1. A UNIVERSAL PRECAUTIONS APPROACH TO IMPROVING CLINICAL COMMUNICATION. EMBEDDING HEALTH LITERACY INTO THE MEDICAL CURRICULUM: Debra Howenstine, MD Associate Professor of Clinical Medicine Family and Community Medicine University of Missouri-Columbia School of Medicine Stan Hudson, MA Associate Director Center for Health Policy University of Missouri-Columbia School of Medicine

2. UNIVERSITY OF MISSOURI-COLUMBIA Over the last four years the University of Missouri-Columbia School of Medicine has systematically reviewed the curriculum, developed educational goals, identified competencies that we want our students to achieve by graduation identified gaps in the curriculum We are currently working on curricular changes to address the gaps

3. The problem with communication is the illusion that it has occurred. 3 -- George Bernard Shaw

4. 4 Over three quarters of physicians (77%) believed patients knew their diagnosis; however, when asked, only slightly over half (57%) of patients actually did ( P.001). Nearly all physicians (98%) stated that they at least sometimes discussed their patients’ fears and anxieties, compared with 54% of patients who said their physicians never did this ( P=.001). Olson DP & Windish DM, Arch Intern Med. 2010;170(15):1302-1307

5. HEALTH CARE COSTS Individuals with limited health literacy skills make greater use of services designed to treat complications of disease and less use of services designed to prevent complications Patients with limited health literacy skills have greater rates of hospitalization and use of emergency services – higher costs Scott, et al. Med Care. 2002;40:395–404 Baker, et al. J Gen Intern Med. 1998;13:791–798 Baker et al. Am J Public Health. 2002;92:1278–1283 Gordon et al. Rheumatology. 2002;41:750–754 Howard et al. Am J Med. 2005;118:371–377.

6. HEALTH CARE COSTS Those with low health literacy have over four times higher average annual health care costs – $13,000 compared to only $3,000 for those with higher literacy levels (AMA Foundation “Health Literacy A Manual for Clinicians” ) Nationally is estimated to cost $238 billion annually - just over 10% of total US health care expenditures. (Vernon, et al. Low health literacy: implications for national health policy, 2007)

7. HEALTH LITERACY AFFECTS HEALTH OUTCOMES Health Literacy Health Outcomes Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004

8. EDUCATIONAL GOAL #7 MU SOM graduates will communicate clearly and effectively using plain language and verbal and non-verbal methods that facilitate patient understanding and improve health literacy.

9. TACCT TOOL FOR ASSESSING CULTURAL COMPETENCY TRAINING INITIALLY COMPLETED AUG 2011 AAMC TOOL MODIFIED TO INCLUDE HEALTH LITERACY AND SEXUAL ORIENTATION Not addressed Touched on IPC 1 Medical Interviewing IPC 2 Physical Exam IPC 3 psychocsocial IPC 4 Epidemiology IPC 5 Diagnostic Tests IPC 6 Psychotherapy and Behavioral Medicine IPC 7 Charting IPC 8 Balance, safety, Health Care system Child Health Internal Medicine Neurology OB/GYN Psychiatry Surgery Family Medicine Partners in Education M1 Orientation Addressed (depth or scope) Addressed (depth and scope) TACCT Domains A. Definition of Cultural Competence * Rational, B1. Definitions of Race * Context, and B2. Definition of Ethnicity Definition B3. Definition of Culture * C. Clinicians' self-assessment and reflection * * Key Aspects A. Epidemiology of Population Health of Cultural B. Patients' healing traditions and systems * * * Competence C. Institutional cultural issues * D. History of patient * * * Understanding impact of stereo-typing on med decision making A. History of Stereotyping * B. Bias, discrimination, and racism * * * C. Effects of stereotyping ** Health Disparities A. History of health-care discrimination * * and Factors B. Demographic patterns of disparities * ** * Influencing C. Factors underlying health-care disparities * *** * Health D. Collaborating with communities A. Differing values, cultures, and beliefs * * ** B. Dealing with hostility/discomfort * * Cross-Cultural C. Eliciting a social and medical history * * Clinical Skills D. Communication skills * ** E. Working with interpreters * ***** * F. Negotiating and problem-solving skills * G. Diagnosis and patient-adherence skills Cultural Competency with Sexual Orientation A. Definitions as they relate to sexual orientation * * *** B. Demographic patterns of disparities (related to sexual orientation) * * * * C1. Discuss sexual orientation in the medical interview * ** * * C2. Elicit information for understanding patient support systems * * * D. Describe own cultural background and bias (related to LGBTQ) * * E. Strategies for addressing biases in others * * F. Value curiosity, empathy, respect related to sexual orientation * * * * ** G. Recognize physician biases and stereotyping * * * * * * H. Recognize the physician patient imbalance * * * * * I. Describe systematic & medical encounter issues for LGBTQ pts * * * * Health Literacy A. Definitions of health literacy * * B. Demographic patterns of low/limited health literacy * C. Health literacy techniques such as teach back, flip-it, plain language, etc. * **** ** D. Recognize biases related to health literacy * * E. Motivational interviewing * F. Relationship-centered care

10. HEALTH LITERACY COMPONENTS ADDED TO TACCT Definition of Health Literacy Demographic patterns of low/limited health literacy Health literacy communication techniques Recognize biases related to health literacy Motivational interviewing Relationship centered care Universal communication precautions

11. HEALTH LITERACY TRAINING IN THE MEDICAL CURRICULUM 2011 Universal Communication Precautions was not in initial assessment

12. HEALTH LITERACY BEFORE AND AFTER CURRICULAR CHANGES 20112014

13. COMPLETING TACCT More of a process than a product Valuable as a tool for communication Facilitated development of ideas: Development of clerkship- specific plain language videos Use of teach back by medical students with all pts being discharged from ER

14. CHALLENGES TO CURRICULAR CHANGE: “Carving out” new time in an already full curriculum Hidden curriculum Can sabotage what is taught “What you do speaks so loudly that I do not hear what you say.” Faculty development is critical

15. OUR APPROACH TO CURRICULAR MODIFICATION Integrated and imbedded throughout the curriculum, not taught in isolation “Touch points” Provide: “Immunization” (taught early in the curriculum) “Boosters” (reinforced and modeled in clinical years) Developmentally appropriate progression

16. EDUCATIONAL COMPETENCIES FOR HEALTH PROFESSIONALS A consensus statement that outlines knowledge (24) and skills (27) that providers and students should know. Clifford A. Coleman, Stan Hudson & Lucinda L. Maine (2013) Health Literacy Practices and Educational competencies for Health Professionals: a Consensus Study, Journal of Health Communication, 18:Sup 1, 82-102 We used these as the basis for developing 5 specific competencies which we used to guide the content to be covered in the curriculum. (listed at end of presentation). See uploaded information from Lecture/discussion LO2a

17. CONTENT TO BE COVERED: Importance of health literacy Involves both the system and the patient Health literacy is contextual All interactions at risk: universal precautions approach

18. CONTENT TO BE COVERED: Health Literacy Communication Techniques: Plain language Focus on 2-3 important messages Teach back Chunk and Check Importance of a shame free approach Actively encourage patient questions

19. COMMON DEFINITION Health literacy is the degree to which people have the capacity to: Obtain, process, and understand basic health information and services Make appropriate healthcare decisions (act on information) Access/ navigate healthcare system Derived from the definition of health literacy in The Institute of Medicine: A Prescription to End Confusion.

20. A MORE INCLUSIVE DEFINITION Health literacy also includes the degree to which the system provides adequate support to allow people to have the capacity to: Obtain, process, and understand basic health information and services Make appropriate healthcare decisions (act on information) Access/ navigate healthcare system Derived from the definition of health literacy in the Institute of Medicine, A Prescription to End Confusion.

21. Patient/Caregiver Skills Complex System Demands Health Literacy

22. EXAMPLES OF HOW HEALTH LITERACY IMPACTS HEALTH OUTCOMES: MEDICATION ERRORS 46% did not understand instructions ≥ 1 labels 38% with adequate literacy missed at least 1 label Davis TC, et al. Annals Into Med 2006

23. “SHOW ME HOW MANY PILLS YOU WOULD TAKE IN ONE DAY? John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill

24. READING VS. COMPREHENSION In a study of adults with literacy below the 6 th grade level: 71% correctly read the instruction to “take two tablets by mouth twice daily” Only 35% could demonstrate the number of pills to actually take (Davis et al, 2006)

25. A communication strategy which assumes that all health care encounters are at risk for communication errors, and aims to minimize risk for everyone (DeWalt et al, 2010)

26. ● Everyone benefits from clear information. ● Many patients are at risk of misunderstanding, but it is hard to identify them. ● Testing general reading levels does not ensure patient understanding in the clinical setting. Universal Communication Principles Adapted from: Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. AMA, 2007

27. 1.Use plain language and analogies 2.Focus on the 2 or 3 most important “need to know” and start with these 3.Check for understanding using a “teach back” method Proven Clear Communication Techniques

28.  “Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on the strength of scientific evidence.” AHRQ, 2001 Report, Making Health Care Safer Teach-back is Supported by Research

29. HEALTH LITERACY IS DYNAMIC Health literacy is highly contextual A state not a trait Health literacy demands change over time based on the setting and circumstance Most individuals will encounter health literacy barriers at some point in their life. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004

30. STRATEGIES FOR TEACHING HEALTH LITERACY Lectures (two) Modeling Role-playing/simulated patients Revised evaluation tools looking at HL techniques Required reading Handout of teach back “scripts” Using existing videos to develop a “video library” Developing our own videos targeted to specific curricular needs

31. TEACH BACK SCRIPTS  “I want to make sure that I explained everything clearly. Can you explain back to me in your own words …”  “I want to make sure that I did a good job of explaining this to you because it can be confusing. Can you tell me what changes we decided to make and how you will take you medicine when you get home?  “I know we talked about a lot of things. Your wife wasn’t able to be here with you today. When she asks what we talked about, what are you going to tell her?”

32. EXAMPLES OF ADDITIONS TO EXISTING CURRICULUM Video explaining Guillain Barre in plain language complementing the study of GBS in another part of the curriculum (3 min). Short role model using plain language at the end of several lectures. Addition of health literacy component to the written evaluations for already existing student role plays.

33. EXAMPLES OF ADDITIONS TO EXISTING CURRICULUM Family Medicine Clerkship: Adding teach-back to a role play utilizing language interpreters. Embedding a role play using HL techniques into lectures addressing HTN and dyslipidemia (modeled by one student and faculty lecturer) Hand out of scripts checking for understanding /teach back

34. EXAMPLES OF ADDITIONS TO EXISTING CURRICULUM Family Medicine and Internal Medicine clerkships added “PLOGS” about health literacy Simulated patient encounter on use of a metered dose inhaler for asthma management-added a health literacy component Internal medicine clerkship modified a simulated pt encounter to involve teach back and other communication techniques at hospital discharge

35. VIDEOS: PLAIN LANGUAGE/JARGON Wilson Countersink Flanges. Saturday Night Live skit demonstrating the importance of plain language (1 min) http://www.hulu.com/watch/277081 Rockwell Retro Encabulator – Another non- medical look at the importance of plain language. An earlier version of the SNL video (2 min) https://www.youtube.com/watch?v=RXJKdh1KZ0w

36. VIDEOS: PATIENT STORIES HEALTH LITERACY CHALLENGES American College of Physicians (ACP) Health literacy video (6:27 min) Patient testimonials and overview. https://www.youtube.com/watch?v=ImnlptxIMXs AMA video on health literacy (22 min long) Filmed with same patients and providers used in the 6:27 min ACP video with additional basic guidelines for improving health literacy with your patients https://www.youtube.com/watch?v=cGtTZ_vxjyA

37. VIDEOS DEVELOPED BY THE UNIVERSITY OF MO-COLUMBIA SOM Limited-Access YouTube links: Plain Language and Analogies (4 min) https://www.youtube.com/watch?v=JPdd6uRB_ks Ways to ask for teach back/clarify understanding (1:50) https://www.youtube.com/watch?v=loBcRosW8Wc Focus on the 2-3 most important messages: what the patient needs to know/needs to do https://www.youtube.com/watch?v=bEnMCa9jOGQ

38. VIDEOS DEVELOPED BY THE UNIVERSITY OF MO-COLUMBIA SOM Teach Back with Patient Interaction (5:17 min) https://www.youtube.com/watch?v=UKaow6P7RR4 Plain Language: Diagnosis of Guillain Barre (3:01 min) https://www.youtube.com/watch?v=D3p5RHFMaR4& feature=youtu.be

39. https://www.youtube.com/watch?v=loBcRosW8Wc Ways to ask for teach back/clarify understanding

40. DEVELOPMENT OF VIDEOS FOR YOUR OWN CURRICULUM Benefits: Can be tailored to specific curriculum needs Students see faculty they know modeling the desired behavior Ability to edit is helpful

41. DEVELOPMENT OF VIDEOS FOR YOUR OWN CURRICULUM Identify content to cover Easiest if faculty have skills in health literacy If not can serve as a training exercise if feedback can be given and received. Scripts of key phrases may be helpful.

42. https://www.youtube.com/watch?v=D3p5RHFMaR4&feature=youtu.be Plain language explanation of Guillain Barre (3 mi)

43. http://www.ahrq.gov/professionals/quality-patient-safety/quality- resources/tools/literacy-toolkit/impguide/healthlit-guide.pdf HEALTH LITERACY UNIVERSAL PRECAUTIONS TOOLKIT

44. HEALTH LITERACY IOWA: ALWAYS USE TEACH BACK Health Literacy Iowa Always Use Teach Back Tool Kit Includes links to several helpful videos and has a teach back module The module takes about 45 minutes and enables you to identify and practice key aspects of health literacy following a patient from hospital to discharge through home health and primary care settings. http://www.teachbacktraining.org

45. Debra Howenstine, MD Associate Professor of Clinical Medicine Family and Community Medicine University of Missouri-Columbia School of Medicine howenstined@health.missouri.edu Stan Hudson, MA Associate Director Center for Health Policy University of Missouri-Columbia School of Medicine hudsonst@health.missouri.edu Questions?

46. HEALTH LITERACY COMPETENCIES: 3. Routinely checks patient understanding of medical advice/instructions and corrects misunderstandings using the teach-back or “show-me” method. 4. Assists patients in overcoming navigational and informational barriers within the health care system.

47. HEALTH LITERACY COMPETENCIES: 5. Routinely uses short action-oriented statements, which focus on one to three “need-to-know” or “need-to-do” concepts during any given oral or written communication with patients.

48. HEALTH LITERACY COMPETENCIES: 1. Adopts a “universal precautions” approach to information exchange with all patients. 2. Demonstrates an ability to translate jargon and complex medical explanations into layman’s terms, providing everyday analogies and words that directly relate to the patient’s cultural background in a slow and clear manner.