Transcript Health Literacy: Skills for Moving from ‘Mission

Health Literacy:
Skills for Moving from
‘Mission Impossible?’ to
‘Mission Accomplished’
April 24, 2013
Sponsored by
R James Dudl, MD
Kaiser Permanente
Care Management
Institute
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Health Literacy:
Skills for Moving from
‘Mission Impossible?’ to
‘Mission Accomplished’
April 24, 2013
Sponsored by
R James Dudl, MD
Kaiser Permanente
Care Management
Institute
Quick Poll
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?
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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Agenda for getting patients
to take action
 What’s
the problem?
 What
hasn’t worked?
 What
works?
‒ Set
a goal & a treatment, then decide
• How to intensify treatment by considering TIA’s
‒ Then
remove barriers to action using Ask Educate
Ask
 Case
study
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Care Management Institute [email protected]
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What’s the problem?
Literacy is part of the problem.
Heath literacy has 3 components:
literacy — Conveying health
information in a clear & actionable way
 Core
 Engaged
literacy — Today’s Topic
‒
Engage & agree upon goals &
treatments, and get action to achieve
those goals
‒
Focuses on interpersonal skills & behavioral
language
 Influential
literacy — Advocacy and
policy
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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What hasn’t worked well enough?

Practitioners making unilateral decisions on
setting goals, deciding on treatments then

Telling people what to do
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How to Start


Assume motivational interviewing was done by
a doctor while establishing
‒
A mutually agreed upon goal & treatment &
satisfactory motivation for both
‒
At least 2 treatments are possible
Provider considers options on a
‒
Treatment intensification scheme
‒
What evidence is there that outcomes are improved
by treatment intensification?
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No matter which action:
“Treatment Intensification” works!
>500,000 pts with medication increased vs not increased.
(Med Care. 2009 Apr;47(4):395-402).
All p<.05
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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Whatever treatment is targeted…

Treatment Intensification (TI) is needed
Which is

Totally dependent on overcoming barriers to
Titration, Initiation or Adherence [TIA] of the
treatment
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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The ways to Treatment
intensification are the TIA’s
Intensification is Titration or Initiation Adherence or Start Strong ……,,,…TIA’s]
Start Strong
Julie A. Schmittdiel J Gen Intern Med 23, 588-594; 2008
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You CAN Overcome Barriers Some
Think Impossible
Slide 14
The barriers to TIA’s are related to…
 Complex
technological barriers:
‒ To
correct, we need to make it so simple*,** that it’s
the easiest thing to do and
 Behavioral
barriers
‒ To
correct we need to focus on motivation, barrier
identification and self solutions
‒ Can
take 3 to 20 contacts
*BJ Fogg, Persuasive Technology location 272 Kindle edition.
**Segall, Insanely Simple. The story of Steve Jobs success.
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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Adherence barriers:
YOU can always discuss
Patient-related
•
•
•
•
•
•
•
•
Forgetfulness
Lack of knowledge
Value of therapy
Cultural/Ethnic
Denial
Financial
Health literacy
Social support
Medication-related
• Complex regimens
• (Fear of) Side effects
• Taking multiple
medications
• Length of therapy
Often there are 3 barriers
per person!
Provider-related
•
•
•
•
Mistrust
Poor communication
Cultural disparity
Lack of feedback &
ongoing reinforcement
• Providers/pharmacists
focusing on negative
aspects of treatment
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To improve treatment
intensification: Barrier busting

You will not likely get TIA
unless you remove YOUR
barrier

Overcome YOUR problem:
TELLING them what to do
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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Ask-Educate-Ask

ASK about the barriers
‒ In
order to start [TIA] regularly tomorrow, what
problems, questions or concerns do you need to deal
with now?
 EDUCATE
around the point, then
 ASK about their next steps: But I’m curious,
‒ What
would work for you?
‒ What will you do to make that happen?
‒ What else?
‒ What will you do NOW? [Teach back]
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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% A1C < mean with teach back…
Arch Intern Med. 2003;163:83-90
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And teach back can be done anywhere!
So I can write this
down correctly
What are you going to
DO?
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The first barrier-busting question
ASK: “In order to start taking your medication
regularly tomorrow, what problems questions
or concerns do you need to deal with now?”
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Patient causes: Forgetfulness
Answer: “I can’t remember to take my pills.”
EDUCATE
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Type in your solutions
Patient causes: Forgetfulness
EDUCATE “Some find it helpful to take it with
something they do every day, like drink morning
coffee, brushing teeth, eating, but I’m curious…”
ASK

What would work for you?

Tell me what you will do to make that happen?

What else?

What will you do now?”
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Medication causes: Complex regimens
Answer: “I am taking too many medicines — up
to 4 times a day and I cannot remember how to
take them.”
EDUCATE “What works for many people is to
change them to once per day or organize them in
a pill box. But I’m curious…”
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Medication causes: Complex regimens
ASK
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
What would work for you?

Tell me what you will do to make that happen?

What else?

What are you going to DO?”
CASE STUDY: LET’S PRACTICE
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Dave Mellitus

50 y.o. African American man who was just
found to have a fasting glucose of 120 mg/dL
on 2 occasions

Physician diagnosed pre-diabetes and gave him
a prescription for metformin

Wt 220 Height 5’ 4” BP 142/80, Cho 200

Patient has been referred to you for follow-up
counseling
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Dave Mellitus’ difficult dilemmas
Now let’s listen to how a
nurse helped Dave Mellitus
using Ask Educate Ask
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Ask-Educate-Ask
ASK In order for you to start taking the metformin regularly tomorrow,
what problems questions or concerns do you need to deal with?
Dave: Well for one thing, I am not sure metformin is really the right
treatment for pre diabetes, I heard on Dr Oz it’s for full blown diabetes,
and does that mean I have diabetes, not pre diabetes?
EDUCATE Nurse: At times there are two uses for one drug: like
aspirin helps headaches and prevents heart attacks. What your doctor
is suggesting you do is take the first medication recommended for prediabetes by the American Diabetes Association and the US
Government’s National Diabetes Education Program.
ASK Nurse: For some people that’s enough, but I’m curious what
would work for you, who do YOU trust?
R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
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Let’s continue to listen in…
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Ask-Educate-Ask
ASK Nurse: So In order to re-start Weight Watchers this coming week,
what problems questions or concerns do you need to deal with
now?
DM: Well, first of all, I don’t think I can do it alone. Last time I started, I
just caved in to my appetite.
EDUCATE Nurse : Hmm... that must have been difficult. For some
people what works is to plan ahead: to include “emergency” snacks,
and a plan to contact the program director if you are close to dropping
out.
ASK Nurse: But I’m curious, what could work for you?
DM: Those are good ideas… but, I just remembered, - my best friend ,
Sammy Supporter, has been after me to join a weight loss program, like
Weight Watchers, with him. I could always call him if I get cravings,
and he would understand and help, and I could do the same for him!
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R. James Dudl, MD, Diabetes Lead, Kaiser Permanente Management Institute [email protected]
Let’s listen to the wrap up…
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RE-CAP AND KEY TAKE AWAYS
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Assuming mutually agreed upon
treatment goals, what is your role?
Treatment intensification is key

Titration Initiation or Adherence [TIA] are three possible actions, &
you can ALWAYS deal with adherence.
Patient motivation and removing barriers to action are key

Ask Educate Ask is YOUR ACTION PLAN to implementing TIA,
including
“In order to start tomorrow what problems questions or concerns do you
need to deal with now? “ uncovers barriers including lack of motivation
‒ “How will you make that happen” is the patients action plan that
accounts for 60% of success
‒ “What else” ensures you get all the barriers out and
‒ “ So I can write it down correctly, what are you going to DO?” is the
very effective teach-back leading to implementation of one key action.
‒

Remember AEA works in other situations too, like…..
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Quick Poll
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Your Turn…

In order for YOU to start using Ask Educate Ask
tomorrow what problems, questions, or
concerns do you need to deal with now?
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TIME FOR YOUR QUESTIONS
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Don’t forget!

Registration is now open for our next webinar on
Wednesday, May 8th “Health Behavior Change: Motivate
Resistant Patients By Changing Your Professional
Role”

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along with slides

Your webinar completion certificate will be available in your
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