Health Literacy: An Education Module for Physician Assistants

Transcription

1 Health Literacy: An Education Module for Physician Assistants Billy Collins, MS, PA-C Antoinette Polito, MHS, PA-C Teaching Fellows Duke University Medical Center Physician Assistant Program

2 Health Literacy: Introduction Low health literacy affects nearly half of all American adults and costs the U.S. health care system almost 200 billion dollars annually It is important that health professionals have a basic understanding of health literacy and its influence on the delivery of patient care This module will discuss various aspects of health literacy including its impact on individuals, society, and the overall health care environment

3 Health Literacy: Module Objectives Upon completion of this module, you should be able to: Define health literacy Identify common concerns related to health literacy Describe low health literacy and its impact on society Review common health literacy assessment tools Formulate a plan to better communicate health information to patients in your practice

4 Health Literacy: Definition The American Academy of Physician Assistants (AAPA) defines health literacy as: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions The American Medical Association (AMA) further defines functional health literacy as: The ability to read prescription bottles, appointment slips and other essential health related materials required to successfully function as a patient

5 Health Literacy: Definition Health literacy also encompasses: the educational, social and cultural factors that influence the expectations and preferences of the individual, and the extent to which those providing health care services can meet those expectations and preferences Joint Commission Report

6 Who is Affected by Health Literacy Issues? Patients Providers Society at Large

7 Health Literacy Affects Us All

8 Video Courtesy of the Institute of Medicine Health Literacy Project Click link to watch video

9 Health Literacy is Our Concern Low health literacy significantly impacts our patients and our ability to care for them

10 Health Literacy: Do the Math 29% of Americans are below average in basic prose skills 22% are below average in basic quantitative skills 5% of Americans are non-literate in English Half the population has difficulty using text to accomplish everyday tasks 77 million Americans with limited health literacy $ billion lost annually by the health care system Healthy People 2010, Health Communication Technology (HRSA)

11 Health Literacy: Common Concerns Over 90 million people (nearly half of American adults) have limited health literacy Joint Commission Report Health literacy is a better forecaster of one s health status than age, income, employment, ethnicity, or education level AAPA

12 Health Literacy: Common Concerns Health literacy has a significant influence on the health and well being of the community Low literacy impacts the delivery and utilization of health care services Health professionals play an important role in delivering health information to the public Communication barriers impair the health worker s ability to effectively deliver health information

13 Health Literacy: Common Concerns Ineffective communication is the leading cause of adverse patient outcomes Joint Commission Report

14 Health Literacy: Common Concerns Health literacy is weakest among patients who report overall poor health The population most in need of health care is least able to read and understand information needed to function as a patient National Center for Education Statistics

15 Health Literacy: Common Concerns Health care providers rely on patients to be capable, motivated partners who share responsibility in the delivery of safe and effective care Joint Commission Report Patients are inadequately informed yet must perform self-care activities AHRQ

16 Health Literacy: Common Concerns A patient s health literacy skills are not typically evident during the health care encounter Patients mask their inadequacies Joint Commission Report

17 Health Literacy: Some Clues Patients may be low in health literacy if they: Do not complete medical forms Forget their glasses Carry around a lot of unrelated papers together Are unable to identify their medications or directions for taking them Seem anxious or unable to focus during the interview

18 Health Literacy: Some Clues Sometimes we mislabel patients with low health literacy: Lazy Poor Historian Non-compliant Unwilling to take responsibility for their own health

19 Video Courtesy of The ACP Foundation Promoting Health Literacy Click link to watch video

20 Health Literacy: Common Concerns Patients with limited health literacy may have difficulty with the following: Locating providers and services Filling out complex health forms Sharing their medical history with providers Seeking preventive health care Knowing the connection between risky behaviors and health Managing chronic health conditions Understanding directions on medications

21 Health Literacy: Common Concerns Limited health literacy has been repeatedly linked to problems with: The use of preventive services Delayed diagnoses Understanding of one's medical condition Adherence to medical instructions Self-management skills Health status Greater mortality risk AHRQ

22 Health Literacy: Common Concerns Low health literacy has been associated with the following health behaviors: Increased rates of smoking among adults Lower rates of breastfeeding Less proficient management of chronic diseases such as asthma or diabetes

23 Health Literacy: Common Concerns A systematic review of the available literature concludes: Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome Dewalt, et al

24 For people with low literacy skills, navigating the health system is a nightmare Health Literacy Joint Commission Report

25 Health Literacy: Common Concerns 21 million Americans have limited English proficiency That number is only likely to grow with future immigration

26 Health Literacy: Common Concerns Who is a Limited English Proficient (LEP) individual? Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English

27 Health Literacy: Common Concerns Patients are unwilling or unable to explain that they don t speak English well enough to manage their health care The Amiable Nod People want to be agreeable This should not be confused with either comprehension or consent

28 Health Literacy: Common Concerns Among immigrant families: 26% could not understand when their next appointment was scheduled 42% could not understand instructions to take medication on an empty stomach 49% could not determine if they were eligible for free care JAMA

29 Health Literacy: Common Concerns Utilizing professionally-trained interpreters is an important part of the solution for caring for LEP patients Interpreter services must be reimbursed appropriately Only three percent of hospitals receive reimbursement for interpretation services, yet 80 percent of hospitals treat LEP patients Health Research and Educational Trust

30 How is Society Affected by Health Literacy? Cost in Dollars Cost in Quality of Care Cost in Quality of Life

31 Health Literacy: Do the Math Avoidable adult health care spending suggests high costs due to low health literacy patients Estimates run as high as $69 billion in avoidable expenditures AAPA

32 Health Literacy: Impact on Society Those with limited health literacy: Are hospitalized more often Are hospitalized for longer periods of time Use the Emergency Room more often Contribute to the accompanying financial inefficiencies on the system Joint Commission Report

33 Health Literacy: Impact on Society Low health literacy is also associated with societal factors such as: Increase in the misuse of alcohol among boys Violent childhood behavior Increased risk of mortality DHHS AHRQ: Evidence Report

34 Health Literacy: Module Topics Topic 1: Communication Topic 2: Cultural Competence Topic 3: Adult Learning Topic 4: Assessment Tools Topic 5: Tools for Change

35 Topic 1: Communication According to the recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety: Communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes

36 Topic 1: Communication Establishing effective communication is imperative in achieving health literacy Establish a calm, controlled and non-stressful learning environment Easy-to-read pamphlets and brochures are useful Patient education materials should be written at or below the 5 th grade reading level

37 Topic 1: Communication Providers should speak in simple terms while delivering health information in a basic format

38 Topic 1: Communication Provide complete, plain language answers Spend time fully answering all questions Provide pictures, schematics, and diagrams to help visualize important concepts Use interactive activities in educating the patient

39 Topic 1: Communication Physicians and pharmacists self-reported most common techniques to communicate with patients with low health literacy: 94.7% used simple language 70.3% handed out printed materials 67.3% spoke more slowly Schwartzberg

40 Topic 1: Communication An Excellent Resource North Carolina Institute of Medicine Task Force on Health Literacy: Effective Communication Practices

41 Don t forget: Topic 1: Communication Informed consents are written by lawyers for lawyers Joint Commission Report

42 Topic 2: Cultural Competence Cultural differences can influence the reception and delivery of health information Language, belief systems, traditions and alternative medical practices collectively influence health literacy Cultural competence prepares health professionals in working with diverse populations

43 Topic 2: Cultural Competence Be respectful and acknowledge cultural differences Remain cognizant of alternative medical practices Understand that men and women may have different roles in making health care decisions in different cultures Ensure that health information is relevant and culturally sensitive

44 Topic 3: Adult Learning 4 Principles of Adult Learning Adults need to feel respected in order for learning to take place Adults must have the will to learn Most adults learn best by active performance Adults value receiving feedback regarding their progression

45 Topic 3: Adult Learning Strategies to Enhance Health Literacy Establish good verbal and visual communication Address patient concerns with empathy and understanding

46 Topic 3: Adult Learning Request that patients repeat your stated instructions in their own words Allow them to demonstrate their understanding Tell me what I just told you

47 Topic 3: Adult Learning Providers should always encourage their patients to understand the answers to: What is my main problem? What do I need to do? Why is it important for me to do this? Direct your patients to npsf.org/askme3 for information on the program

48 Topic 3: Adult Learning In a study of sleep apnea patients with low health literacy, study subjects displayed a higher level of knowledge about sleep apnea with video instruction Low health literacy women with cervical cancer learned better learned better with illustrated materials versus written information Murphy Michielutte

49 Topic 3: Adult Learning One study found comparable effectiveness in improving health literacy using video-taped information versus easy-to-read data A study of middle-aged women found that the use of video, brochure, various coaching tools and verbal recommendation improved mammography utilization Illustrated materials have been shown to improve self-care in patients undergoing treatment for cervical cancer DHHS AHRQ: Evidence Report

50 Topic 4: Assessment Tools The Newest Vital Sign (NVS) Screening tool that identifies the risk of low health literacy Participants are asked to read a nutritional label and answer a series of questions Devised to be used in a clinical setting

51 Topic 4: Assessment Tools NVS Provides a general estimate of health literacy Improves communication and patient outcomes Nutrition Label Grading sheet: pdf

52 Topic 4: Assessment Tools Rapid Estimate of Adult Literacy in Medicine (REALM) Takes 2-3 minutes to complete Provides an estimate of patient reading abilities Proven to correlate well with standardized reading test

53 REALM Topic 4: Assessment Tools Practical for use in busy primary care settings Useful in assessing literacy in adolescents aged years of age Assessment Form: r_wordlist.pdf Examiners Guide and Grading Scale 0PtEd_REALM_Instr.pdf

54 Topic 4: Assessment Tools Test of Functional Health Literacy in Adults (TOFHLA) Takes approximately 12 minutes to complete Measures health literacy in numeracy and reading comprehension Helps determine the ability to understand basic health information and instruction Sample document:

55 Topic 5: Tools for Change Identify patients with low literacy levels Build systemic awareness Encourage teamwork with nurses, health educators, billing agents, pharmacists, front office Provide health literacy training to all staff

56 Topic 5: Tools for Change The Joint Commission Report details models that do work: Teach back Technique Teach to goal Technique Iowa Health Systems Health Literacy Collaborative Healthy People 2010 Patient Centered Places

57 Topic 5: Tools for Change The Report stresses the need for shared decision making: The more involved the patient is the less likely there is to be an error

58 Topic 5: Tools for Change Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency Free online tool Improves your patient communication skills Increases awareness and knowledge of factors affecting communication with your patients Facilitates implementation of patient-centered communication practices

59 Topic 5: Tools for Change Facilitate cooperation with the community Sponsor or advertise adult literacy classes Consider gifting books to children at their well-child visits Be a positive force for improving local health literacy

60 Health Literacy: Physician Assistants Join the Campaign!

61 National Physician Assistant Health Literacy Campaign Our goal is to remedy low health literacy by targeting children at a young age and instilling in them the importance of health care and valuable communication with health providers

62 Health Literacy Frequently Asked Questions

63 Frequently Asked Questions What is health literacy? Answer: Health literacy is a person s ability to gather, process and understand health information in order to make sound health care decisions

64 Frequently Asked Questions Understanding general health topics is important A basic understanding of common health topics influences daily health behavior When health literacy is present, patients are able to make better health care choices Source:

65 Frequently Asked Questions What is plain language? Answer: People should be able to read or listen to information, comprehend it, and have the ability to apply it in a reasonable amount of time

66 Frequently Asked Questions Write in a plain and easy-to-understand format Speak plainly using simple terms to describe technical concepts Emphasize important points first Source:

67 Frequently Asked Questions Why is health literacy important? Answer: According to the National Assessment of Adult Literacy, only 12 % of adults have proficient health literacy

68 Frequently Asked Questions High literacy has been associated with the utilization of preventive services Low literacy is known to be associated with higher rates of hospitalizations Unnecessary use of emergency services has been associated with low literacy, resulting in increased health care costs

69 Frequently Asked Questions What populations are most at risk? Answer: Low health literacy is most prevalent among: Non-high school graduates Older adults Lower income families Ethnic minorities

70 Frequently Asked Questions How can we overcome low health literacy? Answer: We must work together to ensure that health information and services can be understood and used by all Americans Source:

71 Health Literacy: Summary Building a Patient-Centered Health Practice

72 Health Literacy: Summary Health literacy should impact the broader discussion on the way we deliver health care Health information must be communicated clearly, concisely, consistently, and in a timely way There should also be constant opportunities for feedback between providers and patients AHRQ

73 Health Literacy: Summary The challenge to health care practices and systems alike will be to find ways to have sustainable processes in place to address health literacy We must routinely identify and track patients who may be struggling to properly comply with medical instructions and who may benefit from educational interventions AHRQ

74 Health Literacy: Food for Thought Health Literacy can t be the sole responsibility of health care providers, it must include: Health care policymakers Purchasers and payers Regulatory bodies Health care consumers themselves Joint Commission Report

75 Health Literacy: Food for Thought Pay for performance based on outcomes could help to realign health care in the United States towards a more effective, patient-focused system Health literacy could be proposed as a measurable outcome Joint Commission Report

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77 Health Literacy: Quiz Please complete the following 10 question quiz to evaluate your knowledge of health literacy Questions

78 Health Literacy: Quiz 1. Limited health literacy affects approximately what percentage of the US adult population? Click on one answer choice below < 5 % 10 % 30 % 50 %

79 Health Literacy: Quiz The correct answer is: 50%. Over 90 million people (nearly half of all American adults) have limited health literacy. Next Question

80 Health Literacy: Quiz 2. Health literacy is a better indicator of an individual s health status than either ethnicity or education level? Click on one answer choice below True False

81 Health Literacy: Quiz The correct answer is: True. Health literacy is also a better forecaster of one s health status than age, income, or employment. Next Question

82 Health Literacy: Quiz 3. Which of the following may suggest that your patient is impacted by low health literacy? Click on one answer choice below Appropriately completed intake forms Brings a well-researched list of questions to the visit Frequently forgets their glasses Provides detailed history of present illness

83 Health Literacy: Quiz The correct answer is: Frequently forgets their glasses. This may be a signal to you that the patient is not comfortable reading. Next Question

84 Health Literacy: Quiz 4. Patients with limited English proficiency are likely to let you know when they are unable to follow the conversation. Click on one answer choice below True False

85 Health Literacy: Quiz The correct answer is: False. Patients often wish to be amiable and not call attention to their deficits. They may also not know enough English to tell you that they don t understand what you are saying. A smile and a nod should not be construed as agreement or comprehension. Next Question

86 Health Literacy: Quiz 5. Which of the following health outcomes have been linked to low health literacy? Click on one answer choice below Delays in diagnosing medical problems Increased use of alcohol among boys Longer hospitalizations Lower rates of breastfeeding All of the above

87 Health Literacy: Quiz The correct answer is: All of the above. Low health literacy has also been linked to billions of dollars in avoidable health care expenditures. Next Question

88 Health Literacy: Quiz 6. What is the appropriate reading level for patient education materials? Click on one answer choice below 12th grade 9th grade 7th grade 5th grade

89 Health Literacy: Quiz The correct answer is: 5th grade. Materials should be written so as to be understandable to someone reading at the 5th grade level. Language should be as plain and simple as possible. Next Question

90 Health Literacy: Quiz 7. In educating patients with low health literacy, which of the following strategies may be most effective? Click on one answer choice below Having them call if they have any questions Having them listen to you explain the procedure as you walk out the door Having them read a three-page handout Having them watch a video that explains the information

91 Health Literacy: Quiz The correct answer is: Having them watch a video that explains the information. Video instruction has been shown to be an effective patient education tool. Other important methods of instruction include asking the patient to tell me what I just told you. Patients learn best with interaction and repetition. Next Question

92 Health Literacy: Quiz 8. Health literacy issues should be considered separate from those of cultural competency. Click on one answer choice below True False

93 Health Literacy: Quiz The correct answer is: False. Respect and knowledge of a patient s culture goes hand-in-hand with effective communication and patient education. All are necessary to insure best health outcomes. Next Question

94 Health Literacy: Quiz 9. Groups most commonly affected by low health literacy levels include all of the following except: Click on one answer choice below Ethnic minorities High school graduates Recent immigrants The elderly

95 Health Literacy: Quiz The correct answer is: High school graduates. Adults who did not graduate from high school are another group commonly affected by low health literacy levels. Next Question

96 Health Literacy: Quiz 10. It is difficult to quantify an individual s health literacy skills as no objective assessment tools exist. Click on one answer choice below True False

97 Health Literacy: Quiz The correct answer is: False. Many well-researched, easy to use tools are available for health literacy assessment. These include NVS, REALM, TOFHLA and others outlined in this module and readily available online.

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99 Health Literacy: Resources Center for Health Care Strategies Health Literacy Month Harvard School of Public Health: Health Literacy Studies U.S. Department of Health and Human Services: Health Resources and Services Administration HRSA Health Literacy U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion: Health Literacy Improvement

100 Health Literacy: Resources Limited English Proficiency: A Federal Interagency Website National PA Health Literacy Campaign Easy-to-Read Tutorial at Medline Plus Health Literacy Innovations REALM Sample document:

101 Health Literacy: Resources Health Literacy Costs What is Health Literacy?

102 Health Literacy: References American Medical Association. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 1999;281: Davis TC, Wolf MS, Bass PF 3rd, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145: Department of Health and Human Services Agency for Health Research and Quality. Literacy and Health Outcomes Evidence Report/Technology Assessment Number 87. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and Health Outcomes: A Systematic Review of the Literature. J Gen Intern Med. 2004;19: Kean, DE. Curriculum Development for Medical Education. Baltimore, MD: Johns Hopkins University Press; Kirsch IS, et al. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. National Center for Education Statistics, Department of Education, Kutner, M, Greenberg, E, Jin,Y, and Paulsen, C. The Health Literacy of America s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES ).U.S.Department of Education. Washington, DC: National Center for Education Statistics

103 Health Literacy: References Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Pub Health. 1994;84(1): Metlay JP, Cohen A, Polsky D, Kimmel SE, Koppel R, Hennessy S. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc. 2005;53: Michielutte R, Bahnson J, Dignan MB, et al. The use of illustrations and narrative text style to improve readability of a health education brochure. J Cancer Ed 1992;7(3): Murphy PW, Chesson AL, Walker L, et al. Comparing the Effectiveness of Video and Written Material for Improving Knowledge Among Sleep Disorders Clinic Patients with Limited Literacy Skills. Southern Med J. 2000;93(3): Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Int Med. 2003;163(1): Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31:S96-S104.

104 Health Literacy: References The Joint Commission. What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The Joint Commission; Accessed May 30, Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. Accessed May 30, Sinusitis photo courtesy of healthliteracy.ie