Health LiteracyImproving Communication Between Health Care

Professionals and Older Adults

Jermarx Marsh MBAGuest Relations Manager

Hurley Medical Center

Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a).

Learning Objectives1. Define health literacy.

2. Recognize the impact of health literacy on an individual’s health and quality of life.

3. Identify strategies health care professionals may utilize to assess the ability of adults and family members to understand health information.

4. List techniques to implement processes in clinical practice to improve health literacy and the individual’s ability to make informed choices regarding their health outcomes.

Definition: Health LiteracyClients/Patients:

• Education/ Literacy/ Language

Health Literacy:

Capacity to

• Obtain, process, understand basic health information and services

• Make appropriate healthcare decisions (act on information)

• Access/ navigate healthcare system

IOM Report on Health Literacy• 90 million adults have trouble understanding

and acting on health information

• Health information is unnecessarily complex

• Providers need health literacy training

Healthy People 2010• Improve health communication/health literacy

Joint Commission (1993)• Patients must be given information they

understand

Factors that contribute to low health literacy

• General literacy• How information is communicated• Complexity of the health care system• Age, culture, language• Illness, emotions, hearing, vision, cognition

Implications of poor health literacy

• Inadequate health knowledge• Poorer health outcomes• Lower health status• Medical miscommunications• Increased medical costs• More hospitalizations

“As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve.

Health care professionals do not recognize that patients do not understand the health information we are trying to communicate.

We must close the gap between what health care professionals know and what the rest of America understands.”

Dr. Richard Carmona,Former U.S. Surgeon General

mentioned health literacy in 200 of last 260 speeches

2003 National Adult Health Literacy SurveyScored on 4 levels:

• Below Basic: Very concrete literacy activities

• Basic: Simple, everyday literacyactivities

• Intermediate: Moderately challenging literacy

activities

• Proficient: Complex and challenging literacyactivities

2003 National Adult Health Literacy Survey: Health Literacy Proficiency Level

Age 65+0

5

10

15

20

25

30

35

40

2930

38

Below Basic Basic Intermediate

Perc

ent

Only 3% of adults age 65+ have ‘proficient’ health literacy

Red Flags for Low Literacy• Frequently missed appointments

• Incomplete registration forms

• Non-compliance with medication

• Unable to name medications, explain purpose or dosing

• Identifies pills by looking at them, not reading label

• Unable to give coherent, sequential history

• Ask fewer questions

• Lack of follow-through on tests or referrals

MEET PATIENTS DISCUSSING THEIR HEALTH LITERACY EXPERIENCES

AMA Foundation: http://www.youtube.com/watch?v=cGtTZ_vxjyA

Strategies to Enhance Health

1. Improve communication with patients

2. Reduce barriers to care by creating a patient centered environment

Mismatched Communication

Provider Process: Giving informationPatient Process: Understanding, remembering, and acting

on information

We expect more from patients Prevention (eating, exercise, sunscreen, dental) Immunization Self Assessment of Health Status

w Peak flow meter w Glucose testing

Self-treatmentw Insulin adjustments

Health Care Usew When to go to clinic/ER

w Referrals and follow-up

w Insurance/ Medicare

Process is Becoming More Complex

Patient’s continuum

of confusion

Pre-visitScheduling the

appointmentPre-visit

Visit reason, obtain

records, directions

In office, PPRegistration,

new forms,

insurance

In office, PPProblem, health

status, history

See ProviderMed list, sources of care

With ProviderAdjust/Add med, newTests or referrals

See EducatorPamphlets,

charts, videos

CheckoutNew tests, samples,

instructions

CheckoutSchedule f/u,

referrals, insurance,

billing

Health Literacy and Patient Safety: AMA Foundation, 2007

PP – Prior to seeing physicianED – Emergency DepartmentF/U – Follow upHCP – Health care professional

• 46% did not understand instructions ≥ 1 labels

• 38% with adequate literacy missed at least 1 label

‘How would you take this medicine?’ 395 primary care patients in 3 states

Davis TC , et al. Annals Int Med 2006

Patient Safety: Medication Errors

‘Show Me How Many Pills You Would Take in 1 Day’

Slide by Terry Davis

Rates of Correct Understanding vs. Demonstration ‘Take Two Tablets by Mouth Twice Daily’

0

20

40

60

80

100

Low Marginal Adequate

Corr

ect (

%)

Patient Literacy Level

Understanding

Demonstration

7180

89

63

84

35

Davis TC , et al. Annals Int Med 2006

Lessons Learned From Patients• Tell me what’s wrong (briefly)• What do I need to DO & why• Emphasize benefits (for me)

If meds, break it down for me:

1. What it is for

2. How to take (concretely)

3. Why (benefit)

4. What to expect

Remember: what’s clear to you is clear to you!

Focus on ‘Need-to-know’& ‘Need-to-do’

What do patients need to know/do…?

• When they leave the exam room• When they check out• What do they need to know about?

• Taking medicines• Self-care• Referrals and follow-ups• Filling out forms

Strategies to Improve Patient Understanding

• Focus on ‘need-to-know’ & ‘need-to-do’• Demonstrate/ draw pictures• Use clearly written education materials • Use ‘Teach Back’

‘Teach-back’ Improves Outcomes: Diabetic Patients with Low Literacy

Audio taped visits – 74 patients, 38 physicians

Patients recalled < 50% of new concepts

Physicians assessed recall 13% of time

When physicians used “teach back” the patient was more likely to have HbA1c levels below the mean

Visits that assessed recall were not longer

Schillinger, D. Archives of Internal Med, 2003

Understanding

Clarify

Assess

Explain

Teach-back

Confirm patient understanding

“Tell me what you’ve understood”

“I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine?”

Do you understand?

Do you have any questions?

Patient Education: What We Know• Written materials alone do not adequately inform• Patients prefer key messages from their clinician with

accompanying pamphlets• Focus on “need-to-know” & “need-to do”• Patients with low literacy ask fewer questions• Bring family member and

medication to appointment

IOM: Report on Health Literacy 2004 Berkman et al. AHRQ Report 2004

Visuals Improve Understanding/ Recall

Pictures/demonstrations most helpful to patient with low literacy & visual learners

Most health drawings too complicated

Physician drawings often very good (not too complex)

Patients say “show me” & “I can do it”

7 Tips for Clinicians

• Use plain language

• Limit information (3-5 key points)

• Be specific and concrete, not general

• Demonstrate, draw pictures, use models

• Repeat/Summarize

• Teach-Back (Confirm Understanding)

• Be positive, hopeful, empowering

Use Plain Language20 complicated and commonly used words

• Dermatologist

• Immunization

• Contraception

• Hypertension

• Oral

• Diabetes

• Annually

• Depression

• Respiratory problems

• Community Resources• Monitor

• Cardiovascular

• Diet

• Hygiene

• Prevention

• Referral

• Eligible

• Arthritis

• Screening • Mental Health

Examples of Plain Language

Annually Arthritis Cardiovascular

Dermatologist Diabetes Hypertension

• Yearly or every year• Pain in joints• Having to do with the heart• Skin doctor• High sugar in the blood• High blood pressure

Plain Language

The Plain Language Thesaurus for Health Communications

http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf

Is your site patient-centered?What is the ‘tone,’ 1st impression?

• Welcoming, calm environment• Attitude of helpfulness by all staff• Patients treated as if your family• Patient-centered check-in

& scheduling • Easy-to-follow instructions/

directions• Patient-centered handouts• Brief telephone follow-up• Case management

In Summary:• Looking back, have there been instances when you

suspected, or now suspect, that a patient might have low literacy? What were the signs?

• Do you do things in your setting that make it easier for patients with low literacy to understand services and information?

• What strategies could all of us adopt to minimize barriers and misunderstanding for low literacy patients?

ResourcesCheck how well you are doing in addressing health

literacy issues for older adults at

http://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.html

Older Adults: Designing Health Information to Meet their Needs

Are You Communicating Effectively with Older Adults?

POGOE (Portal of Geriatric Online Education,) University of Arizona College of Medicine, “Health Literacy and the Older Adult” (web-based interactive module)http://healthlit.fcm.arizona.edu/

Resources

Ohio State University “Health Literacy Distance Education Program”

http://healthliteracy.osu.edu/modules

Resources

The Health Literacy Environment of Hospitals and Health Centers: Partners for Action: Making Your Healthcare Facility Literacy Friendly

Rima Rudd & Jennie Anderson Harvard School of Public Health (2006)www.hsph.harvard.edu/healthliteracy

Resources