Health Literacy in Pharmacy: Health Literacy in Pharmacy: Communication StrategiesCommunication Strategies

Curricular ModulesCurricular Modulesfor Pharmacy Facultyfor Pharmacy Faculty

Content adapted from Kripalani and Jacobson Content adapted from Kripalani and Jacobson (2007)(2007)

OverviewOverview

Health Literacy in PharmacyHealth Literacy in Pharmacy Communication StrategiesCommunication Strategies

– Recognizing Low Health LiteracyRecognizing Low Health Literacy

– Improving CommunicationImproving Communication

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HEALTH LITERACY IN HEALTH LITERACY IN PHARMACYPHARMACY

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Health Literacy: Health Literacy: An InteractionAn Interaction

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Patient-Level ConsequencesPatient-Level Consequences

Poorer health outcomes Poorer health outcomes Increased hospitalizations Increased hospitalizations Greater use of emergency care Greater use of emergency care Missed prescription refills Missed prescription refills Difficulty understanding medication Difficulty understanding medication

instructions and warning labels instructions and warning labels – Inappropriate dosing or timing of medsInappropriate dosing or timing of meds

– Failure to recognize side effects or drug Failure to recognize side effects or drug interactionsinteractions

SOURCESOURCE: 1) Agency for Healthcare Research and Quality. : 1) Agency for Healthcare Research and Quality. Health Literacy Interventions Health Literacy Interventions and Outcomes: An Updated Systematic Reviewand Outcomes: An Updated Systematic Review. March 2011. 2) American Medical . March 2011. 2) American Medical Association Foundation. Association Foundation. Health Literacy and Patient Safety: Help Patients Health Literacy and Patient Safety: Help Patients Understand. Understand. August 2007. August 2007. 5

Societal and Pharmacy-Level Societal and Pharmacy-Level ConsequencesConsequences

Societal ConsequencesSocietal ConsequencesNonadherence Nonadherence

– Missed refills Missed refills – Inappropriate dosing or timing of medsInappropriate dosing or timing of meds– Failure to recognize side effects or drug interactionsFailure to recognize side effects or drug interactions

Increased emergency department costs among low health literacy Increased emergency department costs among low health literacy patients patients

Undermines efforts to increase patient self-management and Undermines efforts to increase patient self-management and engagement in careengagement in care

Pharmacy-Level ConsequencesPharmacy-Level ConsequencesImpact on customer loyalty/satisfaction Impact on customer loyalty/satisfaction Decreased profits due to missed refillsDecreased profits due to missed refillsLiability—NYS settlement for LEP patientsLiability—NYS settlement for LEP patients

SOURCES: SOURCES: 1) AMA (2007) 2) AHRQ (2011)1) AMA (2007) 2) AHRQ (2011)6

COMMUNICATION STRATEGIES COMMUNICATION STRATEGIES

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Opportunity: Pharmacists Opportunity: Pharmacists are Trusted Resources are Trusted Resources

Opportunities for InteractionsOpportunities for InteractionsMedication Therapy Management (MTM)Medication Therapy Management (MTM)Dispensing Dispensing CounselingCounselingOther Pharmacy Other Pharmacy

ServicesServices

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Apply Apply Universal PrecautionsUniversal Precautions

Everyone benefits when communication Everyone benefits when communication is clear:is clear:Looks can be deceiving. Offer help to all. Looks can be deceiving. Offer help to all. Worry or illness can cloud understanding. Worry or illness can cloud understanding. Offer clear explanations.Offer clear explanations.Check to see if Check to see if youyou have been clear. have been clear.

SOURCE: SOURCE: DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. Health Health Literacy Universal Precautions Toolkit.Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF. Rockville, MD. Agency for AHRQ Publication No. 10-0046-EF. Rockville, MD. Agency for Healthcare Research and Quality. April 2010.Healthcare Research and Quality. April 2010.

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Recall the Findings Recall the Findings from Education Studiesfrom Education Studies

Nearly 9 out of 10 adults have difficulty using the Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely everyday health information that is routinely available in our health care facilities, retail available in our health care facilities, retail outlets, media, and communities.outlets, media, and communities.

(Kutner et al., 2006)(Kutner et al., 2006)

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Recognize Patients Who Recognize Patients Who Need Extra HelpNeed Extra Help

Look for Common SignsLook for Common SignsPatients who… Patients who… Do not know the name of Do not know the name of

their medicine but rely their medicine but rely instead on shape, size, or instead on shape, size, or color color

““Forgot their glasses” Forgot their glasses”

Delay in picking up Delay in picking up medicines or renewalsmedicines or renewals

Have problems asking Have problems asking questions or explaining questions or explaining their concerns their concerns

Help outHelp out ““A lot of people have A lot of people have

trouble reading labels trouble reading labels and remembering how and remembering how to take their to take their medications. medications.

– Is this a problem for Is this a problem for you? you?

– How can I help?”How can I help?”

SOURCE: 1) Weiss, BD. Epidemiology of Low Health Literacy. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. AMA Press; 2005:19. 2) Katz MG, Jacobson TA, VeledarE, Kripalani S. Patient Literacy and Question-Asking Behavior During the Medical Encounter: A Mixed-Methods Analysis. Journal of General Internal Medicine 2007;22(6):782-786.8 Found in: Kripalani, Jacobson (2007)

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Recommended Strategies Recommended Strategies to Improve Communicationto Improve Communication

1.1. Explain things using everyday words.Explain things using everyday words.

2.2. Focus on and repeat key messages/actions. Focus on and repeat key messages/actions.

3.3. Use a “teach back” or “show me” technique Use a “teach back” or “show me” technique to check clarity and understanding.to check clarity and understanding.

4.4. Encourage questions.Encourage questions.

5.5. Use patient-friendly educational materials.Use patient-friendly educational materials.

SOURCE: 1) Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003. 2) Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson TA. Predictors of Medication Self-management Skill in a Low-literacy Population. Journal of General Internal Medicine. 2006;21(8):803-900. Found in: Kripalani, Jacobson (2007). 3) AHRQ Health Literacy Universal Precautions Toolkit. 12

1. Explain Things Clearly1. Explain Things Clearlyin Everyday Words in Everyday Words

Slow down the pace of your speech.Slow down the pace of your speech. Use plain, Use plain, non-medicalnon-medical language. language.

– ““Blood pressure pill” [instead of Blood pressure pill” [instead of “antihypertensive”]“antihypertensive”]

Include key information about timing.Include key information about timing.– Morning, noon, night, bedtime [instead of 4X a day]Morning, noon, night, bedtime [instead of 4X a day]

Avoid jargon. Avoid jargon. – ““Take 2 hours before lunch or 2 hours after lunch[ instead of “Take on an Take 2 hours before lunch or 2 hours after lunch[ instead of “Take on an empty empty

stomachstomach”]”]

SOURCE: 1) Kripalani, Jacobson (2007); 2) AHRQ Universal Precautions Toolkit (2010)

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Use Everyday Words:Use Everyday Words:

Instead of:Instead of: ChooseChoose

Utilize……………….…...Utilize……………….…...UseUse Adverse reaction…..…...Adverse reaction…..…...Side effectSide effect Hypoglycemia……..……Hypoglycemia……..……Low sugarLow sugar PRN………………….….PRN………………….….When you need itWhen you need it Suppository………….….Suppository………….….Medication that Medication that goes in goes in

your bottom your bottom Topical……………….….Topical……………….….On the skinOn the skin

SOURCE: Kripalani, Jacobson (2007

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2. Focus on & Repeat Key2. Focus on & Repeat KeyMessages/Actions Messages/Actions

Limit informationLimit information

– Focus on 1-3 key pointsFocus on 1-3 key points Develop short explanations for common Develop short explanations for common

medical conditions and side effectsmedical conditions and side effects Discuss specific behaviors rather than Discuss specific behaviors rather than

general conceptsgeneral concepts

– What the patient needs to doWhat the patient needs to do Review each key point at the endReview each key point at the end

SOURCE: 1) Kripalani, Jacobson (2007). 2) AHRQ Health Literacy Universal Precautions Toolkit.

3. 3. Use a “Teach-Back” – Check Use a “Teach-Back” – Check for Clarity & Understandingfor Clarity & Understanding

SOURCE: SOURCE: Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K; Castro C, Bindman AB. Closing the Loop: Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K; Castro C, Bindman AB. Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 2003;163:83-90. Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 2003;163:83-90. Found in: Found in: Kripalani, Kripalani, Jacobson (2007)Jacobson (2007)

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Teach-Back ScriptsTeach-Back Scripts

I want to make sure I explained everything clearly. If you were I want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, trying to explain to your husband how to take this medicine, what would you say?what would you say?

I want to be sure I mentioned the main side effects of this new I want to be sure I mentioned the main side effects of this new medicine. Could you tell me the two things to watch out for?medicine. Could you tell me the two things to watch out for?

Show me how you would use this inhaler so I can make sure I Show me how you would use this inhaler so I can make sure I explained it well.explained it well.

SOURCE: Kripalani, Jacobson (2007)

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4. Encourage Questions 4. Encourage Questions & Interaction& Interaction

DO ASK:DO ASK:

What questions do you What questions do you have?have?

How can I make it easier for How can I make it easier for you to take your medicines?you to take your medicines?

Did anyone explain what to Did anyone explain what to do if you miss a dose?do if you miss a dose?

DON’T ASK:DON’T ASK:

Do you have any questions?Do you have any questions?

Questions?Questions?

SOURCE: Kripalani, Jacobson (2007)

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5. Use Patient-Friendly 5. Use Patient-Friendly MaterialsMaterials

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Characteristics: Characteristics: Key information is offeredKey information is offered The material is a tool for action The material is a tool for action The content is designed to help action steps The content is designed to help action steps Everyday words are usedEveryday words are used The design eases reading The design eases reading Relevant illustrations are used [show how-to]Relevant illustrations are used [show how-to] Evidence that the designers tested it with Evidence that the designers tested it with

audience membersaudience membersSOURCE: Kripalani, Jacobson (2007)

Patient-Friendly Materials Patient-Friendly Materials Simplify TasksSimplify Tasks

How do we make it easier for a patient How do we make it easier for a patient who must manage all this?who must manage all this?

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Use Patient Friendly MaterialsUse Patient Friendly Materials

How can we improve this tool?How can we improve this tool?

John Smith Dr. Red

Take two tablets by mouth twice daily.

Humibid LA 600MG1 refill

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Use Patient Friendly MaterialsUse Patient Friendly Materials (cont’d)(cont’d)

Are these directions an improvement?Are these directions an improvement?

John Smith Dr. Red

Take 2 pills by mouth at 8 am and 2 pills at 6 pm.

Humibid LA 600MG1 refill

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SummarySummary

To make sure I’ve explained things clearly To make sure I’ve explained things clearly so far…so far…

How do you know if a patient has limited or low health How do you know if a patient has limited or low health literacy?literacy?

Name at least 2 techniques to improve Name at least 2 techniques to improve communication with low-literacy patients.communication with low-literacy patients.

Provide an example of the teach-back.Provide an example of the teach-back.

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Active Learning ExerciseActive Learning Exercise

Divide into groups of three. Each person in Divide into groups of three. Each person in the group will have a role to play:the group will have a role to play:

– PharmacistPharmacist– PatientPatient– ObserverObserver

Refer to the handouts for instructions for each Refer to the handouts for instructions for each role. role.

After each round, the “observer” will provide After each round, the “observer” will provide feedback to the “pharmacist.”feedback to the “pharmacist.”

Switch roles after each round. Each person Switch roles after each round. Each person should have a chance to play the pharmacist.should have a chance to play the pharmacist.

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Role Play DiscussionRole Play Discussion

What was different? What was different?

Was it hard?Was it hard?

What did you learn?What did you learn?

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Wrap Up Wrap Up

Build on existing trustBuild on existing trust– Encourage dialogue and questionsEncourage dialogue and questions

Adopt Universal PrecautionsAdopt Universal Precautions Improve CommunicationImprove Communication

— Plain Language (everyday words, no jargon)Plain Language (everyday words, no jargon)— Focus on Key MessagesFocus on Key Messages— Teach BackTeach Back

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ReferencesReferences

Agency for Healthcare Research and Quality. Health Literacy Interventions and Outcomes: An Updated Systematic Review. March 2011. Available at http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf

American Medical Association Foundation. Health Literacy and Patient Safety: Help Patients Understand. August 2007. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

Centers for Disease Control and Prevention Health Literacy Training for Public Health Professionals: http://www2a.cdc.gov/TCEOnline/registration/detailpage.asp?res_id=2074

Davis T.C., Wolf M.S., Bass P.F. 3rd, Thompson J.A., Tilson H.H., Neuberger M., Parker R.M.. Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine. December 2006. 19;145(12).

DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

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References References (cont’d)(cont’d)

Kirsch, I., Jungeblut A., Jenkins, L. and Kolstad, A. (1993) ‘Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS)’, National Center for Education Statistics, US Department of Education Washington, DC.

Kutner, M., Greenberg, E. and Baer, J. (2005) ‘A First Look at the Literacy of America’s Adults in the 21st Century’, National Center for Education Statistics, NCES 2006–2470, Washington, DC.

Kripalani, S. & Jacobson, K. L. (2007). Strategies to improve communication between staff and patients: Training program for pharmacy staff. Rockville, MD: Agency for Healthcare Research and Quality.

Spector S.L. and Youdelman, M. Analysis of State Pharmacy Laws: Impact of Pharmacy Laws on the Provision of Language Services. National Health Law Program (2010).

Warholak T.L., Nau D., (Editors). Quality & Safety in Pharmacy Practice. New York, NY: McGraw- Hill Medical; 2010

Warholak T.L, West D., Holdford D.A. Educating Pharmacy Students and Pharmacists to Improve Quality. Journal of the American Pharmacists Association (2003). 2010 Jul-Aug;50(4):534-8.

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