# Presentation: 926657

## Raising health literacy sensitivity throughout the healthcare system and the community: A way to maximize the effectiveness of current health promotion and disease prevention practices

- Kate Vergara
- Department of Medicine and Public Health
- American Medical Association
- October 24th ,2005

## Overview

- Overview of health literacy and the current US healthcare system
- The AMA Health Literacy Training-Of-Trainers (TOT) Program
- Results from the TOT
- Suggestions to improve communication and maximize disease prevention and health promotion efforts

## Health Literacy

- Health literacy is the degree to which individuals can obtain, process, and understand basic health information and services they need to make appropriate health decisions.

**Notes:**
Definition used in the US Dept of Health and Human Serv. Health Communication (Chap 11) Healthy People 2010 2nd ed, With Understanding and Improving Health and Objectives for Improving Health, 2vols Washington Dc: US gov Printing Office, Nov 2000

## National Adult Literacy Survey

**N = 26,000**
**Most accurate portrait of literacy in U.S.**
**Scored on 5 levels**
**Result:  48% of US population have inadequate or marginal literacy skills**

**American Medical Association Foundation & American Medical Association**

**Notes:**
(0:05)
Purpose:  To describe the study that showed that 1⁄2 of the population is at risk.

The National Adult Literacy Survey was conducted in 1992 and published in 1993.  
This study was conducted by the Department of Education.  
26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US. 
The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy)
Based on this study we know that almost 50% of US population falls in the first two levels, inadequate or marginal literacy.
There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which you have received.
Transition:  The full results for the 5 levels are represented in the following chart........

## 1993 National Adult Literacy Survey

**Level 5**

**Notes:**
Purpose:  To describe the 5 levels in NALS.
Level 1:  The red section of the diagram represents the lowest level, and have inadequate literacy.  At Level 1 individuals can only perform basic tasks such as signing their name or finding a word or fact in a short written article. Although they can perform some reading and writing tasks, their limited literacy skills prevent full functioning in today’s society.
Level 1 represents 21% of the population.
Level 2:  The yellow section of the diagram represents those with marginal literacy skills.  Individuals in this level have somewhat more advanced skills than those in Level 1, but  they are still substantially limited in their ability to read and understand text.
Level 2 represents 27% of the population.
Together, Level 1 and Level 2 include 48% of the population, almost half of the US adult population.
In contrast, persons at NALS levels 3, 4 and 5 have sufficient literacy skills to permit full functioning in society
Transition:  More specifically, what does it mean to be in the lowest levels?..........

## How health information is given..

- Complicated language, medical-ese
- Consent forms written at advanced literacy level
- Prescriptions with complicated written instructions

## Not addressing low health literacy in the US 

- Hinders health promotion
- Screening recommendations written on pamphlets
- Public health messages not tailored to target population
- Threatens patient safety
- Medication errors
- Delay of treatment or proper diagnostic tests

## Inadequate Health Literacy

- 90 million adult Americans may be at risk
- Misunderstanding
- Mistakes
- Excess hospitalizations
- Poor health outcomes

- Module 1

**Notes:**
Purpose:  To describe the seriousness of the problem.
We are here because there is a serious and growing problem that is affecting our ability to deliver care.....low levels of health literacy.  In fact,....
1/2 of the US population may be at risk for:
Misunderstanding health care instruction, prescription bottles, appointment slips
Mistakes taking medications incorrectly or preparing for diagnostic tests
Excess hospitalizations due to inability to self-manage chronic disease
Poor health outcomes such as higher HbA1c among patients with diabetes

Transition:  Why are so many at risk?.............

## Improving Communication to Improve Patient Safety

- JCAHO Sentinel Events
- Communication breakdowns remain the primary root cause of more than 80% of the 2034 sentinel events analyzed.

- Module 1

**Notes:**
We know that checking for understanding by using a “teach back” technique in interactions with patients is effective.

## The Continuum of Confusion

## To break the continuum of confusion....

- AMA Health Literacy Training-of-Trainers Program
- Aimed to increase health literacy awareness
- You can’t tell by looking...
- Offer techniques to create a Shame-free environment
- Offer strategies to improve communication with patients with low health literacy
- TEACHBACK METHOD

## Teachback Method

- Engage the patient to verbalize what they understand of their health situation and the plan for the future.
- “Teach back” in their own words what you have told them.
- 	“*Let me see if I have explained it clearly to you...”*
*	**“**Tell me in your own words*...”

## “Teach back” works

- “Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on strength of scientific evidence. (AHRQ, 2001 Report on *Making Health Care Safer)*
- Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients. (Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”)

- Module 1

**Notes:**
We know that checking for understanding by using a “teach back” technique in interactions with patients is effective.

## The Success of the Health Literacy Training-of-Trainers Program (TOT)

- 2 TOTs given
- 11 teams of prominent healthcare key players trained
- 197 subsequent training sessions given by the teams at their home institutions
- 8,000+ healthcare community members trained (and growing!)
- 15,000+ Health literacy kits distributed

**Notes:**
Kate – refer to the two only, because our figures are for the work of 25 people not the 19 teams after the 3rd TOT.

## American Medical Association Foundation & American Medical Association

**American Medical Association Foundation & American Medical Association**

**Notes:**
(0:05)
Purpose:  To describe the study that showed that 1⁄2 of the population is at risk.

The National Adult Literacy Survey was conducted in 1992 and published in 1993.  
This study was conducted by the Department of Education.  
26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US. 
The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy)
Based on this study we know that almost 50% of US population falls in the first two levels, inadequate or marginal literacy.
There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which you have received.
Transition:  The full results for the 5 levels are represented in the following chart........

## Health Literacy Training: Changing Clinical Practice

- As a result of the TOT, 76% of MDs that responded to a follow-up survey reporting making some change in their clinical practice.
- Breakdown of Changes:
_**Area of Practice Changed   **__**	**__**	**__**%  yes**_
- Communication with Patients		100%
- Patient Education 			  	  80%
- Patient Monitoring			  	  37%
- Therapeutic Practices  			    8%
- Diagnostic Practices  			    0%

## Changes in Patient Behavior

- _Patient Behavior_                      _MDs reporting change_
- Better compliance                                      32.6%
- Increased patient satisfaction 		  30.4%
- Better health outcomes 			  15.2%
- Fewer missed appointments 			   8.6%

## Further suggestions for creating safer healthcare environments for patients with low health literacy

- The SOAP-UP note
- SBAR (Situation-Background-Assessment-Recommendation)
- Safe Communication Universal Precautions

## The SOAP-UP NoteA prompt for providers to address health literacy in every clinical encounter and to  document their interaction

- S	- Subjective
- O	- Objective
- A	- Assessment
- P	- Plan
- U	- Utilize “teachback” to assess
-             for understanding
- P	- Plan for health literacy help
**SOAP- UP**** for Health Literacy Success!**

## SBARTo streamline communication and documentation for and between healthcare staff

- Situation
- Background
- Assessment
- Recommendation

## Safe Communication Universal Precautions

- Frontline Communication
- Use Plain, non-medical language (oral and written)
- Slow Down
- Organize into 2 or 3 concepts and check for understanding, “chunk and check”
- Ask patients to **TEACH-BACK** what they learned
**SOAP-UP** note for assessment of understanding and documentation

## Safe Communication Universal Precautions

- Communication Aids
- Use Appropriate reading level on all written healthcare information
- Offer to read aloud and explain
- Underline or Circle Key Points
- Provide Interpretation if appropriate
- Use Visual aids to help navigate the healthcare system and understand health information

## Safe Communication Universal Precautions

- System-wide Communication Strategies
- Improve office safety culture through training for all staff
- Medication Reconciliation for all patients, at all patient encounters
- Simplify paperwork demands
- Avoid duplicative paperwork
- Use SBAR for staff to staff communication
- Schedule time for patient education and questions
- Reminder calls to patients
- Identify Community Resources

## Conclusions

- To make current health promotion and disease prevention practices more effective and efficient, and to increase patient safety
- Must continue to raise health literacy awareness
- Promote communication techniques that aim to successfully reach the patient and assess for understanding
- Continue to adopt system-wide communication strategies that are sensitive to a low health literate population

## Resources

- _[www.amafoundation.org](http://www.amafoundation.org/)_
- AMA Health Literacy kit
- “Health Literacy: Help Your Patients Understand” kit, order through 1-800-621-8335
- AMA Health Literacy textbook
- Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding health literacy: implications for medicine and public health. Chicago: AMA Press 2005.
- E-mail:
- _[Katherine.Vergara@ama-assn.org](mailto:Katherine.Vergara@ama-assn.org)_, _[k8vergara@gmail.com](mailto:k8vergara@gmail.com)_

## Thank you 

- Joanne G. Schwartzberg, MD
- Director, Aging and Community Health,
- American Medical Association
- Patricia E. Sokol, RN JD
- Scientist, Clinical Quality Improvement and Patient Safety
- American Medical Association