geriatric health literacy: a skills-based workshop seema s. limaye, md section of geriatrics and...

Geriatric Health Geriatric Health Literacy:Literacy:

A Skills-Based A Skills-Based WorkshopWorkshop

Seema S. Limaye, MDSeema S. Limaye, MD

Section of Geriatrics and Palliative MedicineSection of Geriatrics and Palliative Medicine

University of ChicagoUniversity of Chicago

I have no conflict I have no conflict of interestof interest

AcknowledgementsAcknowledgements

Sincere thanks to the Stanford Geriatric Education Center for Sincere thanks to the Stanford Geriatric Education Center for the granting me the privilege of re-producing, incorporating, the granting me the privilege of re-producing, incorporating, and disseminating geriatric health literacy materials and disseminating geriatric health literacy materials developed for use as part of the Stanford Faculty developed for use as part of the Stanford Faculty Development Program in Health Literacy and Geriatric Development Program in Health Literacy and Geriatric Education. Education.

Stanford Geriatric Education Center Faculty Development Stanford Geriatric Education Center Faculty Development Program in Health Literacy and Ethnogeriatrics Curriculum. Program in Health Literacy and Ethnogeriatrics Curriculum. Stanford CA: Stanford Geriatric Education Center, Stanford Stanford CA: Stanford Geriatric Education Center, Stanford University. 2009.University. 2009.

Health Literacy Workshop Health Literacy Workshop (HLW):(HLW):GoalsGoals

1.1. Understand the impact of low Understand the impact of low health literacy with geriatric health literacy with geriatric patientspatients

2.2. Develop communication skills to Develop communication skills to improve patients’ understanding of improve patients’ understanding of their medical issues.their medical issues.

3.3. Analyze what constitutes effective Analyze what constitutes effective patient handout materials.patient handout materials.

Nuts and BoltsNuts and Boltsof HLWof HLW

Low costLow cost Need facilitatorNeed facilitator Seminar style formatSeminar style format 4-20 learners ideal size4-20 learners ideal size About 2.5hoursAbout 2.5hours

Nuts and Bolts of HLW Nuts and Bolts of HLW ((cont)cont)

Educational MethodsEducational Methods TimeTime

On line module On line module http://www.reynolds.http://www.reynolds.med.arizona.edu/Edumed.arizona.edu/EduProducts/HealthLit/iProducts/HealthLit/index.html ndex.html

Self-studySelf-study 25 min25 min

Lecture on Geriatric Lecture on Geriatric Health LiteracyHealth Literacy

Instructor ledInstructor led 40 minutes40 minutes

Role-playing and Role-playing and teach-back cardsteach-back cards

Dyads or triadsDyads or triads 10 minutes each 10 minutes each person in dyadperson in dyad

Patient handout Patient handout materials materials assessmentassessment

Individual or Small Individual or Small group (2-3 learners)group (2-3 learners)

30-45 minutes30-45 minutes

Models of Health Care Models of Health Care MessagesMessages

In what ways can health care In what ways can health care messages be delivered?messages be delivered? Oral Oral

TEACH BACK/ ROLE PLAYINGTEACH BACK/ ROLE PLAYING

Written or printed information: Written or printed information: ASSESS PATIENT HANDOUT MATERIALASSESS PATIENT HANDOUT MATERIAL

VisualVisual TechnologicalTechnological

Stanford Geriatric Education CenterStanford Geriatric Education Center

HLW: Findings To DateHLW: Findings To Date

PGY1 Mean Ratings of Health Literacy Skills: 1/2010 - 8/2011

.0000

1.0000

2.0000

3.0000

4.0000

5.0000

Health Literacy Skills

Me

an

Ra

tin

gs

(1

=P

oo

r,

5=

Ex

ce

llen

t)

Retro Pre-test 3.3300 3.3800 3.2900 3.4700 3.1100

Post-test 4.1200 4.0238 3.9800 3.8700 3.8700

Explain dose change N=21

Explain new diagnosis N=21

Explain diagnostic test N=21

Explain referral N=19 Select materials N=19

How did learners rate their abilities to communicate before and after the workshop?

*p<0.001 for all

** ** *

Part I:Part I:Excerpts from Excerpts from

lecturelecture

Take two tablets Take two tablets by mouth twice by mouth twice

daily…daily…

Understand - “Take Two TabletsUnderstand - “Take Two Tabletsby Mouth Twice Daily”by Mouth Twice Daily”

Davis T., Wolf M.S., Bass, P.T., et. al. (2006) Literacy and Misunderstanding Prescription Drug Labels, Annals of Internal Medicine. 145, 887-894. Stanford Stanford Geriatric Education CenterGeriatric Education Center

80.9

Importance of Enhanced Importance of Enhanced Communication with Geriatric Communication with Geriatric

PatientsPatients High-risk patients!High-risk patients!

Cognitive impairmentCognitive impairment Impaired sensoriumImpaired sensorium Low functional health literacyLow functional health literacy Complicated medical history with Complicated medical history with

multiple, chronic medical problems and multiple, chronic medical problems and complex medical regimens.complex medical regimens.

US Census Bureau 2000US Census Bureau 2000: : Projected Population Growth Projected Population Growth

of Elderlyof Elderly

Whites

Blacks, American Indian/Alaska Natives, Asian and Pacific Islander, Hispanic/Latino

84%

41%59%

16%

2000 2050

U.S. Census. U.S. Census. www.census.gov..

Functional Health Functional Health LiteracyLiteracy

Measure of person's capacity to Measure of person's capacity to function in the health care setting as function in the health care setting as determined by literacy and determined by literacy and numeracynumeracy Literacy: comprehension of written Literacy: comprehension of written

health care materialshealth care materials Numeracy: ability to understand and Numeracy: ability to understand and

act on numerical health care act on numerical health care instructions instructions

What the Levels Mean What the Levels Mean


What the Levels MeanWhat the Levels Mean


Millions of Americans haveMillions of Americans have“Below Basic” Literacy“Below Basic” Literacy


Low Health Literacy Low Health Literacy OutcomesOutcomes

People with low health literacy:People with low health literacy: Use screening/preventive services lessUse screening/preventive services less Present for care with later stages of diseasePresent for care with later stages of disease Are more likely to be hospitalizedAre more likely to be hospitalized Have poorer understanding of treatment and their Have poorer understanding of treatment and their

own healthown health Adhere less to medical regimensAdhere less to medical regimens Have increased health care costsHave increased health care costs Die earlierDie earlier

Schwartzberg , VanGeest , & Wang , 2004.Schwartzberg , VanGeest , & Wang , 2004.

Sudore, et al, 2006.Sudore, et al, 2006.

First Step: Bringing Up the First Step: Bringing Up the TopicTopic

““What things do you like to read?”What things do you like to read?” ““We need help fixing the information we We need help fixing the information we

give to people, what do you think we give to people, what do you think we could make better?”could make better?”

““How far did you go in school?”How far did you go in school?” Ask patient to read prescription bottle.Ask patient to read prescription bottle.

BIGGEST BARRIER: SHAME!BIGGEST BARRIER: SHAME!


Before Patients Leave …Before Patients Leave …These questions should be answered:These questions should be answered: What health problems do I have?What health problems do I have? Why is that important to me?Why is that important to me? What should I do about them?What should I do about them? Where do I go for any tests, medicine, Where do I go for any tests, medicine,

and appointments that I need next?and appointments that I need next? How should I take my medicine?How should I take my medicine? Any other instructions necessary?Any other instructions necessary? Who to call with questions?Who to call with questions?


Workshop—Part Workshop—Part II Teach-back II Teach-back

MethodMethod

Teach-back MethodTeach-back Method

Technique to improve communication and Technique to improve communication and confirm understanding, esp among confirm understanding, esp among individuals with limited literacy skillsindividuals with limited literacy skills

Involves individuals to recall or explain in Involves individuals to recall or explain in their own words what has been discussed. their own words what has been discussed. Eg: “I always ask my patients to repeat things Eg: “I always ask my patients to repeat things

back to me to make sure I explained things back to me to make sure I explained things clearly. I’d like you to tell me how you’re going clearly. I’d like you to tell me how you’re going to take the new medicine we discussed today.”to take the new medicine we discussed today.”


Copyright © 2009 Wolters Kluwer. 3

Figure 1

Closing the loop: physician communication with diabetic patients who have low health literacy

Schillinger D; Piette J; Grumbach K; Wang F; Wilson C; Daher C; Leong-Grotz K; Castro C; Bindman ABArchives of Internal Medicine. 163(1):83-90, 2003 Jan 13.

Teach-back CardsTeach-back Cards

3 cards to complete during rotation3 cards to complete during rotation Remind your attending that they’ll Remind your attending that they’ll

need to directly supervise you and need to directly supervise you and sign-off on the cardsign-off on the card

Workshop—Part II Workshop—Part II Role Playing ExerciseRole Playing Exercise

Have your group break into teams of Have your group break into teams of 2-3 learners.2-3 learners.

Assign one learner to be clinician, one Assign one learner to be clinician, one patient, and if needed, one to be patient, and if needed, one to be observerobserver Providing feedback is importantProviding feedback is important

Cases are posted on pogoe.orgCases are posted on pogoe.org NursingNursing SWSW PhysicianPhysician

Workshop—Part II Workshop—Part II Direct-observation Direct-observation

checklistchecklist Explain things clearly and use plain Explain things clearly and use plain

languagelanguage Emphasize 1 to 3 key points during visit Emphasize 1 to 3 key points during visit

and repeat ideas throughout visitand repeat ideas throughout visit Effectively encourage patients to ask Effectively encourage patients to ask

questions—use an open-ended approachquestions—use an open-ended approach Use teach-back method to confirm patient Use teach-back method to confirm patient

understanding (use demonstration of skill, understanding (use demonstration of skill, if needed)if needed)

Write down important information for Write down important information for patientpatient

Kripalani and Weiss, 2006.

Workshop—Part IIIWorkshop—Part III

Task: Analyze patient Task: Analyze patient education materials: 40 mineducation materials: 40 min

Tools to analyze material and find a Tools to analyze material and find a patient handoutpatient handout

Homework: revise the actual patient Homework: revise the actual patient discharge handout material and discharge handout material and bring it back to classbring it back to class

Creating Effective Health Creating Effective Health CareCare

Messages for Older AdultsMessages for Older Adults Realistic objectivesRealistic objectives Focus on behaviors Focus on behaviors

and skills, less on and skills, less on factsfacts

Establish a context for Establish a context for new informationnew information

Partition/”chunk” Partition/”chunk” complex instructionscomplex instructions

Cultural values/beliefsCultural values/beliefs

Include interactive or Include interactive or experiential activity experiential activity

Repeat important Repeat important informationinformation

Motivate the learnerMotivate the learner Relate to past experienceRelate to past experience Write for the patient, Write for the patient, notnot

the formulathe formula

Doak, Doak, and Root, 1996Doak, Doak, and Root, 1996

An older learner must understand what todo and feel enabled to take action.


Tools for Assessing the Tools for Assessing the SuitabilitySuitability

of Health Messagesof Health Messages

How suitable is the health How suitable is the health information?information?

Understandable?Understandable? Acceptable?Acceptable? Helpful?Helpful?


Categories ofCategories ofAssessment ToolsAssessment Tools

Attribute checklistsAttribute checklists

Readability formulasReadability formulas

Suitability of Assessment of Suitability of Assessment of Materials (SAM)Materials (SAM)


Attribute ChecklistsAttribute Checklists

Simple and quick method of assessing Simple and quick method of assessing appropriateness of health messagesappropriateness of health messages

Assessment categories:Assessment categories: OrganizationOrganization Writing styleWriting style AppearanceAppearance AppealAppeal

What would be important for

older adults from different cultures?

Area Health Education Center, Biddeford, Maine


Readability FormulasReadability Formulas

Assess Assess reading difficulty reading difficulty based onbased on Word difficulty (number of syllables)Word difficulty (number of syllables) Length of sentencesLength of sentences

NotNot suitable for tables, charts, word lists suitable for tables, charts, word lists Many Many different formulasdifferent formulas exist exist

Micrsoft Word ProgramMicrsoft Word Program Simple Measure of Gobbledygook (SMOG): Simple Measure of Gobbledygook (SMOG):

http://www.harrymclaughlin.com/SMOG.htm

Many are available in different languagesMany are available in different languagesStanford Geriatric Education CenterStanford Geriatric Education Center

Suitability of AssessmentSuitability of Assessmentof Materials (SAM)of Materials (SAM)

Used for printed materials, illustrations, Used for printed materials, illustrations, videos and audio taped instructionsvideos and audio taped instructions

Validated with different ethnic populations Validated with different ethnic populations and different medical specialities and different medical specialities

Indicates need for supplemental Indicates need for supplemental instructions instructions

Doak, Doak, & Root, 1996Doak, Doak, & Root, 1996


SAM CategoriesSAM Categories

1.1. ContentContent

2.2. Literacy demandLiteracy demand

3.3. GraphicsGraphics

4.4. Layout and typographyLayout and typography

5.5. Learning stimulation, motivationLearning stimulation, motivation

6.6. Cultural appropriatenessCultural appropriateness

Doak, Doak, & Root, 1996

Ratings: Superior material; Adequate material; Not suitable


Task: Use the SAMTask: Use the SAM

Choose a patient HO material Choose a patient HO material you frequently use or one you you frequently use or one you think may be usefulthink may be useful

Put the HO to the test!Put the HO to the test! Score the HOScore the HO Improve the HOImprove the HO

Questions/Questions/Thoughts?Thoughts?

geriatric health literacy: a skills-based workshop seema s. limaye, md section of geriatrics and...

Documents

health literacy workshop

geriatric patients

minutes slide

impact of low health

stanford university

models of health care

stanford ca

learners ideal size