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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. Module 1. Definitions:.

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Health literacy implications for patient safety l.jpg

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


Definitions l.jpg

Module 1

Definitions:

General Literacy:

“ An individual’s 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


1993 national adult literacy survey l.jpg

Module 1

1993 National Adult Literacy Survey

  • 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


1993 national adult literacy survey4 l.jpg

17%

32%

Level 4

Level 5 - 3%

Level 3

Level 1

21% -

InadequateLiteracy

Level 2

27% -

Marginal Literacy

Module 1

1993 National Adult Literacy Survey


Up to of us population may be at risk for l.jpg

Module 1

Up to ½ of US population may be at risk for…

  • Medical Errors

  • Medical Miscommunications

  • Inappropriate hospitalizations

  • Poorer health outcomes


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Module 1

What do we know from a decade of research?

  • Low health literacy leads to:

    • Lower health knowledge and less healthy behaviors.

    • Poorer health outcomes

    • Greater health costs


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Module 1

Low literate diabetic patients less likelyto know correct management….

Know symptoms

of low blood sugar

(hypoglycemia)

Know correct action

for hypoglycemic

symptoms

Percent

Williams, et al. Arch Int Med 1998


Poor health outcomes for diabetic patients l.jpg

Module 1

Poor health outcomes for diabetic patients……

  • 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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Module 1

Patients with low literacy more likely to be hospitalized

%

Baker, Parker, Williams, et al. JGIM 1999


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Module 1

Research also shows that:

  • 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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Module 1

The Costs of Poor Health Literacy: Estimated to be $50+* billion/year!

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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Module 1

Why are those with inadequate literacy at risk?

  • Increased reliance on printed handouts for patient instruction

  • Increasingly complex health system

    • More medications

    • More tests and procedures

    • Growing self-care requirements


Changes in the health care system l.jpg

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

(M&R Guidelines)

10,000 +

outpatient

0-3 hours diabetic

education classes

written materials

internet

telemedicine

Module 1

Changes in the Health Care System

35 Years Ago

Today

Treatment of Acute Myocardial Infarction

Available Prescription Drugs

Treatment of new onset diabetes


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Module 1

Inadequate health literacy increases with age…

%

Gazmararian, et al. JAMA 1999


Exercise l.jpg

Module 1

Exercise :

  • What is it like to have low health literacy?


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Module 1

What can we do to help?

  • 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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Module 1

Video: The patient’s voice...

  • 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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Module 1

Two specific goals to enhance health literacy…

  • Create a shame-free environmentwith improved patient assessment

  • Improve interpersonal communication with patients


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Module 2

Goal #1: Creating a “Shame-Free” Environment

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


Strategy 1 adopt an attitude of helpfulness l.jpg

Module 2

Strategy # 1: Adopt an Attitude of Helpfulness….

  • 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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Module 2

Strategy #2: Create a Safe, Non-judgmental Environment...

  • Provide privacy for all discussions

  • Ask and listen before you advise

  • Give the patient time to respond

  • Take the patient’s 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


Strategy 3 be alert to clues of low health literacy using assessment to address literacy issues l.jpg

Module 2

Strategy #3: Be alert to clues of low Health Literacy…Using assessment to address literacy issues….

  • Be alert for “red flags”

  • Use the “social history” to assess literacy

  • Use “medication reviews” to identify and address problems


Red flags patients may seek to protect themselves by l.jpg

Module 2

Red Flags:Patients may seek to protect themselves by….

  • 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


Red flags patient communication l.jpg

Module 2

Red Flags:Patient Communication

  • Unable to name medications, or explain purpose or timing of administration

  • Difficulty explaining medical concerns

  • Has no questions


Red flags lack of follow through l.jpg

Module 2

Red Flags:Lack of follow-through

  • Incomplete registration forms

  • Frequently missed appointments

  • Skipped tests and referrals

  • Non-compliant with meds


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Module 2

Use the “social history” to ask:

  • Ask about education, reading, learning styles – be non-judgmental.

  • Use this discussion to open a space for the patient to talk about literacy issues.


Use a medication review to identify problems l.jpg

Module 2

Use a “medication review” to identify problems:

  • 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


Exercise planning for medication reviews l.jpg

Module 2

Exercise :Planning for Medication Reviews

  • 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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Module 2

Strategy #4: Engage the entire staff…(or, what is it like being a patient in your setting?)

  • 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?


All staff need to be involved in l.jpg

Module 2

All staff need to be involved in…..

  • 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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Module 2

Goal # 2: Improving Communications with Patients

2 Key Strategies:

  • Improving Face-to Face Communications

  • Improving Written Patient Education Materials


Strategy 1 enhancing face to face communications with patients l.jpg

Module 3

Strategy #1: Enhancing face-to-face communications with patients:

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


1 conduct patient centered visits l.jpg

Module 3

1. Conduct patient-centered visits

  • Engage in a dialogue with the patient

  • Listen more and speak less

  • Encourage questions

  • Understand and address the patient’s concerns.


2 explain things clearly using plain language l.jpg

Module 3

2. Explain things clearly using plain language.

  • 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”


Exercise practice using plain non medical language l.jpg

Module 3

Exercise : Practice using plain, non-medical language

  • Anti-inflammatory

  • Benign

  • Contraception

  • Hypertension

  • Echocardiogram


3 focus on key messages and repeat l.jpg

Module 3

3. Focus on key messages and repeat.

  • Limit information by focusing on 1-3 key messages per visit

  • Review each point and repeat several times

  • Have other staff reinforce key messages.


Exercise what s the key message l.jpg

Module 3

Exercise : What’s the Key Message?

Type II DM diagnosed at today’s 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


4 use teach back or show me techniques l.jpg

Module 3

4. Use “teach back” or “show me” techniques.

  • 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?” .


Strategy 2 developing patient friendly written educational materials l.jpg

Module 3

Strategy # 2: Developing patient-friendly written educational materials:

  • 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.


Exercise simplifying patient handouts example strep throat l.jpg

Module 3

Exercise : Simplifying Patient Handouts Example: Strep Throat

  • 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.


Guidelines for creating patient friendly written materials l.jpg

Module 3

Guidelines for creatingpatient-friendly written materials:

  • 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.


Review five steps to enhance your interactions with patients l.jpg

Module 3

Review: Five steps to enhance your interactions with patients

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.


In summary l.jpg

Module 2

In Summary:

  • 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


In summary what can we do to help l.jpg

Module 1

In Summary: What can we do to help?

  • Strategies for change include:

    --- Creating shame-free

    healthcare environments

    --- Improving communications

    ---Face to face with patients

    ---Simplified written handouts


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