“ What Are the Influences of Patient Literacy, HbA1c Understanding, and Socio-Demographic Variables on the Effectiveness, Attendance and Retention of VA Diabetes Patient Educational Initiatives? ” Department of Veterans Affairs Medical Center, North Chicago, IL USA Dr. Tariq Hassan, M.D. Veterans Affairs Medical Center, North Chicago, IL Dr. Barry Weiss, M.D. University of Arizona, Tucson Dr. George Lutz, Ph. D, Veterans Affairs Medical Center, North Chicago, IL Dr. Tom Muscarello, Ph. D, DePaul University David R. Donohue. M.A. Qualitative Technologies, Inc. and Northwestern University [email_address]

♦ North Chicago VA Medical Center North Chicago, IL USA, December 2007 Research Challenge The (NCVAMC) North Chicago VA Medical Center in 2006 had 625 high-risk diabetes patients defined as those with a HbA1c of 9.5 or greater of whom 48% either dropped out from, or did not participate in a prescribed VA Diabetes self-management education intervention program. The remaining 52% of these high-risk patients participated by attending a one-day self-management education seminar. Hundreds of NCVAMC patients with diabetes (high-risk group HbA1c = 9.5% or greater) do not adhere to therapy, can experience repeated hospital admissions, and have or are at risk for multiple diabetes complications. The lack of compliance, is often due to poor HbA1c knowledge, understanding and control of diabetes, resulting, in turn from unrecognized low health literacy, and socio-demographic factors.

Research Challenge

The (NCVAMC) North Chicago VA Medical Center in 2006 had 625 high-risk diabetes patients defined as those with a HbA1c of 9.5 or greater of whom 48% either dropped out from, or did not participate in a prescribed VA Diabetes self-management education intervention program. The remaining 52% of these high-risk patients participated by attending a one-day self-management education seminar.

Hundreds of NCVAMC patients with diabetes (high-risk group HbA1c = 9.5% or greater) do not adhere to therapy, can experience repeated hospital admissions, and have or are at risk for multiple diabetes complications. The lack of compliance, is often due to poor HbA1c knowledge, understanding and control of diabetes, resulting, in turn from unrecognized low health literacy, and socio-demographic factors.

♦ VA Research Challenge What is the impact of low-literacy and illiteracy on healthcare outcomes? Describe the health-related consequences of inadequate health literacy Identify all VA patient populations at risk for service and medication non-compliance

What is the impact of low-literacy and illiteracy on healthcare outcomes?

Describe the health-related consequences of inadequate health literacy

Identify all VA patient populations at risk for service and medication non-compliance

♦ Objectives Develop new patient education tools for communication challenged VA diabetes patients that will influence patient behavior, and be measurable Use the three questions from the Ask-Me-3 campaign and the Indian Health Service Patient Counseling technique during a patient interaction to ensure patient understanding of instructions and medication regimens

Develop new patient education tools for communication challenged VA diabetes patients that will influence patient behavior, and be measurable

Use the three questions from the Ask-Me-3 campaign and the Indian Health Service Patient Counseling technique during a patient interaction to ensure patient understanding of instructions and medication regimens

Definitions

Health Literacy Definition: “ Health Literacy,” goes beyond the individual obtaining information. “Health Literacy,” emerges when the expectations, preferences, and skills of individuals seeking health information and services meet expectations, preferences, and skills of those providing information and services . “Health Literacy,” arises from a convergence of education, health services, and social and cultural factors.

“ Health Literacy,” goes beyond the individual obtaining information. “Health Literacy,” emerges when the expectations, preferences, and skills of individuals seeking health information and services meet expectations, preferences, and skills of those providing information and services . “Health Literacy,” arises from a convergence of education, health services, and social and cultural factors.

♦ Health Literacy: The ability to read, understand, and act on health information and services to make appropriate health decisions. (Healthy People 2010 and IOM 2004) Pill bottles Appointment slips Informed consents Discharge instructions Health education materials Insurance applications Treatment instructions

The ability to read, understand, and act on health information and services to make appropriate health decisions. (Healthy People 2010 and IOM 2004)

Pill bottles

Appointment slips

Informed consents

Discharge instructions

Health education materials

Insurance applications

Treatment instructions

Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System A Large US Study Conducted on Health Literacy Found That… Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82 33% Were unable to read basic health care materials 42% Could not comprehend directions for taking medication on an empty stomach 26% Were unable to understand information on an appointment slip 43% Did not understand the rights and responsibilities section of a Medicaid application 60% Did not understand a standard informed consent

National Adult Literacy Survey 2003 U.S. Department of Education ▲ 47 % of the adult U.S. population - approximately 87 million people - has only a basic or below basic literacy levels

Limited health literacy is not restricted to adults with limited overall literacy Most health education materials are also “above the heads” of average readers When context is unfamiliar, most of us are confused, and don’t ask questions Many of us have low health literacy at times We don’t ask detailed and useful questions

Limited health literacy is not restricted to adults with limited overall literacy

Most health education materials are also “above the heads” of average readers

When context is unfamiliar, most of us are confused, and don’t ask questions

Many of us have low health literacy at times

We don’t ask detailed and useful questions

♦ Increased Hospitalizations Patients with inadequate health literacy are twice as likely to be hospitalized Potential impact Medication reconciliation Adverse drug events Non-adherence in treatment Serious drug-drug interactions Increased emergency room visits

Patients with inadequate health literacy are twice as likely to be hospitalized

Potential impact

Medication reconciliation

Adverse drug events

Non-adherence in treatment

Serious drug-drug interactions

Increased emergency room visits

Increased Health Care Costs ♦ University of Connecticut Study 2007 $106 - $236 billion more in additional health care costs, because of low health literacy More physician visits Increased emergencies room visits Higher medical/medication charges More days hospitalized

$106 - $236 billion more in additional health care costs, because of low health literacy

More physician visits

Increased emergencies room visits

Higher medical/medication charges

More days hospitalized

♦ Increased Legal Risks Lack of attention to health literacy could become an organizational negligence issue, impacting patient safety and quality In the future, providers may be negligent if problems related to health literacy are not addressed Lost of accreditation, hospitals and clinics in non-compliant status, because of low-literacy

Lack of attention to health literacy could become an organizational negligence issue, impacting patient safety and quality

In the future, providers may be negligent if problems related to health literacy are not addressed

Lost of accreditation, hospitals and clinics in non-compliant status, because of low-literacy

Accreditation Issues 2008 Joint Commission on Accreditation of Healthcare Organizations JCAHO recommends 2008: “ The patient receives education and training specific to the patient’s abilities…” Scoring includes evaluating whether education is presented in a manner understandable to the patient All patients must be screened for baseline literacy level

JCAHO recommends 2008:

“ The patient receives education and training specific to the patient’s abilities…”

Scoring includes evaluating whether education is presented in a manner understandable to the patient

All patients must be screened for baseline literacy level

Creating Solutions

Improve patient education materials Increase use of non-written information Ensure patient understanding at all levels Promote health literacy as a strategic objective within the VA healthcare organization Measure patient behaviors over-time

Improve patient education materials

Increase use of non-written information

Ensure patient understanding at all levels

Promote health literacy as a strategic objective within the VA healthcare organization

Measure patient behaviors over-time

Do you, as a health-care professional have the capability of identifying quality on-line or printed patient health information?

Do you, as a health-care professional have the capability of identifying quality on-line or printed patient health information?

♦ NCVAMC Proposed Initiatives Re-design of Primary Care Patient and Family Education Initiative Multidisciplinary commitment to develop, implement, and disseminate appropriate education materials Expand methods of delivery and presentation Use integrated communication channels Survey all patient groups for literacy level Build trust between all stakeholders Get buy-in from all participants

Re-design of Primary Care Patient and Family Education Initiative

Multidisciplinary commitment to develop, implement, and disseminate appropriate education materials

Expand methods of delivery and presentation

Use integrated communication channels

Survey all patient groups for literacy level

Build trust between all stakeholders

Get buy-in from all participants

♦ Quality of Education Materials Meet patients’ educational needs and literacy level Need-to-know information essential to the plan of care Based on the adult learning theory Plain and simple language Clear and inviting layout, ample white space Employ several learning methods Printed materials, interactive tutorials, and new digital tools

Meet patients’ educational needs and literacy level

Need-to-know information essential to the plan of care

Based on the adult learning theory

Plain and simple language

Clear and inviting layout, ample white space

Employ several learning methods

Printed materials, interactive tutorials, and new digital tools

♦ Goal for Patient Written Drug Information Evaluate and recommend multiple patient drug information education resource for VA Medical Center patients Resource would be available on-line and readily accessible Measure effectiveness of communications by patient behaviors

Evaluate and recommend multiple patient drug information education resource for VA Medical Center patients

Resource would be available on-line and readily accessible

Measure effectiveness of communications by patient behaviors

♦ Evaluation Criteria Patient usability Health professional usability Currency (does it add-value to the patient experience?) Content rich, according to patient level of understanding

Patient usability

Health professional usability

Currency (does it add-value to the patient experience?)

Content rich, according to patient level of understanding

Finding a Solution

Ask Me 3 – Creates Shared Responsibility for Clear Health Communication Patient Provider De-stigmatize and Reduce Embarrassment of Low Health Literacy Recognize Patient Coping Mechanisms Provides a consistent approach to patient-provider dialogue Allows patients to get information they need to manage their health Time-efficient for providers to reinforce healthcare instructions

Provides a consistent approach to patient-provider dialogue

Allows patients to get information they need to manage their health

Time-efficient for providers to reinforce healthcare instructions

What Is Ask Me 3 Promotes three simple, but essential, questions and answers for every healthcare interaction: Why Is It Important for Me to Do This? Context What Do I Need to Do? Treatment What Is My Main Problem? Diagnosis

Promotes three simple, but essential, questions and answers for every healthcare interaction:

Why Is It Important for Me to Do This?

Indian Health Service Technique Promotes three simple, but essential, questions and answers for every pharmacy interaction: What should I expect from this medication? How do I take the medication? What is the medication for?

Promotes three simple, but essential, questions and answers for every pharmacy interaction:

What should I expect from this medication?

♦ General Considerations Create a shame-free environment and offer assistance when needed Personalize patient messages Create open and trusting relationships Invite family or friends to participate in patient care visits

Create a shame-free environment and offer assistance when needed

Personalize patient messages

Create open and trusting relationships

Invite family or friends to participate in patient care visits

♦ General Considerations Use simple and clear language Reinforce and repeat information often Link information to previous knowledge Use “Teach Back” method; ask questions Tailor the information to the individual by giving examples and explaining the relevance

Use simple and clear language

Reinforce and repeat information often

Link information to previous knowledge

Use “Teach Back” method; ask questions

Tailor the information to the individual by giving examples and explaining the relevance

IN CONCLUSION Our findings suggest low-health literacy exacts enormous costs on both the health system and society, and that current expenditures could be far better directed through a commitment to improving health literacy at all levels. Public policy plays an important role in addressing low-health literacy and its effects. Conversely, the failure to act carries high costs in terms of individual health, healthcare spending, and the economic well-being of the nation as a whole. Providing the U.S. population with access to affordable coverage creates a more level playing field among those who are and are not health literate. It is particularly challenging to improve literacy among populations who lack affordable access to timely and appropriate health care.

IN CONCLUSION

Our findings suggest low-health literacy exacts enormous costs on both the health system and society, and that current expenditures could be far better directed through a commitment to improving health literacy at all levels.

Public policy plays an important role in addressing low-health literacy and its effects. Conversely, the failure to act carries high costs in terms of individual health, healthcare spending, and the economic well-being of the nation as a whole.

Providing the U.S. population with access to affordable coverage creates a more level playing field among those who are and are not health literate. It is particularly challenging to improve literacy among populations who lack affordable access to timely and appropriate health care.