Enhancing Patient Health Literacy: Universal Health Literacy Approaches

Hello hello good to see you all okay let's see look like people are popping in perfectly [Music] all right well good afternoon and thank you all for joining us for this important health professions educators series health systems science open forum session today's presenter is joining us to help enhance our patients health literacy using universal health literacy approaches so dr kathleen porter is a phd trained registered dietitian and behavioral scientist she's an assistant professor in the department of public health sciences at the university of virginia school of medicine she is also an affiliate of the uva cancer center the overarching goal of dr porter's program of research is to reduce cancer disparities and improve population health in rural and other health disparate communities by fostering the implementation of evidence-based interventions that address energy balance related behaviors and outcomes as well as cancer control priorities so specifically she has a growing program of independent research related to rural cancer survivorship and she contributes to trials as a qualitative methodologist and implementation scientist dr porter also studies the application of universal health literacy precautions in community-based settings so dr porter i'm going to go ahead and turn the floor over to you now thank you so much for joining us thank you i'm happy to be here so just a quick even with that bio i really do always like to make clear why i'm talking to you about health literacy especially within the context of a health healthcare organizations and a lot of you being medical educators um i do do a lot of behavioral intervention work but really what's always at the heart of what i'm doing is the consideration of health literacy and the incorporation of these health literacy universal precautions and so i'm very involved as i just said kind of really utilizing these in the real world but i'm also very interested in understanding how they get implemented and really assessing and trying to figure out ways that we can make them better and more efficient and so i really think that that plays nicely into today's presentation and also just to be i guess fully clear on this i have no conflicts of interest to declare so sort of from that standard financial piece but i do want to share my husband is a carillion employee and although i work for uva i'm actually located in christiansburg so i am actually a carillion patient as well and while that obviously does not bias what i'm going to say here is going to put some of the things um that i talk about in context when i use health literacy and talk about health literacy as an example i utilize i tend to talk about myself and use how even someone in my position when i'm in a medical setting how the health literacy conversation really does matter even with my educational background i am also going to be turning off my video um when i'm really actively engaged in the slides so just in case i have any wind up having any bandwidth issues so i'm going to be turning that off right now so as we get started one thing i really do want to bring up is that this is the schematic that you all have been using throughout this training series and when we think about health literacy a lot of the times we kind of get stuck and or limit ourselves to really thinking well this is something that's at the patient or the family or the community level because it's something that we really consider as being a demographic variable but what i'm hoping you'll be able to see through today's presentation is that health literacy is something that's much broader and that really touches all of these wider pieces that actually influence the patient the family and the community and so really health literacy is as much about interaction and communication between the patient and the provider the patient and any other clinician she or he may be interacting with as much as is about their individual needs as patients and so with all of this being said the objectives of today's presentations really would hope that you all are going to be able to walk away recognizing the impact that health literacy has on patients behaviors and health and many of you are probably already well versed in this anyway um identify the different types of literacy that influence um health literacy really come to appreciate the importance of a universal health literacy approach identify strategies to enhance patient health literacy at the patient clinician and organizational levels and this fourth bullet is really where we're going to be spending most of our time and also towards the end really want to present and have you be able to walk away being able to describe the attributes of a health literate organization and so what i'll be doing is at sort of stopping points along the way that are natural stopping points just stopping to pause and to see if anybody has any questions or thoughts as we are going through so that way we're not saving all the questions towards the end so if anybody has anything feel free to just either chime right in or add something into the chat at this point and if not i'll just kind of do my usual i'll count to 10 and if i don't hear anything or see anything by then i will move ahead to the next section so i want to start off with a joke it's a bit of a punny joke um kind of was working on this um over father's day weekend so a punny joke seemed to have made sense a woman walks into her doctor's office she's a little overweight so her doctor puts her on a diet he tells her i want you to eat regularly for two days then skip a day and repeat this procedure for two weeks the next time i see you you'll have lost at least five pounds the woman returns in two weeks and she's lost nearly 20 pounds doctor's amazed just wondering you followed my instructions correct and she nods and she goes i tell you though i thought i was gonna drop dead that third day from hunger asked the doctor nope from all the skipping so we're going to come back to this but kind of a joke just kind of thinking through of what a patient caregiver interaction might lead to and as before we go back to that though really kind of pinching us into what is health literacy and we think about health literacy at two levels personal and organizational and the definition that many of us see the most common one is this one that the cdc um promotes is it's the degree to which individuals have the capacity to obtain process and understand basic health information and services that are needed to make appropriate health decisions however the more you really dig into health literacy and dig into the definitions you realize how multi-dimensional it is and how many different individual and systems level factors really influence it and um this model comes from a systematic review conducted by sorensen and colleagues back in 2012 and really that we're able to see is that their situational determinants personal determinants as well as how they're engaging in their healthcare system the costs their outcome their personal sense of empowerment um issues around equity and that all also shifts whether it's in a healthcare setting if it's related to disease prevention or health promotion so there's a lot going on that influences personal health literacy in a more recent review that was conducted really looked at well what are these key elements of health literacy and one of them obviously is knowledge but it's not just knowledge of health it's knowledge of health care in general but also navigating those health systems it also includes things related to processing and using information in dairy in various formats related to both health and engaging with the health care process and so the information that it really considers are written instructions oral communications but also numerical information and how that's used but then as we're getting more and more into our heavily electronic based age with all of our social media but also we need to also consider electronic information but also how folks um engage with media related to health information also thinking about how folks are confident in their ability to process and utilize health information where that health information is coming from and where and what can actually be accessed and also their ability to engage in self-management behaviors and with that whole larger picture a newer definition probably is emerging and i will say there is no consensus on what the definition of health literacy is but this is one that i just take as being a little bit more all-encompassing than the one that we tend to go by is that it looks at the the same things that we were talking about the ability of an individual to obtain and translate knowledge and information but they're able to do it in a way that's appropriate to the individual and systems context so really understanding that all of this is happening within a larger context and our organizational health literacy is looking at how organizations are able to make someone be able to capitalize as much as possible on their personal health literacy i have two definitions here one that's used by the cdc one that's used by the institute of medicine and you can see that put them up here because again we don't have complete consensus on this but you can see that they're relatively aligned and when we go back to this idea of personal health literacy we have no recent national numbers health literacy is not something that we capture on and or we capture through berfus it is nowhere and the numbers that we tend to cite and what we tend to say is that nearly nine and ten adults have difficulty using everyday health information this number comes from a report that was a research trial that was conducted in 2003. um in 2003 i was still in college so that was an incredibly long time ago and something that was published in 2006 but that's what we cite consistently with our data around health literacy and we also know that 40 of patients with low functional health literacy they admit feeling shame so number one we know a lot of people may have difficulty using this information that a good proportion of those individuals feel shameful that they don't know how to use this information and then even further so is that we know that health someone's health literacy is a stronger predictor of their health than measures that we tend to use as standard proxies age income employment status education level and race and this is how it really can drive our poorer health outcomes we see someone who's health literacy who has lower health literacy we know that they're less likely to be compliant with recommendations they engage in less healthful behaviors they're less likely to use their medications properly and through all of this they have difficulty managing their chronic conditions even before that we may see that they're missing their appointments more frequently they're not following through on their tests or their referrals and they're actually having more er visits than potentially well visits or kind of standard visits and even before that some of the things that we may be noticing with our patients is that they may be less likely to complete the forms in the office they're not responding or engaging around written materials they're not giving as strong of a coherent or sequential health history and then they're asking fewer questions and then all of this really drives it we always think about this when we talk about health literacy and the impacts but we can see that it goes back even to how the patients engage with us as a clinician or as a health care provider in our various settings whether it's for care or in my case a lot around prevention and we know that through all of this that the patient provider interaction can really impact patient health literacy and so if we go back to this joke what actually happens is we learn all of this it goes less from the smiley happy baby telling a joke to that baby who is very very upset um and probably a little inconsolable and really starting to wonder well what's so funny about a misconception sorry miscommunication that led to a patient who had an unhealthy weight loss i'm not a medical provider but i am trained as a dietitian and i will tell you 20 pounds in two weeks is definitely not a good weight loss i'm a patient who is most likely embarrassed at themselves and frustrated at their doctor for the way that the last um those um encounters went a doctor who's frustrated by their patient for not engaging with the medical recommendation that was shared and what really it comes down to is a patient with a health condition who may or may not return for follow-up and so with all of this we can see that there's gaps in practice and research and that there is a need to elevate the role of health professionals in how we address health literacy and so one of these ways is to structure the delivery of care as if everyone may have limited health literacy you can't tell by looking who has good health literacy or proficient health literacy and who doesn't literacy does not mean understanding and a lot of times this has happened because we assume people can read and we also assume that because somebody can read they can do all the other facets that make up health literacy one of the examples i like to give is as we've mentioned i do prevention programs related to cancer a lot of what we focus on is sugary drinks we had one woman in our trial who is actually a literacy coach at our local literacy volunteers organization and when you actually looked at her health literacy scores she was incredibly low because she could do all she was very very confident at the reading and the understanding but she could not do the numeracy parts of it we also know that anxiety can reduce the ability to manage health information so regardless of somebody's literacy skills numeracy skills or even their education and their understanding of health if you put somebody in a highly stressful situation they may not be able to act on them in this situation we also know that everyone benefits from clear communications and so the way to do this and to structure this care is to integrate health literacy universal precautions into practice and i really just want to stress as we're moving forward is that utilizing these strategies allows for clear communication with the patient and or their caregiver it is not talking down to them or dumbing down the content it is making sure that the content is understood and we also know and what's very important is that these strategies are acceptable across all health literacy levels um a few years ago i was a co-investigator on a trial that was called the talking health trial and we had embedded these precautions in different ways throughout our trial and we found that our participations i'm sorry our participants were equally satisfied with these health literacy components that we had included in here regardless of their health literacy level and this was a community-based trial so we had everybody from college faculty members in the trial to folks who had not completed high school and that we did not see any differences um in there and so what i'd really like to dig into for pretty much the remainder of this session is to talk with you about these health literacy universal precautions and everything that i'm going to be talking to you today comes from this toolkit that is made by ahrq there's 21 overall tools in this toolkit that address five domains a path to improvement was really something to started thinking about the organizational level and really how to move things through there spoken communication written communication patient self-management and empowerment and then also supportive systems however before i really start digging into these i wanted to just check in to see if folks have any questions or thoughts before we move ahead or any needs um can we just unmute ourselves with the questions yes cheryl that's completely fine yes uh one thing that occurs to me is whether or not this um addresses uh sensory impairments so you're talking about you know health literacy and accessing and understanding information does it include addressing visual impairment and hearing impairment so i would say yes it addresses because all of that will impact how we communicate with someone and how we are able to make sure that they're understanding the information i will say however as these tools are developed they really do focus primarily on written and or oral but we can definitely bring in those other senses um as we're going as i'm going through these examples related to especially as you were saying visual and hearing any other thoughts or questions that folks want to chime in as we move forward yeah like dr hartman did feel free to unmute or you can post your questions in the chat and we would be happy to relay those yes and the one that came in through the chat and this is incredibly important that health delivery is influenced by insurance coverage um the type and the um i'm gonna say like appropriateness of the coverage which really can make navigation quite difficult and there are some strategies in the toolkit that can help with some of that navigation um as well and so i'm going to definitely jot that down so as i'm going through these other examples just to really kind of highlight on these questions and specific points that were brought up all right i'm gonna and dr misra you're unmuted did you have a question yes i did um and it's more of a comment actually it seems like this really hits the key point about the three pillars you know um because it's actually the care delivery the care delivery is what we missed out on in the past it was like was i a good clinician was i a good scientist did i give them the right information and all that stuff is great but how does it actually translate to the care being delivered and that's what that miscommunication showed it showed that you know we were great about saying okay you should do this this and this but uh we didn't clarify that the message was understood properly yes and so i think a few of these tools are going to get into ways of clarifying if the messages are received and kind of providing some guidance for that so i know that these sort of five domains are how ahrq organizes them i tend to think a little bit differently and this is how i tend to think about the tools there's tools that help assess there's tools that help develop and there's tools that help with engagement and i think about engagement in terms of use and so within assess there's these tools that help us understand patient health literacy exploring your health literacy practices and you'll see i have your as we move forward in the presentation in italics you we can think about your in a few ways it could be you as an individual clinician you as educators um you as in working with your team of learners it could be you as in the larger you of your clinic or unit or it could be you as at the organizational level of carillion assessing your patients perceptions of your health literacy practices when we think about developing what are ways that you can improve your health literacy related skills and then engaging and so this is again within the presentation where we'll be spending most of our time but this is how we integrate health literacy uniform precautions into practice and establishing yourself as a health literate organization and again you being a very broad and potentially very expansive you so when we think about understanding patient health literacy there's definitely strategies that can be used one can just be talking with the with patients about their health literacy needs and obviously a lot of that's going to depend on how many are you seeing and how it's done are you seeing your patient again what type of practice are you in um were you maybe seeing your patient and really needing to develop that rapport with them and understanding their specific needs and that might be very important especially like thinking through the question earlier if you have a patient who does have a visual or a hearing impairment as well as what we would think of as more of our traditional literacy with being able to utilize written language and numbers there's ways to administer health literacy measures formally or informally during potentially a visit um there are existing measures that are out there there is the realm which is one of the first developed and it's basically a patient word list we've used that in some of our research i think it has a number of limitations and it doesn't really capture the holistic piece of health literacy however it is one that is quicker to use there is the newest vital sign which is actually a series of six questions based on answering um that are centered around answering questions around a food label it's a general health literacy one but it also really addresses some nutrition topics as well and then there is the toefl which is a much more comprehensive measure and then there also is the true health literacy screener which is a three item screener um within my research we tend to use the newest vital sign a lot within our measures packets um once folks are enrolled in the trial but we use a screener like the chew um in a lot of our screeners so that we're understanding who's enrolling into our program and also something like chew is very simple and actually could be with our other ones potentially this is a longer term thing is embedding these health literacy questions within the um your health record and figuring out how that could be incorporated so that you're aware of that um at your patient visits but also if you're doing any of this measuring the health literacy formally or informally during a visit definitely documenting that in the patient's chart for moving forward when we think about exploring your own health literacy practices it could be simple as reflecting on how you communicate with patients whether it's something that you're thinking about on yourself talking with your team talking with your group of learners as they're developing there also is a tool within ahr queues within this tool kit where you're able to conduct a formal self-assessment and identify areas of your growth and so it looks at how you're able to do a lot of different of these things and it was developed for primary care we've had good success actually adapting this for use in a public health setting we actually a graduate student probably about four or five years ago utilized this tool as the base and adapted it for use with our health departments and trying to understand how they were engaging with their um with their clients assess patient perceptions of your health literacy related practices um i guess one thing that can be done here real surface is reviewing patient comments whether formally through the organization or looking more informally on websites i mean they are mentioning how clear folks are there but a more systematic way is to actually conduct a formal assessment and there's tools through ahrq here there also is a health literacy responsiveness survey that was created specifically too and just trying to figure out within this of what are they seeing i mean and this is just a standard questionnaire but you could also really go deeper and sitting and meeting with groups of patients and really starting to understand what is their experience like and how is their experience meeting their needs so before i move forward to start really talking about thinking about improving skills um are there any questions at this point so dr porter i was wondering um with your uh slide one side back um when you have the different types of us maybe it was two sides back sorry about that um the different types of assessment how do you approach giving a patient like the word list to me that would seem sort of offensive to some degree where the other screening tools look much more we did that a lot one-on-one that was actually embedded into one of our research trials and i was debating whether or not to put it in here i just really wanted to show that there's different types one of the most awkward things sure i've had to do um one because i mean all of us are probably i would say you guys have all graduated from medical school the majority of you i have a phd i would not be able to comfortably do this right um we don't realize how often we get into sight words and there is a little bit of a um i would say like a classist what i would call classes pieced on this because things have to be pronounced correctly like technically if somebody said diabetes um it was incorrect even though the intention's there um that was pretty biased um and also we would go from doing the realm to doing the nvs with patients and so they'd be stressed from that one and moving into something else got it okay thank you yes i was just clarification okay anyone else before i move ahead so it looks like there's a comment in the chat um self-assessment of successful communication is necessarily biased are there ever are these ever completed by patients or staff about your communication about mine in specific um probably about the providers themselves is that is that true deirdre she may not have access sorry i'm i had to find where the mute thing was yeah i mean i'm just wondering you know it's very easy to look i i can't tell you how many times i will sit with um a co-worker as we're speaking with either a patient or um even just someone else say in an interview or something like that and and people will speak and they think they're being clear and understanding and i'm picking up on all kinds of things where where i'm recognizing that the person that we're speaking to has no clue what we're talking about even though we may think we're being clear and so um sometimes i think self-assessment can be um you know it's biased i mean you think you're being clear uh it's it has have there been studies done at all where patients actually complete that assessment tool regarding their their provider and so it's this one actually so this is like so this tool so these um the hrq um health literacy patient survey and the responsiveness they're actually patient completed and so but they address they address the same domains but they're shorter okay so it same domains is the one that's in the provider self-assessment one yes yeah okay yeah and and we're also going to talk through a few things as once we get into sort of this more engaged section of kind of ways to just kind of check in on yourself to during these conversations to make sure that you're being clear i know i'll just say personally because when you said you're i was like i know that i'm not always the clearest person and so that's why i actually jumped to that and i know to check in with that's why i have the like i know personally i can get excited about things and i can talk very fast and i also take for granted what people know which is i would say personally why i've built in these check-in parts and so that's you're going to see something similar um in a few minutes that the ahrq recommends okay great and so for you to start developing your own health literacy skills um if a self-assessment has been completed and it's been completed thoughtfully and with less bias than we would hope creating a plan based off of that assessment and that personal plan could be something that you as an individual complete you complete again as a unit and just really thinking that through or that plan can actually be taken where the self-assessments from clinicians across um disciplines and patients can all be pulled together and it could be something that the health system or the unit like the larger unit within the health system utilize to create a plan to improve their health literacy aspects um there also are different specific professional development activities um that you can undergo and kind of like more trainings into ways to get ceus and so now what i'd really like to dig into is some of these actual practices um some of it's going to be a little bit dry um kind of walking through what they say but really thinking through what can be done to integrate these into your practice and so first we have this engaging and clearer or engaging in practices that can support clear verbal communication may be a better way of doing this but greeting patients warmly making eye contact um listening carefully and making sure that it's clear that you're listening um and you all probably heard using plain medical language reflecting the patient's words slowing down but things that we and i feel like these top four we think about a lot i mean i think they've come pretty natural to us through a lot of our training but one of the other things that we're not as always good at is focusing the content being specific and concrete and limiting and repeating content as much as possible using graphics and demonstrations this can get to folks who might not have the best hearing or just are not good auditory learners being able to see things done different ways engaging the participant by encouraging questions and using the teach back method which we'll be talking about in a second and then this teach-back method is a i'm sure some of you may have heard of this before the teach-back method is a pretty it's growing to be a somewhat standardized way of really allowing the patient to speak back to you with what they've either learned or what they're going to be doing when they leave the appointment and one of the easiest ways to embed this and one of the more efficient ways to embed this is to actually talk to them what are you going to be doing now that we've had this conversation what are you going to be doing when you leave here so that they're able to go through either the recommendations that you've set for them if they're having to change their diet for example or how they're going to utilize their medications and i'm going to try and play this short video that's um from the um niddk i'm just kind of demonstrating health literacy i'm sorry the teach back being used it's a little awkward because neither of these um gentlemen are actors and you can tell that it's definitely something that's being screened but it provides a good example of teach back being used the teach-back method the back helps you confirm that your patient understands what you are explaining after explaining a plan or concept ask the patient to tell you back in their own words sometimes all it takes is the question what are you going to do when you get home or let's make sure i covered everything tell me what you're going to do this video has two brief examples of using the teach back method to give you a feel for how it works the first example is adjusting the dose of insulin well i think there are two things that we need to talk about uh have we ever talked about what to do when you have a low blood sugar before no okay we need to talk about that today um the other thing so we want to talk about what happens when you get a blow blood sugar and then i want to talk about uh how can we keep you from having these low blood sugars again all right so the first thing i want to say is i want to uh cut back your morning insulin dose i think you might be on a little bit too much okay and so instead of 25 units i'd like you to take 20 units in the morning okay okay and then how many do you take at night 12 20. okay so then how much will you be taking i'll be about four four or five okay so tell me break it down for me tell me how much you're going to take in the morning and how much in the evening it's going to break down and be taking 20 in the morning okay in 2018. perfect okay exactly that's what i want you to do okay the second example is adjusting the dose of blood pressure medicine uh mr holt i see that your blood pressure is still running a little bit high yes sir i tried but uh i took all my mess and took my blood pressure medicine when i came in for the visit this morning the doctor gonna tell me my blood is high okay so we started you on this last visit and we put you on five milligrams of lysine april so tell me have you been able to take that every day um i take it every day what time of day do you take it i take it in the morning early in the morning okay do you have any side effects from it um you don't feel light-headed or anything like that like sometimes i'll be walking like a loser you look dizzy sometimes you know okay um well your blood pressure today was 155 over 88. and so i think we ought to go ahead and increase that medicine [Music] uh and when did you have it filled last oh a day ago you just had a feel that's this is your bottle right here it's full um okay so these are five milligram tablets and i think what we need to do is go ahead and put you on 10 milligrams um since you just had this field what you can do is just take two tablets at a time okay and you can take them together you don't have to split them up you just take two tablets in the morning instead of one okay all right and then i'll give you a prescription for a bigger pill okay for when this runs out it'll have it'll have 10 milligrams in the pill okay so when you get the new pill when you get the new prescription you only have to take one okay all right all right so tell me uh so tell me how you're going to take this now yeah i'm going to take two little if i take them one take two things that'll be ten milligrams yeah okay i'm trying to take all of them i didn't go back and you just dropped me to one piece so i'll be taking one pillow out the opportunity that's right that's exactly right so you'll take two until this is done and then you'll switch over to the new prescription which is just one pill perfect so that was an example just of two different ways of using teach back and just trying to get the patient to really recall what their next steps are not even recall but really state what their next steps are going to be other techniques include and this should have been deleted of course utilizing a brown bag medicine review which really allows the patient and the clinician to go through all of their medications together and to understand how they're working together and to make sure that the patients are utilizing um and taking their medications correctly um the next steps um their next um tools really relate to engaging in steps that move you towards being able to practice cultural humility really understanding and being able to address language differences whether it's literally you do not speak the same language you're working with somebody who is um not proficient in english or there's just differences in terminology and how we use words and just and how those different things um happen but also starting to consider how culture customs and belief may actually impact the ability of the health literacy of the individual and then another really important one is to create and use written materials clearly and i know you all are clinicians you're not really going to be creating materials per se but what you do have the ability to do is to look at the materials that are coming in and that you are using and so finding ways to assess those materials just to make sure that they're following some of the best practices some of the things that i mean i'm sure you all considered before we think a lot about those readability formulas but there's coming out with these larger understandability assessments that are really useful because they get beyond just is my language at the x grade level that i want it to be but really thinking through how readily the document itself is to understand is it set up in a way that really facilitates somebody taking it all in and also it considers the uses of numbers and they're one of the ones i really like is the cdc's clear communications index we actually formally use that um to assess materials in one of our programs and it was a great experience i mean a great learning experience but quite embarrassing because we went through we had developed materials knowing that we were thinking about health literacy and we scored horrifically on them just thinking about the layout of our materials and it really helped us revamp how we go through and to our participants in our research trials present information to them and then also utilize materials that you have effectively don't assume materials get read but not to something to get passed off spend the time to review them with the patient or have a member of your team review with the patient and then when reviewing actively engage with the handout highlight key sections circle them utilize teach back as you're reviewing the um the paper recognize that the paper if the paper is important or that you're utilizing that material refer back to it in future visits and but then also make sure patients know how to use or access the information if the materials that you are pushing them towards happen to be electronic i know um i'm a new parent and as i was meeting with my pediatrician for the first time she was recommending a very specific website to go to and even thinking through so if you're moving your patients to kind of utilize different websites or different applications just making sure that they know how to use them um encourage questions um invite questions both directly and indirectly um something i mean asking them if they have questions not all patients are able to articulate questions and i can say that that's definitely me as a patient some of the times i however has developed the reflex of asking the provider if there's a question that i should be asking them because sometimes i feel put on the spot um or also indirectly asking questions i know one of the things that i tend to do um when i'm in the shoes of the one transmitting information is saying that i know sometimes i can't be clear um is there anything that you would like me to clarify for you or is there anything that we need to build on and kind of humbling myself a little bit um in there and not doing it falsely um but doing it to really just say that i know that i'm not always able to communicate clearly if you do have patients who come in with a ton of questions really helping them prioritize those questions but also while you are encouraging questions really be mindful of your body language use your body language to show that you have the time to answer and take in the questions which really involves looking at the patient and giving them that time one comment came up through the chat that there are built-in assumptions that patients are aware of things that they may not know um and really yeah exactly trying to help and not make assumptions about what the patient may or may not know and dear if there's anything else that you'd like to chime in on that um if you have an example feel free to well no just in that video when the doctor said to the the gentleman are you having any side effects my first thought was does the patient know what side effects that he might expect to have from this have has anyone educated him on this um and that's a question that we ask patients all the time you're having side effects they don't know they may not know what to be even looking for in order to report on them so you know there are we get used to using clinical language and and i think we have built-in assumptions a lot of times that patients um understand what we're talking about and that may be a really good way to if we think through kind of utilizing written materials that if someone is getting a new medication really being able to have something very clear that talks about these are the potential side of and i will be bringing these up with you at your next appointment it might be a way to really bring these two things together i know the only time i usually see side effects from medications are when i get the pill from the pharmacy and i don't read that because even for me that that is incredibly overwhelming another thing that is incredibly useful are making action plans and that actually has been my reaction to watching this health literacy video a few times is that he is verbally going over a medicaid the provider is verbally going over a medication shift with this patient and none of it's getting written down um and kind of saying like this is what i'm going to do and just assuming that it's all being taken in um verbally and we know that action plans are one of the most effective behavior change techniques that are out there and so thinking through with your patients um are there ways to create plans with patients that include their motivations potentially for making the changes there's a big difference between asking somebody to exercise more and somebody to take an asthma inhaler more regularly and just trying to figure out why they would want to do it one you might need a lot more intrinsic motivation for what are the goals that they want to do what's the behavior you want them to engage in what are the steps potentially what are the strategies for overcoming barriers um creating a process potentially to track progress how would someone know i mean just thinking about the gentleman in the video if he's taking two of those pills in the morning how is he making sure that he's taking two every morning um if he's old if he's been taking one for so long that it might have become sort of a rope process for him making sure that these plans are written out versus just talking it through and makes them much more realistic but also letting the patient drive the formation of a plan and this latter bullet's really important if it is a true behavior change so if you're working with a diabetic patient um and you need them to engage in more physical activity for example it's more of a behavior change than a medication change letting them do that because they're the ones who really know their lives and can set the steps that really make and the goals that make the most sense for them and then this also this gets towards one of the comments that was brought up very early on on how insurance and other things can really impact navigation um and really this idea of how do we how are we able to direct to medical and non-medical resources because that's an incredibly important part of also promoting health literacy and something that can be done to an extent at like a true individual level but is something that really needs to be thought about a little bit more in that bigger sense of the you but trying to be able to assess patients needs both and their support systems including challenges to those so that those challenges can be documented and potentially finding ways to address those challenges so things like being able to pay for medicines their food security status literacy um just because we are talking about health literacy and then really being mindful of their insurance um both do they have insurance or not but also where can and who can their insurance take um i've recently had a family friend need to have her daughter referred to an outpatient facility related to mental health and the facility that they were sent to did not take her insurance at all so even just trying to scramble and this is someone who is relatively health litter trying to and good at navigating the larger healthcare system trying to navigate to figure out well was there a reason i was pushed here and i should kind of follow through with it or like kind of what's going on and how can i get something that can be both financially possible and make sure my daughter's getting the care that she needs um and then thinking through it that how can community resources be identified either that can directly provide those um ways to solve those challenges or are there community resources where folks can be referred who are actually able to help them navigate that process themselves and also figuring out those pathways to connect patients with resources the next section we're going to talk about is a little bit more around some of these ideas around organizational health literacy but before i jump into that were there any other thoughts or points with what we've been talking about so far okay and so when we think about becoming an a health literate organization the institute of medicine has identified these 10 attributes that really form the foundation for a health literate organization and so when we think about organizations we think of something very large we think about carillion as a whole but there are also things that you can do within the training program um or within your own clinical units that you can actually take some of these traits and actually embed them into those practices and the ones that really stand out to me or this idea is that the leadership promotes health literacy so it's something that's integral to the mission structure and operations for example it could become a key way that you're training your group of learners it prepares the workforce and this ties directly into that prepares the workforce to be health literacy and really monitoring the process of engaging in that um strive to meet the needs of populations with a range of health literacy skills while avoiding stigmatation really embedding those um health literacy universal precautions in there and then utilizing health literacy strategies pretty much consistently and really being able to assess when they're being used and how they're being used and having an open dialogue around them and so some of the things that are in this toolkit that can really help support this are raising awareness of health literacy forming and engaging a health literacy focused on quality improvement team finding means to elicit patient feedback we've already talked earlier about ways to assess whether or not the patients feel that their health literacy needs are being met and to actually assess the providers and then there's other larger things that are in here as well that the system could consider um strengthening protocols for follow-up strengthening um telephone access um strengthening the practices the practices by with um patients are welcomed into the clinics and strengthening referral processes and a lot of this all ties back together with some of the other pieces that we've been talking about but i also wanted to within this context kind of share some resources because obviously at the individual level this um health literacy universal precautions toolkit is incredibly useful but thinking at a larger becoming a health literate organization the 2012 iom roundtable on health literacy their summary which is very easy to find through a search has a list of actions per each of these 10 attributes and then within ahrq they've also organized one of their pages around these 10 attributes and actually have clickable resources that can be clicked on to then start being able to engage but then also just knowing there is so much time and effort that goes into making these changes and that support is often needed nih has a number of announcements related to health literacy within the context of health services research um that can be applied for and they really do a lot of it's um related to our level grants but they're out there but then also um i don't know how many of you received the i thrive emails but just literally this morning their next round of grants came out and it could be that if like health literacy was something that's incredibly important to you is this a way to look at improving health literacy practices and thinking through one of those clinically or those translational grants and so i think there's if this is something that winds up being important to you guys as a big you or even as a little you there are resources to support moving forward so one of the things i was hoping to have for you all today was sort of an own action plan to help you move forward but just want you to really think about how you plan to put what you've learned about health literacy and health literacy practices today into action what's is there going to be a takeaway and an action step um for you from that and with all of that um thank you and i will um put my video back on and i know we only have about six more minutes but if folks have any questions that we can kind of finish out the session with dr farrell uh dropped a little message in the chat that more details on these i thrive brands will be in the research newsletter coming out tomorrow how timely it was i that's i looked at my email this morning and i was like this is like literally perfect timing because that's one of the things i feel like i health literacy is so important in how we engage in it and making it systematic but it does require a change of practice and it does require time and that's something that we don't always have a lot of and we can make more of it when there's something to cover some of our time in doing it are there any questions or thoughts or things that folks would like to know more about that i could send um mariah or sherry um as we after this presentation feel free to either type them in the chat or unmute yourselves well do not hesitate to contact us and we will put you in contact with dr porter or get your questions to her if um if need be questions comments any requests for additional information and i'm sure i just put my email in the chat too so folks can definitely email me directly wonderful thank you so much this is sherry hartman again um you're in psychiatry i thank you for this presentation that the content was so important i wondered if anybody knows of a resource act carillion that we could turn to to check on our understandability and readability of materials that we're developing that i'm not sure about um it's possible that in the marketing um marketing and communications there there they might have resources but i'm not sure um beyond that that is something that we should look into i agree um with sherry on that i think that the um you know that we really don't have that area and i think that dr porter was talking about having a quality um an area within quality that takes a look at that i think it would be really helpful um and while marketing is good they're not clinicians and so they may not be able to really understand and know either so um it is an area that i think that we could develop within um you know a gap at carillion that i think we could develop actually carillon uh this doctor buff bunny and krillian has eric solinger who is a manager for patient and family education and does review clinical documents for patient level sort of you know so that the language is translated into a language that a patient will understand we use them for many of our educational things so i think that's an area you can use that's great is that accessible for the entire organization uh the gentleman his career in clinic so i presume great could you put his name in the chat i've never heard of him i'm actually just picking back in on that this is bankole we're not actually allowed to change any patient material except you go through that office so if you make any change um you are meant to submit it to them um the first check to make sure legally there's no issues and then they check the reading grade so that it's set at and i can't remember what grade it is i think it's like sixth or seventh grade level or something like that um and that's what he does so any any time you have a letter you want is like a template letter or patient educational resource that you want that's where you're meant to send them to and he does do this work thank you so much is do uh do you know what his office is called or is it uh patient educational services or something like that dr babani just put it in the chat the office the name and contact information wonderful the perfect thing just think i mean just just because i work with students so much like i don't know just as carilion's growing with the i know obviously this is not a medical student thing but if there's other groups that could do it like this would be a very interesting like master's level project and even just having somebody kind of go through and do just a qi and then be able to start that process like using something like the cci to do it that's a great idea okay we're right on the hour don't hesitate to contact dr porter or go through us and we will contact her on your behalf if you have any other questions concerns comments that'd be great i hope you all have a wonderful rest of the day.