Health Literacy: Implications for Patient Safety

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Health Literacy Implications for Patient Safety

• Presented by
• Barbara Meyer Lucas, M.D., MHSA
• Mary Antonette Flowers, R.N.
• The Michigan State Medical Society Foundation
• American Medical Association Foundation
  American Medical Association

10/03
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Definitions
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• General Literacy
• An individuals ability to read, write, and
  speak in English, and compute and solve problems
  at levels of proficiency necessary to function on
  the job and in society...
• National Literacy Act of 1991
• Health Literacy
• The degree to which individuals have the
  capacity, to obtain, process, and understand
  basic health information and services needed to
  make appropriate health decisions.
• Healthy People 2010

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1993 National Adult Literacy Survey
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• n 26,000
• Most accurate portrait of literacy in U.S.
• Scored on 5 levels
• Result 48 of US population have inadequate or
  marginal literacy skills

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1993 National Adult Literacy Survey
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Up to ½ of US population may be at risk for
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• Medical Errors
• Medical Miscommunications
• Inappropriate hospitalizations
• Poorer health outcomes

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What do we know from a decade of research?
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• Low health literacy leads to
• Lower health knowledge and less healthy
  behaviors.
• Poorer health outcomes
• Greater health costs

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Low literate diabetic patients less likelyto
know correct management.
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Know symptoms of low blood sugar (hypoglycemia)
Know correct action for hypoglycemic symptoms
Percent
Williams, et al. Arch Int Med 1998
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Poor health outcomes for diabetic patients
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• Diabetic patients with low health literacy have
  poorer glycemic control than patients with
  adequate literacy.
• (Schillinger D, et al. JAMA. 2002.)
• Diabetic children (ages 5-17) had poorer glycemic
  control if their parents had lower literacy
  skills.
• (Ross LA, et al. Diabetic Med. 2001.)

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Patients with low literacy more likely to be
hospitalized
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Baker, Parker, Williams, et al. JGIM 1999
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Research also shows that
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• Literacy is a predictor of health status
• It is a stronger predictor than age, income,
  employment status, education level, or racial and
  ethnic group

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The Costs of Poor Health Literacy Estimated to
be 50 billion/year!
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• Costs affect all segments of society
• 39 paid by Medicare through FICA taxes on
  workers
• 17 paid by employers
• 16 paid by patients out-of-pocket
• 14 paid by Medicaid
• The remaining 14 comes from other public and
  private sources.

Estimated by the National Academy on an Aging
Society using 1998 figures
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Why are those with inadequate literacy at risk?
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• Increased reliance on printed handouts for
  patient instruction
• Increasingly complex health system
• More medications
• More tests and procedures
• Growing self-care requirements

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Changes in the Health Care System
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35 Years Ago
Today

• 4 - 6 weeks bed rest
• in hospital
• 650
• 3 weeks in hospital
• 2 hours a day of diabetic education classes

• 2-4 days in hospital
• (MR Guidelines)
• 10,000
• outpatient
• 0-3 hours diabetic
• education classes
• written materials
• internet
• telemedicine

Treatment of Acute Myocardial Infarction Availab
le Prescription Drugs Treatment of new onset
diabetes
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Inadequate health literacy increases with age
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Gazmararian, et al. JAMA 1999
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Exercise
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• What is it like to have low health literacy?

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What can we do to help?
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• Understand the problem
• Identify the barriers faced by both patients and
  clinicians
• Identify and implement strategies to enhance
  health literacy
• Advocate for system change

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Video The patients voice...
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• This video was made by the AMA in 2003
• You will see real patients and real physicians
  talking about literacy issues

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Two specific goals to enhance health literacy
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• Create a shame-free environment with improved
  patient assessment
• Improve interpersonal communication with patients

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Goal 1 Creating a Shame-Free
Environment
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• 4 Key Strategies
• Adopt an attitude of Helpfulness
• Convey a safe, non-judgmental environment
• Identify red flags for low literacy
• Engage the entire office staff

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Strategy 1 Adopt an Attitude of
Helpfulness.
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• First impressions make a big difference!
• Attitude of helpfulness, caring and respect by
  all staff
• All patients treated as if they are your parents
• Easy-to-follow instructions for appointments,
  check-in, referrals and tests
• Assistance provided confidentially

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Strategy 2 Create a Safe, Non-judgmental
Environment...
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• Provide privacy for all discussions
• Ask and listen before you advise
• Give the patient time to respond
• Take the patients concern seriously
• Discuss how you can best help the patient care
  for themselves
• Ask patients how they want information
  communicated to them
• Be positive, hopeful, empowering

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Strategy 3 Be alert to clues of low Health
LiteracyUsing assessment to address literacy
issues.
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• Be alert for red flags
• Use the social history to assess literacy
• Use medication reviews to identify and address
  problems

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Red Flags Patients may seek to protect
themselves by.
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• Seeking help only when illness is advanced
• Walking out of the waiting room
• Making excuses
• Pretending they can read
• Becoming angry, demanding
• Clowning around, using humor
• Being quiet, passive
• Detour, letting doctor miss the concern

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Red FlagsPatient Communication
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• Unable to name medications, or explain purpose or
  timing of administration
• Difficulty explaining medical concerns
• Has no questions

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Red FlagsLack of follow-through
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• Incomplete registration forms
• Frequently missed appointments
• Skipped tests and referrals
• Non-compliant with meds

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Use the social history to ask
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• Ask about education, reading, learning styles
  be non-judgmental.
• Use this discussion to open a space for the
  patient to talk about literacy issues.

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Use a medication review to identify
problems
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• Ask patients to bring in all their medications
• Ask them to name and explain the purpose of each
  one
• Discuss exactly how and when they take each one
• Use this discussion to identify areas of
  confusion and to answer questions

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Exercise Planning for
Medication Reviews
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• Goal To conduct medication reviews with all
  patients
• What are the benefits?
• What are the barriers?
• How do we overcome them?

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Strategy 4 Engage the entire staff(or, what
is it like being a patient in your setting?)
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• What forms will you be given?
• Will you be offered confidential assistance?
• Are check-in personnel friendly?
• Were you given easy-to-follow instructions?
• First impressions? Non-verbal communication of
  staff?

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All staff need to be involved in..
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• Understanding the scope of the problem
• Identifying patient barriers to care
• Creating strategies to address the barriers
• Implementing and assessing the effectiveness of
  these strategies
• Conducting on-going follow-up and evaluation

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Goal 2 Improving Communications
with Patients
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• 2 Key Strategies
• Improving Face-to Face Communications
• Improving Written Patient Education Materials

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Strategy 1 Enhancing face-to-face
communications with patients
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• 1. Conduct patient-centered visits
• 2. Explain things clearly in plain language
• 3. Focus on key messages and repeat
• 4. Use a teach back or show me technique to
  check for understanding

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1. Conduct patient-centered visits
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• Engage in a dialogue with the patient
• Listen more and speak less
• Encourage questions
• Understand and address the patients concerns.

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2. Explain things clearly using plain
language.
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• Slow down the pace of your speech
• Use analogies
• Arthritis is like a creaky hinge on a door.
• Use plain, non-medical language
• Pain killer instead of analgesic

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Exercise Practice using plain,
non-medical language
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• Anti-inflammatory
• Benign
• Contraception
• Hypertension
• Echocardiogram

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3. Focus on key messages and repeat.
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• Limit information by focusing on 1-3 key messages
  per visit
• Review each point and repeat several times
• Have other staff reinforce key messages.

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Exercise Whats the Key Message?
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• Type II DM diagnosed at todays visit
• Sugar level in blood is high
• How the body controls blood glucose
• Self-management of diabetes medications
• Start medicine to lower sugar
• Potential complications of diabetes
• Testing the blood sugar level
• Proper diet

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4. Use teach back or show me techniques.
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• Ask patient to demonstrate understanding
• What will you tell your spouse about your
  condition?
• I want to be sure I explained everything
  clearly, so can you please explain it back to me
  so I can be sure I did.
• Do not ask,
• Do you understand? .

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Strategy 2 Developing patient-friendly
written educational materials
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• Focus only on key points
• Emphasize what the patient should do
• Show or draw only simple pictures
• ---Minimize info about anatomy and
  physiology
• Be sensitive to cultural preferences.

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Exercise Simplifying Patient Handouts
Example Strep Throat
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• Refer to your Handout, Practice Key Messages
  Strep Throat Streptococcal Pharyngitis (Strep
  Throat)
• Working with a partner, review this information
  and determine 3 key messages for the patient.

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Guidelines for creatingpatient-friendly written
materials
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• Simple words (1-2 syllables)
• Short sentences (4-6 words)
• Short paragraphs (2-3 sentences)
• No medical jargon
• Headings and bullets
• Lots of white space.

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Review Five steps to enhance your interactions
with patients
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• 1. Conduct patient-centered visits
• 2. Explain things clearly in plain language
• 3. Focus on key messages and repeat
• 4. Use a teach back or show me technique to
  check for understanding
• 5. Use patient-friendly educational materials to
  enhance interaction.

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In Summary
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• 48 of the U.S. population have inadequate or
  marginal literacy skills
• This places them at high risk for
• --Medical errors
• --Poor compliance with care plans
• --Inappropriate hospitalizations
• --Poorer health outcomes

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In Summary What can we do to help?
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• Strategies for change include
• --- Creating shame-free
• healthcare environments
• --- Improving communications
• ---Face to face with patients
• ---Simplified written handouts