Practical Strategies for Advancing Pharmacy Health Literacy in

Practical Strategies for Advancing Pharmacy Health Literacy in

Practical Strategies for Advancing Pharmacy Health Literacy in the Ambulatory Care Setting Anna Dutton, PharmD, BCACP Taylor Hermiller, PharmD Megan Lyons, PharmD, BCACP Objectives Define health literacy and compare various screening tools available Identify risk factors and describe negative outcomes associated with low health literacy Describe methods to communicate with and motivate patients Review extent of health literacy problem within Health Care Systems and discuss strategies for improvement

Defining and Assessing Low Health Literacy Taylor Hermiller, PharmD Definition Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Prevalence Nearly 9 out of 10 adults have

difficulty using everyday health information available in health care facilities Approximately 90 million adults lack needed literacy skills to effectively use US health system Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. National Assessment of Adult Literacy Performance Levels Level 4: Proficient 12% Simple math

Inferences Simple text Routine Tasks Level 1: Below Basic 14% Kutner, M., et al. National Center for Education Statistics. 2006. Level 2: Basic 22% Level 3: Analyze and Intermediate

integrate 53% information Find facts in Multi-step math problems denser text Find/apply data to solve simple math problems Health Literacy Domains Fundamental Reading/writing Numeracy Arithmetic

Scientific Body organs Medical tests Mathematical concepts Zarcadoolas C., et al. Health Promotion International. 2005; 20 (2): 195-203. Health Literacy Civic Applying health information to make public policy decisions

Cultural Religious/social beliefs Value systems Risk Factors Age > 65 years old Less than high school education Low income English as a second language Immigrants Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Negative Clinical Outcomes

Increased difficulty interpreting labels and health messages Decreased adherence Decreased utilization of preventative care services Negative disease outcomes Greater use of emergency care More hospitalizations Higher mortality rates among elderly National Institutes of Health. 2018. Berkman ND, et al. Ann Intern Med. 2011;155:97107 Negative Clinical Outcomes Bennett, 2008 Lower likelihood of: -Receiving the flu shot -Taking medicines correctly

-Understanding medical labels and instructions Nielson-Bohlman, 2004 -Lower health status -Less likely to use preventative care Baker, 2002 -More likely to be hospitalized -More likely to have negative disease outcomes Schillinger, 2002 -Worse glycemic control in patients with DM -Higher rates of

retinopathy National Institutes of Health. 2018. Schillinger D, et al. Journal of the American Medical Association. 2002;288(4):475-482. Bennett IM, et al. Annals of Family Medicine, 2009, May-Jun;7(3):204-11. Baker, 2007 - Higher mortality rates within a Medicare managed care setting Negative Cost Outcomes Howard, 2004

Inpatient spending increases by $993 for patients with limited health literacy Vernon, 2007 Annual cost of low health literacy to the U.S. economy is $106 billion to $238 billion Howard DH, et al. Journal of General Internal Medicine, 2006, Aug;21(8):857-61. Vernon JA, et al.Low health literacy: Implications for national health policy. 2007. Screening Tools: Rapid Estimate of Adult Literacy in Medicine (REALM)

Adults pronounce 66 common words related to anatomy or illnesses One point for every word pronounced correctly Shorter versions available (REALM-R: 8 items and REALM-SF: 7 items) Only available in English Validated in the United States Davis T., et al. Rapid Estimate of Adult Literacy in Medicine (REALM). 1993. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Screening Tools: REALM 0-18 words (3rd grade and below): Not able to read easy materials, need repeated oral instructions, materials

composed primarily of illustrations, audio, or videotapes 19-44 words (4th to 6th grade): Need easy materials, not able to read prescription labels 45-60 words (7th & 8th grade): Struggle with most patient education materials and will not be offended by low literacy materials 61-66 words (High school): Able to read most patienteducation materials Davis, T, et al. Rapid Estimate of Adult Literacy in Medicine (REALM). 1993. Screening Tools: Test of Functional Health Literacy in Adults (TOFHLA) 50 reading and 17 numeracy items involving common medical situations Assesses numeracy and reading comprehension

Shorter version (s-TOFHLA) uses 36 reading questions Results categorized into inadequate, marginal, or adequate levels of health literacy Available in multiple other languages Validated in the United States North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Screening Tools: TOFHLA Parker RM, et al. J Gen Intern Med 1995; 537-41. Screening Tools: Newest Vital Sign (NVS) Six questions regarding interpretation of a standard

nutrition label Assesses both numeracy and comprehension Includes arithmetic calculations Validated in English and Spanish Has been tested in primary care settings Weiss BD, et al. Ann Fam Med. 2005;3(6):514-22. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Screening Tools: NVS Q: If you eat the entire container, how many calories will you eat? Weiss BD, et al. Ann Fam Med. 2005;3(6):514-22.

Screening Tools: Single Item Literacy Screener (SILS) Single item How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Response scale is from 1 (never) to 5 (all of the time) Responses > 2: high risk of low health literacy Developed initially and validated in VA clinics but also tested in primary care Morris NS, et al. BMC Fam Pract 2006;7:21. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014.

Screening Tools: Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA-50) Reading 50 words; choice between two distractors is used to indicate understanding Tests pronunciation and comprehension Based on REALM but not a Spanish translation of REALM Score between 0-37 indicates inadequate health literacy Validated in the United States Lee, SY, et al. Health Serv Res. 2006; 41(4 Pt 1):1392-412. North Carolina Program on Health Literacy. Literacy Assessment Instruments. 2014. Screening Tools:

SAHLSA-50 Lee, SY, et al. Health Serv Res. 2006; 41(4 Pt 1):1392-412. Comparing Assessment Tools REALM TOFHLA SILS NVS SAHLSA

Constructs measured Medical word recognition and pronunciation Reading comprehension and numeracy skills Reading comprehension , need for assistance, and

confidence Reading and comprehension of a nutrition label, numeracy skills Medical word pronunciation and comprehension Administration time (minutes)

2.5 long 1 short 22 long 7 short 1 3 4.5 Performancebased

Selfadministered Available in Spanish

Comparing Assessment Tools REALM Communication (pronunciation, verbalization) TOFHLA SILS NVS

Comprehension (prose/reading, problem solving) Numeracy/Quantitative Decision making/critical

thinking Confidence (self-efficacy) Need for assistance SAHLSA

Communicating with Low Health Literate Patients Anna Dutton, PharmD, BCACP Patient-Centered Communication Establish a connection Create rapport Prioritize patient concerns

Plan the visit Explore and integrate patients perspective Ask and acknowledge Affirm and incorporate Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools. Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. Patient-Centered Communication Demonstrate interest and empathy Acknowledge emotions Respond appropriately

Collaborate and educate Involve patient in decision-making Propose plan Assess baseline knowledge of plan Discuss patients level of agreement Provide education and verify understanding Complete visit Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools.

Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. Patient-Centered Communication Communicate with finesse Maintain rapport

Effective question style Verbal expression Appropriate language for patients health literacy Non-verbal expression Confidence and professionalism Organization Special considerations Grice GR, Prosser TR, Gattas N, et al. Patient- Centered Communication Tools. Available at http://stlcop.edu/health-literacy/pact.html. Accessed July 20, 2018. Incorporating Health Beliefs: Health Belief Model Incorporating Health Beliefs: Health Belief Model

Whale Conley CE, Olson AD, Howard JS, et al. Use of an Adaption to the Health Belief Model to Influence Rehabilitation Adherence in Athletic Training. ATSHC Identifying Patients with Low Health Literacy AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/ Universal Precautions Approach Structuring the delivery of care as if everyone may have limited health literacy Higher literacy skills understanding

Anxiety can reduce ability to manage health information Everyone benefits from clear communications Focus on need to know and need to do Checking out and follow up Self-care and taking medications AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/ Using Plain Language Anxiety Dose Hazardous Medication Outcome

Preventable Respiratory CDC. Everyday Words for Public Health Communication. May 2016. Worry, fear Amount, number of times Not safe, dangerous, risky Medicine Result Can keep from happening Breathing, related to the lungs Teach Back Method

Schillinger D, Piette J, Grumback K, et al. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Confirm Patient Understanding Tell me what youve understood. I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine? Do you understand? Do you have any questions? AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/ Interacting with Low Health

Literate Patients AHRQ. Health Literacy: Hidden Barriers and Practical Strategies. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/ Healthy People 2020 HC/HIT-1 Improve the health literacy of the population HC/HIT-1.1 Increase the proportion of persons who report their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health condition. HC/HIT-1.2 Increase the proportion of persons who report their health care provider always asked them to describe how they will follow the instructions. HC/HIT-1.3 Increase the proportion of persons who report their health care providers office always offered help in filling out a form. US DHHS. Healthy People 2020. Available at

https://www.healthypeople.gov/2020/topics-objectives/topic/health- Healthy People 2020 HC/HIT-2 Increase the proportion of persons who report that their health care providers have satisfactory communication skills HC/HIT-2.1 Increase the proportion of persons who report that their health care providers always listened carefully to them. HC/HIT-2.2 Increase the proportion of persons who report that their health care providers always explained things so they could understand them. HC/HIT-2.3 Increase the proportion of persons who report that their health care providers always showed respect for what they had to say. HC/HIT-2.4 Increase the proportion of persons who report that their health care providers always spent enough time with them. US DHHS. Healthy People 2020. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/health-

Health Communication CAN Increase knowledge and awareness Influence perceptions, beliefs, and attitudes Prompt action Demonstrate or illustrate healthy skills Reinforce knowledge, attitudes, or behavior Show benefit of behavior change Increase demand or support for health services Refute myths and misconceptions US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004. Health Communication

CANNOT Compensate for inadequate health care or access to health care services Produce sustained change in complex health behaviors without the support of a larger program for change Be equally effective in addressing all issues or relaying all messages Complexity of the topic or suggested behavior change Preconceptions about the topic or message sender Controversial nature of the topic US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004. Health Communication with Other Strategies CAN

Cause sustained change in which: Individuals adopt and maintain new health behaviors Organization adopts and maintains a new policy direction Overcome barriers/systemic problems, such as insufficient access to care US DHHS, NIH, and NCI. Making Health Communication Programs Work. August 2004. Health Literacy and the Health Care System Megan Lyons, PharmD,

BCACP Patient Demands https://ncphn.org.au/archives/programs/health-literacy. Accessed July 20, 2018. Health Care Outcomes and Resource Use Reported lower health status Less likely to use preventive care More likely to be hospitalized and experience poor disease outcomes Experienced higher mortality rates Less likely to comply with treatment and self-care More medication or treatment errors Lacked the skills needed to navigate the health care system

Responsible for higher inpatient costs and overall health care spending by Medicare and Medicaid Healthwise. HealthLiteracy-Not All Patient Education is Created Equal. Available at https://www.healthwise.org/blog/health-literacy-and-patient-education.aspx. Accessed July 18, 2018. Patient Skills CDC. Health Literacy. Available at https://www.cdc.gov/healthliteracy/planact/steps/index.html. Accessed July 10, 2018. Provider Skills CDC. Health Literacy. Available at https://www.cdc.gov/healthliteracy/planact/steps/index.html. Accessed July 10, 2018. Patient Case

69 yo Black male with PMH sig for Afib, DM2, ESRD on hemodialysis, HFpEF, and CAD s/p stents. Pt referred to Pharmacy Anticoagulation clinic for warfarin management and Pharmacotherapy clinic for medication compliance Pt is originally from Africa, speaks French Medication List Atorvastatin 80 mg Isosorbide mononitrate 60 mg Calcium acetate 667 mg Losartan 50 mg Carvedilol 25 mg

Melatonin 3 mg Clopidogrel 75 mg Nitroglycerin 0.4 mg Famotidine 20 mg Torsemide 10 mg Insulin glargine Warfarin 5 mg Patient Case 1/9/18:

Admitted: influenza and NSTEMI 1/17/18: Presents for follow up with pharmacy clinics Complex medication regimen 3/30/18: 1/22/18: Multiple chronic disease states Presents for follow Presents to ED; up with pharmacy Frequent

health care system use diagnosed with UTI clinics Multiple appointments Emergency department use Hospital admissions Dialysis Financial barriers 1/24/18: Insurance terminated Presents for follow Paperwork required for reinstatement up with pharmacy

Cost of healthcare clinics Cultural/language barriers Patient Case 6/28/18: Returns to UCMC, PCP visit 7/11/18: Complex medication regimen Presents for follow Multiple chronicup disease

states with pharmacy Frequent healthclinics care system use Multiple appointments Emergency department use Financial barriers Hospital admissions Transportation Dialysis Food insecurity Financial

7/3/18:Support barriers 7/24/18: Insurance terminated Re-establishes with family support Presents for follow Limited Paperwork required for reinstatement pharmacy clinics up with pharmacy Cost of healthcare clinics Cultural/language barriers

National Action Plan Everyone has the right to health information that helps them make informed decisions Health services should be delivered in ways that are understandable and beneficial to health, longevity, and quality of life. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC. Goals: National Action Plan Develop and disseminate health and safety information that is accurate, accessible, and actionable Promote changes in the health care system that improve health

information, communication, informed decision-making, and access to health services Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC. Goals: National Action Plan Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community Build partnerships, develop guidance, and change policies

Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy Increase the dissemination and use of evidence-based health literacy practices and interventions U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.

Health Literate Organization Leadership promotes Plans, evaluates and improves Prepares workforce Includes consumers Meets needs of all Communicates effectively Ensures easy access Designs easy to use material Targets high risk Explains coverage and costs

Institute of Medicine. Ten Attributes of Health Care Literate Organization. 2012. Benefits to the Health Care System Increased patient safety Decreased hospital re-admissions Increased patient satisfaction Reduction of health disparities Quality improvement initiatives Creation of a welcoming environment for all patients Wisconsin Literacy. Improving the Health Literacy of Hospitals. October 2010. Appropriate utilization of health

care services Increased ability of patients to manage chronic conditions and health care needs Positive public relations Community benefit Health Literacy Mindset ODPHP. Shifting the Health Liteacy Mindset to Enhanc People-Centered Health Services. Checklist for Patient Understanding What is my main problem? What do I need to do (about the problem)? Why is it important for me to do this?

Where do I go for tests, medicine and appointments? How should I take my medicine? Who do I call if I have questions? Other instructions Next steps AMA Foundation. Health Literacy and Patient Safety: Help Patients Understand. May 2007. Resources Agency for Healthcare Research and Quality (AHRQ): Health Literacy CDC: Health Literacy Centers for Medicare & Medicaid Services (CMS): Toolkit for Making Written Material Clear and Effective Health Literacy Online National Network of Libraries of Medicine (NNLM): Health Literacy NIH National Library of Medicine's MedlinePlus: Health Literacy NIH: Clear Communication

PlainLanguage.gov Practical Strategies for Advancing Pharmacy Health Literacy in the Ambulatory Care Setting

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