Health LiteracyImproving Communication Between Health Care
Professionals and Older Adults
Jermarx Marsh MBAGuest Relations Manager
Hurley Medical Center
Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a).
Learning Objectives1. Define health literacy.
2. Recognize the impact of health literacy on an individual’s health and quality of life.
3. Identify strategies health care professionals may utilize to assess the ability of adults and family members to understand health information.
4. List techniques to implement processes in clinical practice to improve health literacy and the individual’s ability to make informed choices regarding their health outcomes.
Definition: Health LiteracyClients/Patients:
• Education/ Literacy/ Language
Health Literacy:
Capacity to
• Obtain, process, understand basic health information and services
• Make appropriate healthcare decisions (act on information)
• Access/ navigate healthcare system
IOM Report on Health Literacy• 90 million adults have trouble understanding
and acting on health information
• Health information is unnecessarily complex
• Providers need health literacy training
Healthy People 2010• Improve health communication/health literacy
Joint Commission (1993)• Patients must be given information they
understand
Factors that contribute to low health literacy
• General literacy• How information is communicated• Complexity of the health care system• Age, culture, language• Illness, emotions, hearing, vision, cognition
Implications of poor health literacy
• Inadequate health knowledge• Poorer health outcomes• Lower health status• Medical miscommunications• Increased medical costs• More hospitalizations
“As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve.
Health care professionals do not recognize that patients do not understand the health information we are trying to communicate.
We must close the gap between what health care professionals know and what the rest of America understands.”
Dr. Richard Carmona,Former U.S. Surgeon General
mentioned health literacy in 200 of last 260 speeches
2003 National Adult Health Literacy SurveyScored on 4 levels:
• Below Basic: Very concrete literacy activities
• Basic: Simple, everyday literacyactivities
• Intermediate: Moderately challenging literacy
activities
• Proficient: Complex and challenging literacyactivities
2003 National Adult Health Literacy Survey: Health Literacy Proficiency Level
Age 65+0
5
10
15
20
25
30
35
40
2930
38
Below Basic Basic Intermediate
Perc
ent
Only 3% of adults age 65+ have ‘proficient’ health literacy
Red Flags for Low Literacy• Frequently missed appointments
• Incomplete registration forms
• Non-compliance with medication
• Unable to name medications, explain purpose or dosing
• Identifies pills by looking at them, not reading label
• Unable to give coherent, sequential history
• Ask fewer questions
• Lack of follow-through on tests or referrals
MEET PATIENTS DISCUSSING THEIR HEALTH LITERACY EXPERIENCES
AMA Foundation: http://www.youtube.com/watch?v=cGtTZ_vxjyA
Strategies to Enhance Health
1. Improve communication with patients
2. Reduce barriers to care by creating a patient centered environment
Mismatched Communication
Provider Process: Giving informationPatient Process: Understanding, remembering, and acting
on information
We expect more from patients Prevention (eating, exercise, sunscreen, dental) Immunization Self Assessment of Health Status
w Peak flow meter w Glucose testing
Self-treatmentw Insulin adjustments
Health Care Usew When to go to clinic/ER
w Referrals and follow-up
w Insurance/ Medicare
Process is Becoming More Complex
Patient’s continuum
of confusion
Pre-visitScheduling the
appointmentPre-visit
Visit reason, obtain
records, directions
In office, PPRegistration,
new forms,
insurance
In office, PPProblem, health
status, history
See ProviderMed list, sources of care
With ProviderAdjust/Add med, newTests or referrals
See EducatorPamphlets,
charts, videos
CheckoutNew tests, samples,
instructions
CheckoutSchedule f/u,
referrals, insurance,
billing
Health Literacy and Patient Safety: AMA Foundation, 2007
PP – Prior to seeing physicianED – Emergency DepartmentF/U – Follow upHCP – Health care professional
• 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
Patient Safety: Medication Errors
‘Show Me How Many Pills You Would Take in 1 Day’
Slide by Terry Davis
Rates of Correct Understanding vs. Demonstration ‘Take Two Tablets by Mouth Twice Daily’
0
20
40
60
80
100
Low Marginal Adequate
Corr
ect (
%)
Patient Literacy Level
Understanding
Demonstration
7180
89
63
84
35
Davis TC , et al. Annals Int Med 2006
Lessons Learned From Patients• Tell me what’s wrong (briefly)• What do I need to DO & why• Emphasize benefits (for me)
If meds, break it down for me:
1. What it is for
2. How to take (concretely)
3. Why (benefit)
4. What to expect
Remember: what’s clear to you is clear to you!
Focus on ‘Need-to-know’& ‘Need-to-do’
What do patients need to know/do…?
• When they leave the exam room• When they check out• What do they need to know about?
• Taking medicines• Self-care• Referrals and follow-ups• Filling out forms
Strategies to Improve Patient Understanding
• Focus on ‘need-to-know’ & ‘need-to-do’• Demonstrate/ draw pictures• Use clearly written education materials • Use ‘Teach Back’
‘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
Understanding
Clarify
Assess
Explain
Teach-back
Confirm patient understanding
“Tell me what you’ve understood”
“I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine?”
Do you understand?
Do you have any questions?
Patient Education: What We Know• Written materials alone do not adequately inform• Patients prefer key messages from their clinician with
accompanying pamphlets• Focus on “need-to-know” & “need-to do”• Patients with low literacy ask fewer questions• Bring family member and
medication to appointment
IOM: Report on Health Literacy 2004 Berkman et al. AHRQ Report 2004
Visuals Improve Understanding/ Recall
Pictures/demonstrations most helpful to patient with low literacy & visual learners
Most health drawings too complicated
Physician drawings often very good (not too complex)
Patients say “show me” & “I can do it”
7 Tips for Clinicians
• Use plain language
• Limit information (3-5 key points)
• Be specific and concrete, not general
• Demonstrate, draw pictures, use models
• Repeat/Summarize
• Teach-Back (Confirm Understanding)
• Be positive, hopeful, empowering
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
Examples of Plain Language
Annually Arthritis Cardiovascular
Dermatologist Diabetes Hypertension
• Yearly or every year• Pain in joints• Having to do with the heart• Skin doctor• High sugar in the blood• High blood pressure
Plain Language
The Plain Language Thesaurus for Health Communications
http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf
Is your site patient-centered?What is the ‘tone,’ 1st impression?
• Welcoming, calm environment• Attitude of helpfulness by all staff• Patients treated as if your family• Patient-centered check-in
& scheduling • Easy-to-follow instructions/
directions• Patient-centered handouts• Brief telephone follow-up• Case management
In Summary:• Looking back, have there been instances when you
suspected, or now suspect, that a patient might have low literacy? What were the signs?
• Do you do things in your setting that make it easier for patients with low literacy to understand services and information?
• What strategies could all of us adopt to minimize barriers and misunderstanding for low literacy patients?
ResourcesCheck how well you are doing in addressing health
literacy issues for older adults at
http://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.html
Older Adults: Designing Health Information to Meet their Needs
Are You Communicating Effectively with Older Adults?
POGOE (Portal of Geriatric Online Education,) University of Arizona College of Medicine, “Health Literacy and the Older Adult” (web-based interactive module)http://healthlit.fcm.arizona.edu/
Resources
Ohio State University “Health Literacy Distance Education Program”
http://healthliteracy.osu.edu/modules
Resources
The Health Literacy Environment of Hospitals and Health Centers: Partners for Action: Making Your Healthcare Facility Literacy Friendly
Rima Rudd & Jennie Anderson Harvard School of Public Health (2006)www.hsph.harvard.edu/healthliteracy
Resources
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