9 th Annual MCH Summer Institute Addressing Health Disparities: Culture, Communications and Health July 24, 2007

1. Health Literacy:Helping Patients Understand Alisha Ellwood, MA, LAMFTHealth Care Improvement, Blue Cross and Blue Shield of MinnesotaActing chair of MN Health Literacy Partnership, a program of the MLC 9th Annual MCH Summer Institute Addressing Health Disparities: Culture, Communications and Health July 24, 2007 © 2006 Blue Cross and Blue Shield of Minnesota

2. What is Health Literacy? Health Literacy: • “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to makeappropriate health decisions.” • - Healthy People 2010

3. Why are Patients at Risk? • Reliance on the written word for patient instruction • Increasingly complex healthcare system • More medications • More tests and procedures • Growing self-care requirements • Esoteric language • An aging population • More culturally diverse patient population

4. NAAL 2003 – Health Literacy Results

5. Percentage of Adults With Below Basic Health Literacy in each Prose, Document and Quantitative Literacy Level

6. Low health literacy increases US health care costs by $50 – 73 billion annually1 • Predicted inpatient spending for a patient with inadequate health literacy was $993 higher than that of a patient with adequate reading skills.2 • Those with low health literacy have an average health care cost of $13,000 compared to only $3,000 for those with higher literacy levels. 1 Estimated by National Academy on an Aging Society using 1998 figures 2 Baker, et al. Am J Public Health, 2002 3 AMA Foundation "Health Literacy A Manual for Clinicians“ by Barry Weiss, MD

7. Patients with Low Literacy are More Likely to be Hospitalized Baker, Parker, Williams, et al. JGIM 1999

8. 3 Gazmararian, et al. JAMA 1999 4 Wilson, et. al. Journal of General Medicine, 2007 Implications of Low Health Literacy for Seniors JAMA study3 • 40% reported some kind of nonadherence4 • Of those reporting 3 or more chronic conditions: more than half (52%) were not taking medicines as directed4

9. What Do We Know? • Low Health Literacy (LHL) is prevalent • LHL leads to: • Lower health knowledge and less healthy behaviors • Greater health costs • Poorer health outcomes • Health literacy can predict health status • Strategies may be used to address health literacy

10. Strategy: Recognize Red Flags • Seeking help only when illness is advanced • Making excuses • Becoming angry/demanding or quiet/passive • Unable to name medications or explain purpose or timing of administration • Difficulty explaining medical concerns • Has no questions • Frequently missed appointments, tests • Non-compliant with meds or treatment

11. Strategy: Create a Shame-Free Experience • Convey an attitude of helpfulness, caring and respect (by all staff) • Ask questions to help them open up • What is it like being a member of your program? • Are there forms or instructions that could be confusing? • Encourage patients to ask questions • Provide assistance confidentially

12. Strategy: Incorporate Effective Teaching Practices • Start by asking what the patient already knows • The next question is “What do you want to know?” • Demonstrate empathy • Build trust • Solicit patient’s feedback • Provide culturally relevant interpretation • Do not rely on written documents alone

13. Strategy: Improve Interpersonal Communication • Slow down • Take your time • Use plain, non-medical language • “living room” language • Use analogies & pictures • arthritis like a creaking door, body charts/diagrams • Limit to most important concepts and repeat them • Focus on 1-3 key messages • Use AskMe3

14. What Is My Main Problem? • Why Is It Important for Me to Do This? What Do I Need to Do? Diagnosis Treatment Context What is Ask Me 3?

15. Strategy: Use Teach-Back Method • Ask patients 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.” • Chunk and Check • Incorporate throughout entire encounter vs. waiting until the end • Do NOT ask . . . • “Do you understand?”

16. Teach Back in action • Use of “Teach Back” for patients with Diabetes (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 9 times more likely to have Hb A1c levels below the mean • Visits that assessed recall were not longer Schilinger, D. Arch Int Med, 2003

17. Strategy: Use Patient-Friendly Materials and Forms • Keep content concise and focused • Focus only on 1-3 key points • Emphasize what the patient should do • Tips for easy-to-read materials • Simple words (1-2 syllables) • Short sentences (4-6 words) • Short paragraphs (2-3 sentences) • Limit medical jargon • Headings, bullets and lots of white space • Active voice

18. What can you do right away? • Begin to incorporate strategies learned today. • Do a ‘walk through’ at your facility and identify barriers. • Review registration forms and consider if they could be simplified. • Develop a plan to educate all staff about low health literacy

19. Start gathering data Research your own information • Customer satisfaction ratings • Understandability • Ease of use • Wayfinding • Repeat hospitalizations; ER utilization; non adherence to medication/treatment regimens • ethnicity; preferred language & reading level

20. Statistics – specific to you! Location specific literacy information https://www.casas.org/lit/litcode/Search.cfm Use the Prevalence Calculator http://www.pfizerhealthliteracy.com/public-policy-researchers/prevalence-calculator.html

21. MN Collaborative Efforts Minnesota Health Literacy Partnership http://healthlit.themlc.org • Program of the Minnesota Literacy Council • Formed in 2006 • Over 20 health care, public health, community and academic organizations • Health Literacy and Informed Consent: a panel discussion (August 1, 2007)

22. MN Collaborative Efforts Multilingual Health Resource Exchange www.health-exchange.net • Over a dozen health care organizations • Over 2,200 health education pieces • Expanding to include resources and information from other initiatives to reduce health disparities

23. What can you do in the future? • Form a team to determine a long-term strategy • Discuss methods for improving communication with providers and staff • Incorporate “Ask Me 3” components into patient information

24. Myths • Literate patients are insulted by low literacy materials • You can “tell” by looking someone has low literacy • Patients will share with you that they have health care literacy problems • A college degree means the patient will understand medical information • My patients don’t have low literacy problems

25. Resources • American Medical Association http://www.amafoundation.org • Institute of Medicine Health Literacy: A prescription to end confusion http://iom.edu/ • Joint Commission Resources http://www.jcrinc.com/education.asp?durki=11276&site=5&return=11114 • Agency for Healthcare Research & Quality (AHRQ) Health Literacy and Outcomes Evidence Report www.ahrq.gov • Health Literacy Innovations – consulting company www.healthliteracyinnovations.com My contact information: e-mail: alisha_ellwood@bluecrossmn.com & phone: 651-662-0986

26. © 2006 Blue Cross and Blue Shield of Minnesota