Geriatric Intern Rotation:Geriatric Intern Rotation:Health Literacy WorkshopHealth Literacy Workshop

Seema S. Limaye, MDSeema S. Limaye, MDSection of Geriatrics and Palliative MedicineSection of Geriatrics and Palliative MedicineUniversity of ChicagoUniversity of Chicago

GoalsGoals

Health Literacy Workshop:Health Literacy Workshop:1.1. Understand the impact of low health literacy Understand the impact of low health literacy

on our geriatric patientson our geriatric patients2.2. Develop communication skills to improve Develop communication skills to improve

patientspatients’’ understanding of their medical issues.understanding of their medical issues.3.3. Develop and utilize effective patient HO Develop and utilize effective patient HO

materials.materials.

Part I:Part I:

Functional Health LiteracyFunctional Health Literacy

Measure of person's capacity to function in the Measure of person's capacity to function in the health care setting as determined by literacy and health care setting as determined by literacy and numeracynumeracy

Literacy: comprehension of written health care Literacy: comprehension of written health care materialsmaterialsNumeracy: ability to understand and act on Numeracy: ability to understand and act on numerical health care instructions numerical health care instructions

Importance of Enhanced Importance of Enhanced Communication with Geriatric PatientsCommunication with Geriatric Patients

HighHigh--risk patients!risk patients!Cognitive impairmentCognitive impairmentImpaired Impaired sensoriumsensoriumLow functional health literacyLow functional health literacyComplicated medical history with multiple, chronic Complicated medical history with multiple, chronic medical problems and complex medical regimens.medical problems and complex medical regimens.

US Census Bureau 2000US Census Bureau 2000: :

Projected Population Growth of ElderlyProjected Population Growth of Elderly77

Whites

Blacks, American Indian/Alaska Natives, Asian and Pacific Islander, Hispanic/Latino

84%

36%64%

16%

2000 2050

U.S. Census. U.S. Census. www.census.govwww.census.gov..

National Health Disparities ReportNational Health Disparities Report

Many racial/ethnic groups as well as poor and Many racial/ethnic groups as well as poor and less educated patients report:less educated patients report:

Poor communication with their physicians Poor communication with their physicians More problems with some aspects of the patientMore problems with some aspects of the patient--provider relationships provider relationships Greater difficulty accessing healthcare information, Greater difficulty accessing healthcare information, including information on prescription drugsincluding information on prescription drugs

National Healthcare Services AHRQ, 2004AHRQ National Health Care Disparities Report 2003, AHRQ Publication, July 2003

What the Levels Mean What the Levels Mean

What the Levels MeanWhat the Levels Mean

Millions of Americans haveMillions of Americans have““Below BasicBelow Basic”” LiteracyLiteracy

Low Health Literacy OutcomesLow Health Literacy Outcomes

People with low health literacy:People with low health literacy:Use screening/preventive services lessUse screening/preventive services lessPresent for care with later stages of diseasePresent for care with later stages of diseaseAre more likely to be hospitalizedAre more likely to be hospitalizedHave poorer understanding of treatment and their own Have poorer understanding of treatment and their own healthhealthAdhere less to medical regimensAdhere less to medical regimensHave increased health care costsHave increased health care costsDie earlierDie earlier

Schwartzberg , VanGeest , & Wang , 2004.Sudore, et al, 2006.

Identifying Low Health Identifying Low Health Literacy PatientsLiteracy Patients

Identifying Low Literacy PatientsIdentifying Low Literacy Patients

Highest risk groupsHighest risk groupsDid not complete high school, minority, elderlyDid not complete high school, minority, elderly

Frequent missed appointments Frequent missed appointments Do not know names of medicinesDo not know names of medicines““I forgot my glassesI forgot my glasses””

Always comes with someone else Always comes with someone else --““surrogate readersurrogate reader””Eyes wandering over page, very slow to finish, Eyes wandering over page, very slow to finish, sounding out words, look confusedsounding out words, look confusedMimic behaviorsMimic behaviors

First Step: Bringing Up the TopicFirst Step: Bringing Up the Topic

““What things do you like to read?What things do you like to read?””““We need help fixing the information we give to We need help fixing the information we give to people, what do you think we could make people, what do you think we could make better?better?””““How far did you go in school?How far did you go in school?””Ask patient to read prescription bottle.Ask patient to read prescription bottle.

BIGGEST BARRIER: SHAME!BIGGEST BARRIER: SHAME!

Before Patients Leave Before Patients Leave ……

These questions should be answered:These questions should be answered:What health problems do I have?What health problems do I have?Why is that important to me?Why is that important to me?What should I do about them?What should I do about them?Where do I go for any tests, medicine, and Where do I go for any tests, medicine, and appointments that I need next?appointments that I need next?How should I take my medicine?How should I take my medicine?Any other instructions necessary?Any other instructions necessary?Who to call with questions?Who to call with questions?

AMA VIDEOAMA VIDEO

WorkshopWorkshop——Part II Part II TeachTeach--back Methodback Method

TeachTeach--back Methodback Method

Technique to improve communication and Technique to improve communication and confirm understanding, confirm understanding, espesp among individuals among individuals with limited literacy skillswith limited literacy skillsInvolves individuals to recall or explain in their Involves individuals to recall or explain in their own words what has been discussed. own words what has been discussed.

EgEg: : ““I always ask my patients to repeat things back I always ask my patients to repeat things back to me to make sure I explained things clearly. Ito me to make sure I explained things clearly. I’’d like d like you to tell me how youyou to tell me how you’’re going to take the new re going to take the new medicine we discussed today.medicine we discussed today.””

Copyright © 2009 Wolters Kluwer. 3

Figure 1

Closing the loop: physician communication with diabetic patients who have low health literacy

Schillinger D; Piette J; Grumbach K; Wang F; Wilson C; Daher C; Leong-Grotz K; Castro C; Bindman ABArchives of Internal Medicine. 163(1):83-90, 2003 Jan 13.

TeachTeach--back methodback method

Preferred method to confirm understanding of Preferred method to confirm understanding of consent informationconsent informationUse is advocated by National Quality Forum Use is advocated by National Quality Forum and AHRQand AHRQ

TeachTeach--back Cardsback Cards

3 cards to complete during rotation3 cards to complete during rotationRemind your attending that theyRemind your attending that they’’ll need to ll need to directly supervise you and signdirectly supervise you and sign--off on the cardoff on the card

WorkshopWorkshop——Part II Part II DirectDirect--observation checklistobservation checklist

Explain things clearly and use plain languageExplain things clearly and use plain languageEmphasize 1 to 3 key points during visit and Emphasize 1 to 3 key points during visit and repeat ideas throughout visitrepeat ideas throughout visitEffectively encourage patients to ask Effectively encourage patients to ask questionsquestions——use an openuse an open--ended approachended approachUse teachUse teach--back method to confirm patient back method to confirm patient understanding (use demonstration of skill, if understanding (use demonstration of skill, if needed)needed)Write down important information for patientWrite down important information for patient

Kripalani and Weiss, 2006.

WorkshopWorkshop——Part IIIPart III

Task: Analyze patient education Task: Analyze patient education materials: 40 minmaterials: 40 min

Tools to analyze material and provide HOTools to analyze material and provide HOHomework: revise the actual patient Homework: revise the actual patient discharge handout material and bring it back discharge handout material and bring it back to classto class

U.S. Health Literacy MandatesU.S. Health Literacy Mandates

Plain language Plain language lawslawsJoint Commission of Accreditation of Health Organizations (JC Joint Commission of Accreditation of Health Organizations (JC aka JCAHO) aka JCAHO) -- hospitalshospitals must assure and document patient must assure and document patient understanding of health care instructionsunderstanding of health care instructionsIncrease in health literacy Increase in health literacy fundingfunding initiatives (NCI, CDC, initiatives (NCI, CDC, AHCPR, others)AHCPR, others)Increase in health literacy related Increase in health literacy related researchresearchAdult Basic Education (ABE) Adult Basic Education (ABE) classesclassesIncreased emphasis on nonIncreased emphasis on non--print print mediamedia

DoakDoak, , DoakDoak, & Root, 2001, & Root, 2001

Plain Language LawsPlain Language Laws

Legislation requires use of plain language in all consumer Legislation requires use of plain language in all consumer documents (varies by state, public and private sector documents (varies by state, public and private sector agencies/organizations)agencies/organizations)

Plain language Plain language –– not not ““dumbingdumbing downdown”” but assures thatbut assures thatPeople find what they needPeople find what they needUnderstand what they findUnderstand what they findAct appropriatelyAct appropriately

www.health.gov/communication/literacy/plainlanguage

Expected HealthExpected HealthLiteracy OutcomesLiteracy Outcomes

Desired results from patient education:Desired results from patient education:Reducing health care costsReducing health care costsImproving patient outcomesImproving patient outcomesReducing errorsReducing errorsUltimately improving quality of lifeUltimately improving quality of life

In spite of the mandates, resources, and training, minimum In spite of the mandates, resources, and training, minimum competencies in health literacy skills have been difficult to competencies in health literacy skills have been difficult to achieveachieve

Schwartzberg, VanGeest, & Wang, 2004

Models of Health Care MessagesModels of Health Care Messages

In what ways can health care messages be In what ways can health care messages be delivered?delivered?

Oral Oral Written or printed informationWritten or printed informationVisualVisualTechnologicalTechnological

Creating Effective Health CareCreating Effective Health CareMessages for Older AdultsMessages for Older Adults

Realistic objectivesRealistic objectivesFocus on behaviors and Focus on behaviors and skills, less on factsskills, less on factsEstablish a context for new Establish a context for new informationinformationPartition/Partition/””chunkchunk”” complex complex instructionsinstructionsCultural values/beliefsCultural values/beliefs

Include interactive or Include interactive or experiential activity experiential activity Repeat important Repeat important informationinformationMotivate the learnerMotivate the learnerRelate to past experienceRelate to past experienceWrite for the patient, Write for the patient, notnot the the formulaformula

DoakDoak, , DoakDoak, and Root, 1996, and Root, 1996

An older learner must understand what todo and feel enabled to take action.

Ethnogeriatric ConsiderationsEthnogeriatric Considerationsfor Health Informationfor Health Information

TranslatedTranslated and and pilotpilot--testedtested messages messages Cultural Cultural appropriatenessappropriateness of topic or interventionof topic or interventionEducation levelEducation level and ability to read/write and ability to read/write Individual vs. family Individual vs. family orientationorientationCommunityCommunity support, input, and assistance from support, input, and assistance from key informants or cultural navigatorskey informants or cultural navigatorsIndigenousIndigenous /other communication methods/other communication methods

Tools for Assessing the SuitabilityTools for Assessing the Suitabilityof Health Messagesof Health Messages

How suitable is the health information?How suitable is the health information?

Understandable?Understandable?Acceptable?Acceptable?Helpful?Helpful?

Categories ofCategories ofAssessment ToolsAssessment Tools

Attribute checklistsAttribute checklists

Readability formulasReadability formulas

Suitability of Assessment of Materials (SAM)Suitability of Assessment of Materials (SAM)

Attribute ChecklistsAttribute Checklists

Simple and quick method of assessing appropriateness Simple and quick method of assessing appropriateness of health messagesof health messagesAssessment categories:Assessment categories:

OrganizationOrganizationWriting styleWriting styleAppearanceAppearanceAppealAppeal

What would be important for older

adults from different cultures?

Area Health Education Center, Biddeford, Maine

Readability FormulasReadability Formulas

Assess Assess reading difficulty reading difficulty based onbased onWord difficulty (number of syllables)Word difficulty (number of syllables)Length of sentencesLength of sentences

NotNot suitable for tables, charts, word listssuitable for tables, charts, word listsMany Many different formulasdifferent formulas existexist

MicrsoftMicrsoft Word ProgramWord ProgramSimple Measure of Gobbledygook (SMOG)Simple Measure of Gobbledygook (SMOG)Many are available in different languagesMany are available in different languages

SMOG DemonstrationSMOG Demonstration

http://www.harrymclaughlin.com/SMOG.htm

Suitability of AssessmentSuitability of Assessmentof Materials (SAM)of Materials (SAM)

Used for printed materials, illustrations, videos Used for printed materials, illustrations, videos and audio taped instructionsand audio taped instructionsValidated with different ethnic populations and Validated with different ethnic populations and different medical different medical specialitiesspecialitiesIndicates need for supplemental instructions Indicates need for supplemental instructions

DoakDoak, , DoakDoak, & Root, 1996, & Root, 1996

SAM CategoriesSAM Categories

1.1. ContentContent2.2. Literacy demandLiteracy demand3.3. GraphicsGraphics4.4. Layout and typographyLayout and typography5.5. Learning stimulation, motivationLearning stimulation, motivation6.6. Cultural appropriatenessCultural appropriateness

Doak, Doak, & Root, 1996

Ratings: Superior material; Adequate material; Not suitable

Task: Use the SAMTask: Use the SAM

Choose a patient HO material you Choose a patient HO material you frequently use or one you think may be frequently use or one you think may be usefulusefulPut the HO to the test!Put the HO to the test!

Score the HOScore the HOImprove the HOImprove the HO

ASSIGNMENTS DUEASSIGNMENTS DUE

At wrapAt wrap--up session: up session: SAM evaluation and revision of your chosen HOSAM evaluation and revision of your chosen HOJournal Club presentationJournal Club presentation

3 Direct observation cards completed and signed3 Direct observation cards completed and signed