Transcript Challenges - DC Prim care

Addressing Health Literacy in a
Multilingual Population:
A community health center
approach
Andrea Anderson, MD, FAAFP
Luis Padilla, MD, FAAFP
Outline
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Brief History of Unity Health Care
Upper Cardozo Health Center
Definition of Health Literacy
Impact of Health Literacy
How Our Patients Obtain, Process, and
Understand our Health Information
Current and Future Initiatives
Challenges
Unity Health Care, Inc
MISSION
Unity Health Care, Inc. offers a citywide network of
quality health and human services to the medically
underserved regardless of race, ethnic background
or ability to pay.
VISION
Unity Health Care, Inc. will become the preeminent
health care delivery system for the medically
underserved of Washington, DC and recognized by
them as the provider of choice.
www.unityhealthcare.org
Unity as a Community Health Center
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More than 20 years experience in Washington, DC
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Initially a health care for the homeless model
Now a “medical home” model of care
Present in all 8 Wards of the District of Columbia
Mobile Medical Units
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Currently 32 service sites throughout DC
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321,000 visits in 2007
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Healthcare for DC inmates began October 1, 2006
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Unity Health Care 2006
Total Users
70,749
Total Visits
321,803
Working
Poor,
Uninsured,
Immigrants
Homeless
59,096
(83.5%)
Working
Poor,
Uninsured,
Immigrants
Homeless
271,889
11,653
(16.5%)
49,914
Unity Health Care’s
Upper Cardozo Health Center
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Ward one Northwest DC
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One of DC’s most diverse wards ethnically and
economically
Over 17, 000 patients enrolled in the center
Over 76,000 visits in 2007
Most diverse center in Unity Health Care’s network
Predominately non-English speaking clients
Low Literacy and Low English Proficiency (LEP) with
average estimated reading level at third to fourth grade
Upper Cardozo: Services Offered
Primary and
Preventive Care
 Dental
 Social Services
 Pharmacy
 WIC
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OB/GYN
 Mental Health
 Laboratory
 Specialty Care (HIV,
Pulmonary, Cardiology,
Ophthalmology,
Endocrinology,
Podiatry)
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Where do our patients come from?
The Americas
Canada
Mexico
USA
Argentina
Bolivia
Brazil
Chile
Columbia
Ecuador
Guyana
Paraguay
Peru
Uruguay
Venezuela
Costa Rica
Cuba
Dominican
Republic
El Salvador
Guatemala
Haiti
Honduras
Jamaica
Nicaragua
Panama
Trinidad
Where do our patients come from?
Africa
Benin
Burkina Faso
Cameroon
Central African
Republic
Chad
Congo
Egypt
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Ivory Coast
Kenya
Liberia
Malawi
Mali
Mauritania
Morocco
Mozambique
Nigeria
Niger
Republic of
Guinea
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Tanzania
Togo
Tunisia
Uganda
Where do our patients come from?
Asia, Europe , South Pacific, Middle East
Bangladesh
China
India
Korea
Laos
Mongolia
Nepal
Russia
Sri Lanka
Thailand
Turkey
Vietnam
Albania
England
France
Greece
Ireland
Italy
Poland
Spain
Australia
New Zeeland
Polynesia
Jordan
Iraq
Israel
Syria
Iran
Upper Cardozo: Ethnic Background
Upper Cardozo Health Center User Profile
1%
0% 11%
Hispanic
African-Ameircan
2%
57%
29%
Caucasian
Asian
Native American
Other
Upper Cardozo: Insurance Status
Insurance Status
60
Percentage
50
48.41
40
25.15
30
23.02
20
10
2.17
1.25
Medicare
Private
Insurance
0
Uninsured
Self Pay
Medicaid
Insurance Class
Upper Cardozo- Income Level by
Percent of Poverty Level
70
60
50
Percent
40
30
20
10
0
<100
100-200
>200
Unknown
Federal Poverty Income
Requirements
Group Size
Annual FPL
100% FPL
Monthly
150% FPL
Monthly
200% FPL
Monthly
1
$ 9800
$816.67
$1,225.00
$1633.33
2
$13200
$1,100.00
$1,650.00
$2,200.00
3
$16,600
$1,383.33
$2.075.00
$2,766.67
4
$20,000
$1,666.67 $2,500.00 $3,333.33
5
$23,400
$1,950.00
$2,925.00
$3,900.00
6
$26,800
$2,233.33
$3,350.00
$4,466.67
7
$30,200
$2516.67
$3,775.00
$5,033.33
8
$33,600
$2,800.00
$4,200.00
$5,600.00
9
$37,000
$3,083.33
$4,625.00
$6,166.67
10
$40,400
$3,366.67
$5,050.00
$6,733.33
Health Literacy Definition
"The degree to which individuals have the capacity
to obtain, process, and understand basic health
information and services needed to make
appropriate health decisions".
-Healthy People 2010
Impact of Low Health Literacy
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36 % of the adult U.S. population has basic or
below basic health literacy level
Major source of economic inefficiency in the
U.S. healthcare system.
Cost of low health literacy to the U.S. economy
is in the range of $106 billion to $238 billion
annually
About 7 and 17 % of all personal healthcare
expenditures
Impact of Low Health Literacy
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Potential Savings - $106 billion to $238
billion annually
This would translate into enough funds to insure
every one of the more than 47 million persons
who lacked health care coverage in the United
States in 2006
Real day present costs of $1.6 trillion to $3.6
trillion, accounting for the future costs of low
health literacy that result from current actions
(or lack of action).
Impact of Low Health Literacy
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Women with inadequate literacy had significantly greater odds of
never having had a Pap smear or no mammogram in the past 2 years
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black patients were significantly more likely than white patients to
present with late-stage cancer; after adjusting for literacy, the
researchers reported a smaller odds ratio that was no longer
statistically significant
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lower S-TOFHLA scores were related to worse glycosylated
hemoglobin (HbA1c) levels and reports of retinopathy and
cerebrovascular disease
“Agency for Healthcare Research and Quality. January 2004. Literacy and Health Outcomes. Evidence
Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina
Evidence-based Practice Center under Contract No. 290-02-0016). Berkman ND, DeWalt DA, Pignone MP,
Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. AHRQ Publication No. 04-E007-2.
Rockville, MD”
Assessment Tools
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TOFHLA/sTOFHLA
sTOFHLA version in English available at:
http://www.peppercornbooks.com/catalog/product_info.php?products_id=2
765&osCsid=
Cost $10.00
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sTOFHLA version in Spanish available at:
http://www.peppercornbooks.com/catalog/product_info.php?products_id=2
766&osCsid=
Cost $10.00
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Validation article
Baker D, Williams M, Parker R, Grazmararian J, Nurss J. Development of a brief test
to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.
Source: Health Literacy Assessment Tools Paul D. Smith,
[email protected]/7/07
Assessment Tools
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Newest Vital Sign
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English and Spanish versions available. Scoring sheets and
patient sheets available at:
http://www.pfizerhealthliteracy.com/physicians-providers/newest-vitalsign.html
Cost: Free!
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Validation article
Quick Assessment of Literacy in Primary Care: The Newest Vital
Sign. Weiss B, Mays M, Martz W, Castro K, DeWalt D,
Pignone M, Mockbee J, Hale F. Ann Fam Med 2005;3:514-552.
Available to download at:
http://www.pfizerhealthliteracy.com/physicians
providers/newest-vital-sign.html
Source: Health Literacy Assessment Tools Paul D. Smith,
[email protected]/7/07
Healthy Literacy and Ethnic
Minorities
While ethnic minority groups are
disproportionately affected by low health
literacy, the majority of those with low
health literacy skills in the United States are
white, native-born Americans, as the latter
group represents the largest segment of the
population.
Health Literacy and Latino
Populations
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May be more pronounced in Latino populations
Low literacy and language barrier
Decreased access to insurance
Decreased educational attainment
Increased difficulty managing medicines
Metric versus English measurement system
Difficulty in understanding specialist
instructions
How Our Patients Obtain Information
 Flyers
 Web
and Brochures
based educational materials
 Point
of care internet access
 Language
Line
How Our Patients Obtain
Information
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Oral instructions from bilingual staff
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Medline-Plus tutorials in Spanish
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Community Partnerships
 Reach Out and Read
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Clinic Color Guide
Forms and Signs
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Written at a third to
fourth grade level
Distributed multiple
times by providers and
staff
Color coded
Double sided bilingual
Printed also in Amharic
when applicable
Point of Care Computer Access
Internet Access in
each exam room made
possible through a
NLM grant
 Web image searches
 MedlinePlus Tutorials
 Demonstration of
medications, dosing,
etc
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Web-based Patient Information
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www.boystownpediatrics.org
www.familydoctor.org
www.mdconsult.com
www.medlineplus.gov
https://secure.medactionplan.com
www.epocrates.com
Preliminary Data from Upper
Cardozo NLM Study
Initial and Final HGBA1c Mean
Hemoglobin A1c
10
9
Initial
8
Final
7
6
Control
Intervention
Group
Preliminary Data from Upper
Cardozo NLM Study
Initial and Final Systolic Mean
Systolic bp
130
120
Initial
Final
110
100
Control
Intervention
Group
Phone Interpretation Services
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Language Line
Over 100 major
languages and dialects
available
Speaker phones
available in each exam
room
Multilingual Staff
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17 out of 19 primary care providers speak Spanish
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Over 90% of support staff are bilingual or multilingual
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Languages Spoken By Upper Cardozo Staff
Spanish
Tagalog
French
Farsi
Amharic
Tigrinya
Chinese
Vietnamese
Reach Out and Read Program
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National Program
designed to promote
early childhood
literacy
Literacy Promotion
and books are
encouraged at wellchild visits ages
6months-5 years
Reach Out and Read Program
Millions of books distributed nationwide
 Over 3,000 bilingual and culturally diverse
books shared by providers in well child
visits
 Reading is encouraged as a factor of health
 Introducing early childhood literacy
encourages the discussion of adult literacy
 Adults can be referred to adult literacy
programs, family literacy is encouraged
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Literacy Rich Environment
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Printed Material
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Donated Books
Community Partnerships
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Books for America
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Unity Wide Book Drive
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Read Out Loud Program
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Reading is Fundamental (RIF)
Clinic Color Guide
Future Initiatives
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Computer Lab
 English Second Language skills building
 Computer skills development
Health System Access Education
 Understanding health benefits
 Disability claims
 Patient language access rights
 DC 2004 Language Act
Patient Directed Web Searches
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Computer Lab
sponsored by a NLM
grant
Patients can research
new diagnoses and
online medical
information
http://www.nlm.nih.gov/m
edlineplus/spanish/tutori
al.html
Future Initiatives
 Heath
Literacy Assessment Tool
 Community
 Shared
Education Days
Decision Making
 Pictorial
Prescriptions
Continued Challenges
 Mental
Illness
 No mental health benefit under
current Alliance safety net
 Resources needed to expand and
provide language services
 Resources and staff to assess how
patients process and degree they
understand information
Continued Challenges
 Resources
outcomes
to track changes and
 Bilingual
providers
 Bilingual
nurses and case managers
 Cultural
making
barriers to shared decision
Email Contacts
[email protected]
[email protected]