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 For Providers: How Does Clear Health Communication Affect Your Practice – Tips for Enhancing Patient – Provider Communication

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. 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

8. 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

9. 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.

10. 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.

11. 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

12. Finding a Solution

13. Solutions: Focus on Care Providers and Materials Agree that focusing on the patient-provider relationship would provide the most immediate and impactful solution to the issue of low HL –2/3 feel that low HL is driven by poor patient/doctor communication Believe that providing easy-to-understand health information is key Healthcare Thought Leaders: Source: A National Survey of Health Industry Influencers and Change Agents, KRC Research and Consulting, April 2002

14. 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

15. 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

16. 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

17. 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

18. 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 Create an Environment of TRUST 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

19. Reaching the Solution Best Opportunity for Immediate Impact Enhance Patient-Provider Communication Focus on Clear Health Communication What Needs to Be Done Improve the Patient-Provider Relationship Best Way to Do It

20. Finding a Solution The Partnership for Clear Health Communication

21. Reaching a Solution The Partnership for Clear Health Communication is a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomes Introducing the Partnership for Clear Health Communication

22. Partnership: Steering Committee Members Consumer Organizations American Federation of Aging Research California Health Literacy Initiative National Coalition for Literacy National Council for La Raza National Alliance for Caregiving ProLiteracy Health Worldwide Provider Organizations American Medical Association Foundation American Nurses Association American Pharmaceutical Association David Baker, MD – Northwestern School of Medicine National Medical Association National Alliance for Hispanic Health Thought Leaders American Public Health Association Janet Ohene-Frempong, President, JO Frempong and Associates National Health Council Partnership for Prevention Pfizer Inc (member and convener)

23. Purpose – Advance the Health Literacy issue, gain critical mass, leverage credibility and drive through the grass roots Who – Nationally recognized organizations with local membership experienced in building and leading coalitions, representing a broad range of constituencies in research, policy and service delivery What – Develop and execute a prioritized and coordinated Health Literacy Action Agenda to drive: Awareness/education, solutions/tools, advocacy, policy, research and evaluation Shared Interest in Improving Health Outcomes Partnership for Clear Health Communication

24. National Action Agenda Conduct an active advocacy program to increase support for health literacy policy and funding Expand awareness and educate patients and providers Develop and apply practical solutions to improve patient-provider communication, and motivate the healthcare system to adopt them Conduct nationally coordinated research and evaluation to define the health literacy issue and evaluate solutions

25. Finding a Solution

26. The Partnership’s First Solution Addresses the highest priority Action Agenda items –Awareness and education Creates a compelling solution and 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

27. 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

28. 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 For Providers Health Care Providers Want Patients to Know:

29. 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

30. 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

31. Ask Me 3 – Program Materials Available in English and Spanish Patient Brochure Organizational Brochure Website Posters Provider Brochure

32. 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!

33. 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

34. 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

35. Ask Me 3 – For Providers Element: Organization brochure Description: –Explains the scope and impact of low health literacy –Provides ideas and complementary roles in advancing health literacy Implementation: –Distribute to partner/ affiliate organizations

36. 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

37. How to Become Involved Solutions Into Action

38. 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

39. 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

40. How Can Your Organization Become Involved? Visit www.clearhealthcommunication.org. It has background information and tools on Health Literacy/Clear Health Communicationwww.clearhealthcommunication.org To Understand the Issue To Know What Percentage of Your Practice Is Affected Use the prevalence calculator – gives the approximate percentage of patients at risk of low health literacy in a physician’s practice

41. How Can Your Organization Become Involved View the webcast at www.AskMe3.orgwww.AskMe3.org Conduct an in-service training on health literacy Include an article on the scope and impact of health literacy and the solutions in your newsletter and on your web site To Educate Your Staff To Educate Your Patients Download or order the materials you need to start acting on Clear Health Communication at www.AskMe3.org and display themwww.AskMe3.org Request a speaker to speak to a group of your patients by calling 1-877-4-ASK-ME-3

42. How Can Your Organization Become Involved? Join the Partnership for Clear Health Communication. Sign up as a member at www.AskMe3.org. Adopt the Action Agenda within your own workwww.AskMe3.org Learn how to create easy to read materials using the Pfizer Principles for Clear Health Communication – available at www.clearhealthcommunication.org www.clearhealthcommunication.org Dedicate a section or panel to health literacy at your next convention or meeting. Request a speaker by calling 1-877-4-ASK-ME-3 To Become Actively Engaged To Advocate for CHC Share your concern about low health literacy and Ask Me 3 with your state legislators, congressional representatives and senators and advocacy groups in which you participate

43. For Providers: How Does Clear Health Communication Affect Your Practice? Tips for Enhancing Patient – Provider Communication

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. The Practical Solution: