Meeting Health Literacy Needs: Best Practices for Older Adult Well-being

1. Best Practices to meet and promote health literacy with your clients: A refresher/primer to better meet older adult health and well-being needs OT and Health Literacy: Current practices and recommended actions Kay Graham, PhD, OTR/L and Lisa Howard, MS

2. Objectives ● Review basic health literacy information ● Discuss poor health outcomes and vulnerable populations associated with low health literacy ● Identify and apply Health Literacy Universal Precautions within Area Agency on Aging (AAA) settings ● Evaluate AAA staff current knowledge and practices regarding health literacy in various settings ● Develop next steps within own areas of AAA regarding health literacy

3. Definition • Obtain, process, communicate, and understand basic health information (CDC, 2015) • Making appropriate health decisions • Beyond literacy • Numeracy play a role

4. Both client and providers have responsibilities

5. The Problem • Average American reading level is 6th grade • Health information at 10th grade level (Smith & Gutman, 2011) • Difficulty with recalling information

6. Health Literacy Levels • Below Basic ---how often to have a test; what to drink before a test • Basic-identify reasons should have a screening done from brochure • Intermediate-solve multistep problem like time to take meds/eating; interpret graph • Proficient –figure out money responsible for insurance Source: The National Assessment of Adult Literacy (Kutner et al.,2006)

7. Poor outcomes with low health literacy • Inadequate knowledge of health issues • Medication errors • Hospital readmissions • Healthcare costs • Decreased health status • Limited access to preventative services Source: Agency for Healthcare Research and Quality [AHRQ], 2015

8. Older Adults are a Vulnerable Population • Older adults (65 and over) - 29% had Below Basichealth literacy level • Other groups more vulnerable: • Low income • Minorities – Hispanic adults rated as having lowest health literacy • Limited education - 49% adults <high school completion - Below Basic • Non-English speaking

10. Older adults • More frequent use of health services • Higher prevalence of chronic diseases • More likely to have difficulty understanding forms or charts • More likely to have difficulty interpreting numbers and calculations

11. Area Agencies on Aging (AAA) and health literacy • Part of DAS mission to help “achieve safe, healthy, independent and self-reliant lives • Low health literacy has a $106-238 billion dollar burden on the U.S. economy. https://nnlm.gov/initiatives/topics/health-literacy

12. DATA from 2019 AAA survey 92 staff members completed recent survey sent out to all AAA in state of Georgia • 96% work full time • 4% worked part time • Average length of working with older adults: 15.5 years (range < 1 year up to 45 years ) • Average length of working at AAA: 7 years (range < 1 year up to 39 years)

13. Gerontology program curriculum and health literacy • Gerontology programs surveyed in Georgia were not linked to medical professions • 6 programs responded (5 schools), 3 graduate and 4 undergraduate • None had courses that specifically included health literacy • Most felt they addressed indirectly

15. Formal training could include school, training at AAA, or continuing education.

16. Promoting health and wellbeing through improving health literacy • Healthy People 2030 added health literacy as a goal • Meet health literacy needs of clients • Build health literacy skills through evidence-based programs • Chronic Disease Self-Management Programs • A Matter of Balance Program Source: https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

17. Assessing health literacy • Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) • Test of Functional Health Literacy in Adults (TOFHLA); Spanish version available, TOFHLA-S. • Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) • Short Assessment of Health Literacy-Spanish and English (SAHL-S&E) • Newest Vital Sign (NVS) • Health Literacy Questionnaire

18. Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF)

19. Newest Vital Sign (NVS)

20. Indicators of low health literacy • Excuses made, i.e. “I will read it later.” • Being late to appointments • Being a member of a vulnerable population • Other factors related to client understanding ok (i.e. vision and hearing)

21. Using a Universal Precautions approach • Assess grade level of communication, both verbal and written • Ease of locating and using services • Health Literacy Universal Precautions Toolkit • Communicate at 5th grade level to reach most effectively • CDC great resource about improving health literacy for older adults: https://www.cdc.gov/healthliteracy/developmaterials/audiences/olderadults/index.html

22. Strategies to ensure understanding of information • Ask me 3 • What is my main problem? • What do I need to do? • Why is it important for me to do this? • Teach-Back • Clarify that it’s not a test but a means to assess understanding • "Chunk and Check" (AHRQ, 2015) • Use of clear communication/plain language Source: https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication

23. Acronym: STEPS • Speak slowly • Teach-back • Encourage questions • Plain language • Show examples http://deltamo.org/health-literacy/

24. Ensuring Access for Older Adults • Can they read it? • Use 14pt font • Bullets • High contrast • Use readability formulas to examine written materials • Flesch-Kincaid Grade Level- outputs U.S. grade level equivalent • SMOG/FOG • Add readability option in Microsoft Word https://support.office.com/en-us/article/test-your-document-s-readability-85b4969e-e80a-4777-8dd3-f7fc3c8b3fd2 • Use short sentences, short words

25. Practice Addressing Readability • With a partner, look over handout • Make suggestions regarding word use and phrasing to improve readability • Make suggestions for visual organization (information chunking)

27. What’s Next? • Pursue training for better awareness, use of strategies and knowledge as well as use of available resources. • Incorporate health literacy strategies into practice, especially when treating vulnerable populations. • Shift from treating chronic diseases to promoting health and self-advocacy for patients.

28. Resources for readability of print material • Developing effective print materials for older adults with low health literacy: • Toolkit for Making Written Material Clear and Effective—Part 9: Things to know if your written material is for older adults:https://www.cms.gov/Outreach-and-education/Outreach/WrittenMaterialsToolkit/ToolkitPart09.html • Clear and Simple (developing health information materials for people with limited literacy: https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/clear-simple

29. Putting it into context and practice In your practice area: • What are your perceived barriers to assessing, meeting, and promoting health literacy for the older adults you serve? • Suggestions to overcome these barriers? • Next steps in your facility or organization regarding health literacy? I

30. References Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit, 2nd Edition. (2015). Retrieved from http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/ quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68 (Suppl. 1), S1–S48. doi:10.5014/ajot.2014.682006 Centers for Disease Control and Prevention. (2015). Learn about health literacy. Retrieved from http://www.cdc.gov/healthliteracy/learn/index.html Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2006/2006483.pdf Department of Health and Human Services, Office of Disease Prevention and Health Promotion (US) National action plan to improve health literacy. Available from: URL: http://www.health.gov/communication/HLActionPlan. Smith, D. L., & Gutman, S. A. (2011). Health literacy in occupational therapy practice and research. American Journal of Occupational Therapy, 65(4), 367-369. doi: 10.5014/ajot.2011.002139