Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy

September 19, 2012 Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the ...
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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy

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Welcome to Today’s Medical Education Program! • I am pleased to be here with you on behalf of Merck, who is sponsoring this medical education program. • The program that you are participating in is not an accredited Continuing Medical Education program. • The information presented throughout the program will be consistent with FDA guidelines.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

What Is Health Literacy? Institute of Medicine1

American Medical Association2

Evolving3…

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions The ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment The inclusion of health care professionals and their responsibilities,4 etc

1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004. 2. American Medical Association. amaassn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program.shtml. Accessed November 5, 2010. 3. Baker DW et al. J Gen Intern Med. 2006;21:878–883. 4. US Department of Health and Human Services. health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. Accessed November 5, 2010.

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Health Literacy Gap

Individual Skills & Abilities

Complexity & Demands of Health & the Health Care System

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Health Literacy Is Dynamic  Health literacy demands can change over time and differ by setting and circumstance1 – Age (eg, young adult vs senior citizen) – Life event (eg, birth of a child, menopause) – Medical condition (eg, new diagnosis, chronic illness)

12 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

Why Is Health Literacy Important?  Health literacy affects an individual’s ability to1: – – – – – – – –

Understand how to take medicines Share personal information, such as a health history Locate appropriate providers and services Manage chronic diseases Select and obtain a health insurance plan Fill out complex forms Act on health-related news and public health alerts Promote healthy families and communities

13 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Who Is Affected By Health Literacy?  Health literacy can affect anyone, but certain populations are affected to a greater extent.1,2  Practitioners who have worked with low-literacy patients for years are often surprised at the poor health literacy levels of some of their most poised and articulate patients.

 Populations disproportionally affected by limited health literacy1,2 – Adults over the age of 65 years – Racial and ethnic minorities – People with less than a high school degree or GED – Recent refugees and immigrants – People with incomes at or below the poverty level – Non-native speakers of English

 Do not make assumptions; practice universal health literacy precautions with all patients.3 1. Kutner M et al. The Health Literacy of America’s Adults. US Department of Education, Institute of Education Sciences, National Center for Education Statistics; 2003. 2. US Department of Health and Human Services. health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. Accessed November 5, 2010. 3. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

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Cultural Context Is an Important Component of Health Literacy  Culture influences several determinants in health literacy1 – Comprehension – Decision-making – Motivation to action

 Cultural beliefs affect1: – How people think and feel about their health and health problems – When and from whom people obtain their health care – How people respond to health care interventions – Treatment adherence – How people respond to recommendations for lifestyle change

17 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

How Big Is the Problem? (continued) 100% 90%

12%

Define a medial term from a complex document Calculate an employee’s share of health insurance costs

80% 70% 60%

Proficient

53%

50%

Intermediate Determine a healthy weight from a BMI chart Interpret medication drug labels

40%

Basic

30% 20%

22%

10% 0%

14%

Give 2 reasons why a person with no symptoms of a disease should be tested, based on a pamphlet

Below Basic Recognize what you are allowed to drink before a medical test

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1. Kutner M et al. The Health Literacy of America’s Adults. US Department of Education, Institute of Education Sciences, National Center for Education Statistics; 2003.

Health Care Professionals’ Recognition of Health Literacy Issues May Be Limited  Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy1  A survey of health professionals and educators has shown that less than a third were aware of2: – Issues surrounding health literacy – Available resources – Their institutional policy or goals to address health literacy

1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004. 2. Brown DR et al. J Allied Health. 2004;33:150–155.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Physicians May Be Unaware of a Patient’s Health Literacy  Some patients with limited health literacy1: – Have completed high school or college – Are well-spoken – May look over written materials and say they understand – Hold white-collar or health care jobs – Function well when not under stress

 Patients often use coping mechanisms that mask their problem3

 Coping mechanisms and behaviors2 – Behaviors • Frequently missed appointments

– Responses to questions about medications • Unable to name medications • Unable to explain what medications are for • Unable to explain timing of medications

– Responses to written material • I forgot my glasses. Can you read this to me? • Let me take this home, so I can discuss it with my family

1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010. 2. Weiss BD. Health Literacy and Patient Safety. American Medical Association Foundation and American Medical Association; 2007. 3. Parikh N. Patient Educ Counsel. 1996; 27:33–39.

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Health Literacy Challenges Are Increasing1         

Increase in chronic disease care and self-management Proliferation of consumer information available from numerous and diverse sources Need to coordinate care across multiple complex networks Increased use of technologies Need to understand complex health insurance options Limitations on provider time Increased individual involvement in health care choices Legal and regulatory requirements New demands and challenges of widespread EMR adoption and usage 25

EMR=electronic medical record. 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Chronic Disease: A Growing Challenge  Nearly one half of Americans have 1 or more chronic diseases.1,2  Chronic diseases account for 70% of all deaths in the United States.2,3  75% of US health-spending dollars are spent on treating patients with chronic diseases.2

Total US Population

45% Chronic Disease

125 million Americans have at least 1 chronic disease.1,2

1. Wu SY et al. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Health; 2000. 2. Partnership to Fight Chronic Disease. fightchronicdisease.org/pdfs/2009_PFCDAlmanac.pdf. Accessed November 5, 2010. 3. Kung HC et al. Nat Vital Stat Rep. 2008;56:1–120.

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Chronic Disease and Health Literacy Health System1  Advances in the care of chronic diseases – Availability of home-monitoring tools – New therapeutic options – Risk factor modification for prevention of comorbid conditions – Disease management programs

Patient1  Self-management in chronic disease care – Remember self-care instructions – Be able to correctly interpret symptoms or results of selfmonitoring – Be able to problem-solve adjustments to treatment – Know when/how to contact health professionals

29 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Health Literacy Affects Health Outcomes1  Knowledge about medical conditions and treatment  Use of preventive services  Rates of hospitalization  Health status  Medical costs  Patient safety

Health Literacy

Health Health Outcomes Outcomes

31 1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

Use of Preventive Services  Individuals with low health literacy are likely to skip important preventive services – – – –

Immunizations1 Mammograms1 Pap smears1 Colorectal cancer screening2

32 Pap=Papanicolaou. 1. Scott TL et al. Med Care. 2002;40:395–404. 2. Dolan NC et al. J Clin Oncol. 2004;22:2617–2622.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Knowledge of Medical Conditions and Treatment  Patients with limited health literacy skills have less knowledge of their illness and its management. – – – –

Asthma1 Diabetes2 High blood pressure2 HIV/AIDS3,4

AIDS=acquired immunodeficiency syndrome; HIV=human immunodeficiency virus. 1. Williams MV et al. Chest. 1998;114:1008–1015. 2. Williams MV et al. Arch Intern Med. 1998;158:166–172. 3. Kalichman SC et al. Am J Prev Med. 2000;18:325–331. 4. Kalichman SC et al. J Int Assoc Physicians AIDS Care. 2008;7:317–323.

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Rates of Hospitalization Study of 3,260 Elderly Managed Care Enrollees3

 Patients with limited literacy skills are less likely to follow up after abnormal test results.5

Hospitalized Once

Hospitalized 2 or more times

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15

Hospitalized, %

 Patients with limited health literacy have greater rates of hospital visits and admissions.1–4

10

5

0 Adequate

Marginal

Inadequate

Health Literacy

Patents with limited health literacy were more likely to be hospitalized 2 or more times. 1. Baker DW et al. Am J Public Health. 1997;87:1027–1030. 2. Baker DW et al. J Gen Intern Med. 1998;13:791–798. 3. Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admissions among Medicare managed care enrollees. Am J Public Health. 2002;92:1278–1283. 4. Gordon MM et al. Rheumatology. 2002;41:750–754. 5. Lindau ST et al. J Gen Intern Med. 2006;21:829–834.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Health Status  Individuals with inadequate health literacy skills are more likely to report their health as poor than persons with adequate health literacy skills.1–3

1. Baker DW et al. Am J Public Health. 1997;87:1027–1030. 2. Baker DW et al. Am J Public Health. 2002;92:1278–1283. 3. Kutner M et al. The Health Literacy of America’s Adults. US Department of Education, Institute of Education Sciences, National Center for Education Statistics; 2003.

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Medical Costs  Individuals with limited health literacy skills make greater use of services designed to treat complications of disease and less use of services designed to prevent complications.1–4  Patients with limited health literacy skills have greater rates of hospitalization and use of emergency services.2–4 Greater use is associated with greater health care costs.5,6  Low health literacy costs the US health system $106–$238 billion annually.7

1. Scott TL et al. Med Care. 2002;40:395–404. 2. Baker DW et al. J Gen Intern Med. 1998;13:791–798. 3. Baker DW et al. Am J Public Health. 2002;92:1278–1283. 4. Gordon MM et al. Rheumatology. 2002;41:750–754. 5. Howard DH et al. Am J Med. 2005;118:371–377. 6. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of 36 Medicine. The National Academies Press; 2004. 7. Vernon JA et al. Low health literacy: implications for national health policy. University of Connecticut, National Bureau of Economic Research, 2007.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Patient Safety  Patients with low literacy have difficulty understanding prescription pharmacy warning labels.1

How would you take this medicine?2

 Examples1:  

46% misunderstood 1 or more of the labels 38% with adequate literacy misunderstood at least 1 label

37 1. Davis TC et al. J Gen Intern Med. 2006;21:847–851. 2. Davis TC et al. Ann Intern Med. 2006;145:887–894.

Incorporate Mindfulness  Be mindful of the patient’s perspective, including his or her access to care, attitudes, behavior, culture, demographics, language, literacy skills, socioeconomic status, and spiritual beliefs1,2

39 1. US Department of Health and Human Services. health.gov/communication/literacy/quickguide/healthinfo.htm. Accessed November 5, 2010. 2. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Strategy 1: Use Plain Language     

Slow down1 Limit content1 Avoid medical and scientific jargon2,3 Use the patient’s own words whenever possible1 Consider: – Using familiar analogies to explain physiologic processes and medical explanations – Avoiding vague terms and statistics

1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010. 2. Weiss BD. Health Literacy and Patient Safety. American Medical Association Foundation and American Medical Association; 2007. 3. Office of Disease Prevention and Health Promotion. health.gov/communication/literacy/quickguide/factsbasic.htm. Accessed November 5, 2010.

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Strategy 2: Focus on Need to Know and Need to Do  Focus on what patients need to know and need to do for1: – taking medicine, self-care, referrals, follow-ups, filling out forms  Consider organizing information so that what the patient needs to do comes first. Then repeat what the patient needs to do as you explain why it is necessary. Action first: “Check your blood sugar frequently.” Explanation second: “You need to check your blood sugar frequently to adjust your insulin dose. This will help avoid the high and low blood sugars that can lead to complications.” 44 1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Strategy 3: Use Teach-Back Method1  Teach-back is asking the patients to repeat what they need to know or do in their own words.  It is not a test of the patient’s knowledge. It is a way to check for understanding and, if necessary, reteach the information.  For more than 1 concept, you should chunk and check. – Present 2 to 3 pieces of information and then check for understanding using the teach-back method.

Teach-Back Explain

Assess understanding

Clarify misunderstanding

repeat

Understanding 45

1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

Teach-Back Examples Teach-Back Scripts1  “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?”  “We covered a lot about your diabetes, and I want to make sure that I explained things clearly. So let’s review what we discussed. What are the 3 things that will help you control your diabetes?”  “What are you going to do when you get home?” Teach-back resource: Teach-back video (North Carolina Program on Health Literacy) nchealthliteracy.org/teachingaids.html 46 1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Strategy 4: Encourage Questions to Solicit Understanding1 Encourage Questions1

Encourage questions resource :

1. Solicit questions • •

What questions do you have? That was a lot of information. What do I need to go over again?

2. Use body language that invites questions • • •

Sit at the same level as patient Look at patients when talking and listening Don’t appear rushed

Agency for Healthcare Research and Quality nchealthliteracy.org/toolkit

Avoid: Do you have any questions? Do you understand?

3. Involve entire staff in soliciting questions

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1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

Provide a Patient-Centered Environment    

Welcome patients with a warm greeting.1 Provide help with forms.1 Ensure signs are easy to read.1 Encourage an attitude of helpfulness by all staff2: – – – –

When scheduling appointments During office check-ins When providing patients with information When referring patients

49 1. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010. 2. Weiss BD. Health Literacy and Patient Safety. American Medical Association Foundation and American Medical Association; 2007.

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September 19, 2012

Alliance Learning Circle: Clearly Confusing or Crystal Clear Communication? Communicating a Clear Path Forward: Understanding the Challenges of Health Literacy Andrew Pleasant, PhD, Canyon Ranch Institute

Summary  Health literacy is the ability to obtain, process, and understand health information to make informed decisions about health care.1  Issues related to health literacy can affect anyone.2,3  Health literacy impacts health outcomes.1  A universal health literacy approach fosters clearer communication with everyone.4

1. Nielsen-Bohlman L et al, eds. Health Literacy: A Prescription to End Confusion. Institute of Medicine. The National Academies Press; 2004. 2. Kutner M et al. The Health Literacy of America’s Adults. US Department of Education, Institute of Education Sciences, National Center for Education Statistics; 2003. 3. US Department of Health and Human Services. health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. Accessed November 5, 2010. 4. Agency for Healthcare Research and Quality. nchealthliteracy.org/toolkit. Accessed November 5, 2010.

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Thank you for attending this Medical Education Program! • I appreciate your attention to my presentation today, which was conducted on behalf of Merck. • The program you participated in is not an accredited Continuing Medical Education program. • The information presented throughout the program was consistent with FDA guidelines.

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