Help your patient “get” what you just said: A health literacy guide

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Applied Evidence

Help your patient “get” what you just said: A health literacy guide

J Fam Pract. 2012 April;61(4):190-196

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References

1. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.

2. Kutner M, Greenburg E, Jin Y. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education Statistics; 2006.

3. Vernon JA, Trujillo A, Rosenbaum S, et al. Low health literacy: implications for national health policy. National Patient Safety Foundation; 2007. Available at: http://www.npsf.org/askme3/pdfs/Case_Report_10_07.pdf. Accessed March 21, 2011.

4. Schillinger D, Machtinger EL, Wang F, et al. Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment. J Health Commun. 2006;11:651-664.

5. Adams RJ, Appleton SL, Hill CL, et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol. 2009;124:601-602.

6. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.

7. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57:334-345.

8. Kirsch I, Jungeblut A, Jenkins L, et al. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. 3rd ed. Washington, DC: National Center for Education, US Department of Education; 2002:201.

9. Davis T, Crouch M, Wills G, et al. The gap between patient reading and comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533-538.

10. Brach CP, Cheyarley FM. Research findings #28: Demographics and health care access and utilization of limited-English-proficient and English-proficient Hispanics. 2008. Agency for Healthcare Research and Quality. Available at: http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf28/rf28.pdf. Accessed May 20, 2011.

11. Ngo-Metzger Q, Telfair J, Sorkin DH, et al. Cultural Competency and Quality of Care: Obtaining the Patient’s Perspective. New York, NY: The Commonwealth Fund; 2006:963.

12. Bass PF, Wilson JF, Griffith CH, et al. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039-1041.

13. Schwartzberg JG, Van Geest JB, Wang CC. eds. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, Ill: American Medical Association Press; 2005.

14. Kripalani S, Henderson LE, Chiu EY, et al. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med. 2006;21:852-856.

15. US Department of Health and Human Services. National Healthcare Disparities Report. 2010. Available at: http//www.ahrq.gov/qual/nhdr10/nhdr10.pdf. Accessed March 9, 2011.

16. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-594.

17. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391-395.

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19. Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.

20. Shah LC, West P, Bremmeyr K, et al. Health literacy instrument in family medicine: the “Newest Vital Sign” ease of use and correlates. J Am Board Fam Med. 2010;23:195-203.

21. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the Newest Vital Sign. Ann Fam Med. 2005;3:514-522.

22. Welch VL, VanGeest JB, Caskey R. Time, costs, and clinical utilization of screening for health literacy: a case study using the Newest Vital Sign (NVS) instrument. J Am Board Fam Med. 2011;24:281-289.

23. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; April 2010. 10-0046-EF. Available at: http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf. Accessed March 21, 2011.

24. Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96:219-222.

25. Shillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.

26. Wolf M, Bailey S, You W, et al. Improving patient understanding of preeclampsia, a randomized controlled trial. Am J Obstet Gynecol. 2011;206(suppl 1):S312.-

27. Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns. 2007;66:368-377.

28. Clancy DE, Huang P, Okonofua E, et al. Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med. 2007;22:620-624.

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The focus of “teach back” should be on how well the provider has explained things, AHRQ emphasizes. Thus, the toolkit suggests saying something along the lines of, “I want to be sure that I explained your medication correctly. Can you tell me how you’re going to take this medicine?”²³ In a study of patients with diabetes, those whose providers assessed their recall or comprehension of new concepts were almost 9 times more likely to achieve HbA1c targets than patients whose doctors did not do so.²⁵

FAST TRACK

In one study in which 9 practices implemented brown bag medication reviews, errors were found in 80% of the reviews.

Zero in on medication adherence
Another method highlighted in AHRQ’s toolkit is the “brown bag” medication review—asking patients to bring every prescription drug and over-the-counter product they take every time they come in and carefully reviewing each one (TABLE 2).²³ The NAAL found that 36% of patients do not read at the level required to understand medication labeling.²³ The percentage of adults who do not adhere to prescribed medication regimens is considerably higher.

In one study in which 9 practices implemented brown bag medication reviews, errors were found in 80% of the reviews. Among the most common errors: patients who stopped—or started—taking a drug without the knowledge of their provider, or continued to take a medication after it had been discontinued.²³

Table 2
How to conduct a “brown bag” medication review

Before the visit	Tell the patient what to bring to the next visit: All prescription medicines (including pills and creams) All OTC medicine taken regularly All vitamins, supplements, and herbal remedies Remind the patient: On the appointment card During the appointment reminder call With posters in the exam rooms and waiting room and (anonymous) case studies posted on a bulletin board, eg, “Miss Smith brought all her medications to her last visit and found out that she was still taking a blood pressure medicine that she no longer needed.” Offer encouragement: Emphasize benefits (eg, a brown bag review may result in the provider stopping some medications) Provide a medication container (a small canvas, paper, or plastic sack, possibly with a printed reminder on one side and the name of your practice on the other)
During the visit	Display the medications A nurse or medical assistant should place all of the medications on the counter in the exam room Thank the patient Stress the importance of bringing all of his or her medications to every visit Review the medications Ask whether the patient has any questions about the medications Ask follow-up questions, eg: Clarify medication instructions Review the medications to be taken and how to take them Discard any drugs or OTC products that are old, discontinued, or must be changed Ask the patient to “teach back” to you Update the patient’s chart Clearly document medication inconsistencies and what the patient is directed to take Give the patient an updated medication list Include how often and at what time each one should be taken
After the visit	Document and code the medication review Note in the chart when full medication reviews are done and when partial or updated reviews are conducted Select the correct code (ICD-9 V58.69)*
OTC, over-the-counter. This code alone may not always be reimbursable, but may be used as a practice tracking tool in conjunction with the appropriate diagnosis. Adapted from:* Agency for Healthcare Research and Quality. Health Literacy Universal Precautions Toolkit. Available at: http://www.ahrq.gov/qual/literacy/index.html. Accessed February 8, 2012.

Consider visual aids, group visits, and other interventions

In attempting to simplify patient handouts, consider using simple graphics (TABLE 3).^23-30 In a randomized controlled trial (RCT) including 120 women—48% of whom had limited HL—a graphics-based educational tool significantly improved patient understanding of preeclampsia.²⁶ Another RCT demonstrated that patients who had inadequate or marginal reading skills, had not completed high school, or were cognitively impaired were most likely to regularly refer to a medication schedule illustrated with pictures of their pills. More than 90% of the study group agreed that the illustrated schedule was easy to understand and helped them remember the name and purpose of their medications, as well as the time to take them.²⁷

For patients who have low HL and are chronically ill, having the support of family or friends—any trusted confidante—is associated with better medication adherence. Group visits (in which a physician or other health care professional meets with a group of patients who have the same condition or diagnosis) is one way to provide such support. In one study, patients with diabetes who participated in group visits had higher rates of breast and cervical cancer screening and were more likely to get influenza and pneumococcal vaccinations and take ACE inhibitors, among other measures recommended by the American Diabetes Association.²⁶