1. Health Literacy Paul D. Smith, MD, Associate Professor UW Department of Family Medicine Paul.Smith@fammed.wisc.edu Why it’s important and what you can do about it.

2. Topics today General literacy and health literacy information Why it matters What you can do about health literacy

4. Literacy skills

5. What is Literacy? National Assessment of Adult Literacy (NAAL 2003) “Using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential.”

6. What is Literacy? Literacy is a combination of skills: Verbal Listening Writing Reading

7. More than just reading grade level Prose Literacy Written text like instructions or newspaper article Document literacy Short forms or graphically displayed information found in everyday life Quantitative Literacy Arithmetic using numbers imbedded in print

8. What is Health Literacy? The Institute of Medicine 2004 “The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”

9. What is Health Literacy? The Institute of Medicine 2004 “The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”

10. What is Health Literacy? The Institute of Medicine 2004 “The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”

11. Literacy VS Health Literacy Almost everyone will have difficulty with health literacy at some point. Much harder for those that do not: Read very well. Speak English as their primary language.

12. Two Sides to the Equation It’s all about effective communication Verbal Written Multi-media It has to be presented in a way that is understandable to most people.

13. In Their Own Words Insert video clip here

14. 2003 National Assessment of Adult Literacy Data released 12/05 ~17,000 people participated Over age 15 Living in households and prisons

15. 2003 National Assessment of Adult Literacy 4 categories of literacy Below basic Basic Intermediate Proficient

16. 2003 National Assessment of Adult Literacy Below Basic literacy – one piece of information Can: Sign name on a document Identify a country in a short article Total a bank deposit slip

17. 2003 National Assessment of Adult Literacy Below Basic literacy – one piece of information Cannot: Enter information on a social security card application Locate an intersection on street map Calculate the total cost on an order form

18. 2003 National Assessment of Adult Literacy Basic literacy – two related pieces of information Can: Identify YTD gross pay on a paycheck Determine price difference between tickets for 2 shows

19. 2003 National Assessment of Adult Literacy Basic literacy – two related pieces of information Cannot: Use a bus schedule Balance a check book Write a short letter explaining error on a credit card bill

20. 2003 National Assessment of Adult Literacy 43% 34% 55% 34-55% of adults are at below basic and basic literacy levels

21. 2003 National Assessment of Adult Literacy NAAL health literacy assessment 28 questions specifically related to health 3 clinical 14 prevention 11 system navigation

22. NAAL Health Literacy Assessment Entire population Proficient 12% Intermediate53% Basic 22% Below basic 14%

23. NAAL Health Literacy Assessment Basic and Below Basic Health Literacy Entire population 36% White 28% Native Americans 48% Blacks 58% Hispanics 66%

24. NAAL Health Literacy Assessment Basic and Below Basic Health Literacy Age16-64 28-34% Age 65+ 59%

25. NAAL Health Literacy Assessment Basic and Below Basic by education level In High School, GED or HS grad 34-37% Less than/some High School 76%

26. NAAL Health Literacy Assessment Basic and Below Basic by Self-reported health status Excellent 25% Very Good 28% Good 43% Fair 63% Poor 69%

27. The Impact of Low Literacy on Health  Poorer health knowledge  Poorer health status  Higher mortality  More hospitalizations  Higher health care costs

28. Poorer Health Knowledge  Understanding prescription labels  395 patients  19% low literacy (6 th grade or less)  29% marginal literacy (7-8 th grade)  52% adequate literacy (9 th grade and over)  5 prescription bottles Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

29. Poorer Health Knowledge  At least one incorrect  63% low literacy  51% marginal literacy  38% adequate literacy Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

30. Poorer Health Knowledge “Take two tablets twice daily” Stated correctly Demonstrated correctly 71% low literacy 35% 84% marginal literacy 63% 89% adequate literacy 80% “Show me how many pills you would take in one day.” Counted out 4 tablets-correct

31. Poorer Health Status Diabetics with retinopathy 36% 19%

32. Increased Mortality  Age 70-79  2512 participants  Reading level 8 th grade or less  Five Year Prospective Study Sudore R, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.

33. Increased Mortality Risk of Death Hazard ratio: 1.75

34. More Hospitalizations 2 year hospitalization rate for patients visiting ED 31% 14%

35. Increased Health Care Costs Data 2003 Medical Expenditure Panel Survey 2003 National Assessment of Adult Literacy Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007

36. Increased Health Care Costs Annual cost today: Future costs based on today’s actions (or lack of action): Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007 $106-238 Billion $1.6-3.6 Trillion

37. Low Literacy is Overlooked Patients do not volunteer their literacy problem Many are ashamed Some do not recognize their inadequate literacy Lack of trust

38. The Big Secret % of low literate adults that have not told their: Children52% Friends62% Spouse68% Health care providers75% Co-workers85%

39. More likely to have Low Literacy Older Less education Non-white

40. More likely to have Low Literacy Immigrants Immigrate after age 12 >50% Below Basic literacy level

41. More likely to have Low Literacy Low-income Medical Assistance Incarceration

42. You Can’t Tell by Looking Many below basic people don’t fit the stereotypes 75 % born in USA 50% are white 40% hold full or part time jobs

43. A New Cause for Non-Compliance? Medications No-shows Testing Referral

44. New Joint Commission Standards Effective communication Cultural competence Patient centered care http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A- 9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A- 9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf

45. New Joint Commission Standards Approved 12/2009 Will start evaluating compliance January 2011 Compliance included in accreditation decision no sooner than 1/2012

46. How do we fix this problem? Education Universal Design If it works for people with limited literacy or limited English skills, it will work for everyone.

47. Re-Designing What We Do Team effort In-service and new employee training Health literacy committee? Infuse health literacy concepts in new programs and redesign of current processes

48. Re-Designing What We Do Improved discharge process less re-hospitalizations Find, develop and use plain language materials MedlinePlus http://www.nlm.nih.gov/medlineplus/

49. Improve Verbal Communication SLOW DOWN Sit face to face Plain language, no medical jargon Simple diagrams

50. Check Understanding Teach back method “I imagine you’re really worried about this [diagnosis]. I’ve given you a lot of information. It would be helpful to me to hear your understanding about your [diagnosis] and its treatment.” Kemp E, et al. Patients Prefer the Method of “Tell Back-Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med 2008;21:24 –30.

51. The Difference One Word Can Make Ask the right question: Is there something else you want to address in the visit today? Is there anything else you want to address in the visit today? Reducing patients’ unmet concerns in primary care: The difference one word can make. Heritage j, et al. J Gen Int Med 2007:22;1429-1433.

52. Something VS Anything 280 patients, 20 clinicians, acute care visits Using “some” reduced unmet concerns by 78% Using “any” was no better than usual care No change in visit length

53. Group Exercise Pair up with a partner One starts as patient and one as doctor You have 5 minutes to explain key points about a new diagnosis of type 2 diabetes See handout for key points to discuss

54. Group Exercise Use “teach back” at end “Patient” stops conversation every time doctor uses medical jargon or other big words. Reverse roles after 5 minutes

55. Summary Low literacy is a common problem Low literacy affects health Effective communication is the key

56. What can YOU do? Be a catalyst for change

57. What can YOU do? Raise awareness Colleagues Leadership Friends Legislators

58. Learn More Health Literacy Summit April 12 – 13, 2011 Alliant Center, Madison, WI Health materials development workshop Pre-conference 4/10 -11

59. Learn More National Action Plan to Improve Health Literacy http://www.health.gov/communication/HLAction Plan/pdf/Health_Literacy_Action_Plan.pdf http://www.health.gov/communication/HLAction Plan/pdf/Health_Literacy_Action_Plan.pdf Health Literacy Universal Precautions Toolkit http://www.ahrq.gov/qual/literacy/

60. Learn More www.healthliteracywisconsin.org www.healthliteracymissouri.org Interventions to Improve Care for Patients with Limited Health Literacy Sudore R, Schillinger D. Journal of Clinical Outcomes Management. Jan 2009:16;20-29

61. What can YOU do? Change your own behavior Slow down Remove the jargon

62. What can YOU do? Something VS anything Check understanding

63. What can YOU do? Model effective communication Observe student/resident Give feedback about communication

64. Want a copy? Presentation Health literacy resources list Paul.Smith@fammed.wisc.edu

65. “Action expresses priorities.” “Be the change that you want to see in the world.” ---Mohandas Gandhi