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Karen Rogers MSN, RN-BCDirector of Education
Franklin Memorial Hospital [email protected]
I have no bias and no conflicts of interest I have no relationship with any companies
mentioned in this presentation I do not intend to discuss unlabeled
commercial products or any investigational use of any products
Karen Rogers MSN, RN-BC Franklin Memorial Hospital 2
Describe three reasons nurses need to be competent in health literacy.
Focus - Teachback
Karen Rogers RN-BC MSN Franklin Memorial Hospital 3
“The capacity to: Obtain, process, understand basic health
information and services Make appropriate healthcare decisions
(act on information) Access/navigate healthcare system”
Health Literacy Universal Precautions Toolkit AHRQ p.97
Karen Rogers RN-BC MSN Franklin Memorial Hospital 4
90 million Americans have trouble understanding and acting on health information (2004)
Elderly – greater misunderstanding
Health disparities r/t literacy◦ Age, gender, culture, ESL
Karen Rogers RN-BC MSN Franklin Memorial Hospital 5
• 40- 80 % Adults immediately forget what was said
• 51 % Incorrectly understood (half of what we do remember is wrong)
McGuire (1996)
Karen Rogers RN-BC MSN Franklin Memorial Hospital 6
Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. US Department of Education. National Center for Education Statistics (NCES) Publication No. 2006- 483; September 2006.
Karen Rogers RN-BC MSN Franklin Memorial Hospital 7
Does level of education matter?
◦ Education – High School Graduates (Davis, 2006) 86.5 % adequate literacy 62.8 % marginal literacy 44 % low literacy
◦ National Assessment of Adult Literacy 2003 43 % read at lowest level of reading proficiency
Karen Rogers RN-BC MSN Franklin Memorial Hospital 8
We “translate across” not “dumb down” information. (Sue Stableford, UNE, Literacy Institute)
“All patients of all levels of education preferred simple straight forward information.”
No reason to teach above grade 5
Goal = patient understanding.
Karen Rogers RN-BC MSN Franklin Memorial Hospital 9
IOM Report 2004 National Assessment of Adult Literacy 2003 Study on Health Literacy 2003 The Joint Commission National Quality Forum –Safe Practice 10 Doak, Doak, Root 1996 Healthy People 2010 & 2020
Karen Rogers RN-BC MSN Franklin Memorial Hospital 10
Statistics, literature recognize the problem
Medications – Patient Safety Compliance to treatment Readmission rate Financial impact Accreditation status
Karen Rogers RN-BC MSN Franklin Memorial Hospital 11
Karen Rogers RN-BC MSN Franklin Memorial Hospital 12
Stephen Jencks et al New England Journal of Medicine in April 2009, accessed from www. advisory.com 3/12/2011
Financial◦ Patient Satisfaction Scores◦ Leapfrog◦ State recommendation◦ CMS Readmission Penalty
Accreditation (2011)◦ The Joint Commission PC. 02.01.02, RI.01.01.03◦ CMS
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$2,891
$10,688
Annual Health Care Costs – Medicaid Enrollees
All enrollees
Limited literacy
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Data from: Weiss BD, Palmer R. Relationship between health care costs andvery low literacy skills in a medically needy and indigent Medicaid population.J Am Board Family Pract. 2004;17:44-47
http://www.youtube.com/watch?v=cGtTZ_vxjyA
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What do you see in your practice?
– Missed appointments • (AMA p12– only 26% understood)
– Not NPO for colonoscopy
– Non-compliance to medication regime• Not take furosemide on shopping days
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• 46.3 % misunderstand one or more– 37.7 % adequate literacy– 51.3 % marginal literacy– 62.7 % low literacy
• Errors Made– 51.8 % Dosage– 28.2 % Frequency– 11.1 % Duration
Karen Rogers RN-BC MSN Franklin Memorial Hospital 17
Karen Rogers RN-BC MSN Franklin Memorial Hospital 18
Clear RX – Target.com
How many sets of numbers are present?
Who reads caution stickers?
0-14% all levels (Annals p. 891)
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http://www.youtube.com/watch?v=cGtTZ_vxjyA
More Medication = More Errors
Average - 10
Deliver Quality Care by addressing Health Literacy?
Assess the need for each patient? Develop materials in Plain Language? Use Teachback in all patient/family
teaching? Advocate for appropriate resources?
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Through observation and self assessment 40 patient interactions
◦ Nonclinical areas (registration, billing etc) – 85% did not use teachback during interaction
◦ Clinical personnel – 66% did not use teachback Areas used most often
Maternal Child Health Physical Rehabilitation Dept
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25 % - non-compliant (advisory board 2011)
70 – 80 % Failure to provide complete discharge instructions
Fonarow, G. (2010)
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Karen Rogers RN-BC MSN Franklin Memorial Hospital 23
All Learning is Self
LearningNNSDO
• Knowledge– What is it? How to determine the need?– Resources available
• Attitude– I have “no time to teach” – What does this mean to you?
• Skills– Use of Teachback– Practice using open ended questions
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Emotional impact of health illiteracy on patients.
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• Ask few questions?
• Take longer filling out forms?
• Fill in forms incorrectly?
• Have difficulty giving a history?
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Not follow through on tests or appointments?
Look at the pill to describe what it is for?
Never have their glasses?
Prefer to review it with their spouse?
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# 1 Who are you teaching? Caregiver, shopper, takes to appts ...
Knowledge
Attitude
Skills
• Use all 3 approaches to teach each topic
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More than one concept to teach?
◦ Use Plain Language◦ 2 – 3 main points of first concept◦ Check for understanding◦ Use Teachback
Teach next concept
Health Literacy Universal Precautions Toolkit AHRQ 10-0046-EF
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• So I can be sure I have explained xxxx correctly– Show me, tell me …
• For your safety I want to make sure I ….
• I want to make sure I was clear
• Tell me what you will tell your xxxx when you go home
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Knowledge– Information about medication– Diagnosis – heart failure
– What is the name of ….– What foods should you avoid…– What are the signs/symptoms….– What are the risk factors…– What will you do if…..– What do you do to prevent…
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• Attitude – WHY is it important to:– Take…….. lasix– Avoid………. salt– Watch for……. Tight shoes– Weigh self…….– Call your doctor if….– Learn how to …..– Quit smoking…– Know when to call ….– Learn how to….
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• Skills – Behavior– How will you…
• Remember to …take…weigh….• Plan to follow up• Plan to change… to… your…• Check for …. Symptoms, everyday• Weigh yourself• Take your inhaler, check your blood sugar etc.• Be prepared to ….• How can you prevent….
– SHOW me how… demonstration
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Ask Me 3 encourages patients to understand the answers to three questions:
1.What is my main problem? (K)2.What do I need to do? (S)3.Why is it important for me to do this?
(A)
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Limited Literacy Skills“are a stronger predictor of an individual's health status than age, income, employment status, education level, and racial or ethnic group” Ask me 3
http://www.npsf.org/askme3/PCHC/
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• Decrease awareness of preventive measures (IOM)
• Patients with asthma less likely to know how to use an inhaler
• Patient with diabetes less likely to know symptoms of hypoglycemia
• Patients with hypertension less likely to know that weight loss and exercise lower blood pressure
• Mothers less likely to know how to read a thermometer
• Less likely to understand direct-to-consumer television advertising
(AMA – p. 13)
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More smoking, including during pregnancy
More exposure to violence
Less breastfeeding
Increase occurrence of less healthy behaviors (IOM)◦ More readmissions in the hospital
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Senator “Saviello, R-Wilton, contended that taxpayers shouldn't have to pay medical expenses for smokers through the state's MaineCare program”
“About 41 percent of MaineCare recipients smoke, compared with 17 percent of Maine's adult population, Saviello said”
http://www.pressherald.com/news/bill-would-cut-medicaid-to-mainers-who-smoke_2011-03-02.html
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Nearly 3,600 students did not graduate from Maine’s high schools in 2010; the lost lifetime earnings in Maine for that class of dropouts alone total over $900 million.
Maine could save as much as $48.6 million
in health care costs over the lifetimes of each class of dropouts had they earned their diplomas.
http://www.all4ed.org/files/Maine.pdf accessed Mar16,2011
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Develop Teachback Questions for one of the following:
CHF - lasixDiabetes – checking BSAsthma – inhaler use
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Knowledge
Attitude
Skills
Resources
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What questions do you have for me?
◦ vs Do you have any questions?◦ Vs Do you understand?
◦ What is the one thing you will go tell your colleague from this presentation?
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Karen Rogers RN-BC MSN Franklin Memorial Hospital 43
Care is not patient centered if it does not effectively involve the patient.
• Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf
you do not have to be a joint commission member to access this roadmap.
AHRQ Resource page• http://www.ahrq.gov/browse/hlitix.htm
• Fonarow, G. “Discharging Our Responsibility,” Morbidity & Mortality Rounds on the Web.http://www/webmm.ahrq.gov/case.aspx?caseID=159. accessed 3-12-11Kaiser Permanente Southern California, Pasadena, CA; Nursing Executive Center interviews and analysis. 2010 The Advisory Board Company
• Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy Assessment Tool User’s Guidehttp://www.ahrq.gov/qual/pharmlit/pharmlit.pdf
• Health Literacy Universal Precautions Toolkithttp://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf This is a very
comprehensive toolkit. If you use it via internet then you can click on areas throughout the kit and view videos and download slides etc.
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AMA Health Literacy Resources Health Literacy and Patient Safety: Helping
Patients Understand• http://www.youtube.com/watch?
v=cGtTZ_vxjyA video download
• http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf booklet to accompany AMA video
• http://www.ama-assn.org/ama/no-index/about-ama/8035.shtml resource page
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The Health Literacy and Plain Language Resource Guide
http://www.hoosieralliance.org/pdf/provider/provcom/cultural/health-literacy-guide.pdf
Health Literacy a Prescription to End Confusion(2004, IOM) http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx
The Health Literacy Environment of Hospitals and Health Centers 166 page book http://www.ncsall.net/fileadmin/resources/teach/environ.pdf another site to access this : www.hsph.harvard.edu/healthliteracy
Karen Rogers RN-BC MSN Franklin
Memorial Hospital 46
The Health Literacy Style Manual Prepared for Kids & Familieshttp://www.coveringkidsandfamilies.org/resources/docs/stylemanual.pdf
Healthy People 2020http://www.health.gov/healthliteracyonline/Web_Guide_Health_Lit_Online.pdf
Investigating the Language and Literacy Skills Required for Independent Online Learning (2008)http://lincs.ed.gov/publications/pdf/NIFLOnlineLearningReport.pdf
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• McGuire, LC “Remembering what the doctor said: Organization and Older Adults Memory Experimental Aging Research” 1996,22: 403-28
• National Quality Forum Improving Patient Safety Through Informed Consent for Patients with Limited Literacyhttp://www.qualityforum.org/Publications/2005/09/
Improving_Patient_Safety_Through_Informed_Consent_for_Patients_with_Limited_Health_Literacy.aspx
• Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Engel KG, Heisler M, Smith DM, et al. Ann Emerg Med. 2009;53:454-7461.e15. http://www.annals.org/content/145/12/887.full.pdf+html
• Pfizer Health Literacy Resource Pagehttp://www.pfizerhealthliteracy.com/physiciansproviders/default.html
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• Quick guide to Health Literacy Office of Disease Prevention and Health Promotion, USDHHS download at: www.health.gov/communication/literacy/quickguide
• Teaching Patients with Low Literacy Skills. Doak, Doak, Root 1996 (out of print – download at) http://www.hsph.harvard.edu/healthliteracy/resources/doak-book/
• TOOLKIT for Making Written Material Clear and Effective (Sept 2010) download at: www.cms.gov/WrittenMaterialsToolkit/
• “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety (2007) http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf
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