1. Greater Hudson Valley Family Health Center Health Literacy

2. Health Literacy QI Project Background Health literacy is a problem that has been addressed by our nursing staff. The nurse’s noticed a trend of patients returning to the facility not understanding the instructions given to them during their last visit. Results on patient satisfactory survey. 15% reported they needed help completing survey. Baseline: 0% on 2007 HIVQUAL results.

3. Health Literacy QI Initial Project Goal Goal One: ◦ Assess the effectiveness of discharge plan (to support patient understanding of their HIV status, medication and appointment schedule) by using teach back method. Patient will read back information on discharge plan to nurse or patient advocate. Goal Two: ◦ 50% of our total case load will have a health literacy assessment completed by September 2009.

4. Health Literacy QI Project Team Members Internal Medicine Providers. Internal Medicine Nurses. Internal Medicine Receptionist. Patient Advocate. Program Director. QI Coordinator. QI Specialist.

5. Plan QI project goal one. Discharge form. A nursing discharge form (teach back) was developed and presented to the HIV CQI sub-committee, CQI committee and CAB. Nursing discharge form was approved for testing.

6. Discharge Form

8. QI project goal one Test one 4 patients were identified to try the nursing discharge form. 1 provider and 1 medical assistant tested the discharge form with the four patients. Do Results/Study QI project Goal One Test One 2 Patients did not require teach back. 2 patients did not receive teach back due to time constraint. ◦ Nurse had to see another patient before teach back, thus original patients left. Nurse & Provider stated that the new form increases their workload & form adds more time to total visit time. Patient feedback: useful and easy to read.

9. Act QI project goal one Test one Develop new process & re-implement Tuesday, September 23 rd 2008 (QI project goal one, test two). Provider will continue to fill-out HIV status and medication portion of discharge form. Nurse will continue to use discharge form to conduct teach back.

10. Plan QI project goal one. Test two New process initiated: ◦ Nurse completes patient name, provider name and date of previous labs. ◦ Provider discusses and completes the discharge form. ◦ Provider indicates teach back. ◦ If teach back required, nurse conducts and documents teach back. Do QI project goal one. Test two 8 patients were identified. 2 providers and 2 medical assistants used the form. 7 of the 8 patients were seen as appointments.

11. Results/Study QI project goal one Test two No teach back was done. No feedback was received from patients. Nurses and Providers still state that form increases workload and visit time. Discharge forms were incomplete.

12. Act QI project goal one. Test two Nurse will no longer do teach back. Patient advocate will conduct teach back using the discharge form with patients. Next Step Choose assessment tool to begin trial test for QI project goal two. Use assessment tool to collect baseline data of 50% of the caseload and identify patients with low literacy.

13. Plan/Do QI project goal two. Literacy assessment Tool. Assessment tools were evaluated by HIV CQI committee. ◦ Food Label- assess a patient’s literacy based on their ability to read and understand a food label. ◦ REALM- assess a patient’s literacy based on their ability to read a list of medical terms. ◦ The TOFHLA was discussed but it is no longer an option since it needs to be purchased. Next Step Develop PDSA to test assessment tool. Discharge form modified to be used as a screening tool. ◦ Part one: patients will be asked to read information on the screening tool, which is written in a 4th grade reading level. ◦ Part two: patients will be asked to translate information from their HIV prescription bottle to the medication list on the screening tool.

14. Health Literacy Screen

18. Do QI project goal two. Screening tool will be introduced to staff during IM/HIV collaborative meeting for approval. Patient Advocate will test screening tool on 50% of the case load to collect baseline data. Screening tool will be administered during appointments and walk-in visits.

19. Results/Study 50% (60 patients) have been screened. 55% (33) of the patients screened have been identified with low literacy. Teach back will be done with those patients identified after every visit. Two patients did refuse. ◦ 1 patient refused due to pain management (screened during walk-in visit) ◦ 1 patient was newly diagnosed. Patient was still processing diagnosis but was willing to complete screening at a later date. Patient Advocate expressed concerns of confidentiality. Patients were being presented to patient advocate in the waiting area. ◦ In response to concerns of confidentiality, new process was initiated in which the Patient Advocate is called into the exam room when provider is finished with visit.

20. Results/Study Patient Advocate reports every patient had difficulty responding to question “what does it mean to have HIV?” on the health literacy screen. Per the patient Advocate 75-80% of the patients were not aware of pertinent lab values. Many patients would share they could not read the tool as they did not have glasses. Patient Advocate would read questions on health literacy screen and note response.

21. Act Next Step Remaining 50% of caseload will receive a health literacy screen. New patients will receive a health literacy screen during initial visit. Discharge form (teach back) will be utilized on patients identified with low literacy.