1. Advancing Clear Health Communication to Positively Impact Health Outcomes

2. Presentation Sections The Problem: Low Health Literacy – Scope and Impact Finding a Solution –The Partnership for Clear Health Communication –Ask Me 3 How to Become Involved: Solutions into Action

3. The Problem: Low Health Literacy Scope and Impact

4. Do You Know Which Critical Public Health Issue… Impacts nearly one in every three people living in the United States Can hit any population segment, regardless of age, race, education or income Costs the healthcare system as much as $58 billion a year Can’t be diagnosed by any new medical technology and is not visible to the eye Answer: Low Health Literacy

5. The Issue: Low Health Literacy What is health literacy? –The ability to read, understand and act on health information

6. How Big Is the Problem? Approximately 40 to 44 Million Adults in the US Are Functionally Illiterate 1 Approximately 50 Million Are Marginally Illiterate 1 Average Reading Skills of Adults in the US Are Between the 8 th and 9 th Grade Levels 2 More Than 90 Million People in the US Have Difficulty Reading Sources: 1 Kirsch et al., “A First Look at the Results of the National Adult Literacy Survey” Nat’l Center for Education Statistics, 1993 2 Stedman L, Kaestle C. Literacy and Reading Performance in the US From 1880 to Present. In: Kaestle C, Editor. Literacy in the US: Readers and Reading Since 1880. New Haven (CT): Yale University Press; 1991. P. 75–128 Cannot Perform Basic Reading Tasks Required to Function in Society Have Trouble Reading Maps and Completing Standard Forms

7. Reading Levels & Skills 0-56-9 10-16+

8. How Does Low Health Literacy Affect Your Practice? Chances are high that some of your patients are among the 90 million who have low health literacy You may not know that patients with poor health literacy skills are in your care: –They use well-practiced coping mechanisms that effectively mask their problem –They are often ashamed to admit they have difficulty understanding information and instructions

9. Defining the Problem Scope Coping Mechanisms for Patients With Low Literacy 98% Bring Someone Who Can Read Watch and Copy Others’ Actions Ask for Help From Medical Staff Ask Other Patients 90% 80% 88% Source: Parikh et al., 1996

10. Who Is at Risk for Low Health Literacy? Anyone in the US – regardless of age, race, education, income or social class – can be at risk for low health literacy –Ethnic minority groups are disproportionately affected by low health literacy –The majority of people with low literacy skills in the US are white, native-born Americans –Older patients, recent immigrants, people with chronic diseases and those with low socioeconomic status are especially vulnerable to low health literacy

11. Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System The Largest Study Conducted to Date on Health Literacy Found That… Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82 33% Were unable to read basic health care materials 42% Could not comprehend directions for taking medication on an empty stomach 26% Were unable to understand information on an appointment slip 43% Did not understand the rights and responsibilities section of a Medicaid application 60% Did not understand a standard informed consent

12. Low Health Literacy Negatively Impacts Health Outcomes Adults with low health literacy: –Are often less likely to comply with prescribed treatment and self-care regimens 1 –Make more medication or treatment errors 1 –Fail to seek preventive care 1 –Are at a higher risk for hospitalization than people with adequate literacy skills 2 –Remain in hospital nearly 2 days longer 3 –Lack the skills needed to negotiate the health care system 1 People with low health literacy AND diabetes: –Were found to be less likely to have effective glycemic control 4 –Were more likely to report vision problems caused by their diabetes 4 1 Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 1999 2 Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798. 3 Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993. 4 Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB. Association of Health Literacy With Diabetes Outcomes. JAMA. July 24/31 2002 (288) No 4.

13. Low Health Literacy Impacts Resource Utilization Adults with low literacy: –Averaged 6% more hospital visits 1 * –Stayed in the hospital nearly 2 days longer than adults with higher literacy skills 1 * –Had fewer doctor visits, but used significantly more hospital resources 2 –Had annual health care costs 4 times higher than those with higher health literacy 3 Among adults who stayed overnight in a hospital 1 Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993. 2 Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798. 3 Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 1999.

14. Implications of Low Health Literacy Poor Health Outcomes Under-utilization of preventive services Over-utilization of health services Unnecessary health care expenditures Limited effectiveness of treatment Needless patient suffering Higher patient dissatisfaction Higher provider frustration

15. You Can’t Tell By Looking

16. Finding a Solution

17. Solutions: Focus on Care Providers and Materials SKILLED READERSPOOR READERSMANAGING THE PROBLEMS Interpret meaning Read with fluency Get help for uncommon words Grasp the context Persistent reader Take words literally Read slowly, miss meaning Skip over the word Miss the context Tire quickly Explain the meaning Use common words, examples Use examples, review Tell context first, use visuals Short segments, easy layout Differences between good and poor readers… and how you can manage problems

18. But just 41% of those patients say they have received this kind of assistance 17% of patients report trouble understanding Rx Information The Patient-Provider Relationship 70% of physicians say they provide patients with additional resources to help them understand their medications 75% of physicians report patients have trouble understanding Rx information There Is a Disconnect Between Patient and Provider: Bridging the Information Gap Will Help Improve Health Literacy Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

19. Why is this? Short-term memory has very limited capacity and short storage time Most people can store 7 or fewer independent items at one time This memory lasts less than 1 minute Short-term memory Long-term memory Long-term memory lasts for days and years Long-term memory has no practical capacity limits To move into long-term memory, use association and interaction

20. Getting Into Long-term Memory Gain the patient’s attention Present no more than seven items at a time Get to the point Short-term memory Long-term memory Associate new information with what patient already knows Involve the patient in interaction with the information Repeat or review

21. Written Communication 87% report reading Rx information Yet only 34% believe others read this same information What Do We Do? Develop Written Materials at 6th Grade or Below, Where 160MM Can Understand and Act Written Making Health Information Understandable Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002 50% of adults read at below 8th grade reading levels 20% of adults read at below 5th grade reading levels 40% of seniors read at below 5th grade reading levels Consumer healthcare materials written at 10th grade or above, where only 50MM can understand and act

22. What You Need to Know About Low Blood Sugar Treat low blood sugar quickly. If you have signs of low blood sugar, eat or drink something that has sugar in it. Some things you can eat are hard candy, sugar- sweetened soda, orange juice, or a glass of milk. Special tablets or gel made of glucose (a form of sugar) can be used to treat low blood sugar. You can buy these in a drug store. Always have some of these items handy at home or with you when you go out in case your blood sugar drops too low. After treating a low blood sugar reaction, eat a small snack like half a sandwich, a glass of milk, or some crackers if your next meal is more than 30 minutes away. Source: The National Institute of Diabetes and Digestive and Kidney Diseases Example of Health Communication That May Not Reach a Broad Consumer Audience 70150 Blood Sugar Is Too Low if It Is Under 70 Blood Sugar Is Too High if It Is Over 240 Good Range Too High Too Low 9th Grade Reading Level

23. Example of Clear Health Communication – That Reaches a Broad Consumer Audience Common visual used to explain concept Uses action captions that clarify the point of the visual Creates interaction with the reader

24. Verbal Communication Patients experience shame around the issue Only 14% of patients say they feel awkward admitting they don’t understand; yet 79% feel others don’t understand Providers experience time challenges Providers interrupt patients 30 seconds after they start speaking; if not interrupted, patients will speak less than two minutes Communicate Effectively What Can We Do? Up to 80% of Patients Forget What Their Doctor Tells Them As Soon As They Leave the Doctor’s Office – AND Nearly 50% of What They Do Remember is Recalled Incorrectly Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

25. Reaching the Solution In the Office - Best Opportunity for Immediate Impact 1.Tell patients that instruction is aimed at solving/managing their health problem. Ask what they know, then outline topics you plan to cover. 2.Get to the point quickly. Low literacy skills = short attention span. 3.Ask patients to solve a problem with the new information. Ask them to tell or show you how they will use the information just learned.

26. Limited Education Objectives (example) Objectives (for patient)“Must Include” TopicsInteractive Questions 1. Understand what hypertension is 2. Follows medication regimen What is hypertension & what is patient’s BP? Dangers of hypertension Taking medicine can control hypertension Must take medication every day even if you feel okay What is HBP? What is your blood pressure? What are some dangers to you from HBP? How can you lower your blood pressure? What about taking medication on days you feel okay?

27. Choosing the Right Words Concept words describe a general idea or abstract framework (i.e. eat a ‘variety’ of foods; keep your glucose level within a ‘normal range’) = often misunderstood Category words describe groups of things; people with low literacy skills have trouble understanding categories Value judgment words (i.e. ‘excessive’ bleeding; exercise ‘regularly’); need to be specific Use examples of common ideas to explain uncommon words Use visuals/pictures to emphasize or clarify

28. Guidelines for Health Education Reaching the Solution 1.Set realistic objectives. Use a planning sheet to write down key points. 2.To change health behaviors, focus on behaviors and skills. Emphasize skills, rather than facts. 3.Present context first (before giving new information). State the use for new information before presenting it; relate it to context of patients’ lives. 4.Partition complex instructions. Break instruction into easy-to-understand parts. Provide opportunities for small successes. 5.Make it interactive. Consider including an interaction after each key topic. The patient must: write, tell, show, demonstrate, select or solve a problem.

29. Clear Health Communication – We Can All Be a Part of the Solution Even if you are not in a position to directly answer the three questions, keep clear health communication in mind and in your dialogue when communicating with patients Many people have trouble understanding medical terms. Often, these terms are better understood when explained with common words, an example or visual interpretation

30. Clear Health Communication in Action BenignHarmless ChronicHappens again and again; does not end Cardiac Heart EdemaSwelling; build up of fluid FatigueTired ScreeningTest IntakeWhat you eat or drink GenericNot a brand name Adverse eventsSide effects Consider Using This One Instead Instead of Using This Word Start by Decreasing the Use of Medical Jargon

31. Finding a Solution

32. The Partnership’s First Solution Addresses awareness and education Creates a Call to Action for patients and providers Is designed to promote clear communication between patients and providers to improve health outcomes Was developed with health literacy experts, then tested and validated

33. Ask Me 3 Use of Ask Me 3 resulted in reduction in 30 day readmission rates for heart failure pts. (7.2% to 2.5%) Patient surveys indicated a statistically significant improvement in perceived ability of nursing staff (p =.001) Ask Me 3 does not add time to patient visits Use of Ask Me 3 resulted in reduced call-backs and missed appointments Over 1 million providers use the Ask Me 3 program

34. Ask Me 3 - For Patients Patients Should Not Be Anxious About Asking Their Health Care Provider Questions! Health information can be confusing at times Everyone wants help with health information Asking questions helps patients understand how to prevent or manage illness

35. ProviderPatient All they can about their condition/medication Why this advice/treatment is important for good health Steps to take to prevent a condition or keep it under control Ask Me 3 - For Providers Health Care Providers Want Patients to Know:

36. Ask Me 3 – Creates Shared Responsibility for Clear Health Communication PatientProvider De-stigmatize and Reduce Embarrassment of Low Health Literacy Recognize Patient Coping Mechanisms Provides a consistent approach to patient-provider dialogue Allows patients to get information they need to manage their health Time-efficient for providers to reinforce healthcare instructions

37. What Is Ask Me 3 Promotes three simple, but essential, questions and answers for every healthcare interaction: Why Is It Important for Me to Do This? Context What Do I Need to Do? Treatment What Is My Main Problem? Diagnosis

38. Ask Me 3 – For Patients Element: Poster Description: –Stimulates curiosity about Ask Me 3 –Informs patients and staff about the program Implementation (hang poster): –In waiting areas –In exam rooms –On the ceiling, above the exam table –On a door –In a staff break room –Hang anywhere where provider- patient interaction takes place –Anywhere patients might see it!

39. Ask Me 3 – For Patients Element: Patient brochure Description: –Educates patients about the Ask Me 3 –Motivates patients to ask their healthcare provider questions Implementation: –Display in waiting rooms/registration area –Distribute to patients upon arrival/sign-in –Distribute with any paperwork –Distribute during events or with mailings to patients

40. Ask Me 3 – For Providers Element: Provider brochure Description: –Explains the scope and impact of low health literacy –Offers communication tips –Emphasizes how effective communication can positively impact patient health outcomes Implementation: –Distribute to all staff interacting with patients through staff meetings or mailings –Conduct departmental in-service training on Health Literacy and Clear Health Communication

41. Ask Me 3 – For Providers www.AskMe3.org: www.AskMe3.org –Has everything you need to start acting/implementing –Materials can be downloaded/ ordered from this website –Other health literacy tools available on the site: Bibliography on health literacy List of literacy resources White paper on health literacy Links to other relevant websites Cultural competence primer

42. What Can You Do? Six steps to improving patient understanding 1.Limit the amount of information provided at each visit 2.Slow down 3.Avoid medical jargon 4.Use pictures or models to explain important concepts 5.Assure understanding with the “show-me” technique 6.Encourage patients to ask questions

43. What Else Can You Do? When making an appointment, provide people with simple options and clear facts Appointment Instructions Also see: Urgent Care (if you are too sick to wait for an appointment) Making a medical appointment for the first time, it is straightforward: You call 555-2222 and make a appointment at XYZ Health Services just like you would at any doctor's office.Urgent Care You can request a specific clinician if you have someone in mind, or you can explain your need or problem to the appointment counselor, and he or she will schedule you with an appropriate clinician at the earliest possible date. At your first appointment you will receive a medical record card -- often referred to as your "gold card" -- which you will keep and use as your XYZ Health Services identification. If you are unsure about whether you should make an appointment, you may call the Advice Nurse at 666-7777. Also, in advance of your first appointment, be sure to read "How to Make the Most of Your XYZ Visit."How to Make the Most of Your XYZ Visit Please call 643-7177 to make an appointment in the Specialty Clinics, including Allergy & Travel. Specialty appointments require a referral. You may also drop by the Appointment Office to make a medical appointment. The Appointment Office is located on the first floor in Room 1111. You may also make an appointment in the Specialty Clinics by going to the Specialty Clinic reception desk, located behind the elevators on the first floor. If you need to cancel an appointment, please call our 24-hour cancellation line at 643-7033. Please note that you will be billed for a broken appointment fee if you do not show up for your appointment and have not called to cancel it. Your Name Your Appointment Date Time Place Our Telephone Number: Do not eat or drink for 6 hours before the day and time on this card. People Have Difficulty Making Appointments

44. What Else Can You Do? Phone answered by a tape recording. Speaking quickly, the caller is offered numerous options and alternatives Speak slowly and clearly Provide an easy way to connect with a live person Provide options in other languages People Have Trouble Understanding Phone Recordings

45. What Else Can You Do? Ambulatory Entrance Hospital XYZ Some people become confused about whether this entry was intended for ambulances or for patients Ambulatory Entrance The use of visuals clarify the message Contrast in color makes it easy to read Try to be consistent when hanging signs People Have Trouble Reading Signs

46. What Else Can You Do? To make maps easier to follow: Match the color in the map with the paint color on walls or floors Match the names in the map to the names on the signs Use 14 point font size or larger Maps are usually hard to follow: Too complicated Codes are hard to understand Names and directions not always match Small fonts People Have Trouble Understanding Maps

47. How Can Enhanced Communication With Your Patients Benefit Your Practice? Patients who understand health care information may: –Be more compliant with instructions and medications –Call back less often –Visit less often –Have fewer hospitalizations –Have better health outcomes –Have increased patient satisfaction Greater Provider Satisfaction

48. Help Patients Understand…

49. The Practical Solution: