Findings from the Health Literacy Environment Screening Pilot Project Lauren Antler June 10, 2010 HIV Quality of Care Advisory Committee Meeting

Background

Objectives 1. Gather feedback on the health literacy

environment screening process - Feasibility and usefulness of the information gathered

2. Gather feedback on various health

literacy environment screening tools -Strengths and weakness of various tools, as well as screening tool preferences

Participating Sites Callen-Lorde Community Health Center Evergreen Health Services AIDS Community Services of Western New York, Inc.

Erie County Medical Center (ECMC) Immunodeficiency Clinic Columbia-Presbyterian: Harkness 6 Infectious Disease Clinic Wellness Center at Port Morris Albert Einstein College of Medicine, Division of Substance Abuse

Overview Participants: 5 sites volunteered to participate Lauren Antler (AI), on-site evaluator (one or more), consumer (when available) Procedure: Prior to site visit, sites were sent: – –

Soft copies of the screening tools “Pre-Site Visit” worksheet

Two screening tools were tested (4 out of 5 sites); screening tools were completed by multiple reviewers Screening visits lasted anywhere from 2.5-4.5 hours After visit, sites were sent: – Spreadsheet, tabulating the ratings of each reviewer – “Summary and Feedback” Sheet

Screening Tool 1: Rudd & Anderson Screening Tool Published in 2007 Focuses on the following 5 areas: 1. 2. 3. 4. 5.

Navigation Print Communication Oral Exchange Technology Policies and Protocols

Rudd RE, Anderson JE. 2007. The Health Literacy Environment of Hospitals and Health Centers. Partners for Action: Making Your Healthcare Facility LiteracyLiteracy-Friendly. Cambridge MA: National Center for the Study of Adult Learning and Literacy. Also on line at: www.hsph.harvard.edu/healthliteracy and www.ncsall.net. www.ncsall.net. p. 7.

Rudd & Anderson Screening Tool

Rudd RE, Anderson JE. 2007. The Health Literacy Environment of Hospitals and Health Centers. Partners for Action: Making Your Healthcare Facility Literacy-Friendly. Cambridge MA: National Center for the Study of Adult Learning and Literacy. Also on line at: www.hsph.harvard.edu/healthliteracy and www.ncsall.net. p. 7.

Screening Tool 2: AHRQ “Health Literacy Universal Precautions” Screening Tool “AHRQ Health Literacy Universal Precautions Toolkit”, published in April 2010 Toolkit contains a practice assessment tool, as well as specific intervention tools Focuses on the 4 following areas: – – – –

Improve written health information Improve patient-provider communication Improve patient self-management and empowerment Improve supportive systems http://www.nchealthliteracy.org/toolkit/

AHRQ “Health Literacy Universal Precautions” Screening Tool

http://www.nchealthliteracy.org/toolkit/

Findings from Health Literacy Environment Assessments

Areas of Strength Noted Across Sites Oral Exchange: – All Sites rated as “High” in this category

Need for Improving Health Literacy Noted Across Sites: 1. Build staff awareness of health literacy//

include health literacy in staff orientation (5/5 sites)

2. Improve readability of written patient

materials//develop formalized procedure to review written materials (5/5 sites) 3. Improve facility/HIV clinic signage (4/5 sites) 4. Develop list of literacy resources in the community (3/5 sites)

Need for Improving Health Literacy Noted Across Sites: 5. Improve client satisfaction surveys to address health literacy issues (i.e., navigation/ physical layout of the facility, effective communication) (2/5 sites)

6. Enhance use of audio-visual materials with patients (2/6 sites) 7.

Improve automated telephone system (2/6 sites)

8.

Improve availability of translation services (1/6 sites)

Feedback on the Screening Process

Feedback on Various Screening Tools: Rudd & Anderson Tool

AHRQ Tool

A. Overall screening process

2.89

2.80

B. Screening tool

2.39

2.80

C. Usefulness of rating scale

2.44

2.60

D. Feasibility of conducting screen annually

2.44

3.00

E. Feasibility of conducting screen by category

2.56

2.60

F. Usefulness of information gathered

2.67

3.00

G. Applicability of information gathered for QI

2.78

3.00

H. The need for additional training for sites to engage in this screening process on their own

2.44

2.80

Overall Average Score:

2.58

2.83

1= Not Useful

2= Somewhat Useful

3= Very Useful

Summary: Feedback on Screening Process Screening Tool: – Sites preferred the AHRQ rating scale – All sites expressed a preference for AHRQ tool – Sites felt that useful information was gathered from both tools

Overall Screening Process: – Feedback was overwhelmingly positive – Sites feel comfortable conducting screen on their own

Summary: Feedback on Screening Process Feasibility of Annual Screen: – All reviewers felt confident that conducting an annual screen with AHRQ tool was realistic (3.00 rating) – Majority of reviewers felt an annual review using both tools was feasible

Information Gathered: – Sites felt strongly that information gathered was useful – Sites felt strongly that areas for improvement were identified through this process

Challenges Faced & Preliminary Recommendations

Challenges in Evaluating the Health Literacy Environment Subjective tools – Low inter-rater reliability – Dependant on sites’ willingness to be self-critical

Challenge for an outside reviewer – Difficult to assess oral communication based on observation of limited interactions

Written materials assessment – Scoring is variable, depending on which patient material you choose to assess

Signage and HIV care – Subtleness/ discreetness about signage – Potential barriers to testing/ identification/ navigation of HIV facility

Recommendations Based on piloting the assessment tools, the following recommendations are proposed: Include a separate health literacy question in the existing QM Organizational Assessment tool – i.e. “Has the facility conducting an assessment of the health literacy environment in the last 12 months?”

Enable HIV programs to self-evaluate their organizational health literacy using recommended assessment tools Based on results of baseline screen, link area(s) for focused with QI activity Re-evaluate on an annual basis – Reassess entire environment

Thank You Callen-Lorde: – Sue Weiss, FNP-CS, AAHIVS – Anita Radix, MD

Evergreen Health Services: – Laura Pasquarella – Leland Vann

ECMC: – –

Katie Walsh Leland Vann

Columbia-Presbyterian: – Susan Olender, MD – Pete Gordon, MD

Wellness Center at Port Morris: – Kelly Ramsey, MD

References Agency for Health Care Research and Quality (AHRQ): Health Literacy Universal Precautions Toolkit, April 2010 Health Literacy Assessment Questions: http://www.nchealthliteracy.org/toolkit/tool2A.doc

Rudd RE, Anderson JE. 2007. The Health Literacy Environment of Hospitals and Health Centers. Partners for Action: Making Your Healthcare Facility Literacy-Friendly. Cambridge MA: National Center for the Study of Adult Learning and Literacy. P. 926. Also on line at: www.hsph.harvard.edu/healthliteracy and www.ncsall.net

Additional Resources See handout, “Selected Resources: Eliminating Literacy-Related Barriers At Your Facility” – List of available health literacy environment screening tools – List of selected resources to eliminate literacy related barriers at your facility