The ProblemLow Health Literacy

• Scope and Impact

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Do You Know Which Critical Public Health Issue

• Impacts nearly one in every three people living
  in the United States
• Can hit any population segment, regardless of
  age, race, education or income
• Costs the healthcare system as much as 58
  billion a year
• Cant be diagnosed by any new medical technology
  and is not visible to the eye

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The Issue Low Health Literacy

• What is health literacy?
• The ability to read, understand and act on
  health information

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How Big Is the Problem?
More Than 90 Million People in the US Have
Difficulty Reading
Approximately 40 to 44 Million Adults in the US
Are Functionally Illiterate1 Approximately 50
Million Are Marginally Illiterate1 Average
Reading Skills of Adults in the US Are Between
the 8th and 9th Grade Levels2
Sources 1 Kirsch et al., A First Look at the
Results of the National Adult Literacy Survey
Natl Center for Education Statistics, 1993 2
Stedman L, Kaestle C. Literacy and Reading
Performance in the US From 1880 to Present. In
Kaestle C, Editor. Literacy in the US Readers
and Reading Since 1880. New Haven (CT) Yale
University Press 1991. P. 75128
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Who Is at Risk for Low Health Literacy?

• Anyone in the US regardless of age, race,
  education, income or social class can be at
  risk for low health literacy
• Ethnic minority groups are disproportionately
  affected by low health literacy
• The majority of people with low literacy skills
  in the US are white, native-born Americans
• Older patients, recent immigrants, people with
  chronic diseases and those with low socioeconomic
  status are especially vulnerable to low health
  literacy

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Low Health Literacy Impacts a Patients Ability
to Fully Engage in the Healthcare System
The Largest Study Conducted to Date on Health
Literacy Found That
33 Were unable to read basic health care
materials 42 Could not comprehend directions for
taking medication on an empty stomach 26 Were
unable to understand information on an
appointment slip 43 Did not understand the
rights and responsibilities section of a Medicaid
application 60 Did not understand a standard
informed consent
Source Williams MV, Parker RM, Baker DW, et al.
Inadequate Functional Health Literacy Among
Patients at Two Public Hospitals. JAMA 1995 Dec
6 274(21)1,67782
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Low Health Literacy Negatively Impacts Health
Outcomes

• Adults with low health literacy
• Are often less likely to comply with prescribed
  treatment and self-care regimens1
• Make more medication or treatment errors1
• Fail to seek preventive care1
• Are at a higher risk for hospitalization than
  people with adequate literacy skills2
• Remain in hospital nearly 2 days longer3
• Lack the skills needed to negotiate the health
  care system1
• People with low health literacy AND diabetes
• Were found to be less likely to have effective
  glycemic control4
• Were more likely to report vision problems caused
  by their diabetes4

1 Weiss, BD. 20 Common Problems in Primary Care.
McGraw Hill. December 1999 2 Baker DW, Parker RM,
Williams MV, Clark WS. Health Literacy and the
Risk of Hospital Admission. Journal of General
Internal Medicine. 1998 (13) 791-798. 3 Kirsch
IS, Jugebut A, Jenkins L, Kolstad A. Adult
Literacy in America A First Look at the Results
of the National Adult Literacy Survey.
Washington, DC Department of Education 1993. 4
Schillinger D, Grumbach K, Piette J, Wang F,
Osmond D, Daher C, Palacios J, Sullivan GD,
Bindman AB. Association of Health Literacy With
Diabetes Outcomes. JAMA. July 24/31 2002 (288) No
4.
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Low Health Literacy Impacts Resource Utilization

• Adults with low literacy
• Averaged 6 more hospital visits1
• Stayed in the hospital nearly 2 days longer than
  adults with higher literacy skills1
• Had fewer doctor visits, but used significantly
  more hospital resources2
• Had annual health care costs 4 times higher than
  those with higher health literacy3

• Among adults who stayed overnight in a hospital

1Kirsch IS, Jugebut A, Jenkins L, Kolstad A.
Adult Literacy in America A First Look at the
Results of the National Adult Literacy Survey.
Washington, DC Department of Education 1993.
2Baker DW, Parker RM, Williams MV, Clark WS.
Health Literacy and the Risk of Hospital
Admission. Journal of General Internal Medicine.
1998 (13) 791-798. 3Weiss, BD. 20 Common
Problems in Primary Care. McGraw Hill. December
1999.
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Implications of Low Health Literacy

• Poor Health Outcomes
• Under-utilization of preventive services
• Over-utilization of health services
• Unnecessary health care expenditures
• Limited effectiveness of treatment
• Needless patient suffering
• Higher patient dissatisfaction
• Higher provider frustration

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Finding a Solution
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Solutions Focus on Care Providers and Materials
Healthcare Thought Leaders

• Agree that focusing on the patient-provider
  relationship would provide the most immediate
  and impactful solution to the issue of low HL
• 2/3 feel that low HL is driven by poor
  patient/doctor communication
• Believe that providing easy-to-understand health
  information is key

Source A National Survey of Health Industry
Influencers and Change Agents,KRC Research and
Consulting, April 2002
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The Patient-Provider Relationship
There Is a Disconnect Between Patient and
Provider Bridging the Information Gap Will Help
Improve Health Literacy
70 of physicians say they provide patients
with additional resources to help them
understand their medications
75 of physicians report patients have trouble
understanding Rx information
Source Health Literacy The Prescription Drug
Experience The Front Line Perspective From
Patients, Physicians and Pharmacists, Roper ASW,
May 2002
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Written Communication
Making Health Information Understandable
Written

• 87 report reading Rx information

• Yet only 34 believe others read this same
  information

• 50 of adults read at below 8th grade reading
  levels
• 20 of adults read at below 5th grade reading
  levels
• 40 of seniors read at below 5th grade reading
  levels

• Consumer healthcare materials written at 10th
  grade or above, where only 50MM can understand
  and act

What Do We Do?
Develop Written Materials at 6th Grade or Below,
Where 160MM Can Understand and Act
Source Health Literacy The Prescription Drug
Experience The Front Line Perspective From
Patients, Physicians and Pharmacists, Roper ASW,
May 2002
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Example of Health Communication That May Not
Reach a Broad Consumer Audience
70
150
Good Range
TooHigh
TooLow
What You Need to Know About Low Blood Sugar Treat
low blood sugar quickly. If you have signs of
low blood sugar, eat or drink something that has
sugar in it. Some things you can eat are hard
candy, sugar-sweetened soda, orange juice, or a
glass of milk. Special tablets or gel made of
glucose (a form of sugar) can be used to treat
low blood sugar. You can buy these in a drug
store. Always have some of these items handy at
home or with you when you go out in case your
blood sugar drops too low. After treating a low
blood sugar reaction, eat a small snack like half
a sandwich, a glass of milk, or some crackers if
your next meal is more than 30 minutes away.
Source The National Institute of Diabetes and
Digestive and Kidney Diseases
Blood Sugar Is Too Low if It Is Under 70
Blood Sugar Is Too High if It Is Over 240
9th Grade Reading Level
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Example of Clear Health Communication That
Reaches a Broad Consumer Audience

• Common visual used to explain concept
• Uses action captions that clarify the point of
  the visual
• Creates interaction with the reader

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Verbal Communication
Up to 80 of Patients Forget What Their Doctor
Tells Them As Soon As They Leave the Doctors
Office ANDNearly 50 of What They Do Remember
is Recalled Incorrectly

• Patients experience shame around the issue
• Only 14 of patients say they feel awkward
  admitting they dont understand yet 79 feel
  others dont understand
• Providers experience time challenges
• Providers interrupt patients 30 seconds after
  they start speaking if not interrupted,
  patients will speak less than two minutes

What Can We Do?
Create an Environment of TRUST
Source Health Literacy The Prescription Drug
Experience The Front Line Perspective From
Patients, Physicians and Pharmacists, Roper ASW,
May 2002
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Reaching the Solution
Best Opportunity for Immediate Impact
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Finding a Solution

• The Partnership for Clear Health Communication

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Reaching a Solution
Introducing the Partnership for Clear Health
Communication

• The Partnership for Clear Health Communication
  is a coalition of national organizations that
  are working together to promote awareness and
  solutions around the issue of low health literacy
  and its effect on health outcomes

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Partnership Steering Committee Members
Provider Organizations
ThoughtLeaders

• American Federation of Aging Research
• California Health Literacy Initiative
• National Coalition for Literacy
• National Council for La Raza
• National Alliance for Caregiving
• ProLiteracy Health Worldwide

• American Medical Association Foundation
• American Nurses Association
• American Pharmaceutical Association
• David Baker, MD Northwestern School of
  Medicine
• National Medical Association
• National Alliance for Hispanic Health

• American Public Health Association
• Janet Ohene-Frempong, President, JO Frempong and
  Associates
• National Health Council
• Partnership for Prevention
• Pfizer Inc (member and convener)

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Partnership for Clear Health Communication

• Purpose Advance the Health Literacy issue, gain
  critical mass, leverage credibility and drive
  through the grass roots
• Who Nationally recognized organizations with
  local membership experienced in building and
  leading coalitions, representing a broad range of
  constituencies in research, policy and service
  delivery
• What Develop and execute a prioritized and
  coordinated Health Literacy Action Agenda to
  drive Awareness/education, solutions/tools,
  advocacy, policy, research and evaluation

Shared Interest in Improving Health Outcomes
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National Action Agenda
Expand awareness and educate patients and
providers
Develop and apply practical solutions to improve
patient-provider communication, and motivate the
healthcare system to adopt them
Conduct nationally coordinated research and
evaluation to define the health literacy issue
and evaluate solutions
Conduct an active advocacy program to increase
support for health literacy policy and funding
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Finding a Solution
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The Partnerships First Solution

• Addresses the highest priority Action Agenda
  items
• Awareness and education
• Creates a compelling solution and Call to Action
  for patients and providers
• Is designed to promote clear communication
  between patients and providers to improve health
  outcomes
• Was developed with health literacy experts, then
  tested and validated

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For Patients

• Health information can be confusing at times
• Everyone wants help with health information
• Asking questions helps patients understand how
  to prevent or manage illness

Patients Should Not Be Anxious About Asking Their
Health Care Provider Questions!
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For Providers
Health Care Providers Want Patients to Know

• All they can about their condition/medication
• Why this advice/treatment is important for good
  health
• Steps to take to prevent a condition or keep it
  under control

Provider
Patient
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Ask Me 3 Creates Shared Responsibility for
Clear Health Communication
Patient
Provider
De-stigmatize andReduce Embarrassmentof Low
Health Literacy
RecognizePatient Coping Mechanisms
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What Is Ask Me 3

• Promotes three simple, but essential, questions
  and answers for every healthcare interaction

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Ask Me 3 Program Materials Availablein English
and Spanish
Organizational Brochure
Website
Provider Brochure
Posters
Patient Brochure
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Ask Me 3 For Patients

• Element Poster
• Description
• Stimulates curiosity about Ask Me 3
• Informs patients and staff about the program
• Implementation (hang poster)
• In waiting areas
• In exam rooms
• On the ceiling, abovethe exam table
• On a door
• In a staff break room
• Hang anywhere where provider-patient interaction
  takes place
• Anywhere patients might see it!

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Ask Me 3 For Patients

• Element Patient brochure
• Description
• Educates patients about the Ask Me 3
• Motivates patients to ask their healthcare
  provider questions
• Implementation
• Display in waiting rooms/registration area
• Distribute to patients upon arrival/sign-in
• Distribute with any paperwork
• Distribute during events or with mailings to
  patients

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Ask Me 3 For Providers

• Element Provider brochure
• Description
• Explains the scope and impact of low health
  literacy
• Offers communication tips
• Emphasizes how effective communication can
  positively impact patient health outcomes
• Implementation
• Distribute to all staff interacting with patients
  through staff meetings or mailings
• Conduct departmental in-service training on
  Health Literacy and Clear Health Communication

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Ask Me 3 For Providers

• Element Organization brochure
• Description
• Explains the scope and impact of low health
  literacy
• Provides ideas and complementary roles in
  advancing health literacy
• Implementation
• Distribute to partner/affiliate organizations

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Ask Me 3 For Providers

• www.AskMe3.org
• Has everything you need to start
  acting/implementing
• Materials can be downloaded/ordered from this
  website
• Other health literacy tools available on the
  site
• Bibliography on health literacy
• List of literacy resources
• White paper on health literacy
• Links to other relevant websites
• Cultural competence primer

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How to Become Involved
Solutions Into Action
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Clear Health Communication We Can All Be a
Part of the Solution

• Even if you are not in a position to directly
  answer the three questions, keep clear health
  communicationin mind and in your dialogue when
  communicating with patients
• Many people have trouble understanding medical
  terms. Often, these terms are better understood
  when explained with common words, an example or
  visual interpretation

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Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Consider Using This One Instead
Instead of Using This Word
Benign Harmless Chronic Happens again and again
does not end Cardiac Heart Edema Swelling build
up of fluid Fatigue Tired Screening Test Intake Wh
at you eat or drink Generic Not a brand
name Adverse events Side effects
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How Can Your Organization Become Involved?
To Understand the Issue

• Visit www.clearhealthcommunication.org. It has
  background information and tools on Health
  Literacy/Clear Health Communication

To Know What Percentage of Your Practice Is
Affected

• Use the prevalence calculator gives the
  approximate percentage of patients at risk of
  low health literacy in a physicians practice

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How Can Your Organization Become Involved
To Educate Your Staff

• View the webcast at www.AskMe3.org
• Conduct an in-service training on health literacy
• Include an article on the scope and impact of
  health literacy and the solutions in your
  newsletter and on your web site

To Educate Your Patients

• Download or order the materials you need to start
  acting on Clear Health Communication at
  www.AskMe3.org and display them
• Request a speaker to speak to a group of your
  patients by calling 1-877-4-ASK-ME-3

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How Can Your Organization Become Involved?
To Become Actively Engaged

• Join the Partnership for Clear Health
  Communication. Sign up as a member at
  www.AskMe3.org. Adopt the Action Agenda within
  your own work
• Learn how to create easy to read materials using
  the Pfizer Principles for Clear Health
  Communication available at www.clearhealthcommun
  ication.org
• Dedicate a section or panel to health literacy at
  your next convention or meeting. Request a
  speaker by calling 1-877-4-ASK-ME-3

To Advocate for CHC

• Share your concern about low health literacy and
  Ask Me 3 with your state legislators,
  congressional representatives and senators and
  advocacy groups in which you participate

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For Providers How Does Clear Health
Communication Affect Your Practice?

• Tips for Enhancing Patient Provider
  Communication

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How Does Low Health Literacy Affect Your
Practice?

• Chances are high that some of your patients are
  among the 90 million who have low health
  literacy

• You may not know that patients with poor health
  literacy skills are in your care
• They use well-practiced coping mechanisms that
  effectively mask their problem
• They are often ashamed to admit they have
  difficulty understanding information and
  instructions

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Defining the Problem Scope
Coping Mechanisms for Patients With Low Literacy
80
Ask Other Patients
90
Ask for Help From Medical Staff
88
Watch and Copy Others Actions
98
Bring Someone Who Can Read
Source Parikh et al., 1996
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What Can You Do?

• Six steps to improving patient understanding
• Limit the amount of information provided at each
  visit
• Slow down
• Avoid medical jargon
• Use pictures or models to explain important
  concepts
• Assure understanding with the show-me technique
• Encourage patients to ask questions

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What Else Can You Do?
People Have Difficulty Making Appointments
Appointment InstructionsAlso see Urgent Care
(if you are too sick to wait for an
appointment)Making a medical appointment for
the first time, it is straightforward You call
555-2222 and make a appointment at XYZ Health
Services just like you would at any doctor's
office. You can request a specific clinician if
you have someone in mind, or you can explain your
need or problem to the appointment counselor, and
he or she will schedule you with an appropriate
clinician at the earliest possible date. At your
first appointment you will receive a medical
record card -- often referred to as your "gold
card" -- which you will keep and use as your XYZ
Health Services identification.  If you are
unsure about whether you should make an
appointment, you may call the Advice Nurse at
666-7777. Also, in advance of your first
appointment, be sure to read "How to Make the
Most of Your XYZ Visit." Please call 643-7177
to make an appointment in the Specialty Clinics,
including Allergy Travel. Specialty
appointments require a referral. You may also
drop by the Appointment Office to make a medical
appointment. The Appointment Office is located on
the first floor in Room 1111. You may also make
an appointment in the Specialty Clinics by going
to the Specialty Clinic reception desk, located
behind the elevators on the first floor. If you
need to cancel an appointment, please call our
24-hour cancellation line at 643-7033. Please
note that you will be billed for a broken
appointment fee if you do not show up for your
appointment and have not called to cancel it.

• When making an appointment, provide people with
  simple options and clear facts

Your Name Your Appointment Date Time Place Our
Telephone Number Do not eat or drink for 6 hours
before the day and time on this card.
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What Else Can You Do?
People Have Trouble Understanding Phone Recordings

• Phone answered by a tape recording. Speaking
  quickly, the caller is offered numerous options
  and alternatives

• Speak slowly and clearly
• Provide an easy way to connect with a live
  person
• Provide options in other languages

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What Else Can You Do?
People Have Trouble Reading Signs

• Some people become confused about whether this
  entry was intended for ambulances or for patients

• The use of visuals clarify the message
• Contrast in color makes it easy to read
• Try to be consistent when hanging signs

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What Else Can You Do?
People Have Trouble Understanding Maps

• To make maps easier to follow
• Match the color in the map with the paint color
  on walls or floors
• Match the names in the map to the names on the
  signs
• Use 14 point font size or larger

• Maps are usually hard to follow
• Too complicated
• Codes are hard to understand
• Names and directions not always match
• Small fonts

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How Can Enhanced Communication With Your
Patients Benefit Your Practice?

• Patients who understand health care information
  may
• Be more compliant with instructions and
  medications
• Call back less often
• Visit less often
• Have fewer hospitalizations
• Have better health outcomes
• Have increased patient satisfaction

Greater Provider Satisfaction
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The Practical Solution