1. 1 Health Literacy: A Crisis In Health Care Minnesota Rural Health Conference July 19, 2005 Duluth, MN Developed by Stratis Health with the Permission of the American Medical Association Foundation and the American Medical Association

2. 2 Definitions General Literacy: “ An individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.” National Literacy Act of 1991 Health Literacy: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Healthy People 2010

3. 3 Implications of low health literacy on patient care 33% Unable to read basic health care materials 42% Unable to comprehend directions for taking medication on an empty stomach 26% Unable to understand information on appointment slip 43% Unable to understand rights and responsibilities section of Medicaid application 60% Unable to understand standard informed consent Williams et al., JAMA 12/6/95

4. 4 Cost of poor health literacy: Estimate >$50 billion annually* We all pay! 39% paid by Medicare (FICA taxes on workers) 17% paid by employers 16% paid by patients, out-of-pocket 14% paid by Medicaid 14% from other public and private sources *Estimated by National Academy on an Aging Society using 1998 figures

5. 5 National Adult Literacy Survey (NALS) Conducted in 1992 N=26,000 Most accurate portrait of literacy in the US Scored on 5 levels Not accounted for: Patients who have adequate language skills, but do not have adequate health literacy

6. 6 Results: National Adult Literacy Survey (NALS) (Kirsh I, Jungeblut A, 1993) Level

7. 7 NALS: Results 48%, or 90 million, US adults have inadequate or marginal literacy skills Does not account for patients who have adequate language skills, but do not have adequate health literacy Only 25% of those in Level 1 were new immigrants. Those at levels 1 and 2 did not necessarily perceive themselves as being ‘at risk’ (Kirsh I, Jungeblut A, 1993)

8. 8 Why are patients at risk? Reliance on written word for patient instruction Increasingly complex health care system More medications More tests and procedures Growing self-care requirements Esoteric language Aging population More culturally diverse patient population

9. 9 Understanding the problem What is it like? The following passage simulates what a reader with low general literacy sees on the printed page Read the entire passage out loud You have 1 minute to read (Hint: words are written backwards and the first word is “cleaning”)

10. 10 GNINAELC – Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-der edixo selcitrap. Esu a nottoc baws denetsiom htiw lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.

11. 11 Understanding the problem Hear a few examples from: “As Patients See It” A video created in 2003 by AMA Real patients and real physicians talking about literacy issues

12. 12 Mr. Day Diagnosed with hypertension Reads at second-grade level

13. 13 Mr. Bell Reads at fifth- grade level Gets agitated filling out paperwork

14. 14 Mrs. Cordell-Seiple Film maker Graduated from high school reading at a fifth-grade level Didn’t know she had undergone a hysterectomy

15. 15 What do we know? Low Health Literacy (LHL) is prevalent LHL leads to: Lower health knowledge and less healthy behaviors Greater health costs Poorer health outcomes Techniques and approaches may be used to address health literacy

16. 16 Three strategies I. Create a “shame-free” environment II. Improve interpersonal communication III. Use patient-friendly educational materials and forms

17. 17 Strategy: Create a shame-free environment Recognize red flags: “I forgot my glasses…” Incomplete forms Seeking help only when illness is advanced Convey an attitude of helpfulness, caring, and respect (by all staff): What is it like being a patient in your setting? Are there forms or instructions that could be confusing?

18. 18 Strategy: Improve interpersonal communication Slow down Use plain “living room” language Focus on key messages (www.askme3.org):www.askme3.org What is my main problem? What do I need to do? Why is it important for me to do this? Use “teach back” techniques

19. 19 Strategy II Improve interpersonal communication Mrs. Greigar (reads at third-grade level) Dr. Alvarez Slow down Use analogies Use plain “living room” language

20. 20 Strategy II (continued) Brown bag review Mrs. Tilsley reads at seventh-grade level Dr. Williams

21. 21 Strategy III Develop patient-friendly materials/forms Keep content concise and focused: Focus only on key points Emphasize what the patient should do Keep anatomy and physiology basic Show or draw simple pictures to enhance interaction

22. 22 Strategy III Tips for easy-to-read materials: Simple words (1-2 syllables) Short sentences (4-6 words) Short paragraphs (2-3 sentences) Limit medical jargon Use headings, bullets, and lots of white space

23. 23 What can you do by next week? 1.Explain things clearly in plain non-medical language/analogies. 2.Focus on the key messages using “Ask Me 3”. 3.Use a “teach back” or “show me” technique to check for understanding. 4.Use patient-friendly educational materials to enhance interaction. 5.Create a shame-free environment.

24. 24 What can you do in the future? Form a team to determine a long-term strategy Develop a plan to educate all staff about low health literacy Discuss methods for improving communication skills with providers and staff Do role play and/or identify key terms/messages commonly encountered in your practice Incorporate “Ask Me 3” components into patient information

25. 25 “Understanding is a two-way street.” Eleanor Roosevelt

26. 26 For more information: www.amafoundation.org www.askme3.org

27. 27 Karla Weng, MPH, CPHQ Project Manager (952) 853-8570 kweng@mnqio.sdps.org

28. 28 Brought to you by Stratis Health Minnesota’s Medicare Quality Improvement Organization Stratis Health is a non-profit independent quality improvement organization that collaborates with providers and consumers to improve health care. This presentation was created by Stratis Health under a contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy.