UAMS TRI Grand Rounds July 15, 2015 Cliff Coleman, MD, MPH Oregon Health & Science University...

Curriculum Transformation:

Integrating Health Literacy Teaching in Medical Education

UAMS TRI Grand RoundsJuly 15, 2015

Cliff Coleman, MD, MPHOregon Health & Science [email protected]

“Communication works for those who work at it”

-- John Powell, composer

Funding support:

National Cancer Institute grants number 5K07 CA121457-05 and 3K07 CA121457 04S2 (Behavioral & Social Sciences as Core Elements of the Medical School Curriculum)

Health Resources and Services Administration grant number 1D58 HP15234 01-00 (Curriculum Activities for Learning Mood Disorders and Community Approaches to Residency Education (CALM CARE))

Disclosure statement

1. Describe the state of research in health literacy education for medical professionals

2. Identify a set of educational competencies which underpin health literacy best practices

3. Describe the experience of one institution integrating health literacy training into a case-based curriculum

Learning objectives

Overview

Brief review of health literacy educational research

Health literacy educational competencies development and prioritization

The OHSU experience Lessons learned and next steps

Health literacy educational research

“Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy”

“Professional schools and professional continuing education programs in health and related fields, including medicine, dentistry, pharmacy, social work, anthropology, nursing, public health, and journalism, should incorporate health literacy into their curricula and areas of competence”

(Neilsen-Bohlman et al, 2004, p161)

IOM health literacy report, 2004

(Coleman, Kurtz-Rossi, McKinney, Pleasant, Rootman, & Shohet, 2008)

Healthcare professionals lack adequate knowledge, skills and attitudes

Many best practices for effective communication with low health literacy patients are not routinely used

Calls to improve HL training (e.g., HP 2020, IOM, Joint Commission) Curricula proliferating Variety of approaches described

◦ Stand-alone◦ Series◦ Integrated

Training is effective Development of curricula slowed by lack of educational

competencies

(Coleman, 2011)

Literature review (2011)

Mackert and colleagues (2011)◦ Improved self-perceived knowledge, and planned

behaviors among non-MD volunteers

Coleman & Fromer (In press)◦ Improved self-perceived knowledge, and planned

behaviors among MD and non-MD mandatory attendees

HL educational effectiveness

(Coleman& Appy, 2012)

HL Teaching in US Med Schools 2010 survey of 133 Deans of US allopathic

schools 63 responses (47.4% response rate)

◦ 69% public; 31% private◦ 76% urban; 14% suburban; 10% rural

44 schools (72%) with HL in required curriculum

Median hours of instruction = 3 hours


Year 1 Year 2 Year 3 Year 40

10

20

30

40

50

60

70

80

90

% of respondants

HL instruction by year



Half or less using experiential instructional methods

First HL education study with long-term follow-up (12 months)

Aim: assess effectiveness of HL awareness-raising session using AMA video during Fall of 1st-year

Setting: OHSU School of Medicine, 2011 Sample:128 first-year med students

Longitudinal Training Study

(Coleman, Peterson-Perry, Bumsted, & Dillman, unpublished)

METHODS: Pre-/post-intervention survey with 12-month

pre-/post-intervention survey follow-up Survey instrument developed by Mackert &

colleagues (2011): self-perceived HL knowledge, practices and planned behaviors



METHODS:


YEAR HL TRAINING INTERVENTION

1 Pre-survey23 minute introductory video30 minute facilitated discussionPost-survey

2 HL review article pre-readingPre-survey1-hour didactic lecturePost-survey1-hour small group skill-building workshop:• Avoiding medical jargon• “Teach back”


Preliminary results Response rates:

• Year 1: 110/128 students (86%)• Year 2: 58/128 students (45%)

Immediately following a HL training, 1st-year and 2nd year medical students report broad improvements in knowledge and intentions to use health literacy techniques

Sustained improvements in awareness of prevalence, associated outcomes, and practice of limiting information after 1 year



Longitudinal Training StudyPreliminary results

Awareness-raising is effective Most improvements in self-perceived

practices and planned behavior were not sustained over 12 months among pre-clinical students

Curricula which do not include skill-building experiential training may not improve plain language or patient assessment skills

Longitudinal Training StudyPreliminary conclusions


Development of health literacy educational competencies

Literature review (2010) yielded a diverse array of recommendations (i.e., “best practices”)

• 32 Practice items

• 24 Knowledge items• 28 Skill items Competencies• 11 Attitude items

Some overlap between domains

Selection of potential competencies

(Coleman, Hudson, & Maine, 2013)

Patient-centered protocols and strategies to minimize the negative consequences of low or limited health literacy

(Barrett et all, 2008)

Health literacy practices

The knowledge, skills and attitudes which health professionals need in order to address low health literacy among consumers of health care and health information

Health literacy competencies


Specific Aim:

To develop a consensus agreement on a common set of core health literacy competencies for U.S. health professions school graduates

Methods


Design:

Modified Delphi consensus process

A commonly used method to capture expert opinions of groups

Useful when empiric evidence is lacking Use is well described in healthcare

competencies work “Modified” in that the panel met in person

initially

Methods


Identify proposed competencies (literature review)

Convene expert panel Individuals anonymously rate their agreement

with items on the list Predetermined levels of “agreement” Facilitated group discussion helps “move the

needle” on items prior to re-rating◦ Participants’ opinions important◦ Modifications suggested

Process stops when diminishing returns reached

Delphi: how it works


Best practice

Domain(s)

Competency. The learner…

Operationalization. The learner…

1. Use common words when speaking to patients

KnowledgeSkillsPractices

Knows which kinds of words, phrases, or concepts may be “jargon” to patients

• Selects jargon words from a list• Explains why jargon terms may be misinterpreted

2. Speak clearly and at a moderate pace

SkillsPractices

Demonstrates ability to speak slowly and clearly with patients

• Speech is perceived as appropriate pace, volume and clarity.• Speech is always intelligible

3. Confirm patients understand what they need to know and do by asking them to teach back directions

Knowledge SkillPractices

Routinely uses a “tech back” or “show me” technique to check for understanding

• Confirms patient’s understanding by asking patient to explain back in their own words (or show) what they have heard/seen at end of encounter• Puts onus on self, by saying “I don’t always explain things well. Tell me what you’ve heard.”

Translating best practices into measurable competencies – 3 examples

Example of consensus project rating scheme: knowledge item


Sample:

Executive leadership representatives from member organizations of the Federation of Associations of Schools of the Health Professions (FASHP):

◦ American Association of Colleges of Nursing◦ American Association of Colleges of Osteopathic Medicine◦ American Association of Colleges of Pharmacy◦ American Dental Education Association◦ Association of Academic Health Centers◦ Association of American Medical Colleges◦ Association of Chiropractic Colleges◦ Association of Schools & Colleges of Optometry◦ Association of Schools of Allied Health Professions◦ Association of Schools of Public Health◦ Association of University Programs in Health Admin◦ National League for Nursing◦ Physician Assistant Education Association

Attendees of a 2-day meeting on teaching health literacy to health professions students

St Louis, MO, October 2010 Hosted by Health Literacy Missouri and Saint Louis College of Pharmacy

Methods


Results

Age, mean (n=22) 51.9 yearsFemale (n = 21) 15 (71.4 %)WhiteNon-Hispanic

21 (95.5%)21 (95.5%)

Years in health professions education, mean (n = 22) 19.1 yearsBackground in direct patient care (n = 21) 19 (90.5%)Highest level of education attained (n= 20)

Bachelor’sMaster’sDoctorate

1 (5%)1 (5%)18 (90%)

“Would your peers consider you to have expertise on the topic of health literacy?” (n = 22) YES NO

16 (72.7%)6 (27.3%)

22 FASHP participants


Round One

Round Two

Round Three

Round Four

TotalAccepte

dCompetencies

Knowledge Items 19/24 5/5 -/- -/- 24/24

Skills Items 21/28 2/4* 2/3† 2/3 27/29

Attitude Items 11/11 -/- -/- -/- 11/11

Competencies Total 51/63 7/9 2/3† 2/3 62/64

Practice Items 26/32 4/6 2/3** 0/1 32/33

Total 77/95 11/15 4/6 2/3 94/97

Results62 competencies and 32 best practices accepted after 4 rounds


Limitations of current list and Rationale for a prioritized list

HL practices prioritization study

“Reverse design” starts with desired behaviors (the practices) and works back to the competencies (knowledge, skills & attitudes)

Aligning practices with underlying competencies

1) Rank order the identified health literacy practices

2) Align the competencies (knowledge, skills and attitudes) with the ranked practices

Aims

Q-sort method: Validated method Prioritizes subjective opinions Quantitative means of assessing qualitative

data Used to rank learning objectives for health

professionals (e.g., Meade at al, 2013)

Methods

Start with list of 32 HL practices Convene approximately 45 HL experts Sort items from most important to least

important onto a quasi-normal distribution grid

Analyze group data using standard Q-sort analysis (Meade et al, 2013)

Q-sort procedure

Most important

Neutral Least important

The OHSU Experience

Current OHSU HL curriculumYEAR

INSTRUCTIONAL METHOD ASSESSMENT METHOD

1 23 minute introductory video30 minute facilitated discussion

Multiple choice questions

2 Review article reading1-hour didactic lecture1-hour small group skill-building workshop:• Avoiding medical jargon• “Teach back”

Multiple choice questions

3 None OSCE HL case

4 None None

Moving from systems-based to case-based curriculum

Organized in 7 blocks of related systems Clinical & science “threads” run

longitudinally Compressing pre-clinical curriculum to 18

months Competency-driven

Curriculum Transformation:Guiding principles

Focus on high impact teaching

3. Instructional method

2. Assessment method

1. Learning objective

(Competency)

Interview

Physical Exam

Community / Population Health

Health Systems

Social Determinants / Society

Anatomy/Embryology/Histology

Physiology / Pathophysiology

Immunology

Pharmacology

Diagnostic studies

Self-management

Clinical Assessment

DX / Clinical reasoning

Differential Diagnosis

Case presentations / Write-ups

Clinical management

Pharmacotherapeutics Procedural intervention

“Out”

“In”

Counseling

Quality / Safety / Triple Aim

Clinical ContextHealth LiteracyFamily System

Foundational knowledge

Clinical Skills

& Procedures

Communicatio

n Ethics

Professionalism

Health Syste

ms

& PolicyEBM,

Epidemiology

, Inform

atics

Genetics

Microbiology

MEDICAL KNOWLEDGE

PATIE

NT C

AR

E &

PR

OC

ED

UR

AL S

KILLS

INTER

PER

SO

NA

L &

CO

MM

UN

ICATIO

N

SK

ILLS

PROFESSIONALISM

PRACTICE BASED LEARNING & IMPROVEMENT

SYSTEMS BASED PRACTICE

Clinical Proble

m& Contex

t

Biochemistry / Nutrition

(Figure courtesy of Judith Bowen, MD, 7/7/14)

General health communication Health literacy Cultural competency Limited English proficiency Motivational interviewing Shared decision making Special communications (bad news,

“difficult” patients, adolescents, etc)

Health Communication Thread

Case: Mr. Morales is a 45-year-old car mechanic with type 2 diabetes. He was born in Mexico, did not complete high school, and speaks English as a second language. He now requires transition to insulin therapy because of failed lifestyle management and oral antidiabetic medication therapy. His attempts at weight loss were challenged by the need to participate in family social gatherings and to show appreciation for his wife and mother’s cooking. His primary care physician had sent him to a dietician who provided him with information about an 1800 calorie diet from the American Diabetes Association. He did not understand the written instructions and did not share them with his wife. He also believes that insulin causes blindness and kidney failure and does not intend to use insulin but will instead use Mexican remedies such as prickly pear, offered by his mother.

(Lie, Carter-Pokras, Braun B, & Coleman, 2012)

Case example

Knowledge (cognitive) objectives◦ Focus on rationale for using a “universal precautions

“approach to health communication

Skills (behavioral) objectives◦ Focus on best practices for spoken and written

communication (awaiting prioritization)◦ Focus on developing “habits” for patient-centered

communication

Attitudes (affective) objectives◦ Focus on deployment of universal precautions approach◦ Focus on developing “habits” for patient-centered

communication

Managing the HL competencies

Blends several models for patient-centered communication

Adds health literacy practices

Observable

(Putnum, 2014; Coleman et al, 2013; Baker et al, 2012; Mauksch, 2011; Stein et al, 2005)

The “habits” model

1. Make a positive connection2. Establish an agreed upon agenda3. Facilitate understanding4. Confirm understanding

4 Habits for patient-centered communication

Habit 1: Makes positive connectionEnters room at an unhurried paceSits at patient’s levelMake eye contact to match patient’s style Introduces self to all in the roomGives full attention for first 30 seconds Makes an empathic statement during the

history

Elicits the patient’s full set of concerns at the outset

Negotiates an agreed upon agenda which addresses the patient’s main concern(s) and expectations

Habit 2: Negotiates shared agenda

Speaks slowly and clearly Follows a “universal precautions” approach,

assuming that all patients are at risk for miscommunication

Avoids jargon / uses plain languageSummarizes the plan for addressing the

patient’s main concern(s)

Habit 3: Facilitates understanding

Asks “what questions do you have?”Uses “teach back” to confirm understanding

Habit 4: Assesses understanding

Challenges, lessons learned & next steps

Lack of integrated competencies Lack of faculty role models Case-based and competency-driven

curriculum requires increased faculty development (instruction and assessment)

Lack of validated assessment methods Lack of down-stream outcomes data Pre-clinical period may not offer enough

patient exposure for best practices to take hold

Challenges, lessons learned & next steps

“Communication works for those who work at it”

-- John Powell, composer

Baker LH, Cordaro DT, Platt FW. The first minute. Medical Encounter 2012;26(2):83-4

Barrett SE, Puryear JS, Westpheling K. Health literacy practices in primary care settings: examples from the field. January 2008. Available at http://www.commonwealthfund.org

Coleman C. Teaching Healthcare Professionals about Health Literacy: A Review of the Literature. Nursing Outlook 2011;59:70-78

Coleman C, Appy S. Health literacy teaching in U.S. medical schools, 2010. Family Medicine, 2012;44(7):504-7

Coleman C, Fromer A. “A Health Literacy Training Intervention for Physicians and Other Health Professionals.” Family Medicine, In press

References

http://www.commonwealthfund.org/

Coleman C, Hudson S, Maine L. “Health Literacy Practices and Educational Competencies for Health Professionals: A Consensus Study.” Journal of Health Communication 2013;18:82-102

Coleman C, Kurtz-Rossi S, McKinney J, Pleasant A, Rootman I, Shohet L. The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. The Centre for Literacy of Quebec. Available at http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2011.pdf. Accessed 5/1/14

Lie D, Carter-Pokras O, Braun B, Coleman C. “What Do Health Literacy and Cultural Competence Have in Common? Calling for a Collaborative Health Professional Pedagogy.” Journal of Health Communication, 2012;17:13-22

Mackert M, Ball J, Lopez N. Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques. Patient Education and Counseling, In press (2011)

Mauksch L. Patient Centered Observation Form. ©University of Washington Department of Family Medicine, May, 2011. Available at http://depts.washington.edu/fammed/files/PCOF%205.16.2011_0-2.pdf. Accessed 5/28/14

References

http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2011.pdf.%20Accessed%205/1/14

http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2011.pdf.%20Accessed%205/1/14

Meade LB, Caverzagie KJ, Swing SR, Jones RR, O’Malley CW, Yamazaki K, Zaas AK. Playing with curricular milestones in the educational sandbox: Q-sort results from an Internal Medicine educational collaborative. Academic Medicine 2013;88(8):1142-8

Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Institute of Medicine of the National Academies, Board on Neuroscience and Behavioral Health, Committee on Health Literacy. Washington, D.C.: The National Academies Press, 2004

Putnam JB. Teaching Physician-Patient Communication (AIDET) for Results in All Pillars. Available at http://www.studergroupmedia.com/WRIHC/presentations/teaching_physician_patient_communication_(aidet)_for_results_in_all_pillars_vanderbilt_putnam_kennedy_0028.pdf. Accessed 5/28/14

Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Education and Counseling 2005;58:4-12

References

http://www.studergroupmedia.com/WRIHC/presentations/teaching_physician_patient_communication_(aidet)_for_results_in_all_pillars_vanderbilt_putnam_kennedy_0028.pdf



UAMS TRI Grand Rounds July 15, 2015 Cliff Coleman, MD, MPH Oregon Health & Science University...

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