Transcript Slide 1

Health Literacy Needs and QI
Nanette Brey Magnani, EdD, NQC and
HIVQUAL Consultant
Kathy Donovan, HIV Program Director,
16th Street CHC, Milwaukee, WI
Funded by HRSA
HIV/AIDS Bureau
Learning Objectives
• Understand the need for screening patients
for health literacy.
• Explore several options for health literacy
screening and measurement.
• Learn from peer grantees how they are
addressing health literacy needs of their
patients.
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National Quality Center (NQC)
“It makes me feel bad when I come in here
and somebody hand me something and I
can’t read it...”
“I’ve had a lot of illnesses, but I prefer to stay
home.”
Baker DW, et. al. The Health Care
Experience of Patients with Low
Literacy. Arch Fam Medicine 5, June 1996
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After a teach back by a physician with her patient,
“This patient understood what you said.
The doctors don’t realize the patients don’t
understand them.”
HIV Case Manager, hospital clinic
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National Quality Center (NQC)
How many have observed…?
• Incomplete patient satisfaction forms or
registration forms
• Unable to name medications
• Bring in a family member to speak for them
• Make excuses to not fill out forms
• Medication non-adherence
• Just nod their head in understanding
• Frequently missed appointments
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National Quality Center (NQC)
Quick Needs Assessment
• Raise your hand
I would like to spend more time on:
 Health literacy definitions and understanding
extent of problem
 Screening tools
 Discussing patient materials developed by
grantees
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Extent of Problem
Write down what percentage of people living in
a major city near you have low health literacy.
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National Quality Center (NQC)
Local and National Statistics
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Example of Local Statistics in California
Alameda County: 43%
Del Norte Co: 52%
Humboldt Co: 38%
Lassen Co: 51%
Long Beach, CA: 50%
Los Angeles County: 55%
Los Angeles: 60%
Plumas Co: 39%
Santa Barbara Co: 39%
San Francisco: 46%
Ventura Co: 39%
Reno, NV: 37%
Reder S. Adult literacy estimates. Portland, OR: Portland State University; 1996.
Available at: www.casas.org/lit/litcode/Search.cfm
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HIV and Health Literacy
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How this clinic became aware
I’M VERY INTERESTED IN THIS LITERACY THING. We had a pt go to ________
because Dr ---- said her cd4’s /vl were “acceptable” and she got so upset because she
didn’t understand what he meant that she switched without even letting us explain/ask
for help/nothing! So when I spoke with her this morning I said that that was my role to
teach and explain or get clarification for her on anything….. and I ask her to come back
and she said she think about it because she loves Dr. ------! Go figure. I would come to
_____________ for that even!
What raised your awareness?
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Does this Swiss Cheese Model reflect your clinic?
If so, in what way?
Institute for Healthcare Improvement
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What can you do?
Become Informed
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Research: National Assessment of
Adult Literacy (NAAL)
• 1992 National Adult Literacy Survey (NALS)
• 2003 National Assessment of Adult Literacy
(English literacy)
 1st large-scale assessment in US to include a
health literacy component
 19,000 adult participants, over 16 yrs of age
 In homes
 1200 in prisons (separate estimates)
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National Quality Center (NQC)
Questions designed to include following types of
literacy and knowledge and skills:
 Prose: search, comprehend, use continuous text
• pamphlets
• newspaper articles
 Document: search, comprehend and use non-
continuous texts in various formats
• Train schedule
• food labels
• prescription labels
• appointment slips, HIPAA forms
NAAL research contd
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Contd. Types of literacy knowledge and skills
 Quantitative: identify and perform computations,
alone or sequentially, using numbers embedded in
printed materials
• completing an order form
• balancing a checkbook
• understanding graphs
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Organized around three domains:
 Clinical: provider-patient interaction, clinical
encounters, diagnosis and treatment of illness, and
medication
 Prevention: maintaining and improving health, self
management of illness
 Navigation of health care system: how health
system works and rights and responsibilities;
“The Health Literacy of America’s Adults-Results from the 2003 National Assessment of Adult
Literacy,” NAAL.
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What is 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 (1).
1.U.S. Department of Health and Human Services. Health Communication (Chapter 11). In: Healthy People 2010:
Understanding and Improving Health and Objectives for Improving Health. 2 nd ed. Washington, D.C.: U.S. Government
Printing Office; 2000.
2.“Health Literacy.” National Network of Libraries of Medicine. http://nnlm.gov/outreach/consumer/hlthlit.html
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Health Literacy Therefore Involves
Being Able to:
•
•
•
•
•
•
Evaluate information for credibility and quality
Analyze relative risks and benefits
Calculate dosages
Interpret test results
Locate health information and clinic
Be able to access and use public transportation
NYSDOH AIDS Institute
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National Quality Center (NQC)
The United States has 78 million adults with
“basic” and “below basic” prose literacy.
Below basic means they cannot do much more
than sign a form or search a simple document
to find out what they can and can’t drink before
a medical test.
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Health Literacy as a Concept
National Quality Center (NQC)
Within low level health literacy rates who
is affected more?
• Over 65, then over 50
• Black, Hispanic, American Indian/Alaska
Native (across age spectrum)
• Medicare, Medicaid, No insurance (across age
spectrum)
NAAL research
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Consequences of Low Health Literacy
• Several studies found limited health literacy in people
living with HIV/AIDS to be associated with:
 Less preventive care
 Increase use of ER and hospitalizations
 poor health outcomes such as less HIV knowledge,
 lower CD4 cell counts,
 poor medication adherence, and
 more hospitalizations
than those with adequate levels of health literacy.
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What can you do?
• Develop a measure
• Screen your patients
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HIVQUAL 2008 Indicator
The health literacy of all HIV-infected patients is
assessed within the 12-month review period.
1.0 Was the patient screened for health literacy
during the 12-month review period?
YES: (continue to 1.1)
NO: (stop)
1.1 Was a need for health literacy intervention
indicated?
YES: (continue to 1.2)
NO: (stop)
1.2 Was a health literacy intervention done?
YES: (stop)
NO: (stop)
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HIVQUAL 2008 Indicator Guidance
Health Literacy (suggestions)
• Basic components of health literacy screening include,
but are not limited to:
 Reading ability
 Basic numeracy skills
 Language barriers
 Comprehension of provided health-related information
• A health literacy screening can be performed by any
health care team member over the course of 12 months.
Different health literacy screening tools are allowed as
long as the results are documented in the medical record.
Each HIV program should select a tool that is deemed
appropriate for use and which would provide information
about the need for an intervention.
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Understand Health Literacy Domains
• Functional health literacy: basic reading and writing skills
to understand and follow simple health messages
• Interactive health literacy: more advanced skills to
manage health in partnership with professionals
• Critical health literacy: the ability to critically analyze
information, increase awareness and participate in action
to address barriers
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Screening Environment
•
•
•
•
•
Shame-free
Comfortable
Not draw attention to patient
Trust
Avoid settings that might recall school test
experiences
NYSDOH AIDS Institute
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National Quality Center (NQC)
Summary of Screening Tools
• Standardized health literacy screening tools
 Focus is on measuring reading ability
 Most also test numeracy and reading comprehension of
health-related information
 Context of screening is very important because of the
assessment-like nature of the screening tools
 Cannot identify etiologies, which would help identify
interventions
NYSDOH AIDS Institute
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Which tools are being used?
Standardized Tools
• REALM (Rapid Estimate of Adult Literacy in Medicine)
• REALM-R (Rapid Estimate of Adult Literacy in
Medicine – Revised)
• TOFHLA (Test of Functional Health Literacy in Adults)
• NVS (Newest Vital Sign)
NYSDOH AIDS Institute
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National Quality Center (NQC)
Non-standardized Screening Tools
• BEKHA-HIV
• Single Item Literacy
Screen
• “How confident are you
filling out medical forms
by yourself?”
• SOS Mnemonic
Paasche-Orlow MK and Wolf MS. Evidence Does Not Support Clinical Screening of Literacy. Journal of General
Internal Medicine. 2007, 23(1):100-102.
Jeppesen KM, Coyle JD, and Miser WF. Screening Questions to Predict Limited Health Literacy: A Cross-Sectional
Study of Patients With Diabetes Mellitus. Annals of Family Medicine. 2009, 7(1):24-31.
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Non-Standardized Health
Literacy Screening Tools
• Pill Bottle - Show picture of label or actual bottle and ask:
 Where can you figure out the name of the drug?
 What is the phone number of the pharmacy?
 How do you take this drug?
 Who would you call if you felt sick from this drug?
• The Teach Back method
 “List the three most important things you are going to take away
from your visit today.”
• Recording observations
 Did the patient express understanding of verbal and written
instructions?
 Were there barriers identified?
NYSDOH AIDS Institute
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Non-Standardized Health
Literacy Screening Tools
• Review the med list at every visit and observe
 Does the patient read the label?
 Know the names?
 Identify them on a color picture pill chart?
• Ask me 3 – Encourage patients to ask:
 What is the main problem?
 What do you need to do?
 Why is it important for you to do this?
NYSDOH AIDS Institute
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Example of Non-standardized
Screening Tool - GHVFHC
•
•
•
•
•
•
Combines teach back
Uses plain language that is non-threatening
Tries to make patient comfortable
Identifies patients most at risk
Takes time, less than 100 HIV patients
Uses pictures to help explain content
Did a series of PDSAs to modify the tool and to learn
who would do the screen and when
.
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Partial Screening Form –
Greater Hudson Valley FHC
HIV harms the immune system in your body.
Your immune system fights against disease.
T-cells are part of your immune system. If
you don’t have enough T-cells, you can get
really sick. The CD4 test looks at the number
of CD4 cells you have. If your CD4 count
goes down, it means your medicine is not
working. HIV is winning the fight.
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Partial Screening Form –
Greater Hudson Valley FHC
Labs
Your CD4 (T-Cell) is
Your viral load is
The goal is to keep your T-Cells above 200 and your viral load below 50 copies or undetectable
A high
A
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T-cell count and
low T-cell count and high
a low viral load is very good
viral load is not a good result
National Quality Center (NQC)
Medicine
I have prescribed these medications
# of Pills
AM
# of Pills PM
_________________________________
Name of Medicine
_________________________________
Name of Medicine
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HUDSON VIEW PHARMACY
(845) 561-4370
3 WASHINGTON CENTER
Rx# 6032181
For:
NEWBURGH, N.Y. 12550
Refills Left: 3
Until: 10/08/09
10-08-08
JOHN SMITH
2 Washington Center
Newburgh, NY
12550
TAKE TWO TABLETS TWICE A DAY.
Kaletra 150MG
#120
Dr. Smith, Phillip
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HIV Health Literacy Scoring Sheet
Sample Questions
Patient Reads Materials
Screener Reads it (if you read the information in Part I; then you will have to read the information for Part II.)
Part 1: Basic HIV Information Questions
Circle the patient’s level of understanding after each question.
1. Please explain in your words what it means to have HIV.
Full understanding
Most of it
Very little
Follow up questions if the patient did not fully explain the information.
Do you recall how HIV affects your body?
Able to explain
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Not able to explain
National Quality Center (NQC)
Sample Questions – Medication Label
We’re almost done. I want to make sure you understand
your medication label.
1. Please point out the name of the medication.
able to locate it
not able to
2. For this medication, when would you take your pills?
How many?
take two pills twice/day
does not know
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What can you do with screening results?
Conduct your own PDSAs to improve:
• Patient communication
 Teach Back
 Ask Me 3
 Patient Self-management
 Materials
• Navigation of system
• Family member/friend/partner
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Improvements
• Providers adapt their language
• Extra time and support from nurse, case manager or
treatment adherence counselor
• Patient receives low-level literacy reading materials
• Referral to psychiatrist
• Translators
• Peer support groups
• Patient education about HIV and medications
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MY ACTION PLAN
DATE: __________
I, _____________________________ and
______________________________(clinican name)
have agreed that to improve my health I will:
1. Choose ONE of the activities below (circle one):
Work on
something bothering me:
Take my
medications.
Reduce my
stress.
What: _____________
Improve my
food choices.
Stay more
physically active!
Cut down on my
smoking.
Or choose something myself:
I choose to work on: ________________________________________________
2. Choose your confidence
level:
This is how sure I am that I will
be able to follow my action plan:
10 = Very sure
3. Complete this box for the
chosen activity:
What: __________________________
_______________________________
How much: _____________________
5 = Somewhat
sure
When: _________________________
Developed by Beth Hyde, NP,
St. Luke’s Hospital.
How often: ______________________
_______________________________
0 = Not sure
at all
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Patient: ________________________
Clinician: _______________________
National Quality Center (NQC)
Teach Back Tool – Example of
Functional and Interactive Health Literacy
Developed by Lydia Barakat, Medical Director, Waterbury
Hospital
• A copy of the tool in color is available for Providers to use
for teach back to help patients understand HIV and the
need to take their medications.
• Takes 2-5 minutes. Used usually when starting new
HAART regimen or compliance issue and knows health
literacy is an issue. Asks the patient three questions on the
tool, patient reads it or Provider, then ask the 3 questions
again, and have the patients repeat the answers.
• Copies of the tool in b/w are given to patients who want to
take one.
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Take Your HIV Medicine
On Time and Every Day
Download from www.nationalqualitycenter.org
In English and Spanish.
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How do your HIV medicines work?
When you take your medicine,
the medicines get absorbed into
your body through your stomach.
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= medicine bottle
The medicines run to the
T-Cell to stop the HIV
virus from multiplying.
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Baja Carga Viral Y
Alta Carga de la célula
es un resultado muy bueno
Por otra parte,
Alta Carga Viral Y
Baja Carga de la célula 4
no es un buen resultado
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Critical Literacy Example:
Photonovellas
16th Street Community Health Center HIV Department
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Photonovellas
Pose critical questions about attitudes and
behavior, culturally sensitive, holds adults interest
• 6 photonovellas were created:
-3 targeting MSM, young adults
-3 targeting young adult women, families
• Piloted within the health center
• Edited with input from patients
Download from www.nationalqualitycenter.org in English and Spanish.
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National Quality Center (NQC)
Pilot Results...
• Successful identification of main points
• Easy to read, especially with photos
• Questions were used to generate group discussion
about behavior or discussion with case manager
• Transgender group hopes to develop photonovellas
about their issues
• Parenting group suggested that teen issues be
addressed
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National Quality Center (NQC)
Use of Photonovellas
• New members of groups
• Community prevention events, such as, HIV
Community Forum (to educate the community
on facts vs. myths)
• Schools
• In Prisons
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Patient Satisfaction Surveys
. How happy are you with the time it took to make today’s appointment with your case manager?
Very happy
happy
Just okay
unhappy
Very unhappy
Hard
Very hard
2. How easy is it to reach your case manager?
Very easy
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Easy
Just okay
National Quality Center (NQC)
Patient Satisfaction Surveys
Developed by Kate Sansarino, Erie Family Health Services (Part C CHC;
adapted by AIDS Care Ocean State (Part D, Case Management agency)
9. I take part in my case management visit as much as I want.
yes
Just okay
Not at all.
10. How easy is it to understand your case manager?
Very easy
Easy
Just okay
Hard
Very hard
Hard
Very hard
11. How easy is it for you to understand your care plan?
Very easy
Easy
Just okay
Download: www.nationalqualitycenter.org
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I don’t have
one.
National Quality Center (NQC)
Key Points
• Health literacy is a major problem in health
care
• Even people who can read may not have the
skills to manage complex health information
• Assess health literacy in ways that maintain
the trust between providers and
patients/clients
• Make sure written materials are direct, simple
and clear; use illustrations when you can
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Strategies to Support Health Literacy
National Quality Center (NQC)
FYI: Options for Screening
Standardized Health Literacy
Screening Tools
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National Quality Center (NQC)
The following slides from 57-64 were taken
from a power point presentation by:
Sreela Namboordiri, Health Literacy,
June, 2009 NYSDOH AIDS Institute
Download: www.nationalqualitycenter.org
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Rapid Estimate of Adult Literacy in Medicine
(REALM)
Description
•A 66-item health-related word recognition test arranged in order of
increasing difficulty.
•Provides a reading level grade estimate for patients that read below a
9th- grade level.
•Average administration time: 3-6 min.
Measurement
•Low health literacy
(At or below 3rd-grade reading level): 0 to 18
(4th to 6th-grade reading level): 19 to 44
•Marginal health literacy (7th to 8th-grade reading level): 45 to 60
•Adequate health literacy (9th-grade reading level): 61-66
Strengths
•Word-recognition tests are useful for predicting general reading ability
in English.
•Extensively used in research settings.
Limitations
•Not designed to measure comprehension skills.
•Most useful in a research context.
Location
Available for purchase from Terry C. Davis, PhD: [email protected]
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REALM
Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, and Crouch MA. Rapid Estimate of Adult
Literacy in Medicine: A Shortened Screening Instrument. Clinical Research and Methods. 1993, 25(6):391-395.
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Rapid Estimate of Adult Literacy in Medicine –
Revised (REALM-R)
Description
The word-recognition REALM test was shortened from 66 items to
the following 8 items: osteoporosis, allergic, jaundice, anemia,
fatigue, directed, colitis, and constipation.
Average administration time: 2 min
Measurement
Strengths
•Additional words can be added to this assessment and still maintain
2-minute administration time. This would allow for development of
more disease-specific test, by choosing words related to a particular
disease.
•Short administration time
Limitations
•Poor literacy skills are thought to disproportionately affect the elderly
and minorities, 2 groups who were underrepresented in the study
validating the REALM-R.
•Utility in research and clinical settings less known.
Location
Available for purchase from Terry C. Davis, PhD: [email protected]
Bass PF, Wilson JF, and Griffith CH. A Shortened Instrument for Literacy Screening. Journal of General Internal Medicine.
2003, 18:1036-1038.
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Short Test of Functional Health Literacy in Adults
(S-TOFHLA)
Description
•The original S-TOFHLA was reduced to a 4-item numeracy section and 2
reading comprehension passages with missing words, which are at the 4th
grade reading level (preparation for an upper gastrointestinal series) and
10th grade reading level (the patients rights and responsibilities section of a
Medicaid application).
•Average administration time: 12 min
•The current S-TOFHLA does not include the numeracy section. Similar to
the TOFHLA, patients are asked to select the words that best fit into the
passages.
Average administration time: 8 min
Measurement
Inadequate health literacy: 0-53
Adequate health literacy: 67-100
Strengths
•Assesses reading comprehension
•Tested on a variety of populations (young, elderly)
•Shorter administration time
Limitations
•Numeracy not tested.
Location
Available for purchase from http://www.peppercornbooks.com/ at $60
60
Marginal health literacy: 54-66
National Quality Center (NQC)
Newest Vital Sign
(NVS)
Description
This 6-item assessment measures reading and comprehension of a
nutrition label and was developed through funding from Pfizer
Pharmaceuticals.
Average administration time: 3 min
Maximum administration time: 6 min
Measurement
Patients with low literacy: 0-4 questions answered correctly
Patients unlikely to have low literacy: 5-6 questions answered correctly
Strengths
•Tests for numeracy , reading ability and interpretation skills as applied
to a healthcare setting
•Available in English and Spanish
•Correlates with TOFHLA
•May be more sensitive to patients with marginal health literacy than
other functional health literacy assessments
Limitations
•May overestimate the percent of patients with low literacy, due to its
specificity
•Does not differentiate between adequate and marginal literacy well
Location
Can be ordered online free of charge
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National Quality Center (NQC)
Newest Vital
Sign
Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, and Hale FA. Quick Assessment of Literacy in
Primary Care: The Newest Vital Sign. Annals of Family Medicine. 2005, 3:514-522.
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BEKHA-HIV
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Osborn CY, Davis TC, Bailey SC, and Wolf MS. Health Literacy in the Context of HIV Treatment: Introducing the Brief Estimate of
National Quality Center (NQC)
Health Knowledge and Action (BEKHA)-HIV Version. AIDS Behavior. 2008
Readability Formulas for Patient Materials
• Helps Predict Reading Difficulty
• Measure only 2 factors affecting reading difficulty –
average number of
• Syllables in words
• Words in sentences
• Provide some tangible measure of general difficulty
• Still need to pre-test
Institute for Healthcare Improvement
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National Quality Center (NQC)
Difference in Readability Formulas
• The Flesch-Kincaid:
• In many software programs
• May give scores 2-3 grades below actual grade level
• More accurate formulas are:
• Flesch Reading Ease Scale
• SMOG:
www.harrymclaughealthliteracyin.com/SMOG.htm
• Fry
Institute for Healthcare Improvement
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Resources
To calculate literacy rates in your area:
www.casas.org/lit/litcode/Search.cfm
Online training:
• www.hrsa.gov/healthliteracy/training.htm
• The Quality Academy, Tutorial #23 “Understanding and
Addressing Health Literacy”
www.nationalqualitycenter.org
HIV Health Literacy performance measurement
www.hivqual.org
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National Quality Center (NQC)
Resources
• Overview of the National Assessment of Adult
Literacy: http://nces.ed.gov/NAAL/
• Partnership for Clear Health Communication:
www.askme3.org
• Harvard School of Public Health; Health Literacy
Studies: www.hsph.harvard.edu/healthliteracy/
• The Joint Commission (2007); “What Did the Doctor
Say?:” Improving Health Literacy to Protect Patient
Safety; http://www.mmia.org/uploads/pages/215.pdf
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Other Resources
National Quality Center (NQC)
Resources
Rudd RE and Anderson JE. 2006. The Health
Literacy Environment of Hospitals and Health
Centers. Harvard School of Public Health.
National Center for the Study of Adult
Learning and Literacy.
http://www.ncsall.net/fileadmin/resources/teach/environ.pdf
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National Quality Center (NQC)
Contact Information
• Nanette Brey Magnani, EdD
[email protected]
• Kathy Donovan
[email protected]
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National Quality Center (NQC)
National Quality Center (NQC)
212-417-4730
NationalQualityCenter.org
[email protected]
Funded by HRSA
HIV/AIDS Bureau