1. UAMS TRI Grand Rounds July 15, 2015 Cliff Coleman, MD, MPH Oregon Health & Science University colemanc@ohsu.edu

2. “Communication works for those who work at it” -- John Powell, composer

3. Funding support:  National Cancer Institute grants number 5K07 CA121457-05 and 3K07 CA121457 04S2 (Behavioral & Social Sciences as Core Elements of the Medical School Curriculum)  Health Resources and Services Administration grant number 1D58 HP15234 01-00 (Curriculum Activities for Learning Mood Disorders and Community Approaches to Residency Education (CALM CARE))

4. 1. Describe the state of research in health literacy education for medical professionals 2. Identify a set of educational competencies which underpin health literacy best practices 3. Describe the experience of one institution integrating health literacy training into a case-based curriculum

5.  Brief review of health literacy educational research  Health literacy educational competencies development and prioritization  The OHSU experience  Lessons learned and next steps

7. “Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy” “Professional schools and professional continuing education programs in health and related fields, including medicine, dentistry, pharmacy, social work, anthropology, nursing, public health, and journalism, should incorporate health literacy into their curricula and areas of competence” (Neilsen-Bohlman et al, 2004, p161) IOM health literacy report, 2004

8. (Coleman, Kurtz-Rossi, McKinney, Pleasant, Rootman, & Shohet, 2008)

9.  Healthcare professionals lack adequate knowledge, skills and attitudes  Many best practices for effective communication with low health literacy patients are not routinely used  Calls to improve HL training (e.g., HP 2020, IOM, Joint Commission)  Curricula proliferating  Variety of approaches described ◦ Stand-alone ◦ Series ◦ Integrated  Training is effective  Development of curricula slowed by lack of educational competencies (Coleman, 2011)

10.  Mackert and colleagues (2011) ◦ Improved self-perceived knowledge, and planned behaviors among non-MD volunteers  Coleman & Fromer (In press) ◦ Improved self-perceived knowledge, and planned behaviors among MD and non-MD mandatory attendees

11. (Coleman& Appy, 2012)

12.  2010 survey of 133 Deans of US allopathic schools  63 responses (47.4% response rate) ◦ 69% public; 31% private ◦ 76% urban; 14% suburban; 10% rural  44 schools (72%) with HL in required curriculum  Median hours of instruction = 3 hours (Coleman& Appy, 2012)

14. Half or less using experiential instructional methods

15. (Coleman& Appy, 2012)

17.  First HL education study with long-term follow-up (12 months)  Aim: assess effectiveness of HL awareness- raising session using AMA video during Fall of 1 st -year  Setting: OHSU School of Medicine, 2011  Sample:128 first-year med students (Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

18. METHODS:  Pre-/post-intervention survey with 12-month pre-/post-intervention survey follow-up  Survey instrument developed by Mackert & colleagues (2011): self-perceived HL knowledge, practices and planned behaviors (Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

19. METHODS: YEARHL TRAINING INTERVENTION 1Pre-survey 23 minute introductory video 30 minute facilitated discussion Post-survey 2HL review article pre-reading Pre-survey 1-hour didactic lecture Post-survey 1-hour small group skill-building workshop: Avoiding medical jargon “Teach back” (Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

20.  Response rates: Year 1: 110/128 students (86%) Year 2: 58/128 students (45%)  Immediately following a HL training, 1 st -year and 2 nd year medical students report broad improvements in knowledge and intentions to use health literacy techniques  Sustained improvements in awareness of prevalence, associated outcomes, and practice of limiting information after 1 year (Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

21. Longitudinal Training Study Preliminary results

22.  Awareness-raising is effective  Most improvements in self-perceived practices and planned behavior were not sustained over 12 months among pre-clinical students  Curricula which do not include skill-building experiential training may not improve plain language or patient assessment skills (Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

24. Literature review (2010) yielded a diverse array of recommendations (i.e., “best practices”) 32 Practice items 24 Knowledge items 28 Skill itemsCompetencies 11 Attitude items Some overlap between domains Selection of potential competencies (Coleman, Hudson, & Maine, 2013)

25. Patient-centered protocols and strategies to minimize the negative consequences of low or limited health literacy (Barrett et all, 2008) Health literacy practices

26. The knowledge, skills and attitudes which health professionals need in order to address low health literacy among consumers of health care and health information Health literacy competencies Health literacy competencies (Coleman, Hudson, & Maine, 2013)

27. Specific Aim: To develop a consensus agreement on a common set of core health literacy competencies for U.S. health professions school graduates Methods (Coleman, Hudson, & Maine, 2013)

28. Design: Modified Delphi consensus process  A commonly used method to capture expert opinions of groups  Useful when empiric evidence is lacking  Use is well described in healthcare competencies work  “Modified” in that the panel met in person initially Methods (Coleman, Hudson, & Maine, 2013)

29.  Identify proposed competencies (literature review)  Convene expert panel  Individuals anonymously rate their agreement with items on the list  Predetermined levels of “agreement”  Facilitated group discussion helps “move the needle” on items prior to re-rating ◦ Participants’ opinions important ◦ Modifications suggested  Process stops when diminishing returns reached Delphi: how it works (Coleman, Hudson, & Maine, 2013)

30. Best practiceDomain(s)Competency. The learner… Operationalization. The learner… 1. Use common words when speaking to patients Knowledge Skills Practices Knows which kinds of words, phrases, or concepts may be “jargon” to patients Selects jargon words from a list Explains why jargon terms may be misinterpreted 2. Speak clearly and at a moderate pace Skills Practices Demonstrates ability to speak slowly and clearly with patients Speech is perceived as appropriate pace, volume and clarity. Speech is always intelligible 3. Confirm patients understand what they need to know and do by asking them to teach back directions Knowledge Skill Practices Routinely uses a “tech back” or “show me” technique to check for understanding Confirms patient’s understanding by asking patient to explain back in their own words (or show) what they have heard/seen at end of encounter Puts onus on self, by saying “I don’t always explain things well. Tell me what you’ve heard.” Translating best practices into measurable competencies – 3 examples

31. Example of consensus project rating scheme: knowledge item (Coleman, Hudson, & Maine, 2013)

32. Sample:  Executive leadership representatives from member organizations of the Federation of Associations of Schools of the Health Professions (FASHP): ◦ American Association of Colleges of Nursing ◦ American Association of Colleges of Osteopathic Medicine ◦ American Association of Colleges of Pharmacy ◦ American Dental Education Association ◦ Association of Academic Health Centers ◦ Association of American Medical Colleges ◦ Association of Chiropractic Colleges ◦ Association of Schools & Colleges of Optometry ◦ Association of Schools of Allied Health Professions ◦ Association of Schools of Public Health ◦ Association of University Programs in Health Admin ◦ National League for Nursing ◦ Physician Assistant Education Association  Attendees of a 2-day meeting on teaching health literacy to health professions students  St Louis, MO, October 2010  Hosted by Health Literacy Missouri and Saint Louis College of Pharmacy Methods (Coleman, Hudson, & Maine, 2013)

33. Age, mean (n=22)51.9 years Female (n = 21)15 (71.4 %) White Non-Hispanic 21 (95.5%) Years in health professions education, mean (n = 22)19.1 years Background in direct patient care (n = 21)19 (90.5%) Highest level of education attained (n= 20) Bachelor’s Master’s Doctorate 1 (5%) 18 (90%) “Would your peers consider you to have expertise on the topic of health literacy?” (n = 22) YES NO 16 (72.7%) 6 (27.3%) 22 FASHP participants (Coleman, Hudson, & Maine, 2013)

34. Round One Round Two Round Three Round Four Total Accepte d Competencies Knowledge Items19/245/5-/- 24/24 Skills Items21/282/4*2/3 † 2/3 27/29 Attitude Items11/11-/- 11/11 Competencies Total51/637/92/3 † 2/3 62/64 Practice Items26/324/62/3** 0/1 32/33 Total77/9511/154/6 2/3 94/97 62 competencies and 32 best practices accepted after 4 rounds (Coleman, Hudson, & Maine, 2013)

41.  “Reverse design” starts with desired behaviors (the practices) and works back to the competencies (knowledge, skills & attitudes)

42. 1) Rank order the identified health literacy practices 2) Align the competencies (knowledge, skills and attitudes) with the ranked practices

43. Q-sort method:  Validated method  Prioritizes subjective opinions  Quantitative means of assessing qualitative data  Used to rank learning objectives for health professionals (e.g., Meade at al, 2013)

44.  Start with list of 32 HL practices  Convene approximately 45 HL experts  Sort items from most important to least important onto a quasi-normal distribution grid  Analyze group data using standard Q-sort analysis (Meade et al, 2013)

45. Most important Neutral Least important

46. Most important Neutral Least important

47. Most important Neutral Least important

48. Most important Neutral Least important

49. Most important Neutral Least important

52. YEARINSTRUCTIONAL METHODASSESSMENT METHOD 123 minute introductory video 30 minute facilitated discussion Multiple choice questions 2Review article reading 1-hour didactic lecture 1-hour small group skill-building workshop: Avoiding medical jargon “Teach back” Multiple choice questions 3NoneOSCE HL case 4None

54.  Moving from systems-based to case-based curriculum  Organized in 7 blocks of related systems  Clinical & science “threads” run longitudinally  Compressing pre-clinical curriculum to 18 months  Competency-driven

55. Focus on high impact teaching 3. Instructional method 2. Assessment method 1. Learning objective (Competency)

56. Interview Physical Exam Community / Population Health Health Systems Social Determinants / Society Anatomy/Embryology/Histology Physiology / Pathophysiology Immunology Pharmacology Diagnostic studies Self-management Clinical Assessment DX / Clinical reasoning Differential Diagnosis Case presentations / Write-ups Clinical management Pharmacotherapeutics Procedural intervention “Out” “In” Counseling Quality / Safety / Triple Aim Clinical Context Health Literacy Family System Foundational knowledge Clinical Skills & Procedures Communication Ethics Professionalism Health Systems & Policy EBM, Epidemiology, Informatics Genetics Microbiology MEDICAL KNOWLEDGE PATIENT CARE & PROCEDURAL SKILLS INTERPERSONAL & COMMUNICATION SKILLS PROFESSIONALISM PRACTICE BASED LEARNING & IMPROVEMENT SYSTEMS BASED PRACTICE Clinical Problem & Context Biochemistry / Nutrition (Figure courtesy of Judith Bowen, MD, 7/7/14)

57.  General health communication  Health literacy  Cultural competency  Limited English proficiency  Motivational interviewing  Shared decision making  Special communications (bad news, “difficult” patients, adolescents, etc)

58. Case: Mr. Morales is a 45-year-old car mechanic with type 2 diabetes. He was born in Mexico, did not complete high school, and speaks English as a second language. He now requires transition to insulin therapy because of failed lifestyle management and oral antidiabetic medication therapy. His attempts at weight loss were challenged by the need to participate in family social gatherings and to show appreciation for his wife and mother’s cooking. His primary care physician had sent him to a dietician who provided him with information about an 1800 calorie diet from the American Diabetes Association. He did not understand the written instructions and did not share them with his wife. He also believes that insulin causes blindness and kidney failure and does not intend to use insulin but will instead use Mexican remedies such as prickly pear, offered by his mother. (Lie, Carter-Pokras, Braun B, & Coleman, 2012)

59.  Knowledge (cognitive) objectives ◦ Focus on rationale for using a “universal precautions “approach to health communication  Skills (behavioral) objectives ◦ Focus on best practices for spoken and written communication (awaiting prioritization) ◦ Focus on developing “habits” for patient-centered communication  Attitudes (affective) objectives ◦ Focus on deployment of universal precautions approach ◦ Focus on developing “habits” for patient-centered communication

60.  Blends several models for patient-centered communication  Adds health literacy practices  Observable (Putnum, 2014; Coleman et al, 2013; Baker et al, 2012; Mauksch, 2011; Stein et al, 2005)

61. 1. Make a positive connection 2. Establish an agreed upon agenda 3. Facilitate understanding 4. Confirm understanding

62.  Enters room at an unhurried pace  Sits at patient’s level  Make eye contact to match patient’s style  Introduces self to all in the room  Gives full attention for first 30 seconds  Makes an empathic statement during the history

63.  Elicits the patient’s full set of concerns at the outset  Negotiates an agreed upon agenda which addresses the patient’s main concern(s) and expectations

64.  Speaks slowly and clearly  Follows a “universal precautions” approach, assuming that all patients are at risk for miscommunication  Avoids jargon / uses plain language  Summarizes the plan for addressing the patient’s main concern(s)

65.  Asks “what questions do you have?”  Uses “teach back” to confirm understanding

67.  Lack of integrated competencies  Lack of faculty role models  Case-based and competency-driven curriculum requires increased faculty development (instruction and assessment)  Lack of validated assessment methods  Lack of down-stream outcomes data  Pre-clinical period may not offer enough patient exposure for best practices to take hold

68. “Communication works for those who work at it” -- John Powell, composer

69. Baker LH, Cordaro DT, Platt FW. The first minute. Medical Encounter 2012;26(2):83-4 Barrett SE, Puryear JS, Westpheling K. Health literacy practices in primary care settings: examples from the field. January 2008. Available at http://www.commonwealthfund.org http://www.commonwealthfund.org Coleman C. Teaching Healthcare Professionals about Health Literacy: A Review of the Literature. Nursing Outlook 2011;59:70-78 Coleman C, Appy S. Health literacy teaching in U.S. medical schools, 2010. Family Medicine, 2012;44(7):504-7 Coleman C, Fromer A. “A Health Literacy Training Intervention for Physicians and Other Health Professionals.” Family Medicine, In press

70. Coleman C, Hudson S, Maine L. “Health Literacy Practices and Educational Competencies for Health Professionals: A Consensus Study.” Journal of Health Communication 2013;18:82-102 Coleman C, Kurtz-Rossi S, McKinney J, Pleasant A, Rootman I, Shohet L. The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. The Centre for Literacy of Quebec. Available at http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2 011.pdf. Accessed 5/1/14 http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2 011.pdf. Accessed 5/1/14 Lie D, Carter-Pokras O, Braun B, Coleman C. “What Do Health Literacy and Cultural Competence Have in Common? Calling for a Collaborative Health Professional Pedagogy.” Journal of Health Communication, 2012;17:13-22 Mackert M, Ball J, Lopez N. Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques. Patient Education and Counseling, In press (2011) Mauksch L. Patient Centered Observation Form. ©University of Washington Department of Family Medicine, May, 2011. Available at http://depts.washington.edu/fammed/files/PCOF%205.16.2011_0-2.pdf. Accessed 5/28/14

71. Meade LB, Caverzagie KJ, Swing SR, Jones RR, O’Malley CW, Yamazaki K, Zaas AK. Playing with curricular milestones in the educational sandbox: Q-sort results from an Internal Medicine educational collaborative. Academic Medicine 2013;88(8):1142-8 Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Institute of Medicine of the National Academies, Board on Neuroscience and Behavioral Health, Committee on Health Literacy. Washington, D.C.: The National Academies Press, 2004 Putnam JB. Teaching Physician-Patient Communication (AIDET) for Results in All Pillars. Available at http://www.studergroupmedia.com/WRIHC/presentations/teaching_physicia n_patient_communication_(aidet)_for_results_in_all_pillars_vanderbilt_putna m_kennedy_0028.pdf. Accessed 5/28/14 http://www.studergroupmedia.com/WRIHC/presentations/teaching_physicia n_patient_communication_(aidet)_for_results_in_all_pillars_vanderbilt_putna m_kennedy_0028.pdf Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Education and Counseling 2005;58:4-12