Deborah Slawson, PhD, RD, LDNEast Tennessee State University

College of Public Health

Conference on Practical Strategies in Medication Adherence

June 2012

Health Literacy: partnering with patients to ensure understanding

Cultural Competency: interacting effectively with people from diverse cultures

For Your Tool Kit: essentials to help your patients get the most out of medication & diet regimes

“The degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”

Print literacy Numeracy Oral literacy

ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

• 2006 Institute of Medicine Report, Preventing Medication Errors• Each year: 1.5 million adverse drug events in

U.S.• 33% of these are in outpatient settings

• Poor patient understanding and unintentional misuse of Rx drugs (specifically poor understanding of drug labeling) is a root cause of med errors, poor adherence and poor health outcomes.

Ref in Davis TC, et al. JGIM 2008; 24(1):57-

62.

Health Literacy – Prescribing and Medication ManagementNC Program on Health LiteracyBetsy Bryant Shilliday, PharmD, CDE, CPPRef in Davis TC, et al. JGIM 2008; 24(1):57-62.

Health Literacy: an essential first stepHealth Literacy: an essential first step

American Medical AssociationAmerican Medical Association

One in three English-speaking adults in the United States are limited in health literacy.

Low health literacy is associated with:◦ More emergency room visits◦ More use of inpatient care◦ Among older adults:

Poorer health status Higher risk of death

◦ Poor ability to interpret health messages

ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

Social support, patient self-efficacy, and stigma may impact the relationship between health literacy and health outcomes.

Health literacy has been shown to mediate the effect of key characteristics on health outcomes:◦ Education level◦ Race◦ Income◦ Urbanicity

ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

National Assessment of Adult Literacy, 2003

Achieving clarity is an art…

Present essential information by itself

Present the most important points first

Use direct, plain wording Lower reading level text Use pictures & videos

where appropriate

ARRQ, Evidence Report/Technology Assessment; No. 199, 2011

Tips and tools to enhance your practice How to enhance:

◦ Spoken communication◦ Written communication◦ Patient self-management◦ Engaging your community

AHRQ Pub. No. 10-0046-EF, April 2010AHRQ Pub. No. 10-0046-EF, April 2010

Limit to 3-5 key points Plain, non-medical language Watch your pace Encourage participation – ask open-ended

questions Use graphics: draw pictures, use 3-D

models Use Teach-Back

AHRQ Pub. No. 10-0046-EF, April 2010

NC Program on Health Literacy

LEARN:◦ What did you learn?

CONCERN:◦ We covered several important topics. What may

have confused or concerned you?

DO:◦ What are you going to do now as a result of what

we talked about?

Ask patients to bring in medications and supplements as well as herbal remedies and OTC’s

Consider providing a special bag for meds Ask open-ended questions Clarify med instructions; i.e. teach-back Bill for medication review

(ICD-9 V58.69)

AHRQ Pub. No. 10-0046-EF, April 2010

Well-designed printed materials must be used thoughtfully◦ Front desk personnel should be trained in literacy

awareness: Understand that low literacy is common Work with patients to ensure understanding in a

sensitive manner◦ Review materials fully with patients◦ Ask patients to Teach Back what was discussed◦ Review and reinforce key points

Clear Doc Index

Short sentences Few multi-syllable words Avoid medical jargon: a

“positive” test is not always good!

Use white space & chunk information in sections

Add graphics Bulleted lists Bold key terms

Clear, concise formatting eases understanding

AHRQ Pub. No. 10-0046-EF, April 2010

Medication adherence tips◦ Ask patients how they remember to take their

meds.◦ Use non-judgmental verbiage.“Most people forget to take their pills sometimes.

When was the last time you forgot to take medicine?”

◦ Give precise instructions◦ Provide a pill chart with times and details◦ Will generics will look different? Use pictures to inform patients.

AHRQ Pub. No. 10-0046-EF, April 2010

Cultural CompetencyCultural Competency

Awareness of patients’ ethnic, cultural and religious backgrounds leads to greater understanding and clearer communication.

One approach = CLAS standards◦ Standards that define cultural competency in

health care delivery and practice Source of CLAS standards

◦ Developed by US Department of Health and Human Services, Office of Minority Health

◦ Derived from analysis of current practice and policy on cultural competence

◦ Shaped by input of health providers, advocates, policymakers, researchers, and consumers

Consists of 14 standards in 3 themes◦ Culturally Competent Care (standards 1-3)◦ Language Access Services (standards 4-7) ◦ Organizational Supports for Cultural Competence

(standards 8-14)

DHHS Office of Minority HealthCenter for Linguistic and Cultural Competency in Health Care

Sample standards“Health care organizations should…”1 ensure that patients/consumers receive from all staff

member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

CULTURALLY & LINGUISTICALLY APPROPRIATE SERVICES (CLAS)

Health beliefs and customs Ethnic customs Religious beliefs Dietary customs Interpersonal relations

Culture Clues Tip Sheets

AHRQ Pub. No. 10-0046-EF, April 2010

“I am not familiar with your cultures and beliefs. Can you teach me what I might need to know so I can better treat you?”

“What do you call your illness? What do you think caused your illness? How do you think it should be treated?”

“Do any traditional healers advise you about your health?”

AHRQ Pub. No. 10-0046-EF, April 2010

She believes that entering the hospital will kill her, and opts for traditional therapies. Her family physician desperately wants to work with the patient to manage her diabetes better. But how?Cultural FactSome American Indian cultures, the Navajo for example, believe that mentioning an illness will cause the illness.

A Physician’s Practical Guide to Culturally Competent Care

DHHS Office of Minority HealthCenter for Linguistic and Cultural Competency in Health Care

Practices participating in Medicare/Medicaid are legally required to provide equal access to services for patients who do not speak or understand English well.

AHRQ Pub. No. 10-0046-EF, April 2010

Use an “I speak” card:

Use an interpreter: ◦ American Translators Association

AHRQ Pub. No. 10-0046-EF, April 2010

Don’t rely on children of patients, family members, patient’s friends

Assure patient that all staff are bound by confidentiality

Speak directly to the patient ALL communications must be interpreted Avoid jargon, slang, metaphors Debrief with interpreter: additional cultural

considerations?

Ethnomed.org, 2005

“Ensuring that people understand health care information is critical to a high-quality, safe health care system. Improving health literacy will be a major step in the nation's efforts to enhance health care quality and safety."