Karen Rogers MSN, RN-BC Director of Education Franklin Memorial Hospital [email protected].

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


90 million Americans have trouble understanding and acting on health information (2004)

Elderly – greater misunderstanding

Health disparities r/t literacy◦ Age, gender, culture, ESL


• 40- 80 % Adults immediately forget what was said

• 51 % Incorrectly understood (half of what we do remember is wrong)

McGuire (1996)


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.


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


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.


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


Statistics, literature recognize the problem

Medications – Patient Safety Compliance to treatment Readmission rate Financial impact Accreditation status



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


$2,891

$10,688

Annual Health Care Costs – Medicaid Enrollees

All enrollees

Limited literacy


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


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


• 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



Clear RX – Target.com

How many sets of numbers are present?

Who reads caution stickers?

0-14% all levels (Annals p. 891)


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?


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


25 % - non-compliant (advisory board 2011)

70 – 80 % Failure to provide complete discharge instructions

Fonarow, G. (2010)



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


Emotional impact of health illiteracy on patients.


• Ask few questions?

• Take longer filling out forms?

• Fill in forms incorrectly?

• Have difficulty giving a history?


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?


# 1 Who are you teaching? Caregiver, shopper, takes to appts ...

Knowledge

Attitude

Skills

• Use all 3 approaches to teach each topic


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


• 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


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…


• 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….


• 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


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)


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/


• 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)


More smoking, including during pregnancy

More exposure to violence

Less breastfeeding

Increase occurrence of less healthy behaviors (IOM)◦ More readmissions in the hospital


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


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


Develop Teachback Questions for one of the following:

CHF - lasixDiabetes – checking BSAsthma – inhaler use


Knowledge

Attitude

Skills

Resources


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?



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.


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


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


• 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


• 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


Karen Rogers MSN, RN-BC Director of Education Franklin Memorial Hospital [email protected].

Documents

Transcript of Karen Rogers MSN, RN-BC Director of Education Franklin Memorial Hospital [email protected].