Chapter 15_ Improving the Communication Exchange_ A Focus on Limited Health Literacy.pdf

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy Debra Keller; Urmimala Sarkar; Dean Schillinger OBJECTIVES Object...

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy Debra Keller; Urmimala Sarkar; Dean Schillinger OBJECTIVES Objectives Define health literacy. Identify patient and system level factors that contribute to the challenges faced by patients with limited health literacy. Review best practices in clear communication. Discuss how to facilitate question asking. Illustrate how to confirm comprehension and identify topics for further focused review. Describe characteristics of health literate health­care organizations. INTRODUCTION Mrs. S, a 65­year­old woman with type 2 diabetes, high blood pressure, chronic obstructive lung disease (COPD), and ​lumbar back pain, comes to her primary care clinic for ​routine follow­up. Mrs. S takes metformin, glipizide, benazepril, Advair®, Spiriva®, albuterol, and ibuprofen. She lives alone as her husband passed away. She manages her own medications, shopping, cooking, and cleaning. She has a daughter who visits her weekly. During her appointment, she reports difficulty picking up all of her medications due to “insurance issues.” She has not been regularly checking her blood sugar at home and reports “cheating” a lot lately, especially when baking for her grandchildren. She complains of worsening back pain, limiting her ability to attend her weekly dance class. She missed her scheduled mammogram because she got lost looking for the mammography center at an offsite location. Her recent hemoglobin A1c has increased from 7.5% to 9.0% and her diabetic foot exam shows decreased sensation. She leaves her visit with an appointment with the ​medical social worker to discuss medication insurance coverage, a handout on lower back stretches to practice at home, a referral to prosthetics to pick up diabetic shoes, instructions on daily foot care, a blood sugar tracking form with instructions to monitor her blood sugar three times a day to help decide if she should be started on insulin, a map of the hospital’s offsite facilities to help her find the mammography center, and a ​computer­generated summary of her primary care visit. She is given the phone number to reschedule her mammogram, and follow­up appointments to see the diabetes nurse in 6 weeks and her primary care provider in 3 months. In order to maintain good health, patients are expected to communicate concerns clearly with providers, understand written and verbal instructions, partner with providers to make decisions about screening and choose treatment options, engage in self­management activities at home and in their communities, and negotiate a complicated and often fragmented health­care system. These are complex tasks requiring a high­level of health ​literacy. The various definitions of health literacy (Box 15­1) reflect a dynamic interplay between the literacy demands and attributes of the health­care environment and the personal skills of patients. Box 15­1. Defining Health Literacy Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 Page 1 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 McGraw Hill. All“The Rights Reserved. of Use Privacy Policyto Notice Accessibility Institute of Medicine: degree to whichTerms individuals have the capacity obtain, process, and understand basic health information and services needed to make appropriate health decisions.” partner with providers to make decisions about screening and choose treatment options, engage in self­management activities at home and in their Mount Saint Vincent College communities, and negotiate a complicated and often fragmented health­care system. These are complex tasks requiring a high­level of health ​literacy. Access Provided by: The various definitions of health literacy (Box 15­1) reflect a dynamic interplay between the literacy demands and attributes of the health­care environment and the personal skills of patients. Box 15­1. Defining Health Literacy Institute of Medicine: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” The Patient Protection and Affordable Care Act of 2010, Title V: “The degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.” World Health Organizations: “The cognitive and social skills which determine the motivation and ability of individuals to gain access to understand and use information in ways which promote and maintain good health.” This chapter outlines the difficulties faced by patients with limited health literacy, with a focus on patient and system level factors. The chapter highlights the central role that clear communication plays in promoting health equity and high­quality care. We also provide clinicians with a set of strategies to improve understanding for patients with limited health literacy. These considerations are relevant not only to clinicians but also to anyone on the health­care team who interacts with patients or plays a role in designing or implementing health education or programming. DEFINITIONS AND THE SCOPE OF THE PROBLEM Health literacy skills are broader than general literacy skills. In addition to basic reading skills, the relevant skills needed by a patient include document­reading skills; writing skills; interpersonal communication skills; the ability to use numbers for computation, measurement, and risk assessment; and the skills needed to navigate systems—online, on the phone, and in physical space. Limited health literacy results when the complexity of health tasks and the demands of the health­care system exceed the skills of patients. Health literacy is content and context dependent. Limited health literacy is common and is more likely in people over the age of 65 years, individuals with chronic diseases, minority population groups, immigrants, and those without a high school education.1,2 Acute illness or anxiety over a new diagnosis can also affect patients’ health literacy. As providers increasingly depend on patient skills and knowledge to manage chronic diseases such as diabetes, congestive heart failure (CHF), and COPD, ensuring that the literacy demand of the health­care system matches the literacy skills of individual patients which is of utmost importance. Because all patients, regardless of health literacy level, benefit from clear, direct communication and other literacy­friendly communication techniques, experts recommend “universal precautions,” or applying clear communication strategies, discussed later, in all clinical encounters (Box 15­2). Box 15­2. Common Pitfalls in the Care of Patients with Limited Health Literacy Overestimating patients’ health literacy level Using jargon Discouraging question asking with body language or words Sharing too much information and focusing on non–action­oriented information Relying on words alone Choosing written materials that are too complex or at too high of a literacy level IMPACT ON HEALTH OUTCOMES Limited health literacy has been linked to a wide range of adverse health outcomes.3 Compared with individuals with adequate health literacy, individuals with limited health literacy have higher rates of chronic illness, greater difficulty with medication management and poorer rates of medication adherence,4,5 less knowledge about their chronic diseases,6 higher rates of hospitalizations due to chronic medical conditions such as CHF and diabetes,7,8,9,10 have more emergency room visits and hospitalizations,11,12 and experience worse chronic disease outcomes.13 Recent research among older adults connects literacy level with cognitive decline, such as decreases in executive functioning.14 Downloaded 2024­2­18 9:30health A Your IP is 63.247.225.21 Page 2 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 Hill. Allhas Rights Reserved. Termsinteractions of Use Privacy Policy NoticePatients Accessibility LimitedMcGraw health literacy an impact on patients’ with their providers. with limited health literacy have a more difficult time understanding explanations about medical conditions and instructions about medication changes.15 Owing to embarrassment or shame related to incomplete understanding, patients with limited health literacy are often more passive during encounters, asking fewer questions, despite having Limited health literacy has been linked to a wide range of adverse health outcomes.3 Compared with individuals with adequate health Mount Saintliteracy, Vincent College individuals with limited health literacy have higher rates of chronic illness, greater difficulty with medication managementAccess and poorer rates of Provided by: medication adherence,4,5 less knowledge about their chronic diseases,6 higher rates of hospitalizations due to chronic medical conditions such as CHF and diabetes,7,8,9,10 have more emergency room visits and hospitalizations,11,12 and experience worse chronic disease outcomes.13 Recent research among older adults connects health literacy level with cognitive decline, such as decreases in executive functioning.14 Limited health literacy has an impact on patients’ interactions with their providers. Patients with limited health literacy have a more difficult time understanding explanations about medical conditions and instructions about medication changes.15 Owing to embarrassment or shame related to incomplete understanding, patients with limited health literacy are often more passive during encounters, asking fewer questions, despite having greater need for reinforcement.16 These gaps in understanding make self­management and follow­up activities more difficult, and may contribute to poorer health outcomes. In addition, gaps in understanding can impede shared decision making and informed consent.17 Limited health literacy may affect patients’ ability to access care and navigate the complexities of the health­care system. For example, insurance companies or government programs often introduce hurdles that may be insurmountable to people with limited health literacy. Consequently, people may not seek care or may present for health care late with more advanced disease. While most of these outcomes studies have focused on English­speaking countries, studies from other countries replicate these findings.13 In addition, newer studies are beginning to analyze health literacy skills beyond reading, such as numeracy and listening skills, and explore these skills’ impacts on health outcomes.18,19 SCREENING FOR LIMITED HEALTH LITERACY Miscommunication and misunderstanding are common during health­related interactions. Nonetheless, providers do a poor job of predicting who will have a difficult time understanding. Providers also tend to overestimate patients’ health literacy level.20,21 A number of instruments to assess health literacy have been developed and studied, primarily for use in the research setting. The two most commonly used research tools, the Rapid Estimate of Adult’s Literacy (REALM) and the Test of Functional Health Literacy (TOFHLA), are word recognition and document utilization tests, respectively. While both tools have abbreviated forms, these shortened versions are cumbersome and can be intimidating to use in the clinical setting. A newer screening tool, the Newest Vital Sign, asks patients to interpret information contained on nutrition labels, mimicking real­life health management behaviors.22 In addition, a single­item self­reported screening question, “How confident are you in filling out medical forms?” can be useful in identifying patients with limited health literacy.23,24 However, each of these screening tools focus primarily on reading and document interpretation skills, and to a lesser extent numeracy, as a proxy for health literacy skills overall. These tools omit assessment of interpersonal, bidirectional, communication skills—speaking or explaining and listening or verbal comprehension—literacy skills central to successful health­related exchanges.25 Despite the availability of these screening tools, most health literacy experts and national health policy organizations recommend against routine screening for limited health literacy.15 There is insufficient evidence that screening improves health outcomes or enhances patient–provider relationships.26 SYSTEM LEVEL FACTORS THAT CONTRIBUTE TO HEALTH LITERACY CHALLENGES There is growing appreciation that characteristics of the health­care system contribute to, or can ameliorate, the challenges experienced by individuals with limited health literacy skills.27,28 Training health­care professionals to communicate clearly and to choose literacy­friendly, written reinforcement tools are important steps to promote health equity for individuals with limited health literacy, but these strategies are often insufficient. As we saw in Mrs. S’s case, patients experience health literacy­related challenges not only within the clinic setting and while performing self­management tasks at home, but also as they negotiate health insurance plans, navigate health­care facilities, and communicate with other members of the health­care system team. Health­care organizations can recognize and address the system level factors that increase literacy demands. An Institute of Medicine (IOM)­commissioned paper29 describes 10 attributes of “health literate organizations” (Box 15­3), providing guideposts for organizational change to achieve an environment that promotes access and understanding for all patients, regardless of health literacy level. Box 15­3. Attributes of a Health Literate Organization2 9 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement programs. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes 2024­2­18 populations9:30 served in theIPdesign, implementation, and evaluation of health information and services. Downloaded A Your is 63.247.225.21 Page 3 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger 5. Meets needsHill. of populations with a rangeTerms of health literacy skillsPolicy while avoiding ©2024 McGraw All Rights Reserved. of Use Privacy Notice stigmatization. Accessibility 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. home, but also as they negotiate health insurance plans, navigate health­care facilities, and communicate with other members of the health­care Saint Vincent College system team. Health­care organizations can recognize and address the system level factors that increase literacy demands.Mount An Institute of Medicine Access Provided by: (IOM)­commissioned paper29 describes 10 attributes of “health literate organizations” (Box 15­3), providing guideposts for organizational change to achieve an environment that promotes access and understanding for all patients, regardless of health literacy level. Box 15­3. Attributes of a Health Literate Organization2 9 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement programs. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes populations served in the design, implementation, and evaluation of health information and services. 5. Meets needs of populations with a range of health literacy skills while avoiding stigmatization. 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. 7. Provides easy access to health information and services and navigation assistance. 8. Designs and distributes print, audio/visual materials, and social media content that is easy to understand and act on. 9. Addresses health literacy in high­risk situations, including care transitions and communication about medicine. 10. Communicates clearly what health plans cover and what individuals will have to pay for services. STRATEGIES TO IMPROVE UNDERSTANDING FOR PATIENTS WITH LIMITED HEALTH LITERACY Mrs. S comes into clinic for follow­up after a recent admission to the hospital for cellulitis. During her hospital stay, she is started on insulin. She has been staying with her daughter since leaving the hospital 5 days ago. Since discharge, she has been feeling lightheaded and intermittently shaky. She reports that she has not been checking her blood sugar at home because neither she nor or her daughter know how to use the new glucometer. When asked to explain how she is taking her medications, she pulls out six pill bottles, three inhalers, and insulin. “I am taking medications too many times a day! I take my diabetes pills at breakfast and dinner because the label says take twice a day, but this new one for my leg says take every 12 hours, so I am taking it at breakfast and trying to remember to take it at 8 PM, but I forget most days.” A closer look at her medications show a pill bottle of benazepril 20 mg and a pill bottle of Lotensin® 20 mg. When asked if she is taking both, explaining that both pills are the same medication, she responds “I take all my pills, those two have different names, are different shapes, and different colors!” Her fingerstick glucose is 70 mg/dL 2 hours after breakfast, and her blood pressure is 95/60 mm Hg. Mrs. S’s hospital discharge story highlights how the challenges faced by patients with limited health literacy are directly connected to the complexity of health­related tasks. In order to appropriately and safely manage her health after a hospitalization, Mrs. S is expected to learn a number of new concepts and activities: how to measure and inject insulin, how to recognize the warning signs of hyperglycemia and hypoglycemia, how to use a new glucometer, and how to manage a complex and changing medication schedule. These concepts are challenging for all patients to understand and integrate even under the best of circumstances, particularly when patients are acutely ill. In addition, Mrs. S’s daughter is enrolled as a new caretaker, learning unfamiliar ideas and tasks to help her mother. She is suffering from concerning medication side effects, hypotension and hypoglycemia, due to inadequate preparation for self­management. The remainder of this chapter describes how clear communication strategies can help bridge the literacy gap and support patients to understand and appropriately act on health information, regardless of literacy level. COMMUNICATE CLEARLY AND SIMPLY WITH ALL PATIENTS Since it is difficult to tell who will have a difficult time understanding, clinicians should not make any assumptions about who has limited health literacy. Instead, they should apply “universal precautions,” and aim to communicate clearly and simply with all patients. First, clinicians should use simple, nonmedical words (“living room language”), when speaking with patients. Health­care professionals tend to forget that part of their training focuses on learning a new specialized language and set of concepts that take years of schooling to master. Providers often Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 use jargon—specialized medical words—such as colonoscopy, radiologist, audiology, contraception, benign, that are often meaningless toPage patients. If Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger 4 / 12 a provider must use a medical term, she should take care to provide translation into plain, everyday language, using metaphors relevant to patients’ ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility lives. However, even “translating” jargon into simple terms may not help with understanding.30 The best strategy is to simply avoid jargon and acronyms altogether, whenever possible. In addition, “value” words, such as “regular” exercise, “balanced” diet, “heavy” lifting, “stable” dose, may COMMUNICATE CLEARLY AND SIMPLY WITH ALL PATIENTS Mount Saint Vincent College Since it is difficult to tell who will have a difficult time understanding, clinicians should not make any assumptions about who has limited health literacy. Instead, they should apply “universal precautions,” and aim to communicate clearly and simply with all patients. Access Provided by: First, clinicians should use simple, nonmedical words (“living room language”), when speaking with patients. Health­care professionals tend to forget that part of their training focuses on learning a new specialized language and set of concepts that take years of schooling to master. Providers often use jargon—specialized medical words—such as colonoscopy, radiologist, audiology, contraception, benign, that are often meaningless to patients. If a provider must use a medical term, she should take care to provide translation into plain, everyday language, using metaphors relevant to patients’ lives. However, even “translating” jargon into simple terms may not help with understanding.30 The best strategy is to simply avoid jargon and acronyms altogether, whenever possible. In addition, “value” words, such as “regular” exercise, “balanced” diet, “heavy” lifting, “stable” dose, may mean something very different to patients. Instead, clinicians should provide clear and concrete instructions. The aforementioned examples can be adjusted to the following: “Try to walk for 20 minutes three times a week. And do not lift more than 10 pounds at a time until your surgeon says it is OK to lift more.” In addition, mathematics and numeric concepts are challenging for many patients. Whenever possible, clinicians should do the math for patients, minimizing computational burden. In addition, providers can present statistical information in absolute risk (10 out of 100 people), using frequencies instead of percentages, and should consider using visual aids, such as icon arrays or bar graphs. When speaking about risk over time, clinicians should choose time frames relevant to patients’ lives, such as a 10­year interval.31 EMPLOY CLEAR, CONCISE COMMUNICATION AND AVOID INFORMATION OVERLOAD Large amounts of information presented by providers can easily overwhelm patients. For example, at the start of this chapter, Mrs. S’s primary care provider introduced a variety of concepts and tasked her with numerous activities to do at home, inundating her with new information and activities. Instead, during patient interactions, clinicians should select a discrete set of skills or action items on which to focus, limiting each visit to no more than two or three key ideas. Rather than focusing clinical discussions solely on teaching facts about diagnosis, providers should highlight skills and action items that patients need to know to care for their health. It is also important for clinicians to be specific when giving instructions, especially about medications. If a provider tells a patient, “take two pills twice a day,” how is the patient supposed to know what time of day to do that? If a provider gives a patient a suppository without further instruction, how will the patient know that the medication should not be swallowed? If a provider instructs a parent to “give your child two teaspoons of medication every 4 hours,” will the parent know what a teaspoon is without further clarification? In Mrs. S’s case, she did not realize that the instructions on her medication bottles stating “take twice a day” and “take every 12 hours” meant the same thing, adding unneeded complexity to her medication schedule and causing her to miss doses of her antibiotic. Simplifying medication schedules; adopting a universal medication schedule, a schedule that gives instructions using explicit time intervals, for example, morning, noon, and evening instead of three times a day; and communicating clearly about how and when medications should be taken can assist patients in improving adherence.32,33 In addition, differences in generic versus trade name medications and changes in pill appearance confuse patients as well as providers. Given our current system, with unpredictable changes in covered medications and differences between pharmacies and manufacturers, there is little to be done to avoid confusion at all times. Providers must be aware of these challenges and aim for as much clarity and consistency in prescribing as possible. As such, medication reconciliation is a particularly critical component of each encounter for all patients, but especially those with limited health literacy. ESTABLISH A COLLABORATIVE LEARNING ENVIRONMENT Establishing a collaborative learning environment in which patients are not embarrassed to ask questions can improve open communication exchange. Important steps to establishing this environment are listening actively and reflectively, without interrupting, and assessing patient understanding and eliciting beliefs prior to giving explanations, so that discussions can emerge from a common ground. Individuals with limited health literacy are less likely to ask questions to their providers, despite having greater need for explanation.34 Providers can facilitate and encourage question asking through their body language and the words that they use. Providers who ask, “Do you have any questions?” as they stand up to leave the examination room, will not engender authentic requests for clarification. When clinicians ask patients if they have any questions, patients must believe the clinician has both the time to listen and willingness to answer. Further, providers can normalize questions by asking “What questions do you have?” with body language that suggests that they are open and available to explain things further. Making eye contact and mirroring patients’ language can also help. Clinicians can consider using question­generating tools such as the Ask Me 3 campaign or Questions are the Answer Campaign and encourage patients to write down questions prior to their appointments or while waiting for their providers.35,36 CONFIRM UNDERSTANDING After sharing new information, clinicians should ensure understanding by using the “teach­back” or “show­me” approach. With this technique, Downloaded A back, Your IP is 63.247.225.21 clinicians ask 2024­2­18 patients to 9:30 explain in their own words, any instructions or new information, to ensure that the provider explained things well. When Page 5 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger introducing new tasks, such as learning to use a new glucometer, as in Mrs. S’s case, providers should have patients demonstrate the activity step by ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility step. These methods are not intended to test patients; rather, they are an opportunity to identify gaps in understanding and highlight topics that require further explanation (see Core Competency).37,38 The teach­back and show­me method have been shown to improve patient understanding and language can also help. Clinicians can consider using question­generating tools such as the Ask Me 3 campaign or Questions are the Answer Campaign Mount Saint Vincent College and encourage patients to write down questions prior to their appointments or while waiting for their providers.35,36 Access Provided by: CONFIRM UNDERSTANDING After sharing new information, clinicians should ensure understanding by using the “teach­back” or “show­me” approach. With this technique, clinicians ask patients to explain back, in their own words, any instructions or new information, to ensure that the provider explained things well. When introducing new tasks, such as learning to use a new glucometer, as in Mrs. S’s case, providers should have patients demonstrate the activity step by step. These methods are not intended to test patients; rather, they are an opportunity to identify gaps in understanding and highlight topics that require further explanation (see Core Competency).37,38 The teach­back and show­me method have been shown to improve patient understanding and have been highlighted as a best practice by safety experts.39,40 Confirming comprehension complements strategies to enhance question asking are an opportunity to ensure that all concepts are clear, even when patients say they have no questions. USE COMMUNICATION AIDS In addition to speaking clearly and understandably, and creating a positive learning climate, it is often useful to employ multiple channels for communication. Reinforcement through several teaching modalities can improve comprehension and retention.41 Enlisting help from family members and educating them as well can also support a patient’s self­management skills. In Mrs. S’s case, the loss of her husband, who may have provided key assistance, likely contributed to her deterioration. Teaching her daughter could also help reinforce Mrs. S’s skills. Although not a cure­all for all misunderstandings, literacy­appropriate written handouts, diagrams, videos, interactive media, and telephone interventions can help reinforce, clarify, and remind patients of important health information. Health systems should select printed patient education material that is culturally and linguistically appropriate and adheres to clear communication and low­literacy guidelines. These guidelines include use of plain language, use of the active voice, focus on action items, and adherence to a fourth­ to sixth­grade reading level. Unfortunately, most available health materials are still above the recommended sixth­grade reading level.42 Online resources are available to guide those who develop novel materials.43 Health educators should solicit input from limited literacy populations when developing or choosing new materials whenever possible. There is also promising evidence that automated telephone support, videos, and interactive computer programs can assist with chronic disease management, end­of­life discussions, and medication education.44,45,46,47,48 Medication adherence aids, such as pill boxes, medi­sets, diagrammed pill charts, and improved warning labels can help patients take medications correctly and reduce medicine­ related errors.49,50 In addition, as health­care delivery evolves to a model of team­based care, health system planners should consider the role that all members of the health­care team can play in reinforcing health messages, both during clinic sessions and as follow­up between clinic visits. CONSIDER STRUCTURAL AND INSTITUTIONAL FACTORS THAT HINDER OR ENHANCE UNDERSTANDING In addition to improving communication within the clinical encounter, providers and health­care professionals can serve as health literacy champions, advocating for the system level changes needed to transform their organizations into a “health literate health­care organization” (see Box 15­3).51 This includes advocating for improved navigability of health­care facilities, ensuring that appropriate health educational materials are available and emphasizing the central role of health literacy in organizational planning and quality improvement initiatives. It is important that all members of the health­care team, from the front desk clerk to utilization management staff, be trained in health literacy best practices. CONCLUSION Patients’ ability to understand health information and skillfully navigate the health­care system is at the foundation of high quality, equitable health care. Limited health literacy is one of the numerous communication challenges faced by patients. Physical disabilities, such as hearing and visual impairment, and cognitive decline also impact patients’ ability to comprehend and act on health information. In addition, limited English proficiency (see Chapter 31) and cultural beliefs about health and the health­care system play a central role in communication dynamics, and these barriers often interact and with limited health literacy to further impede communication.52 Nonetheless, it is imperative that health­care ​professionals take responsibility for improving understanding by communicating clearly with all patients, prioritizing information and limiting information overload, creating a safe learning climate, confirming understanding using the teach­back method, and employing communication aids. In addition, health­care professionals can advocate for adaptations at the system level that will lower the literacy demands placed on patients, becoming health literacy champions within their team, their clinic, or their health system. KEY CONCEPTS Steps Providers Can Take To Improve Communication Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 Page 6 / 12 Chapter Improving thewords Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger Use15: plain, everyday during discussions. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Limit your learning objectives to no more than three per encounter. responsibility for improving understanding by communicating clearly with all patients, prioritizing information and limiting information overload, Mount Saint Vincent College creating a safe learning climate, confirming understanding using the teach­back method, and employing communication aids. In addition, health­care Access Provided by: professionals can advocate for adaptations at the system level that will lower the literacy demands placed on patients, becoming health literacy champions within their team, their clinic, or their health system. KEY CONCEPTS Steps Providers Can Take To Improve Communication Use plain, everyday words during discussions. Limit your learning objectives to no more than three per encounter. Be specific in your recommendations and instructions. Assess patient understanding and elicit beliefs prior to launching into explanations. Use the teach­back technique to confirm understanding about concepts and self­management tasks. Use multiple communication channels to reinforce understanding. Focus on a brief set of action items. Create a culture of question asking and authentic dialogue. Teach all members of the care team and health­care organization best practices in clear communication. CORE COMPETENCY Planning for Safe Hospital Discharge by Closing the Loop Mr. J, a healthy 45­year­old man who smokes cigarettes, is admitted overnight for a deep venous thrombosis that developed after driving 12 hours to visit his family in Oregon. The plan is to discharge him home on anticoagulants for 3 months. He will be sent home with a week of enoxaparin injections to take with his warfarin until his anticoagulation is appropriate on the warfarin. The team’s intern, nurse, and pharmacist are to teach Mr. J how to inject enoxaparin, and new concepts related to anticoagulants, including risks signs of bleeding, the meaning of new medical terminology such as INR, and interactions with foods and medications. The nurse reviews the steps Mr. J needs to take to inject his enoxaparin: Mr. J walks through the steps with the nurse observing, but he leaves out the step of cleaning the skin with an alcohol swab before the injection. The nurse again reviews the steps and has Mr. J walk through the steps again. This time, Mr. J gets all of the steps right. Finally, Mr. J administers his morning dose, ensuring that his technique is correct (see Figure 15­1). The intern caring for Mr. J also “closes the loop,” ensuring that Mr. J knows concerning complications of his blood thinner treatment, by employing the teach­back method. Mr. J is able to correctly state signs of bleeding, but forgot that he should hold his warfarin and come to the clinic for a blood test. The intern makes that clarification, and upon a second teach­back loop, Mr. J is able to state all items correctly. The intern closes by asking what questions Mr. J has. Mr. J is unclear on when to stop injecting himself with enoxaparin and where to go to get his blood checked. The intern clarifies these things and gives Mr. J written instructions in simple, clear language. For a video demonstrating the teach­back method, see https://www.youtube.com/watch?v=IKxjmpD7vfY Figure 15­1. Practicing closing the loop. Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 Page 7 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Mount Saint Vincent College Figure 15­1. Access Provided by: Practicing closing the loop. DISCUSSION QUESTIONS 1. Consider a patient you recently worked with. Identify the literacy challenges she may have faced during the encounter and in her attempts to follow up on your recommendations. 2. Discuss how you will integrate two communication strategies introduced in this chapter into your next patient interaction. 3. Describe one thing that you would change about your health­care system or organization to make it a more health literate health­care organization. RESOURCES 1. Centers for Medicare & Medicaid Services. Toolkit for Making Written Material Clear and Effective. 2010. 2. DeWalt DA, Consortium NCN. Health Literacy Universal Precautions Toolkit. 2010. 3. National Patient Safety Foundation ‘Ask me 3’ Website: http://www.npsf.org/for­healthcare­professionals/programs/ask­me­3/; Accessed June, 24, 2014. 4. Agency for Healthcare Research and Quality (AHRQ). ‘Questions are the Answer’ Website: http://www.ahrq.gov/legacy/questions/; Accessed August 26, 2014. 5. Weiss BD, Association AM. Health Literacy and Patient Safety: Help Patients Understand: Manual for Clinicians. 2007. 6. American College of Physicians (ACP) Guides for Diabetes, COPD, Obesity and Rheumatoid Arthritis. Available for download at http://www.acponline.org/patients_families/products/brochures/; Accessed July 3, 2014. 7. American Medical Association Foundation and American Medical Association. Health Literacy and Patient Safety: Help Patients Understand. Video available at https://www.youtube.com/watch?v=cGtTZ_vxjyA; Accessed August 26, 2014. 8. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, DC. 2010. Available at http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf; Accessed Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 August 26,2014. Page 8 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility 9. National Research Council. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press, 2004. Report available for download at http://www.nap.edu/catalog.php?record_id=10883; Accessed August 26, 2014. Associated video available online at http://www.acponline.org/patients_families/products/brochures/; Accessed July 3, 2014. Mount Saint Vincent College 7. American Medical Association Foundation and American Medical Association. Health Literacy and Patient Safety: Help Patients Understand. Video Access Provided by: available at https://www.youtube.com/watch?v=cGtTZ_vxjyA; Accessed August 26, 2014. 8. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, DC. 2010. Available at http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf; Accessed August 26,2014. 9. National Research Council. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press, 2004. Report available for download at http://www.nap.edu/catalog.php?record_id=10883; Accessed August 26, 2014. 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Unraveling the relationship between literacy, language proficiency, and patient–physician communication. Patient Educ Couns 2009;75:398–402. [PubMed: 19442478] Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 Page 11 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Mount Vincent College 51. Brach C, Dreyer BP, Schillinger D. Physicians’ roles in creating health literate organizations: A call to action. J Gen Intern Med Saint 2014;29:273–275. Access Provided by: [PubMed: 24113805] 52. Sudore RL, Landefeld CS, Pérez­Stable EJ, Bibbins­Domingo K, Williams BA, Schillinger D. Unraveling the relationship between literacy, language proficiency, and patient–physician communication. Patient Educ Couns 2009;75:398–402. [PubMed: 19442478] Downloaded 2024­2­18 9:30 A Your IP is 63.247.225.21 Page 12 / 12 Chapter 15: Improving the Communication Exchange: A Focus on Limited Health Literacy, Debra Keller; Urmimala Sarkar; Dean Schillinger ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility