Health Literacy: Help Your Patients Understand

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Health Literacy Help Your Patients Understand
Gail A. Nielsen IHI George W. Merck
Fellow Patient Safety Administrator, Iowa Health
System

• with support from
• American Medical Association Foundation
  American Medical Association

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Definitions

• General Literacy
• An individuals ability to read, write, and
  speak in English, and compute and solve problems
  at levels of proficiency necessary to function on
  the job and in society, to achieve ones goals,
  and develop ones knowledge and potential.
• National Literacy Act of 1991
• Health Literacy
• The degree to which individuals have the
  capacity, to obtain, process, and understand
  basic health information and services needed to
  make appropriate health decisions.
• Healthy People 2010

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Definitions

• An individuals ability to read, understand,
  and use health information to make appropriate
  healthcare decisions and follow instructions for
  treatment.
• Health Literacy
• AMA Foundation, 2003

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Inadequate Health Literacy

• 1/2 of the US population may be at risk
• Misunderstanding
• Mistakes
• Excess hospitalizations
• Poor health outcomes

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Why are they at risk?

• Reliance on the written word for patient
  instruction
• Increasingly complex health system
• More medications
• More tests and procedures
• Growing self-care requirements

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National Adult Literacy Survey

• n 26,000
• Most accurate portrait of literacy in U.S.
• Scored on 5 levels
• Result 48 of US population have inadequate or
  marginal literacy skills

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NALS Level 1Inadequate Literacy (21)

• Able to
• Sign name
• Find a country in an article
• Total a bank deposit entry
• Cannot consistently
• Understand the gist of an article.
• Use a bus schedule
• Enter information on a SS application

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NALS Level 2 Marginal Literacy (27)

• Able to
• Find intersection on street map
• Locate information in newspaper article
• Determine difference in price on tickets
• Cannot consistently
• Use a bus schedule
• Identify information from a bar graph
• Write a brief letter of complaint

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1993 National Adult Literacy Survey
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What Is It Like?

• The following passage simulates what a reader
  with low general literacy sees on the printed
  page
• Read the entire passage out loud.
• You have 1 minute to read.
• Hint The words are written backwards and the
  first word is cleaning

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GNINAELC Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna natspac
revenehw uoy eciton na noitalumucca fo tsud dna
nworb-der edixo selcitrap. Esu a nottoc baws
denetsiom htiw lyporposi lohocla. Eb erus on
lohocla sehcuot eht rebbur parts, sa ti sdnet ot
yrd dna yllautneve kcarc eht rebbur. Esu a pmad
htolc ro egnops ot naelc eht tenibac. A dlim
paos, ekil gnihsawhsid tnegreted, lliw pleh
evomer esaerg ro lio.
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What Is It Like?

• How do you clean the capstan?

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Factors that contribute to health literacy

• General literacy
• Experience with health system
• Complexity of information
• Cultural and language factors
• How information is communicated
• Aging

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Video As Patients See It

• This video was made by the AMA in 2003
• You will see real patients and real physicians
  talking about literacy issues

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Video As Patients See It

• Discussion
• What ideas hit home with you?
• Did any of the situations seem familiar?
• Did anything surprise you?

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Low Health Literacy Problems with

• Medications
• Appointment slips
• Informed consents
• Discharge instructions
• Health education materials
• Insurance applications

Medication Take as directed
Dr. Literate
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What do we know from a decade of research?

• Low health literacy leads to
• Lower health knowledge and less healthy
  behaviors.
• Poorer health outcomes
• Greater health costs
• Specific communication techniques may enhance
  health literacy.

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Limited Health LiteracyPrevalence and Risk

• Over half of English and Spanish speaking public
  hospital patients have limited HL
• Average reading level of Medicaid recipient
  grade 5
• Likelihood of having limited HL higher for ethnic
  minorities (AA 2x odds), Spanish speakers (5x
  odds), elderly (gt65 3x odds), women (1.5x odds)

Williams 1995 Gazmararian 1999 Schillinger 2003
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Limited Health LiteracyImpact on Outcomes

• Lower receipt of preventive services
• Poorer knowledge of chronic conditions
• Worse asthma self-care
• Higher utilization of services
• Worse health outcomes

Williams 1998 Baker 1999, 2002 Scott 2002
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Health Literacy Level and Diabetes Control
Adjusted OR2.03, p0.02
Adjusted OR0.57, p0.05
(Tight Control HbA1c?7.2)
(Poor Control HbA1cgt9.5)
Schillinger 2002
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Diabetes Patients with Inadequate Health
Literacy Experience Lower Quality Communication,
N408
Schillinger 2003
OR1.9p0.04
OR3.2plt0.01
OR3.3p0.02
OR2.4p0.02
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33
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21
20
13
13
13
(Often/Always)
(Often/Always)
(Often/Always)
(Never/Rarely/ Sometimes)
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Schillinger 2003

• Ensures info understood/integrated into memory
  checks for lapses
• Opens dialogue re health beliefs reinforces and
  tailors health messages
• Promotes a common understanding elicits patient
  participation

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Patient-Provider Regimen Concordance is Low, but
Improves When Regimen Assessed with Visual Aid
OR 1.79 plt0.001
Schillinger 2003
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Patients whose physicians asses Recall or
Comprehension were more likely to have A1C levels
below the mean

• Odds Ratio 8.96 (1.1-74.9)
• After multivariate logistic regression
• 2 variables independently associated w/ good
  glycemic control
• higher Health Literacy -- OR 3.97 (1.09-14.47)
• physician application of "teach-back" -- OR 15.15
  (2.07-110.78)

Schillinger 2003
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Results

• Physicians assessed recall or comprehension for
  15/124 new concepts (12)
• Visits using interactive communication loop not
  longer (20.3 min. vs. 22.1 min)
• Application of loop associated with better HbA1c
  (OR 9.0, p.02)

Schillinger 2003
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Costs of Poor Health Literacy

• We all pay! Estimated 50 Billion Annual
• 39 paid by Medicare through FICA taxes on
  workers
• 17 paid by employers
• 16 paid by patients out-of-pocket
• 14 paid by Medicaid
• The remaining 14 comes from other public and
  private sources.

Estimated by the National Academy on an Aging
Society using 1998 figures
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Enhancing Health Literacy

• Enhance assessment techniques
• Create a shame-free environment
• Improve interpersonal communication with patients
• Create and use patient-friendly written materials

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Five steps to enhance your interactions with
patients

• 1. Conduct patient-centered visits
• 2. Explain things clearly in plain language
• 3. Focus on key messages and repeat
• 4. Use a teach back or show me technique to
  check for understanding
• 5. Use patient-friendly educational materials to
  enhance interaction.

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What can we do?

• Understand the problem
• Identify the barriers faced by both patients and
  clinicians
• Identify and implement strategies to enhance
  health literacy
• Advocate for system change

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What can we do?

• Realize that understanding is not necessarily
  related to ability to read
• Understanding can be compromised when we are
  sick, worried, in unfamiliar situations or
  outside our own domain
• Do you know the difference between a certified
  mail and registered mail?

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Teach Back

• Testing what are the trends in patients
  difficulty to understand what is taught ?
• Ask a patient to describe or repeat back in his
  or her own words what has just been told or
  taught
• When the health professional hears gaps in the
  patients understanding, further teaching can be
  accomplished to correct misunderstandings
• Incorporate changes into standard patient
  teaching
• Never ask whether patients understand they
  always say yes
• Return demonstration is a similar technique used
  by diabetic educators, physical therapists, and
  others.

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Teach Back is especially important when
instructions are given for

• New medications
• New diagnoses
• Discharge from ambulatory procedures
• Self care,
• e.g. for CHF patients weighing themselves, ask,
  How are you weighing yourself?
• When to call the doctor for assistance
• How to prevent falls

Iowa Health 2004
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Method for Obtaining Patient Reports

• VERBAL
• Can you tell me exactly how you take your
  warfarin/Coumadin?
• On which days of the week did your doctor tell
  you to take it?
• How many pills did your doctor tell you to take
  on those days?
• What is the number of milligrams (mg) on Mon.,
  Tues., Weds...
• VISUAL
• Can you tell me exactly how you take your
  warfarin/Coumadin by
• pointing to the pill or pills your doctor told
  you to take?
• On which days of the week did your doctor tell
  you to take it?
• How many pills did your doctor tell you to take
  on those days?

By Dean Schillinger
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Return Demonstrations are especially important
when instructions are given for self care, such
as

• Exercises
• Caring for wounds
• Caring for catheters and drains
• Understanding self injections of complex
  medications (e.g. insulin)
• Self testing (e.g. blood sugar)
• Filling medication dispensers at home for the
  first time (for patients with multiple drugs)

Iowa Health 2004
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ASK Me 3 National Program

• How many patients understand what their care is
  all about?
• Teach them to ask 3 questions
• What is my main problem ?
• What do I need to do for my main problem ?
• Why is it important for me to do this ?
• Check the family s understanding
• what the patients main problem is
• what the patient needs to do for my main problem
• why it is important for the patient to do this

http//www.askme3.org
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Teach-Back Testing

• Began with last patient of the day
• Overcame hurdle of reopening the visit
• Surprising results knowledge gaps
• Increased to 2/day, various times
• Accumulated over 30 experiences
• Assured comfort level with new process
• Began sharing with colleagues
• Provided framework for adoption by other providers

Iowa Health 2004
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Teach-Back First Small Tests Results

• 2/6 (33) inaccurate during teach-back
• 28 yo F w/conjunctivitis accurate
• 69 yo F w/DM F/U visit - inaccurate (medication)
• 56 yo F w/DM F/U visit - inaccurate (medication)
• 73 yo F w/tremor - accurate (retired RN)
• 51 yo M w/HA accurate
• 36 yo F w/depression - accurate

Iowa Health 2004
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Teach-BackLessons Learned -1

• Teach-Back takes significant effort as it does
  violate previous closure techniques,
• .but could become second nature with practice.

Iowa Health 2004
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Teach-BackLessons Learned -2

• Surprising misconceptions of patients
  understanding of instructions.
• Nonverbal cues do not seem reliable.

Iowa Health 2004
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Teach-BackLessons Learned -3

• In absence of Teach-Back, the only indicator of
  misunderstanding is medication mistake or patient
  error, which could be harmful

Iowa Health 2004
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Measures - Health Literacy
Sampling Plan Patients with Diabetes who were
seen for a planned care visit at the Ankeny
Clinic that month.
Iowa Health 2004
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Measures - Health Literacy
Iowa Health 2004
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Patients Weighing CorrectlyUse of teach
Back at first call post discharge
Iowa Health System Health Literacy post
discharge intervention with CHF patients Failure
to weigh daily determined to be a primary
contributor to readmission Patients are called at
48 hours and 1 week post discharge Teach Back is
used to clarify their understanding
Iowa Health 2004
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http//www.hsl.unc.edu/Services/Guides/focusonheal
thlit.cfm
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http//www.hsl.unc.edu/Services/Guides/focusonheal
thlit.cfm
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References

• Institute of Medicine Committee on Health
  Literacy. Health Literacy A Prescription to
  End Confusion. The National Academies Press.
  Washington, D.C. 2004
• Institute of Medicine Committee on Quality of
  Health Care in America. Crossing the Quality
  Chasm A New Health System for the 21st Century.
  The National Academies Press. Washington, D.C.
  2001
• Institute of Medicine Committee on Identifying
  Priority Areas for Quality Improvement. Priority
  Areas for National Action Transforming Health
  Care Quality. The National Academies Press.
  Washington, D.C. 2003
• Parker RM, Ratzan SC, Lurie N. Health Literacy
  A Policy Challenge for Advancing High-Quality
  Health Care. Health Affairs 200322147-153
• Wagner EH. Chronic disease management What will
  it take to improve care for chronic illness?
  Effective Clinical Practice. 199812-4

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References

• Schillinger, D et al. Closing the Loop Physician
  Communication w/ Diabetic Patients who have low
  health literacy. Arch Intern Med 200316383-90
• Schillinger et al, Association of Health Literacy
  with Diabetes Outcomes. JAMA, July 2002 V288 No
  4 475-82
• UNC Managing Your Health With Heart Failure
• http//www.hsl.unc.edu/Services/Guides/focusonheal
  thlit.cfm
• Health Literacy
• IOM Health Literacy report  www.nap.edu/catalog/10
  883.html
• www.amafoundation.org
• www.healthliteracy_at_ama-assn.org
• http//gseweb.harvard.edu/ncsall/
• http//www.hrsdc.gc.ca/en/hip/lld/nls/About/new.sh
  tml
• Partnership for Clear Health Communication  
• www.clearlanguagegroup.com
• www.AskMe3.org
• Value    www.literacynet.org/value
• World Education   http//www.worlded.org/projects_
  region_us.htmlnelrc
• Health Literacy  (NALS) Data www.nifl.gov
• Models for Collaboration, Improvement and Spread
• Institute for Healthcare Improvement www.IHI.org