Transcript Health Literacy in Older Adults

Help Your Clients Understand:
A Dual Role for the Social Worker
SUMMER INSTITUTE ON AGING
JUNE 10, 2010
NANCY DAUGHERTY
PROGRAM COORDINATOR
WV GERIATRIC EDUCATION CENTER (WVGEC)
Your Guide to Medicaid
“The Medicaid Pharmacy Program does have a Preferred Drug
List (PDL). Your doctor and pharmacist have copies of this list.
If the drug that is prescribed for you is not on the list, a prior
approval will be required. In most cases, the drug prescribed or
a substitute (approved by your doctor) from the list, can be given
to you while you are in the pharmacy. If not, a three-day
emergency supply of your prescription is always available to you.
You should never leave the pharmacy without some of your
medicine. As soon as the approval is given, you will be able to
get the rest of your prescription.”
Learning Objectives
 Describe the prevalence of low and limited health
literacy (LHL) in the general population and the
impact of LHL on important health outcomes.
 Communicate effectively with all clients, including
those with LHL.
 Coach your clients about strategies for using the
skills they do possess to interact more effectively
with their other health providers and “the system”.
What Do We Mean: “Health Literacy”?
 The ability to obtain, process, and understand
basic health information and services needed to
make appropriate health decisions and follow
instructions for treatment.
What Do We Mean: “Health Literacy”?
Many factors contribute:
 General literacy-the ability to read, write, and
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understand written text and numbers;
Amount of experience in the health care system;
Complexity of information being presented;
Cultural factors;
How material is communicated.
National Assessment-Adult Literacy 2003
 Four levels defined:

Proficient: fully developed skills, can read and understand
virtually all text and numerical info

Intermediate: can deal with “most” of info in health care settings,
including ability to calculate BMI
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Basic: most have difficulty understanding typical patient handouts
or filling in health insurance applications
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Below basic: may be able to identify the date of a medical
appointment from a hospital appointment slip given them
Question #1
 What % of US adult population functions at only
basic or below-basic levels of health literacy?
1.
2.
3.
4.
5.
10-15%
20-25%
35-40%
50-55%
> 60%
National Assessment-Adult Literacy 2003
Survey results:
 Proficient- 12%
 Intermediate- 53%
 Basic- 22%
 Below-basic- 14% (12% women, 16% men)
National Assessment-Adult Literacy 2003
Adults 65+
Survey results:
 Proficient- 3% (0.5)
 Intermediate - 38% (1.3)
 Basic - 30% (0.8)
 Below basic – 29% (1.4)
Note: People with lower HL levels tended to get health
information from the radio and television, instead of
print materials, friends and family, or health
professionals
Question 2

Do you accurately identify which of your patients
have limited health literacy?
1.
2.
3.
4.
5.
Yes, all of the time
Yes, most of the time
Yes, some of the time
Very infrequently
Only if someone tells me the patient is having a
problem
Video
 AMA Foundation

Health literacy and patient safety: Help Patients Understand
2007-2009
 Online courses:
1.
http://www.hrsa.gov/healthliteracytraining.htm
2. http://www.medscape.com/viewprogram/8603_pnt
3. http://www.nynj-phtc.org “Health Literacy and Public
Health”
Patients with limited literacy skills:
 26%: did not understand when their next appointment
was scheduled
 42%: did not understand instructions to “take medication
on an empty stomach”
 78%: misinterpret warnings on prescription labels
 86%: could not understand rights and responsibilities
section of a Medicaid application
LHL a strong predictor of poor health
 Health knowledge deficits
 Pts. less likely to know how to use inhaler
 Pts. w/ DM less likely to know sxs. of hypoglycemia
 Pts. w/ HTN less likely to know wt.loss, exercise lower BP
 Mothers less likely to know how to read thermometer
 Less likely to understand direct-to-consumer TV ads
 Less healthy behaviors
 More smoking, including during pregnancy
 More exposure to violence
 Less breastfeeding
 Less access to routine children’s health care
Increased Costs of LHL
 Annual health care costs of Medicaid enrollees
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$2,891 All enrollees
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$10,688 Enrollees with limited literacy
Weiss BD, Palmer R. “Relationship between health care costs and very low literacy
skills in a medically needy and indigent Medicaid population” J Am Board
Family Pract. 2004;17:44-47
Risk Factors for LHL
 Age greater than 65
 Low income
 Unemployed
 Did not finish high school
 Minority ethnic group (Hispanic, African
American)
 Recent immigrant to US who does not speak
English
 Born in US but English is second language
Behaviors and responses that may indicate LHL
 Behaviors
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Patient registration forms that are incomplete or inaccurate
Frequently missed appointments
Noncompliance with medication regimens
Lack of follow-through w/ laboratory or imaging tests, referrals
Patients say they are taking their medications, but labs or physiological
parameters do not change as expected
 Responses to receiving written information
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“I forgot my glasses. I’ll read this when I get home.”
I forgot my glasses. Can you read this to me?”
Let me bring this home so I can discuss it with my children.”
 Responses to questions about medication regimens
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Unable to name medications or explain what medication are for
Unable to explain timing of medication administration
Non-disclosure of limited literacy
 85%: Co-workers
 75%: Health care providers
 68%: Spouses
 62%: Friends
 52%: Children
Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. “Shame and health literacy: the
unspoken connection” Patient Educ Couns. 1996; 27:33-39
Question 3
 How common do you think LHL is in your practice
setting(s)?
1.
2.
3.
4.
5.
Extremely common
Very common
Common
Uncommon
Very uncommon
Question 4
 Are you confident that you communicate
effectively with patients who have limited health
literacy?
1.
2.
3.
4.
5.
Yes, all of the time
Yes, most of the time
Yes, some of the time
Very infrequently
It seems as if I am never successful
Evidence based strategy for communicating with
LHL patients and/or families
 Use plain language
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Slow down, Create a shame free environment, Encourage
questions, Make relevant to patient
Nonmedical language, terms, e.g. pain killer for analgesic, skin
infection for cellulitis
 Limit the amount of information
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Really no more than 3-5 points per encounter
Learn to prioritize
 “Teach back”
“Teach Back” Technique
 Do not ask a patient, “Do you understand?”
 Instead, ask patients to explain or demonstrate
how they will undertake a recommended treatment
or intervention
 If the patient does not explain correctly (using
their own words), assume that YOU have not
provided adequate teaching. Re-teach the
information using alternative approaches

Remember, patients have different learning styles
Role Play
 81 yo man, lives with his wife, cognitively intact, first
myocardial infarction, followed by LAD stenting.
New prescriptions:
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Toprol XL 25 mg daily
Altace 2.5 mg daily
HCTZ 12.5 mg daily
Plavix 75 mg daily
ASA 81 mg daily
Lipitor 80 mg daily
Ambien 10 mg qhs
NTG 1/150 SL prn chest pain
Role Play (cont.)
 Low cholesterol diet
 Cardiac rehabilitation outpatient referral
 Needs to have stitches out in 10 days
 Follow up appointment with PCP in 2 weeks.
 Follow up appointment with cardiology in 4 weeks.
 No driving until cleared by cardiology (but the
patient is the only driver in the family)
 Off work until cleared by cardiology (but does not
have sick day benefit)
Role Play (cont.)
 So how could we narrow this down and limit the key
concepts when you work with this client?
 What are the “between the lines” issues here that
need to be addressed to keep patient safe and from
returning to hospital unnecessarily?
How Would You Coach Your Team?
 Same case, but this time use it as an example for
coaching your colleagues, the care team, about
discharge teaching and instructions?
 What would your key points be? How many?
How Can You Help Clients with LHL?
 They may not understand how to access the system.
 They may not understand that they need to access
the system.
 They may not understand what the doctors and
nurses tell them, or what they need to do for
themselves.
 They may not feel comfortable asking questions
when they go to see the doctor.
 They may not be able to remember their questions
when they get there, or the answers given.
How You Can Help (cont.)
 Is there someone who can go with the client and help
them communicate with the system (two pairs of
ears and eyes often better than one pair)?
 Can someone help them write their questions down
and devise a system to make sure they take with
them?
 ALWAYS take all of their medicine, including over
the counter with them (MUCH better than lists,
especially for folks with LHL)
Role Play
 You run into Mrs. Jones’ daughter in the parking lot.
She tells you that her mother has become very
forgetful, isn’t eating well or taking care of herself
well.
 You don’t have anything with you (since you just
came from Zumba class)
 What could you do for Mrs. Jones’ daughter, and
how would you know that she understood?
Summary
 Low health literacy is so VERY common that it
makes sense to use effective verbal communication
strategies with every patient and/or family
 Use:
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Plain language
Limit the amount of information to 3-5 points
Teach back
WVGEC Faculty Development in Health Literacy
 3 cohorts so far
 Lead Instructor, Charlotte Nath, RN, MSN, CDE, EdD with
over 10 years practice and teaching experience in the field
 Train the trainer model – effective communication and how
to teach it
 Follow up projects and evaluation as part of secondary and
tertiary outcomes for HRSA grant
 Change clinical outcomes through
improved communication
Health Literacy: More Information
 Contact WVGEC @ [email protected]

Phone: 304-347-1208 or 304-347-1295
 Mark A. Newbrough, MD, Director @
[email protected]
 Nancy Daugherty, WVGEC Program Coordinator @
[email protected]