Exploring the Business and Clinical Cases for Screening for Health Literacy in Primary Care: A Case Study Using the NVS Jonathan B. VanGeest, PhD School of Community Health and Policy Morgan State University Verna L. Welsh, PhD, MPH Rollins School of Public Health Emory University

Verna L. Welch, PhD, MPH, Rollins School of Public Health, Emory University (co-PI) Gregory Strayhorn, MD, Morehouse School of Medicine, Department of Family Medicine (co-I)

Overview 1.Define limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Overview 1.Define limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Health Literacy Is… “The degree to which individuals have the capacity to obtain, process, and understand basic health infor- mation and services needed to make appropriate health decisions.” -Healthy People 2010 Ability to perform essential health care tasks: – Understand appointment slips – Follow health instructions – Obtain information about an illness – Participate in discussions of informed consent – Enroll in health insurance plan

Not Simply a “Patient Problem” One with implications for quality shared by the provider, healthcare system, and community in partnership with the patient Implications for treatment as well as disease prevention/health promotion

Overview 1.Define the scope of limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Health Literacy Is Needed to Navigate Health “Systems” Most patient instructions are written Verbal instructions – Often complex – Delivered rapidly – Easy to forget in stressful situation Increasingly complex health system – More medications – More tests and procedures – Greater self-care requirements – Participatory/informed decision-making Disease prevention/health promotion messages

Outcomes Associated with Health Literacy Health Outcomes General health status Hospitalization Emergency department use Prostate cancer stage Depression Diabetes control HIV control Mammography Pap smear Pneumococcal immunization Influenza immunization STD screening Cost Behaviors Only Substance abuse Breastfeeding Behavioral problems Adherence to medication* Smoking* Knowledge Only Birth control knowledge Cervical cancer screening Emergency department instructions Asthma knowledge Hypertension knowledge DeWalt, JGIM 2004

Overview 1.Define the scope of limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Recommended Approaches for Health Care Providers Use simple, everyday language Stick to a 2-3 key points Draw pictures, write down key instructions for patients to take home Effectively solicit questions: “What questions do you have?” Ask patients to “teach-back” the main points to confirm understanding

Problems Most clinicians often unaware of patient’s health literacy Unable to tailor the clinical encounter to the needs of patients Often identified solely as a patient education issue

Patient Perspective Improve literacy Patient Education Empowerment in the clinical encounter – Ask Me 3

Problems Complexity – Health literacy in context Expert Authority Universal rather than targeted approach

Overview 1.Define the scope of limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Nurses Physicians Health Communication Training Patient AHL LHL Level of Health Literacy (Score) EMREMR Clinical Intervention AHL LHL Patient Outcomes Immed. Post 6 Mth. Post SurveySurvey EMREMR SurveySurvey EMREMR Improve Care Reduce Disparities

Identifying At-Risk Patients  A bilingual (English and Spanish) screening tool that identifies patients at risk for limited health literacy  Developed by Barry Weiss (University of Arizona)  Based on a nutrition label from an ice cream container

Process  Patient is given the label  Asked 6 questions about how they would interpret and act on the information  Responses are recorded by a clinical staff member, scored, and entered into the EMR  Based on the number of correct responses, the health care provider can assess the patient’s health literacy level

Overview 1.Define the scope of limited health literacy 2.Discuss the role of health literacy in health care, outcomes, and disparities 3.Discuss approaches to improve care for at-risk patients 4.Outline clinical intervention to improve care for patients with limited health literacy 5.Study outcomes

Outcomes – Patient Characteristics

Outcomes – Health Literacy At-risk for Limited Health Literacy  Physicians were not identifying at-risk patients or using recommended communication practices

Outcomes – Patient Reaction  Patients’ Reactions to Screening  Over 95% of patients did not have problems with screening for health literacy in primary care.  No difference in the reported prevalence of shame (p<0.33) by literacy level (Fisher’s Exact Test)

Outcomes – Patient Reaction  Patient Recommendations Regarding Screening (n= 135)

Outcomes - Patient  Fff

Outcomes – Business Case

Outcomes – Physician Utilization  Staff training increased awareness of the importance of health literacy and clear health communication  A majority (66.7%) also felt that using the NVS to identify patients with limited health literacy improved their quality of care they were able to deliver

Outcomes – Physician Utilization  Over 60% also felt that scores helped in customizing their communication with patients  Observed tendency to revert back to their normal – pre-intervention – care processes and behaviors