Perfecting the Dismount: Improving the Handoff to the Patient Darren A. DeWalt, MD, MPH University of North Carolina School of Medicine

Disconfirming Evidence Patients remember 17%-60% of information told by a physician McGuire LC. Exp Aging Res. 22:4,

National Assessment of Adult Literacy (NAAL) n = 19,714 ● Most up to date portrait of literacy in U.S. ● Scored on 4 levels ● Lowest 2 levels cannot: ◦ Use a bus schedule or bar graph ◦ Explain the difference in two types of employee benefits ◦ Write a simple letter explaining an error on a bill National Center for Education Statistics, U.S. Department of Education

2003 National Assessment of Adult Literacy Intermediate Basic Below Basic Proficient 14% 13% 44% 29% 93 Million Adults have Basic or Below Basic Literacy Basic or Below Basic 52% of H.S. Grads 61% of Adults ≥ 65

Williams et al. Chest 1998, 114(4): Asthma Patients with Low Literacy have Poorer Metered Dose Inhaler (MDI) Skills Mean MDI Score < 3rd4th-6th7th-8th>9th

Can Patients Comprehend Rx Drug Warning Labels? Davis et al. JGIM 2006; 21:

Simple Familiar Wording Understood by Most Patients 84% (1 st grade.) Slide by Terry Davis

More Complex Message Limited Comprehension 59% (7 th - 8 th grade.) Slide by Terry Davis

Unfamiliar Multi-step Instructions Rarely Understood 8% (12 th -13 th grade) Slide by Terry Davis

“Someone swallowed a nickel” “Indigestion” “Bladder” “Looks like a ghost- Casper ” What does this picture mean? Slide by Terry Davis

“ Show Me How Many Pills You Would Take in 1 Day ” John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill

Rates of Correct Understanding vs. Demonstration “ Take Two Tablets by Mouth Twice Daily ”

Figure 2. Inconsistencies Between Listed Doses and Markings on Measuring Device Yin, H. S. et al. JAMA 2010;304: Copyright restrictions may apply.

Figure 3. Use of Atypical Unit Markings on Measuring Device and Inconsistency With Listed Doses Yin, H. S. et al. JAMA 2010;304: Copyright restrictions may apply.

Figure 4. Presence of a Listed Dose Not Shown on Measuring Device, Resulting in Need to Measure More Than 1 Instrument Full of Medicine Yin, H. S. et al. JAMA 2010;304: Copyright restrictions may apply.

The single biggest problem in communication is the illusion that it has taken place. -- George Bernard Shaw

How do we perfect the dismount? Very carefully!

Improve Skills and Reduce Complexity Skills/Ability Demands/Complexity Slide by Ruth Parker, MD

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Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Care Model

Key Drivers For Improving Outcomes Improve written communication Improve spoken communication Improve self-management and empowerment Improve supportive systems

Improving Written Health Information Most materials written well above the average literacy of the population Guidelines available for better clear written health information We know better materials can improve knowledge and help start behavior change Materials rarely stand alone

Yin HS, et al. Arch Ped Adol Med. 162: ; 2008.

P<0.001

Improving Spoken Communication 13

Understanding Clarify Assess Explain Teach-back 12

Teach to Goal Ensure mastery of content before stopping the teaching Build in reinforcement over time (we all forget or have drift in our understanding) Know what you want the patient to master! 11

Mean self-care scores (95% CI) at Baseline () and 1-month follow-up ( ■ ) J Card Fail Oct;17(10):

Mean heart failure symptom score (95% CI) at baseline () and 1-month follow-up ( ■ ) J Card Fail Oct;17(10):

Improving Self Management and Empowerment 8

Brown Bag Medication Review 7

Verify what the patient is taking Identify and/or avoid medication errors and drug interactions Assist the patient to take medications correctly Answer the patient's questions 6

Brown Bag Medication Review Success to Brown Bag Review 1.Patient is asked to bring in their medicines. Set expectations. 2.Patient brings medicines to appointment. 3.Provider/staff reviews the medicines with the patient. Reinforce adherence. 5

Biggest Barriers Getting patients to bring in their medicines Practices would set up a system but would not stick with it or modify it if it was not working 4

What have we learned about implementation? Gotta have a team Win hearts and minds Start with practice assessment Take the long view (still haven’t seen Pop- Tart® results) 3

You Can’t make a REAL Patient Centered Medical Home without Health Literacy Culturally and linguistically appropriate services Training care teams to coordinate care, provide support in self-management, and in communication skills Treatment goals reviewed and updated Follow up with no-shows Assess patient/family understanding of medications Assesses barriers to adherence Develops and documents self-management plans Maintain resource list Offers health education and peer support Obtains feedback on patient experience Sets goals that address disparities in care 2

Perfecting the Dismount Like a gymnast, takes lots of work Practice until the system is reliable Keep the end in mind (productive interactions!) Everyone is accountable (this isn’t just for some members of the practice, it is a team sport)