Improving Patient-Provider Communication: Needs & Strategies
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Transcript of Improving Patient-Provider Communication: Needs & Strategies
Improving Patient-Provider Communication: Needs &
Strategies
The Ethics of Effective Communication in Healthcare Conference
October 7, 2011Diane L. Smith, Ph.D., OTR/L, FAOTA
Chair & Assistant ProfessorUniversity of Missouri Department of Occupational Therapy
Stan HudsonAssociate Director
University of Missouri Center for Health Policy
Objectives
Participants will be able to: Understand the concepts of health literacy and plain
language Importance to healthcare and the patients we serve Relationship to quality assurance for vulnerable populations
Learn techniques to evaluate professional/patient interaction to determine health literacy level
Learn how to develop interventions to improve patient understanding of information provided
“Be careful about reading health books.You may die of a misprint.”
Mark Twain
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.
EPE Research Center (2008). “Cities in Crisis”
MO high school dropout rate is 25%.U.S. rate is 30%.
Health Literacy Levels Are 4 to 7 Grades Below the Highest Grade Completed
The Problem With Communication Is the Illusion That It Has Occurred
7
-- George Bernard Shaw
• 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
The Health Literacy Gap
Complexity & Demands of Health and the Healthcare System
Individual Skills & Abilities
Solutions must provide adequate support to address
all gaps!
Patient-Centered Care Gaps
Common Definition - RevisitedHealth literacy also includes the degree to which the system provides adequate support to empower 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.
“non-compliant” patients/families?
or
“in-effective communications”?
What makes it complicated? The vocabulary and concepts in medicine Patients & providers from different cultures Health care is disjointed Competing sources of health information
Media, Internet Patients often see numerous doctors and
professionals who can provide the patient with conflicting and even contradictory information
Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004
MO HealthNet ApplicationEligibility App
Application for TARP Capital Purchase Program - Bank bailout
Making the case - the moral imperativeEdmund D. Pellegrino, MD
The nature of illness itself makes medicine a special kind of human activity. The sick person is uniquely dependent, vulnerable, and exploitable.
It is this fundamental vulnerability of the patient and the need for trust in the healing relationship that constitutes the moral imperative for the physician to serve the patient with the patient's best interest in mind.
Second, the physician's knowledge is not proprietary. It is acquired through the privilege of a medical education. Society sanctions certain invasions of privacy………
The physician's knowledge therefore is not private property. Nor is it intended primarily for personal gain, prestige, or power. Rather, the profession holds medical knowledge in trust for the good of the sick.
By accepting the privilege of medical education, physicians enter into a covenant to use their medical knowledge for the benefit of society.
Moreover, this covenant is acknowledged publicly when the physician takes an oath. The oath . . . is a public promise--a "profession"--that the new physician understands the gravity of his or her calling, promises to be competent, and promises to use that competence in the interests of the sick.
It is these 3 aspects--the nature of illness, the nonproprietary character of medical education, and the oath of fidelity to the patients' interests--that define medicine as a moral community and determine the ethical obligations of the individual physician and the profession as a whole.
Edmund Pellegrino
It is a professional obligation to obtain an authentic understanding of the patients that we serve
Health Literacy – the patient experience
Health literacy test? TOFHLA (22 minutes) S-TOFHLA (12 minutes) REALM NVS (Newest Vital Sign) Short screening questions
How often do you have problems learning about your medical condition because of difficulty understanding written information
How often do you have someone help you read hospital materials
How confident are you filling out hospital forms by yourself
Newest Vital Sign Label
Health Literacy Is Dynamic• Health literacy demands can change over
time and differ by setting and circumstance
Age (young adult vs senior citizens) Life event (birth of a child, stress at home) Medical condition (new diagnosis, chronic illness)
• Health literacy is highly contextual and reflects both sides of the interaction.
Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004
Dosing Instructions?
• Numerous ways to get it wrong
• Abbreviation not in dosage instructions
• Use of uncommon measures (drams, cc)
• Dssp?
Universal Precautions
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)
● 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 HealthCare Environment. AMA, 2007
Health literacy is a stronger predictor of health status than age, income, employment status, education level, or racial and ethnic group
Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999
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. he National Academies Press; 2004
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 TL et al. Med Care. 2002;40:395–404Baker DW et al. J Gen Intern Med. 1998;13:791–798Baker DW et al. Am J Public Health. 2002;92:1278–1283. Gordon MM et al. Rheumatology. 2002;41:750–754Howard DH et al. Am J Med. 2005;118:371–377.
Health Literacy 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)
“
• 46% did not understand instructions ≥ 1 labels
• 38% with adequate literacy missed at least 1 label
“How would you take this medicine?” 395 primary care patients in 3 states
Davis TC , et al. Annals Int Med 2006
An Example: Medication Errors
“Show Me How Many Pills You Would Take in 1 Day”
John Smith Dr. Red
Take two tablets by mouth twice daily.
Humibid LA 600MG1 refill
Slide by Terry Davis
Reading vs. Comprehension
In a study of adults with literacy below the 6th 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)
Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth
Twice Daily”
7180
89
63
84
35
Davis TC , et al. Annals Int Med 2006
Communication is the Foundation of Patient-Centered Care
Engage in a dialogue with the patient Make scripts interactive
(Listen more and speak less) Encourage questions and support Understand and address the patient’s
concerns Ensure that the patient understands their
diagnosis and treatment options/planAmerican Medical Association Foundation & American Medical Association
Benefits of Addressing Health Literacy
Key element to providing patient-centered medical care
Compliance with new standards Culturally & Linguistically Appropriate Standards
(CLAS) – released by HHS Joint Commission Accreditation 2012
Preparation for payment reform (ACOs, pay for performance, medical home, etc.)
Use Plain Language20 complicated and commonly used words
• Dermatologist• Immunization• Contraception• Hypertension• Oral• Diabetes
• Annually• Depression• Respiratory problems• Community Resources• Monitor• Cardiovascular
• Diet• Hygiene• Prevention
• Referral• Eligible• Arthritis
• Screening • Mental Health
Provide Explanations in Common Language
Most patients do not take anatomy in school and have little exposure to medical terms
Use familiar, common, & everyday language. If possible, use the patient’s own words/vocabulary.
Use analogies that are relatable to the patient.
Patient Recall of Health Information Is Poor
Patients/Parents forget 40%–80% of what their doctor tells them as soon as they leave the office and nearly 50% of what they do remember is recalled incorrectly
The more information provided, the less a patient/parent is able to recall
Kessels RP. J R Soc Med. 2003;96:219–222
Focus on “Need-to-know” & “Need-to-do”
What do patients need to know/do…?• When they leave the exam room/check out• When they get home• What do they need to know about?
Taking medicines Self-care Referrals and follow-ups Filling out forms
Teach-back is…
● Asking patients to repeat in their own words what they need to know or do, in a non-shaming way.
● NOT a test of the patient, but of how well you explained a concept.
● A chance to check for understanding and, if necessary, re-teach the information.
Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003
Teach-Back: Closing the Loop
Teach-back Examples
Ask patients to demonstrate understanding,using their own words:
● “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?”
● “What will you tell your husband about the changes we made to your blood pressure medicines today?”
● “We’ve gone over a lot of information, a lot of things you can do to get more exercise in your day. In your own words, please review what we talked about. How will you make it work at home?”
“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
“Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.”Schillinger, Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”
Teach-back is Evidence-Based
‘Teach-back’ Improves Outcomes Diabetic Patients with Low Literacy
Audio taped visits – 74 patients, 38 physicians
Patients recalled < 50% of new concepts Physicians assessed recall 13% of time When physicians used “teach back” the
patient was more likely to have HbA1c levels below the mean
Visits that assessed recall were not longer
Schillinger, D. Archives of Internal Med, 2003
Teach-back – Additional Points
● Do not ask yes/no questions like: o “Do you understand?”o “Do you have any questions?”
● For more than one concept:o “Chunk and Check”
Teach the 2-3 main points for the first concept & check for understanding using teach-back…
Then go to the next concept
Teach-back – Using it Well:Elements of Competence
● Ethical responsibility is on the provider.● Use a caring tone of voice & attitude.● Use Plain Language.● Ask patient to explain using their own words (not
yes/no).● Use for all important patient education, specific to
the condition.● Document use of & response to teach-back.
Always try to:● Use plain language and analogies● Slow down and break down into short
statements.● Focus on the 2 or 3 most important need to
know and start with these.● Check for understanding using teach-back.
Health Literacy Strategies
AcknowledgementsMany slides were adapted from materials developed by:
• Karen Edison, MD• Andrew Pleasant, PhD• Darren DeWalt, MD, MPH • Terry Davis, PhD• Mary Ann Abrams, MD MPH
Thanks!For more information please contact:
Stan Hudson Center for Health Policy
[email protected](573) 884-7549
www.healthliteracymissouri.org