Health Literacy Training Program for the Arkansas Department of Health, Local Health Units

1. Health Literacy Training Program for the Arkansas Department of Health, Local Health Units Cathy A. Irwin, PhD, RN University of Arkansas for Medical Sciences (UAMS), Center for Rural Health Sherian Kwanisai, RNP Arkansas Department of Health

2. Objectives Describe the implementation of the Health Literacy Training Program, using the Health Literacy Universal Precautions Toolkit in the Arkansas Department of Health, Local Health Units. Discuss the evaluation plan, instruments, and data analyses for the Health Literacy Training Program and implications for improving health literacy practices in the Arkansas Department of Health, Local Health Units.

3. Purpose of the Health Literacy Universal Precautions Toolkit • Complicated medical care: Patients struggle with understanding medications, self care instructions, and follow-up plans • The toolkit helps health professionals take a systematic approach to reducing the complexity of health care—ensure patients can succeed in the health care environment • Provides step-by-step guidance and tools for assessing your practice and making changes so you connect with patients of all literacy levels

4. Improved patients’ understanding of medications, self-care Improved medication adherence Decreased patient phone calls, hospitalizations and health care costs, returned appointments Improved efficiency and quality of care, increased patient satisfaction and safety Testimonials from clinical practices: “We realized that toolkit is not adding more, it is about learning how to do things differently.” Benefits of the Health Literacy Toolkit

5. Development and Testing of the Health Literacy Toolkit Website: http://www.ahrq.gov/qual/literacy Developed by: Agency for Healthcare Research and Quality (AHRQ) and The Cecil G. Sheps Center for Health Services Research, UNC at Chapel Hill Testing of toolkit in 8 clinical practices

6. What is Health Literacy? “Health literacy is the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”

7. Health Literacy Skills Ability to interpret documents Read and write prose (print literacy) Use quantitative information (numeracy) Speak and listen effectively (oral literacy) Internet

9. Literacy in Arkansas Among Arkansas adults, 20% read at or below a 5th-grade level, which affects their ability to understand written information. 14% lack basic prose literacy skills. 76.5% working-age adults (18-65 y.o.) have not completed any college. 15.5% of these have not completed high school. (Arkansas Literacy Councils, retrieved January 6, 2012 at http://www.arkansasliteracy.org/; NAAL, NCES 2003; 2008, Council for Adult & Experiential Learning, www.cael.org).

10. Limited Health Literacy is Associated with: • Increased hospitalizations/costs • Greater emergency room use • Less likely to engage in disease prevention behavior • Poorer health outcomes • Poorer medication adherence • Inadequate care for chronic diseases • Increased risk of mortality

11. Red Flags for Low Literacy • Frequently missed appointments • Incomplete registration, history forms • Medication non-compliance • Difficulty with understanding medication dosages, instructions on labels • Discharge instructions, consent forms • Information on self-management of diseases • Ask fewer questions • Lack of follow-through on tests, referrals

12. A Hidden Problem Low health literacy is often undetected (not just education!). People who are confused about health information may feel ashamed. They may mask their shame to maintain their dignity.

13. Organizational Health Literacy Practices Health literacy affects chronic disease care and self-management Patient-provider communication Patient safety and health-care quality Access to health care and preventive services Health literacy interventions are most effective when addressed at an organizational level causing systematic change to improve health literacy practices.

14. Universal Precautions • Taking specific actions that minimize risk for everyone when it is unclear which patients may be affected • Health Literacy Toolkit offers health professionals a means to structure services, patient interactions to minimize the risk that any patient will not understand health information. • Allowing patients to make informed decisions about their health care

15. Why Take Universal Precautions? • Providers don’t always know which patients have limited health literacy. • Some patients with limited health literacy • Have completed high school or college • Are well spoken • Look over written materials and say they understand • Hold white collar or health care jobs • Function well when not under stress • Clear communication practices will improve care for all patients, regardless of their level of health literacy.

16. Health Literacy Universal Precautions Toolkit

17. Health Literacy Universal Precautions Toolkit Offers 20 tools to promote health literacy practices in 4 change areas: • Spoken communication • Written communication • Self-management and empowerment • Supportive systems

18. Self-Management and Empowerment • Toolkit tools can be used to help patients manage their chronic conditions—Empower patients to take care of themselves • Improve health care access • Health knowledge • Behavior change • Health outcomes

19. 6 Steps for Improvement in Health Literacy Practices • Watch Health Literacy Video (6 min; ACP) • Form Your Team, Tool 1 • Tool 2, Assess Your Practice • Choose Tools, Limit Number • Raise Staff Awareness about Health Literacy in Clinical Practice (Tool 3) • Plan and Test Your Changes

20. Health Literacy Training Program To begin Fall 2013 (week of September 9th) To include one to two LHUs in each region Multidisciplinary staff to include Nurses and Clerical staff as a constant in each LHU and Administrators, Disease Intervention Specialist, Environmental Health Specialist, and Nutritionists where available. Implement tools in the Health Literacy Universal Precautions Toolkit Provide tools and guidelines for making improvements in health literacy practices Program evaluation system to allow LHUs to identify areas for improvement in spoken and written communication, patients’ self-management of diseases and supportive systems

21. ADH Regions Map

22. Health Literacy Training and Implementation of Tools • Three 1-hour Training Sessions: Education on 11 toolkit tools • Interactive video for some of the LHUs • Tools will be selected based on pretest assessment of health literacy practices—Focus on areas with greatest need for improvement • Facilitator in clinical setting • Establish Teams: Each team will focus on implementing 1 new tool in clinic each month • Assign 5-6 tools to implement over a 6-month period

23. Health Literacy Training Program First Session • Overview of Health Literacy Toolkit, training program, evaluation plan; Health Literacy Video; Pretest Health Literacy Assessment Questions Second Session • Report Results of Pretest Health Literacy Assessment Questions • Form health literacy teams, team leaders • Signs of low literacy • Tools for improving spoken communication • Tools for improving written communication Third Session • Teach-back method, Teach-Back Video • Tools for improving patients’ self-management and empowerment • Tools for improving patients’ supportive systems • Process evaluation meetings by interactive video

24. Key Change 1: Tools to Improve Spoken Communication Tool 4, Communicating Clearly • Warm greeting: Smile, Welcoming attitude • Eye contact • Plain, non-medical language • Slow down; Limit content to 3-5 key points • Repeat key points, summarize • Graphics: Draw pictures, use models • Encourage questions, “What questions do you still have?” • Teach-back: Confirm patients’ understanding

25. Communication Skills: Reminders, Track Your Progress • Hang poster in various locations • Communication Self-Assessment: Complete after one patient encounter a day, during the week

26. Tool 14: Encourage Questions Ask Me 3 Program: Encourage patient to know 3 things before leaving encounter • What is my main problem? • What do I need to do? • Why is it important for me to do this? • Emphasize benefits to patient

27. Tool 14: Encourage Questions • Invite questions using body language • Sit at same level as patient • Look at patient when talking, listening • I have the time to listen to your questions. • Solicit questions • What questions do you still have? • That was a lot of information. What do I need to go over again?

28. Tool 14: Encourage Questions • Encourage patients to bring a relative or friend to clinic visit to help remember information, write down questions • Involveentire staff in soliciting questions • Checkin: Clinical staff talk about patients’ questions while taking vitals • Nurses, health educators, medical assistants: Encourage questions • Checkout: Ask each patient if their questions were answered

29. Tool 14, Encourage Questions: Track Your Progress Ask as patients exit, Did you get a chance to ask all your questions? If patients answer no, ask whether the doctor/nurse said they would address some questions later.

30. Tool 8: Brown Bag Medication Review Encouragespatients to bring all medications and supplements to medical appointments Answer patients’ questions Verify what patient is taking Identify and/or avoid medication errors, drug interactions Assist the patient to take medications correctly, improve adherence

31. Tool 8: Medication Review Get patients to bring in their medications What to bring: All prescription meds., over-the-counter meds. regularly taken, vitamins and supplements, herbal meds. Ways to remind: appt. card, appt. reminder call, during visit, hang posters Set out the medications in exam room Offer praise to patient for bringing meds. Stress importance of bringing meds. to every visit

32. Tool 8: Medication Review Review the medications Purpose of the review Patients’ questions Some helpful questions Are you taking any new medications? Have you stopped taking any meds. since your last visit? How many of these pills do you take each day? What do you take this medication for?

33. Tool 8: Medication Review Clarify medication instructions Confirm patient’s understanding: I want to make sure I explained your medicine correctly. Can you tell me how you will take your medicine? Update medications in patient’s chart Provide patient with updated list of meds. Bill for medication review: Select ICD-9 V58.69 to bill patient’s insurance Document med. review in patient’s record

34. Tool 8, Medication Review: Track Your Progress Document in medical record whether or not a medication review occurred at the visit At the end of a day or week, identify the % of patients who had a medication review completed

35. Tool 5, Teach-Back Method Not a test of patient’s knowledge Test of how well you explained the health information Shame-free way to assess understanding Polite request that the patient state in their own words key points of information Demonstrate back a skill

36. Tool 5, Teach-Back Method: Tips I want to be sure that I did a good job explaining your medication, because this can be confusing. Can you tell me how you are going to take this medication? We covered a lot today about your diabetes, and I want to make sure that I explained things clearly. So let’s review what I discussed. What are 3 things that will help you control your high blood sugar?

37. Try the Teach-Back Method Start slowly—try with last patient of day Plan your approach: What is the most important thing for the patient to know or do? Why is it important for the patient to do these things? Use handouts—review written materials to reinforce the teaching points Practice

38. Teach-Back Method “Chunk and Check”approach: Limit to 1-3 concepts/ideas at a time, Explain Ask patient to state in their own words key points of information Listen—Patient recall and comprehension Affirm understanding Say it again, Rephrase—Don’t just repeat Ask patient to try teach-back again May need to clarify several times Use plain language Action messages: “What you need to do is…” Go slowly, pause often

39. Teach-Back Video, 5-minutes What teach-back strategies did you observe that were helpful for ensuring the patient’s understanding about the medication changes?

40. Teach-Back Method: Track Your Progress Teach-Back Self-Evaluation Log

41. Tool 10: Culture and Other Considerations • Learn about your patients’ health beliefs and cultural practices • I am not familiar with your cultures and health beliefs. Can you teach me what I need to know so I can better treat you? • Causes and treatment of diseases • Ethnic customs • Religious beliefs: Refusing contraception, blood transfusions, etc. • Interpersonal customs: Eye contact, touch • Resources in Toolkit—See Handout on Culture Cues, website on other cultures, Tool 10, p. 47

42. Tool 10, Culture: Track Your Progress • Include assessment of health beliefs and customs in electronic medical record • Randomly select some records and see what % have notes on patients’ health beliefs and customs

43. Key Change 2, Written Communication: Tool 13, Welcome Patients • Create a friendly environment • Easy to navigate • Evaluation: Patient and staff walkthrough to assess feel and navigation at front desk area, waiting room, and signs • Front Desk: Help with forms, assess language preferences, obtain interpreter; practice brochure • Waiting Room: Bulletin Boards—Target patient population, limit to 4 points of interest, easy-to-read, update regularly • Signs: Easy-to-read, clearly visible, identify locations, English/Spanish, simple words

44. Tool 13, Welcome Patients: Track Your Progress • Patient and staff walkthrough to assess feel and navigation at front desk area, waiting room, and signs • After making changes, conduct another walkthrough and compare results

45. Tool 11: Design Easy-to-Read Material Clearly state how to prevent and manage disease without a lot of extra information Use headings and subheadings between sections—a lot of white space Use short sentences and paragraphs Use one- or two-syllable words Use large fonts (minimum 12 point) Use lists in bullet form Underlined or bold print for key words

46. Tool 11: Easy-to-Read Material Write at a reading level of 6th grade or below –HL Toolkit, Free Readability Formulas CRH, Readability Project, Dr. Kristie Hadden, Health Literacy Advisor: www.healthliteracyinnovations.com/products/hla Word choice: Limit the use of medical jargon, define any terms used Use common medical terms—HL Toolkit, Plain Language List

47. Tool 11: Design Easy-to-Read Material Use graphics and visuals to enhance understanding about action to take Patient Forms: Help patient fill out forms Check boxes Don’t know options Bold key words See HL Toolkit for Example Forms: Adult History, Consent to Treat, Lab, Appt.

48. Tool 11: Design Easy-to-Read Material Cultural appropriateness Action steps, desired behaviors: Take your medicine with your meals Test educational material and forms with patients, get feedback Simple, plain language material can benefit all patients.

49. Tool 11, Design Easy-to-Read Material: Track Your Progress • Every 4 months, do a tally of what written materials have been reviewed and revised using plain language guidelines with Tool 11 • See if percentage goes up over time

50. Tool 12: Use Health Education Material Effectively Use in conjunction with spoken instruction Review the material with the patient—ensure understanding, repeat back Repeat and follow-up with phone contact, in future visits Use videos for patient education Manage materials: Location, organization, supply, updated, training for staff on development and use of materials