Summer Institute on Aging

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
• gt 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 childrens 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. 20041744-47

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. Ill 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
  2733-39

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, isnt eating well or taking care
  of herself well.
• You dont 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 _at_ wvgec_at_hsc.wvu.edu
• Phone [phone] or 304-347-1295
• Mark A. Newbrough, MD, Director _at_
  mnewbrough_at_hsc.wvu.edu
• Nancy Daugherty, WVGEC Program Coordinator _at_
  ndaugherty_at_hsc.wvu.edu