RAISING THE BAR ON HEALTH-LITERATE PATIENT CAREA PRIORITY FOR ADVOCATES, WORKERS, AND SYSTEMS

Jennifer Muniak, MD

Geriatrics and Aging, URMC

Karen Brown, MA

Gerontology Institute, Ithaca College

CONFLICT OF INTEREST STATEMENT

This presentation is supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of

Health and Human Services (HHS) as part of the Geriatric Academic Career Award received by Jennifer Muniak. The contents

are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the

U.S. Government.”

OBJECTIVES

Define Health Literacy Universal Precautions.

Identify teach back method as effective universal precaution strategy to

improve health literacy

Recognize the RESPECT model as a means of cultural competency

Recognize the role of healthcare workers and leaders in creating health-

literate organizations

HOUSE KEEPING

Chat box will be monitored in real time – please feel free to comment or

ask questions

Please keep muted

UNDERSTANDING THE PROBLEM

Koh et al. 2012

Courtesy of Cindy Brach: “Health Literate Health Care: Making the Vision a Reality”, European Health Literacy Conference. March 15, 2019

HEALTH LITERACY

“The degree to which individuals have the

capacity to obtain, process, and understand basic

health information and services needed to make

appropriate health decisions.” (Ratzan and Parker, 2000)

CASE PART 1:

Mr. Jones is an 84 y.o. man hospitalized with a hemorrhagic CVA (bleeding stroke) thought to be secondary to non-adherence with antihypertensive medication.

The stroke has caused moderate degrees of dysarthria (trouble articulating words), dysphagia (trouble swallowing), and cognitive impairment. He will need rehabilitation in a Skilled Nursing Facility (SNF).

CASE CONTINUED

Upon arrival to the facility, Mr. Jones is quite anxious. This is his first stay in this environment.

His husband accompanies him to the facility and immediately starts questioning the staff about the need for a modified diet and why Mr. Jones cannot be restrained in order to prevent falls.

Mr. Jones shuts down as his husband speaks to all staff doing their intake work. Mr. Jones’s husband

WHAT ARE SOME RED FLAGS FOR LOW HEALTH LITERACY WITH

MR. JONES?

Non-adherence with medications in the past

Cognitive impairment

Dysarthria

"loud" family member

Anxiety / unfamiliar environment

GENERAL RED FLAGS FOR LOW HEALTH LITERACY

Does not complete paperwork

Does not ask many questions

Use humor / excuses to distract (“Forgot my glasses

– I will read it later”)

Agitation or irritation

Missed appointments

Non-adherent to treatment plan

BUT - DID YOU KNOW?

Nearly ALL adults struggle to

understand health information Therefore….

Universal Precautions are

needed for every interaction with

every patient

Source:AHRQ Health Literacy Toolkit

You cannot tell a person’s health literacy by looking

at them.

Higher literacy skills do not

always equal understanding

Stress and anxiety can reduce ability

to manage health information (Cognitive Burden)

Individuals with low literacy often develop coping

skills that mask their skill level.

HEALTH LITERACY UNIVERSAL PRECAUTIONS

Clear Communication

Create redundancy with instructions - oral &

written

Slow down

Plain language / no jargon

Confirming Understanding

Teach Back Method

Ask patients how they learn best

Cultural Competence

RESPECT Model

Recognizing Limited English Proficiency

EXPANDED UNIVERSAL PRECAUTIONS FOR OLDER ADULTS &

OTHER AT-RISK POPULATIONS

Maximize engagement and empowerment

"Exhaust" the patient's ability to receive and transmit health information, work to understand their

core values (including those with cognitive and / or expressive deficits)

Speak directly to the patient to deliver healthcare information

With patient permission, involve support people in critical conversations and teaching to augment

understanding

Involve surrogates for decision-making when patient lacks capacity

CASE PART 2

The nursing home Social Worker and Nurse Manager overhear staff

talking down to Mr. Jones and getting frustrated with him because he

has trouble making his needs known.

Staff also gossip about him the nurses’ station, which is audible to

other staff and residents. One staff member uses air quotes when

referring to the “husband,” and all grimace when Mr. Jones and his

husband kiss goodbye.

What are some ways that this team can work to both help Mr. Jones’

health literacy and demonstrate cultural competency?

1Mutha, S., Allen, C. & Welch, M. (2002). Toward culturally competent care: A toolbox for teaching communication strategies. San Francisco, CA: Center for Health Professions, University of California, San Francisco

Mr. Jones

RAPPORT

Connect on a social level

See the patient’s point of view

Recognize and avoid making assumptions

Consciously suspend judgement

EMPATHY

Remember the patient has come to you for help

Seek out and understand the patient’s rationale for his / her behaviors.

Verbally acknowledge and legitimize the patient’s feeling.

Mr. Jones

SUPPORT

Ask about understand barriers to care and compliance

Help the patient overcome barriers – involve family members if appropriate.

Reassure the patient you are and will be available to help

PARTNERSHIP

Be flexible

Negotiate roles when necessary

Stress you are working together to address health problems.

Mr. Jones

EXPLANATIONS

Check often for understanding

Use verbal clarification techniques

CULTURAL COMPETENCE

Respect the patient’s cultural beliefs

Understand the patient’s views of you may be defined by ethnic and cultural stereotypes

Be aware of your own cultural biases and preconceptions.

Know your limitations in address health issues across cultures

Understand your personal style and recognize it may not be working with a given patient

Mr. Jones

TRUST

Recognize that self-disclosure may difficult for some patients

Consciously work to establish trust

HOW TO ADVOCATE FOR MR. JONES AND OTHERS

Formal teaching on topics related to

cultural competence (in-service)

Signage in the facility regarding

inclusiveness

Talk to staff members (separately

and in staff meeting)

Empower staff to work with patient

to identify barriers to

communication of needs

CASE PART 3:

Mr. Jones is doing well in rehab, and discharge planning to home begins. A

blood sugar of 250 is noted on a routine blood draw, and HA1c of 9

confirms a new diagnosis of Diabetes. The medical team starts insulin

glargine 10 U QHS and insulin lispro sliding scale with zero nutritional.

The day before discharge, the medical team orders insulin teaching (to be

completed by nursing and writes scripts for both the long and short acting

insulin without reviewing nutritional needs.

Let’s think about this plan in the frame of health literacy….

Did you know?

of medical information patients are told during

office visits is forgotten immediately.Source: www.ahrq.gov tool #540 – 80%

Nearly Half of the medical information is remembered

incorrectly.Source: www.ahrq.gov tool #5

Are you using your inhaler?

https://www.youtube.com/watch?v=zSSoYmQS6Ng

THEREFORE, SIMPLE IS USUALLY BETTER

Fewest possible:

Number of medications

Dosages / day

Steps to complete

Individualize plans accounting for limitations / preferences. Do they have the necessary resources to execute the plan?

Cognitive or physical abilities

Manual dexterity (pills, inhalers)

Finances

Support from others

What about Mr. Jones’ insulin?

Empower Patients

This is an excellent effort that both

health professionals and health

consumers can do together.

http://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx

Confirming Understanding

Teach Back

What is Teach Back?!

http://higherlogicdownload.s3.amazonaws.com/HEALTHLITERACYSOLUTIONS/b33097fb-8e0f-4f8c-b23c-543f80c39ff3/UploadedImages/docs/Teach_Back_-_10_Elements_of_Competence.pdf

Teach Back

Health Lit Res Pract. 2020 Apr; 4(2): e94–e103.

Published online 2020 Apr 9. doi: 10.3928/24748307-20200318-01

CASE CONTINUED: ROLE OF SYSTEMS & LEADERSHIP

Two nurse managers Mr. Jones’ facility discuss his care and are frustrated by lack of systemic initiative to

promote health literacy in residents of the facility. They approach the Director of Nursing, Administrator,

and Medical Director at the facility and ask what can be done to raise the bar for health literacy and

change the culture. They consider a Performance Improvement Project through the facility’s Quality

Assurance Performance Improvement Committee.

Shift in Health Literacy Definition to Include Health System

Patient Health SystemClinician

Leadership Promotes Plans, Evaluates & Improves

Prepares Workforce

Includes Consumers

Meets Needs of All

Communicates Effectively

Ensures Easy Access

Designs Easy to Use Material

Targets High Risk

Explains Coverage & Costs

https://nam.edu/wp-content/uploads/2015/06/BPH_Ten_HLit_Attributes.pdf

CASE CONTINUED: ROLE OF SYSTEMS & LEADERSHIP

The following are implemented at Mr. Jones’ facility:

Standing in-service for front-facing personnel: teach back method and RESPECT model

Standardized discharge documentation: plain language, clearly written follow up plans, verbal instructions. 30-

day readmissions to the hospital of short-stay patients tracked internally over a 6-month period

Plain language “scripts” developed for common, complex discussions: applying to Medicaid, Advanced Care

Planning, What to expect with Dementia / Delirium / Depression, Falls Prevention and Treatment

https://health.gov/sites/default/files/2019-10/HLCM_09-16_508.pdf

Breaking the Cycle of Crisis Care

AHRQ Universal Health Literacy Toolkit

Tools to Start on the Path to Improvement

#1: Form a Team

#2: Create a Health Literacy Improvement Plan

#3: Raise Awareness

Tools to Improve Spoken Communication

#4: Communicate Clearly

#5: Use the Teach-Back Method

#6: Follow Up with Patients

#7: Improve Telephone Access

#8: Conduct Brown Bag Medicine Reviews

#9: Address Language Differences

#10: Consider Culture, Customs, & Beliefs

Tools to Improve Written Communication

#11: Assess, Select, and Create Easy-to-

Understand Materials

#12: Use Health Education Material Effectively

#13: Welcome Patients

Tools to Improve Self-Management &

Empowerment

#14: Encourage Questions

#15: Make Action Plans

#16: Help Patients Remember How & When to

Take Their Medicine

#17: Get Patient Feedback

Tools to Improve Supportive Systems

#18: Link Patients to Non-Medical Support

#19: Direct Patients to Medicine Resources

#20: Connect Patients with Literacy & Math

Resources

#21: Make Referrals Easy

https://www.ahrq.gov/sites/default/files/publications/files/healthlittoolkit2_3.pdf

THANK YOU!

What questions do you have?

(“What questions,” is another health literacy tool! Ask a patient “What questions,”

not “Do you have any questions,” at the end of the encounter. This frames questions

as expected and normal)