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A Focus on Literacy: Communication Skills Training to Improve Outcomes Sarah Coles, MD University of Arizona College of Medicine – Phoenix Family Medicine Residency
Disclosures • I do not have any actual or potential conflicts of interest in relation to this program or presentation.
Objectives • Identify the risk factors for and the consequences of limited health literacy on healthcare outcomes. • Utilize strategies in written and verbal communication to improve communication with patients with limited health literacy. • Demonstrate interactive teaching techniques and activities that can be implemented in family medicine residency training.
Definition • The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
How Is It Measured? • The National Assessment of Adult Literacy (NALS) in 2003 – “Gold Standard” of American Literacy
How Is It Measured? • Literacy: – Three Domains: Prose, Document, Quantitative – Tested directly using real life documents • Health Literacy: – Three Domains: • Clinical: provider-patient interactions, diagnosis, treatment, and meds • Prevention: Maintaining and improving health, selfmanagement • Navigation of health care system – Informed consent falls here
0 Circle the date of a medical appointment on a hospital appointment slip. (101) Identify what is ok to drink prior to testing (145) Give two reasons a person should be tested for a specific disease, based on information in a clearly written pamphlet. (202) Below Basic Average score: 245 Determine what time a person can take a prescription medication, based on information on the drug label that relates the timing of medication to eating. (253) Intermediate 500 Proficient Calculate an employee’s share of health insurance costs for a year, using a table. (382) Slide courtesy of: www. health. gov/communication/literacy/powerpoint/healthliteracy. ppt
Literacy Categories Slide courtesy of: www. health. gov/communication/literacy/powerpoint/healthliteracy. ppt
Scary Summary of Results: • The National Assessment of Adult Literacy (NALS) in 2003 – 25% of the population as having limited literacy ability (fifth grade level or lower) – Average reading level of US adults is eighth grade. – In Arizona, approximately 13% of the population lacks even basic health literacy skills. – Only 12% of US adults have proficient health literacy
Who Is At Risk? • Elderly • Recent Immigrants • Limited education (less than high school) • Unemployed • At or below poverty line • Men > Women • Hispanic Adults • English not primary language • Adults reporting poor health • Lack of Medical Insurance, Medicare, Medicaid Percentage of adults in each health literacy level, by age: 2003
Why Do We Care? • Associated with poorer health outcomes • Poorer control of chronic disease • Higher rate of hospitalizations and rehospitalization • Underutilization of preventive health services • Increased health care costs
Literacy and Costs in Arizona • 2004 study of Arizona Medicaid patients: – Average annual cost for low literacy skill as $10, 688/year vs higher literacy skill $2, 891/year – Difference remained despite controlling for age, ethnicity, self reported health status, education level, primary language
Literacy and Re-hospitalization
Why Would This Happen? • Poorer understanding of diagnosis • Inability read medication dosing instructions – Incorrect 23. 6% of the time • Inability to read appointment slips/follow up instructions • Difficulty managing self-care instructions • Misunderstanding of medication side effects
Chronic Disease Management • Poor control in: – Heart failure – Asthma – Diabetes – Seizure disorder – Chronic anticoagulation
What’s More… • Patients remember little of what is discussed during a clinical encounter. • Written advice can improve recall and compliance with medical instructions. • Pre-written handouts provided to the patient have consistently been shown to be written at too high a reading level.
Government to the Rescue! • Centers for Medicaid and Medicare Services expect physicians to provide a clinical after visit summary (AVS) to patients following at least 50% of encounters in order to meet requirements for stage 2 of meaningful use. – AVS CMS as “an after-visit summary that provides a patient with relevant and actionable information and instructions. ”
Won’t That Fix It?
Systemic Issues • We Are Not Good At Identifying Patients with low literacy – Study evaluating residents • Identified 10% of their patients as low literacy; Actually >33% – Education Level Does Not Necessarily Correspond to Literacy Level – People Do Not Self-Report
Systemic Issues • Training – Four years of medical school and then residency to learn new vocabulary…And they want to use it – Effectively communication with physicians, the healthcare team, and the scientific community: • Not patients – Often no structured training on effective verbal and written communication in the setting of limited health literacy
Successful Clinical Interventions • Actions taken to limit harms of poor health literacy are beneficial for all of our patients – Teach Back Techniques – Ask Me 3 – Written and spoken material at less than 8 th grade level • Study demonstrates patients in all literacy levels prefer to read health information written at lower grade levels – Avoiding technical jargon – Avoiding abbreviations (HTN, DM, F/U, q anything) – Be specific
Why Now? • Physicians struggle to communicate complex medical information in a way that is both useful and understandable to the patient. • This skill is necessary to provide meaningful, quality care to our patients and empower them to understand manage their conditions.
Our Curriculum • Introduce this topic in Intern Orientation • Health Literacy Workshop – Utilizes didactic, video, role playing, small group discussion, and game based interactive teaching strategies
What Should We Include In Patient Handouts? • Positive Content Elements: – Precautions – Medication Instructions – Plain language diagnosis – Time of Next Visit • Negative Content Elements: – – Presence of acronyms Presence of jargon Presence of symbols Elevated reading level
Health Literacy Workshop Outline • Practical Breakout Session: Review of Written Information – Students provided with real-life after visit summaries and patient handout materials – Provided with “Score Card” • Asked to evaluate for clarity, literacy level, and content. – Rewrite it to be “Ideal” handout
Let’s Try It! • You will each be provided an after visit summary • Please evaluate the summary using the score card provided • Once completed, rewrite the after visit summary to be “Ideal” – Goal of the rewritten material is to improve understanding, compliance, and ultimately improve health outcomes.
How Did That Go? Regroup and Discuss: • What did you find when you reviewed your AVS? • What were some challenges you faced in rewriting these? • What are some take away lessons from this experience?
Health Literacy Workshop Outline • Video Example – http: //www. youtub e. com/watch? v=_jl 4 i. L 6 h. Cqs
Health Literacy Workshop Outline • What Grade Level Is It Game? – Utilizes Poll. Everywhere or other electronic polling – Quotes from patient handouts from familydoctor. org
Examples of Reading Levels • 5 th Grade Books: – – Wonder Diary of a Wimpy Kid Shiloh The Adventures of Captain Underpants – Charlie and the Chocolate Factory • 8 th Grade Books: – – – Hunger Games The Hobbit Coraline Maze Runner Divergent Series Little Women
What Grade Level Is It? Your doctor may be able to tell you have adhesive capsulitis just by talking to you about your symptoms and watching you move. Your doctor may press on parts of your shoulder to see what might be causing the pain. Your doctor may also want to take an X-ray or do a magnetic resonance imaging (MRI) scan of your shoulder to look for other problems. A. B. C. D. 5 th Grade 7 th Grade 9 th Grade 11 th Grade
What Grade Level is This? Constipation is a common digestive problem that makes it difficult for you to have a bowel movement. Having a bowel movement is also called “passing stool. ” A. B. C. D. 4 th Grade 6 th Grade 8 th Grade 10 th Grade
Health Literacy Workshop Outline • Practical Breakout Session: Role Playing – Students provided with real-life scenarios and asked to role play – Approximately 10 -15 minutes – One student is the “Physician” and the other a “Patient” with very limited literacy • Patient: At least 8 th grade reading level or below – Ideally: Role play 5 th grade or below
Scenario 1 • “Physician” – Discuss colorectal cancer screening through colonoscopy. Include risks, benefits, and alternatives. • “Patient” – Ask clarifying questions and don’t hold back! • Call the Physician on difficult words, jargon, or complex explanations! Ask “What does that mean? ” or intentionally misinterpret their meaning • Strategize as a team about effectively communicating this complex situation.
Scenario 2 • Switch roles! • “Physician” – Provide informed consent to the patient requiring colposcopy for an ASCUS with high risk HPV positive pap smear result. Explain what the result means and the procedure. • “Patients” – Ask clarifying questions and don’t hold back! • Call the Physician on difficult words, jargon, or complex explanations! Ask “What does that mean? ” or intentionally misinterpret their meaning • Strategize as a team about effectively communicating this complex situation.
Regroup • What went well? • What was challenging? • What strategies or word choices were effective? • What strategies or word choices were ineffective? • How did it feel to be the Physician or the Patient?
What You Say: “Your physician has recommended that you have a colonoscopy. Colonoscopy is a test for colon cancer. ” What They Hear: “Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. ” Source: AMA Foundation: Health Literacy and patient safety: Help patients understand. Barry D. Weiss, MD 2 nd edition, 2007
Health Literacy Workshop Outline • Power. Point: – Screening strategies – One Item Screen • How confident are you at filling out medical forms by yourself?
Health Literacy Workshop Outline • The Role of Shame: – Key to discussion – Significant burden on patients with limited literacy skills – Discussion: How does this impact our practice?
Caution Against Universal Screening • Risks of Screening – Increased shame and embarrassment for our patients • No proven structured intervention to improve health literacy or health outcomes • What might be indication for screening? – Consider screening or increased awareness if high risk – Have a low threshold when addressing informed consent
Recommendations • Keep an open mind about health literacy • Keep discussions and written information at least below at least 8 th grade level – Just be thinking about it. This will already bring your difficulty level WAY down • Be empathetic to your patients. There is a lot of shame around low literacy • Consider single question screening on patients at high risk; Use caution
References • • • • Berkman N, Sheridan S, Donahur K, Halpern D, Crotty K. Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine 2011; 155(2): 97 -107 Berkman N, Sheridan S, Donahur K, Halpern D, et al. Health Literacy Interventions and Outcomes. Rockville (MD): Agency for Healthcare Research and Quality (US): 2011 March. Davis T and Wolf MS. Health Literacy: Implications for Family Medicine. Fam Med 2004; 36(5): 595 -598 Estrada C, Martin-Hryniewicz M, Peek B, Collins C, ans Byrd J. Literacy and Numeracy Skills and Anticoagulation Control. American Journal of the Medical Sciences 2004; 326(2): 88 -93 Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health Literacy and 30 -Day Postdischarge Hospital Utilization. Journal of Health Communication 2012; 17: 325 -338 Peterson P, Shatterly S, Clarke C, Chan P, Allen L, Matlock D, Magid D, Masoudi F. Health Literacy and Outcomes Among Patients with Heart Failure. JAMA 2011; 303(16): 1695 -1701 Powers B, Trinh, J, and Bosworth H. Can This Patient Read and Understand Written Health Information? JAMA 2010; 304(1): 76 -84 Saffer R and Keenan J. Health Literacy: The Gap Between Physicians and Patients. American Family Physician 2005; 72(3): 463 -468 Schuartz K, Bartoces M, Campbell-Voytal K, West P, Monsur J, Sartor A, Neale A. Estimating Health Literacy in Family Medicine Clinics in Metropolitan Detroit: A Metro. Net Study. JABFM 2013; 26(5): 566 -570 Staghano V and Wallace L. Brief Health Literacy Screening Items Predict Newest Vital Sign Scores. JABFM 2013; 26(5): 558 -565 Weis BD, Mays M, Martz W, Castro K, Pigone M, Mockbee J, and Hale F. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Annals of Family Medicine 2005; 3: 514 -522 Weiss BD and Palmer R. Relationship Between health Care Costs and Very Low Literacy Skills in a Medically Needy and Indigent Medicaid Population. JABFP 2004; 17(1): 44 -47 Williams M, Baker D, Parker R, Nurss J. Relationship of Functional Health Literacy to Patients’ Knowledge of Their Chronic Disease. Arch Intern Med 1998; 158: 166 -172
Thank You! • Please feel free to contact me: Sarah Coles, MD Clinical Educator University of Arizona College of Medicine - Phoenix Family Medicine Residency Director, Longitudinal Patient Care Course University of Arizona College of Medicine – Phoenix Department of Family and Community Medicine sarah. [email protected] com
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