10/7/2013
Health Literacy, Medication Reconciliation and Discharge Planning
Disclosure
• Marquita Bradshaw, Pharm.D., BCACP has nothing to disclose concerning possible financial or personal relationships with commercial entities (or their competitors) mentioned in the presentation.
Marquita Bradshaw, Pharm.D., BCACP
Assistant Professor
Department of Pharmacy Practice
SCSHP Fall Meeting
October 10, 2013
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Learning Objectives
Health Literacy Defined
• Define health literacy
• Recognize “red flag” behaviors suggestive of patients with low health literacy
• Identify health literacy strategies and barriers to implementation during medication reconciliation and discharge planning
• List strategies that enhance understanding of information when communicating with patients with low health literacy
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• Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
Nielsen‐Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. 1st ed. Washington DC: National Academies Press; 2004. 4
A Dose of Your Own Medicine…Perhaps
Health Literacy Among Americans
• Over one third of the American population lack skills necessary to:
• Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.
– Understand health information
– Make health care decisions
– Follow medication instructions
• One of the top 20 priorities by which quality improvement could transform health care in America
Johnson JL, Moser L, and Garwood CL. AM J Health‐Syst Pharm. 2013; 70 (11): 949‐954.
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Why Does Health Literacy Matter?
Impact of LHL on Health‐Related Outcomes
• Nearly 9 out of 10 adults have difficulty using everyday health information
• Patients with diabetes twice as likely to have HbA1c > 9.5%
• People are more likely to skip necessary medical tests, end up in the emergency room more often, and have a harder time managing chronic diseases like diabetes or high blood pressure
• HF patients have higher rates of all‐cause mortality
• Related to misperceptions that anti‐HIV treatments reduce risks for sexually transmitting HIV in HIV patients
• Approximately 70% of patients on anticoagulation unable to determine if INR was in goal range
LHL = low health literacy
HbA1c = Hemoglobin A1c Kutner, M., Greenberg, E., Jin , Y., & Paulsen, C. ( 2006). Washington, DC: U.S. Department of Education, National Center for Education Statistics.
Implications of a Health Illiterate Public
HIV = Human Immunodeficiency Virus INR= International Normalized Ratio
Schillinger D, Grumback K, Piette J et al. JAMA. 2002; 288: 475‐82.
Peterson PN, Shetterly SM, Clarke CL et al. JAMA. 2011; 305: 1695‐701.
Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D. Am J Prev Med. 200; 18 (4): 325‐31.
Fang MC, Machtinger EL, Wang F, et al. J Gen Intern Med. 2006; 21: 841‐6.
Rudd, R . E., Anderson, J . E., Oppenheimer S., & Nath C. (2007). Health literacy: An update of public health and medical literature. In J. P. Comings, B. Garner, & C. Smith. (Eds.), Review of adult learning and literacy (vol . 7) (pp 175–204). Mahwah, NJ: Lawrence Erlbaum Associates.
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Potential Points for Intervention in the Health Literacy Framework
• Poorer health status and less likely to use preventive care • More likely to be hospitalized and experience bad disease outcomes
• Inpatient spending increase by approximately $993 • Additional $32 to $58 billion dollars in healthcare spending • Less likely to comply with prescribed treatment and self‐care regimens, make more medication or treatment errors, and lack necessary skills to navigate the healthcare system
Nielsen‐Bohlman, Panzer, and Kindig (2004) , Baker et al (1998; 2002) and Schillinger et al (2002), Howard (2004), Baker et al (2007) Friedland (2002), 9
Weiss (1999) Nielsen‐Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. 1st ed. Washington DC: National Academies Press; 2004. 10
Navigating the Healthcare System: Expectations of a Patient
• Read
The Health System – Labels & inserts
– Names of medicines
– Dosage instructions
– Read between the lines [e.g. BID, TID, QID]
• Listen to explanations and directions
• Talk to busy professionals
– Describe new feelings (e.g., side effects)
• Track experiences
– Watch for side effects and seek appropriate help as needed
– Take action for missed dose when needed • Calculate – Measure doses
– Count pills
– Track amount of meds left and refill as necessary
– Use clocks and calendars to set time/day – Present problems
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– Ask questions 12
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Vulnerable Populations for Low Health Literacy
Other Vulnerable Situations
• Transition points, or “hand‐offs” in health care (e.g., moving from inpatient to outpatient settings) are especially vulnerable to patient communication errors
• Older Adults
• Immigrant Populations
• Minority Populations
• Health literacy may decrease during times of physical or emotional stress
• Low Income
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Nielsen‐Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. 1st ed. Washington DC: National Academies Press; 2004. 14
“Red Flag” Behaviors Suggestive of Low Health Literacy (LHL)
Assessing Health Literacy
• Do not know the name of their medicine but rely instead on shape, size, or color • Patients with LHL are often embarrassed
• You cannot tell by looking
• “Forgot their glasses” • Universal precautions
• Delay in picking up medicines or renewals
• Subjective knowledge can be gained with informal questions
• Have problems asking questions or explaining their concerns – Neutral – Nonjudgmental 15
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Measuring Literacy and Health Literacy
Assessing Health Literacy
• Word Recognition Tests
• Questions that serve as strong predictors
–
–
–
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– How often do you have problems learning about your medical condition because of difficulty understanding written material?
WRAT‐R
REALM
MART
SORT‐R
• Reading Comprehension Tests
– How often do you have someone (family member, friend, or hospital worker) help you read hospital material?
– PIAT‐R
– IDL
– How confident are you when filling out medical forms by yourself?
Johnson JL, Moser L, and Garwood CL. AM J Health‐Syst Pharm. 2013; 70 (11): 949‐954.
Johnson JL, Moser L, and Garwood CL. AM J Health‐Syst Pharm. 2013; 70 (11): 949‐954.
• Functional Health Literacy Test
– TOFHLA
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Andrus MR and Roth MT. Pharmacotherapy. 2002; 22 (3): 282‐302.
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Literacy and Health Literacy Tests
Literacy and Health Literacy Tests
Variable
WRAT‐R
REALM
MART
Variable
SORT‐R
PIAT‐R
IDL
TOFHLA
Description
Word recognition test
Medical word recognition test
Medical word‐
recognition test using prescription bottles
Description
Word
recognition test
Reading recognition and comprehension
test
Reading comprehension
test
Functional health literacy test
Age
All ages
Adults only
5‐74 yrs
Adults only
High‐school age
4 yrs and older
All ages
Age
Administration time (min)
5‐10
60
20‐30
22 (7 for short version)
Scoring
Results
converted to age and grade equivalents
Comprehension
subtest score determines grade level
0‐8, 0= failure at 1st Inadequate,
grade level, 8 = 8th marginal, or functional HL
grade level or above
Advantages
Quick
Assesses comprehension
Available in Spanish
Measures functional HL, available in short form and Spanish
Limitations
Small print and many items intimidating
Long
Long
Long version is time consuming
Administration time (min)
3‐5
2‐7(2‐3 for SF)
3‐5
Scoring
Raw score of 1‐57, converted to grade equivalent
Approximated grade level: 3rd and below, 4th‐6th, 7th‐8th, or 9th
and above
Raw score converted to grade equivalent
Advantages
Quick
Quick, uses medical terminology
Nonthreatening, quick
Limitations
Difficult test
Assigns only grade‐
range equivalents
No clinical experience published
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Literacy and Health Literacy Tests: The Newest Vital Sign
REALM‐SF Form
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Barriers to Implementation of Health Literacy Practices
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Limited Health Literacy and Discharge Planning
• Not enough time
• Significant, independent, and modifiable risk factor for 30‐day hospital reutilization after discharge
• Lack of resources
• Patients indicated greatest benefit from pharmacists’ intervention
• Low priority
• Evidence supports the benefits of pharmacists in transferal from the ICU and immediately after hospital discharge
• Lack of knowledge
Nielsen‐Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. 1st ed. Washington DC: National Academies Press; 23
2004. • Pharmacists’ conducting medication reconciliation at discharge holds promise for ↓ readmissions
Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, et al. Pharmacotherapy 2012; 32 (11):e326‐337.
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Examples of Misunderstanding of Common Medications
Limited Health Literacy and Medication Reconciliation
• Associated with a greater number of unreconciled medications
• Evidence supports the benefits of pharmacists in medication reconciliation processes
Persell SD, Osborn CY, Richard R, Skripkauskas S, and Wolf MS. J Gen Intern Med.2007; 22(11): 1523‐6.
Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, et al. Pharmacotherapy. 2012; 32 (11):e326‐337.
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Pharmacists’ Role and Responsibilities to Improve Care Transitions
• Underutilized
Inpatient Care
Hospital Discharge to Home
Ambulatory Care
Long‐term Care Facilities
Community Pharmacies
Home Health Care
Medically Underserved
Aspirin
½ tablet twice a day
1 tablet once a day
Units and Frequency
I am not aware what aspirin I am taking
81 mg once a day
Strength
I am taking 6‐something
every day
81 mg once a day
Strength
31 mg a day
81 mg once a day
Strength
180 mg a day
81 mg a day
Strength
1 low dose daily
325 mg once a day
Strength
125 mg a day
325 mg once a day
Strength
I am taking it for my blood pressure
Heart medication
Indication
Marvanova M, Roumie CL, Eden SK, Cawtho C, Schnipper JL, and Kripalani S. J Hosp Med. 2011.; 6(9): 488‐493.
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Addressing the Problem and Creating Solutions
• Advance Research
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Implementation: Prevalence Calculator vs. Universal Precautions
• Over 65 years of age
• Enrolled in Medicaid or other public assistance
• White
• African American
• Hispanic
• Mainly speak a language other than English
Coded error
• Enhance Patient Understanding
Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, et al. Pharmacotherapy 2012; 32 (11):e326‐337.
– Estimate percentage of patient population
Correct information
• Increase Use of Nonwritten Information
– Various settings
• Prevalence Calculator
Common incorrect responses
• Improve Patient Education Materials
• Well positioned
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•
•
•
•
•
•
Medications
• Universal Precautions
• Promote Health Literacy
Andrus MR and Roth MT. Pharmacotherapy. 2002; 22 (3): 282‐302.
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Universal Precautions Toolkit
• Designed to be used by all levels of staff in a practice providing primary care for adults and/or pediatric patients
– Designed to help practices take a systematic approach
– Questionable accuracy
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• Step‐by‐step guide on the path to improvement
– Form your team
– Assess your practice
– Raise awareness
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Plain Language Alternatives for Patient Information and Consent Forms
7 Tips for Clinicians
• Use plain language • Limit information (3‐5 key points) • Demonstrate, draw pictures, use models Plain Language Thesaurus
Instead of
Use
• Repeat/Summarize Acidosis
?
• Teach‐Back (Confirm Understanding) Agranulocytosis
?
Hepatotoxicity
?
– “Chunk and Check”
• Be specific and concrete, not general • Be positive, hopeful, empowering
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Strategies to Improve Communication with Patients • Teach‐back method
– If I asked you to explain this to your spouse when you got home, how would you tell them what we discussed?
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Assessing Reading Level of Patient Education Materials
• Solely rely on number of syllables per word and words per sentence
• Large variability
• Ask Me 3®
– Encourages patients to ask their health care providers three questions
• What is my main problem?
• Common Examples
– Flesch‐Kincaid • Available in current versions of Microsoft® Word
• What do I need to do?
– Simplified Measure of Gobbledygook (SMOG)
• Why is it important for me to do this?
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Commonly Used Readability Formulas in Healthcare
Formula
Criteria for reading grade level
Dale‐Chall
McCall‐Crabbs Standard Test Lessons in 50% on a Multiple‐choice test
Reading (1926)
Expected Comprehension
Flesch Reading Ease
McCall‐Crabbs Standard Test Lessons in 75% on a Multiple‐choice test
Reading (1926)
Flesch‐Kincaid
Lowest reading grade level in which 35% on a Cloze test
50% of tested navy personnel scored at least 35% on a Cloze test
Additional Training for Health Care Professionals
• Health Literacy for Public Health Professionals
– Length: 1.5‐2 hours
Fog
McCall‐Crabbs Standard Test Lessons in 90% on a Multiple‐choice test
Reading (1926)
SMOG
McCall‐Crabbs Standard Test Lessons in 100% on a Multiple‐choice Reading (1961)
test
Fry
Book publisher determined reading grade level
Wang L, Miller MJ, Schmitt MR, and Wen FK. Res Soc Adm Pharm 2013; 9 :503‐516
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Assumed to be adequate
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– Continuing Education: The continuing education credits offered for this course are as follows; 1.25 CME for physicians, 1.25 CME attendance for non‐physicians, 1 CNE for nurses, 0.1 CEU for other professionals, 1 CHES for certified health education specialists and 0.1 CPE for pharmacists.
– Cost: Free
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Community Resources to Improve Literacy Skills
• The Literacy Directory – National Institute of Literacy • http://literacydirectory.org/
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Health Literacy, Medication Reconciliation and Discharge Planning
Marquita Bradshaw, Pharm.D., BCACP
Assistant Professor
Department of Pharmacy Practice
SCSHP Fall Meeting
October 10, 2013
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