1. Health Literacy: Implications for Patient Safety Presented by: Barbara Meyer Lucas, M.D., MHSA Mary Antonette Flowers, R.N. The Michigan State Medical Society Foundation American Medical Association Foundation & American Medical Association 10/03

2. Definitions: General Literacy: “ An individual’s 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…...” 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 Module 1

3. 1993 National Adult Literacy Survey l n = 26,000 l Most accurate portrait of literacy in U.S. l Scored on 5 levels l Result: 48% of US population have inadequate or marginal literacy skills Module 1

4. 1993 National Adult Literacy Survey Level 3 Level 2 Level 1 Level 4 Level 5 - 3% 17% 32% 27% - Marginal Literacy 21% - Inadequate Literacy Module 1

5. Up to ½ of US population may be at risk for… –Medical Errors –Medical Miscommunications –Inappropriate hospitalizations –Poorer health outcomes Module 1

6. 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 Module 1

7. Low literate diabetic patients less likely to know correct management…. Know correct action for hypoglycemic symptoms Percent Know symptoms of low blood sugar (hypoglycemia) Williams, et al. Arch Int Med 1998 Module 1

8. Poor health outcomes for diabetic patients…… Diabetic patients with low health literacy have poorer glycemic control than patients with adequate literacy. (Schillinger D, et al. JAMA. 2002.) Diabetic children (ages 5-17) had poorer glycemic control if their parents had lower literacy skills. (Ross LA, et al. Diabetic Med. 2001.) Module 1

9. Patients with low literacy more likely to be hospitalized % Baker, Parker, Williams, et al. JGIM 1999 Module 1

10. Research also shows that: Literacy is a predictor of health status It is a stronger predictor than age, income, employment status, education level, or racial and ethnic group Module 1

11. The Costs of Poor Health Literacy: Estimated to be $50+* billion/year! Costs affect all segments of society: 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 Module 1

12. Why are those with inadequate literacy at risk? Increased reliance on printed handouts for patient instruction Increasingly complex health system –More medications –More tests and procedures –Growing self-care requirements Module 1

13. Changes in the Health Care System 4 - 6 weeks bed rest in hospital 650 3 weeks in hospital 2 hours a day of diabetic education classes 2-4 days in hospital (M&R Guidelines) 10,000 + outpatient 0-3 hours diabetic education classes written materials internet telemedicine Treatment of Acute Myocardial Infarction Available Prescription Drugs Treatment of new onset diabetes 35 Years AgoToday Module 1

14. Inadequate health literacy increases with age… % Module 1 Gazmararian, et al. JAMA 1999

15. Exercise : What is it like to have low health literacy? Module 1

16. What can we do to help? Understand the problem Identify the barriers faced by both patients and clinicians Identify and implement strategies to enhance health literacy Advocate for system change Module 1

17. Video: The patient’s voice... This video was made by the AMA in 2003 You will see real patients and real physicians talking about literacy issues Module 1

18. Two specific goals to enhance health literacy… Create a shame-free environment with improved patient assessment Improve interpersonal communication with patients Module 1

19. Goal #1: Creating a “Shame-Free” Environment 4 Key Strategies: Adopt an attitude of Helpfulness Convey a safe, non-judgmental environment Identify “red flags” for low literacy Engage the entire office staff Module 2

20. Strategy # 1: Adopt an Attitude of Helpfulness…. First impressions make a big difference! Attitude of helpfulness, caring and respect by all staff All patients treated as if they are your parents Easy-to-follow instructions for appointments, check-in, referrals and tests Assistance provided confidentially Module 2

21. Strategy #2: Create a Safe, Non-judgmental Environment... Provide privacy for all discussions Ask and listen before you advise Give the patient time to respond Take the patient’s concern seriously Discuss how you can best help the patient care for themselves Ask patients how they want information communicated to them Be positive, hopeful, empowering Module 2

22. Strategy #3: Be alert to clues of low Health Literacy… Using assessment to address literacy issues…. l Be alert for “red flags” l Use the “social history” to assess literacy l Use “medication reviews” to identify and address problems Module 2

23. Red Flags: Patients may seek to protect themselves by…. Seeking help only when illness is advanced Walking out of the waiting room Making excuses Pretending they can read Becoming angry, demanding Clowning around, using humor Being quiet, passive Detour, letting doctor miss the concern Module 2

24. Red Flags: Patient Communication Unable to name medications, or explain purpose or timing of administration Difficulty explaining medical concerns Has no questions Module 2

25. Red Flags: Lack of follow-through Incomplete registration forms Frequently missed appointments Skipped tests and referrals Non-compliant with meds Module 2

26. Use the “social history” to ask: Ask about education, reading, learning styles – be non-judgmental. Use this discussion to open a space for the patient to talk about literacy issues. Module 2

27. Use a “medication review” to identify problems: Ask patients to bring in all their medications Ask them to name and explain the purpose of each one Discuss exactly how and when they take each one Use this discussion to identify areas of confusion and to answer questions Module 2

28. Exercise : Planning for Medication Reviews Goal: To conduct medication reviews with all patients What are the benefits? What are the barriers? How do we overcome them? Module 2

29. Strategy #4: Engage the entire staff… ( or, what is it like being a patient in your setting?) What forms will you be given? Will you be offered confidential assistance? Are check-in personnel friendly? Were you given easy-to-follow instructions? First impressions? Non-verbal communication of staff? Module 2

30. All staff need to be involved in….. Understanding the scope of the problem Identifying patient barriers to care Creating strategies to address the barriers Implementing and assessing the effectiveness of these strategies Conducting on-going follow-up and evaluation Module 2

31. Goal # 2: Improving Communications with Patients 2 Key Strategies: Improving Face-to Face Communications Improving Written Patient Education Materials Module 2

32. Strategy #1: Enhancing face-to-face communications 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 Module 3

33. 1. Conduct patient-centered visits Engage in a dialogue with the patient Listen more and speak less Encourage questions Understand and address the patient’s concerns. Module 3

34. 2. Explain things clearly using plain language. Slow down the pace of your speech Use analogies –“Arthritis is like a creaky hinge on a door.” Use plain, non-medical language –“Pain killer” instead of “analgesic” Module 3

35. Exercise : Practice using plain, non-medical language Anti-inflammatory Benign Contraception Hypertension Echocardiogram Module 3

36. 3. Focus on key messages and repeat. Limit information by focusing on 1- 3 key messages per visit Review each point and repeat several times Have other staff reinforce key messages. Module 3

37. Exercise : What’s the Key Message? Type II DM diagnosed at today’s visit: –Sugar level in blood is high –How the body controls blood glucose –Self-management of diabetes medications –Start medicine to lower sugar –Potential complications of diabetes –Testing the blood sugar level –Proper diet Module 3

38. 4. Use “teach back” or “show me” techniques. Ask patient to demonstrate understanding –“What will you tell your spouse about your condition?” –“I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.” Do not ask, –“Do you understand?”. Module 3

39. Strategy # 2: Developing patient-friendly written educational materials: Focus only on key points Emphasize what the patient should do Show or draw only simple pictures ---Minimize info about anatomy and physiology Be sensitive to cultural preferences. Module 3

40. Exercise : Simplifying Patient Handouts Example: Strep Throat Refer to your Handout, “Practice Key Messages: Strep Throat” “Streptococcal Pharyngitis (Strep Throat)” Working with a partner, review this information and determine 3 key messages for the patient. Module 3

41. Guidelines for creating patient-friendly written materials: Simple words (1-2 syllables) Short sentences (4-6 words) Short paragraphs (2-3 sentences) No medical jargon Headings and bullets Lots of white space. Module 3

42. Review: 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. Module 3

43. In Summary: 48% of the U.S. population have inadequate or marginal literacy skills This places them at high risk for: --Medical errors --Poor compliance with care plans --Inappropriate hospitalizations --Poorer health outcomes Module 2

44. In Summary: What can we do to help? Strategies for change include: --- Creating shame-free healthcare environments --- Improving communications ---Face to face with patients ---Simplified written handouts Module 1