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[@8 g4KdKd -a0ppp@  <4!d!d8K*0l<4dddd8K*0lg4PdPd, -a0nxph pB( ʚ;y.ʚ;<4dddd8)08,^___PPT10> .&kmcmorr.___PPT9O(a(?  %O  =U=DStrategies to Improve Communication Between Pharmacists and PatientsED0`[Presenters Names Here] Developed by Sunil Kripalani, MD, MSc and Kara L. Jacobson, MPH, CHES 4aP($F$;#&Training Curriculum for Pharmacy Staff''(Developed and used by the PILL Study (Pharmacy Intervention for Limited Literacy) Emory Center on Health Outcomes and Quality Rollins School of Public Health, Emory University Grady Memorial Hospital Atlanta, GA ~S07,R f >vOverview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!@nO Definition   zHealth Literacy:  The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Pl2PP " dP" 4      1Health Literacy in America: Results from the NAALAHigh Risk Groups "Elderly Minorities Immigrants Poor## 2Homeless Prisoners Persons with limited education  23 B,Functional Literacy of High Risk Populations--(Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@n>TtHealth Care ExperiencesLow-literacy patients commonly hide their difficulty Many feel ashamed Avoidant behaviors When do you suspect low literacy? Your experiences?(Z4*Possible Indicators of Low Health Literacy+*3Excuses:  I forgot my glasses. Lots of papers folded up in purse/pocket Lack of follow-through with tests/appts. Seldom ask questions Questions are basic in nature Difficulty explaining medical concerns or how to take medsUniversal PrecautionsCan t tell by looking Communicate clearly with everyone Confirm understanding with everyone Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@nU+YLow Literacy and Medication Use (> Ability to identify their own medications 12-18 x greater odds Understanding of how to take medications Take med every 6 hrs 52% correct Take med on empty stomach 46% correct Understanding of drug mechanisms and side effects Warfarin works by thinning blood 70% correct Bleeding/bruising most common SE 49% correct Misinterpretation of common warning labels 3-4 x more likely to misinterpret P3+3*M35---$]z"Health Literacy and Medication Use##& Understanding of numerical information If your blood test result for warfarin is just right when it is between 2.0 and 3.0, which of the following results would be  just right ? 29% correct Medication adherence Adverse drug events (?) Health care costs ZZ3(3 33   IQ+Some Challenges in Trying to Improve Things,+RIncreasingly complex health system Greater self-care requirements More medications for chronic conditions Formulary and manufacturer changes Medication reconciliation Most patient instructions are written Low-literacy pts have trouble understanding Verbal instructions Often complex Delivered rapidly Easy to forget in stressful situation#ZZ&Z,ZZFZ#e&,F  What questions do you have? Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@nF-a/Recommended Strategies to Improve Communication"0/$3 0  Explain things clearly in plain language Focus on key messages and repeat Use a  teach back or  show me technique to check understanding Effectively solicit questions Use patient-friendly educational materials to enhance interactionn (    .b+1. Explain Things Clearly in Plain Language,+(Slow down the pace of your speech Use plain, non-medical language  Blood pressure pill instead of  antihypertensive Pay attention to patient s own terms and use them back Avoid vague terms  Take 1 hour before you eat breakfast instead of  Take on an empty stomach CkM-  36Md~fUsing Plain Language: What could we say instead of& *4$$37Adverse reaction Hypoglycemia PRN Suppository Topical $7ZZ8/c#2. Focus on Key Messages and Repeat$#(Limit information Focus on 1-3 key points Develop short explanations for common medical conditions and side effects Discuss specific behaviors rather than general concepts What the patient needs to do Review each point at the end`0dX3. Use a  Teach Back to Check Understanding-*  1eTeach Back Scripts   VI want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, what would you say? Let s review the main side effects of this new medicine. What are the 2 things that I asked you to watch out for? Show me how you would use this inhaler. 0+ZZ+" 2f 4. Effectively Solicit Questions!! Don t say: Do you have any questions? Any questions? Instead say: What questions do you have?  * *  "  5. Patient-Friendly Materials8Appropriate Content Plain Language Layout IllustrationsxnHelp me make sure I ve explained things clearly so far&  87(0 How do you know if a patient has low health literacy? Name at least 2 techniques to improve communication with low-literacy patients. Provide an example of the teach-back.V7ZZPZZ&ZoWhat questions do you have? Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!*@nHands on Practice!In this section, you will divide into groups of 3. Each person in the group will have a role to play: Pharmacist Patient Observer Refer to the handouts for instructions for each role. After each round, the  observer will provide feedback to the  pharmacist. Switch roles after each round. Each person should have a chance to play the pharmacist.PfnA3$3fRole Play Discussion7What was different? Was it hard? What did you learn? Wrap UpAdopt Universal Precautions Implement Strategies to Improve Communication, e.g., Plain Language Focus on Key Messages Teach Back What questions do you have? `Q0Q0 ReferencesvDavis TC, Wolf MS, Bass, PF III, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S, Parker RM. Low Literacy Impairs Comprehension of Prescription Drug Warning Labels. Journal of General Internal Medicine. 2006;21(8):847 851. Fang MC, Machtinger EL, Wang F, Schillinger D. Health Literacy and Anticoagulation-related Outcomes Among Patients Taking Warfarin. Journal of General Internal Medicine. 2006;21(8):841-846. Freidland RB. Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy. Washington, DC: National Academy on an Aging Society; 1998. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP. Health Literacy Among Medicare Enrollees in a Managed Care Organization. JAMA. 1999;281:545-551. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors Associated with Medication Refill Adherence in Cardiovascular-related Diseases: A Focus on Health Literacy. Journal of General Internal Medicine. 2006;21(12):1215-C15. Howard DH, Gazmararian J, Parker RM. The Impact of Low Health Literacy on the Medical Costs of Medicare Managed Care Enrollees. The American Journal of Medicine. 2005;118(4):371-377. Katz MG, Jacobson TA, Veledar E, 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. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education; September 1993. 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. Kripalani S, Weiss BD. Teaching About Health Literacy and Clear Communication. Journal of General Internal Medicine. 2006;21(8):888-890. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006. National Quality Forum. Safe Practices for Better Healthcare, 2003; Washington, D.C. Parikh N, Parker R, Nurss J. Shame and health literacy: the unspoken connection. Patient Education and Counseling. 1995;25:109 199. 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. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report No. 43 from the Agency for Healthcare Research and Quality. AHRQ Publication No. 01-E058; 2001. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000. 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. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003.: nP $  $ i   $    % A \  $ f $ ? t   /   ( R  !    O<   "  M  j    /1jz|?@ABCDe~ 0` 33PP` 3333` ___MMM` 13` 333fpKNāvI` j@v۩ῑ΂H` Q_{>?" dd@,?n<d@ `7 `2@`7``2 n?" dd@   @@``@n?" dd@  @@``PR    @ ` ` p>>^N0    H< ( 5% H H < @  H T$d @  H <U_ @  H TDk d>& @  H Nk P @  H < k p @  H C xk ?d?bUv @   H 6 U k  T Click to edit Master title style! !  H 0k    k  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  H 6k  @ k  \*   H 6|k  @`  k  ^*   H 6!k  ` k  ^* B H s *޽h ? 3333 colored boxes   0^N0 Q I 0L( ^Qw LBF + L +8T P@ L# DwoZ L s *PPr L Bd P@8T P 0  L# NyZ L s *P  r L BdP 0 l  L < a*Z  L s *  L  f?d?+)  L <}m  ?pP m  T Click to edit Master title style! !  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'ay___PPT10Y+D='  = @B +  z0^N0 s(  ~  s *s  Hg  s    c $ԣs  H   s   @ !  T4s  ??a AU.S. Department of Health and Human Services. Healthy People 2010$B.  A  H  0޽h ? 'a___PPT10e.+D='  = @B +  0^N0   P   (   x  c $|s  HU  s    T\s  ??K^ Proficient: Define medical term from complex document, Calculate share of employee s health insurance costs"l 2 a0  Ts  ??>  nIntermediate: Determine healthy weight from BMI chart, Interpret prescription and over-the-counter drug labels"o 2 b  Ts  ??] D  p2Basic: Understand simple patient education handout"3 2-&  T dBelow Basic: Circle date on appointment slip, Understand simple pamphlet about pre-test instructions"e 2 Y z .   .,$D 0   Z??"`K  2  `A ? ? H.  s    T4s  ?? 712% 2   TTs  ??  714% 2   Ts  ??Z A  722% 2   Ts  ??   753% 2  Ts  ??t _Kutner et al 2006 2  H  0޽h ? 3333IA___PPT10!.=0p+&D'  = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D7' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =-s6Bwipe(down)*<3<* +  0^N0  `u(  `r ` S >  HU   x ` c $@s  HI l    r ` S |s  H l  s   ` T@  ??t EKirsch et al 1993 2 H ` 0޽h ? 3333___PPT10i.J]2x+D='  = @B +   0^N0 )wd(  dr d S N  HU     wd #">2    Nd  `W ?? L71 @` Hd Z^  ??  9+ yrs prior educ @` ,d  `Y ??  L91 @`  )d Zq  ??  Immigrants: 0-8 yrs prior educ @` (d ZLk  ??   L55 @` %d Z  ??   U HS/GED2 @` $d  `pR ??   L81 @` !d ZH  ??   W 9-12 yrs  2 @`  d  `4 ??   L96 @` d Z8  ??   fEducation level: 0-8 yrs2 @` d  `< ??   L78 @` d Z  ??   W Hispanic  2 @` d  `< ??  L77 @` d Z  ??  T Black2 @` d Z  ?? L41 @` d Z  ?? hRacial/Ethnic group: White2 @` d  ` ?? L81 @`  d Z  ?? pElderly (e" 65)"  @`  d Z  ?? L50 @`  d Z  ?? KAll @` d Z  ?? \Low Literacy (%) @` d Z"  ?? OGroup @`B -d Zo ??B .d T1 ??B /d T1 ??B 0d T1 ??B 1d T1 ??B 2d T1 ??  B 3d T1 ??  B 4d T1 ??  B 5d T1 ??  B 6d T1 ??  B 7d Zo ??B 8d Zo ??B 9d T1 ??B +#.<*[}%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*}%(+[  0^N0 jb0 (   x  c $  H3a   x  c $  Hm     T`  ??!  <P 2B  Z  ??Fo pWeiss 2003. Katz et al 2007.$ n<  8XH  0޽h ? fp=y___PPT10Y+D='  = @B +  0 D T(  D ~ D s *0  HU    D c $  H    *gGH D 0޽h ? 3333___PPT10i.+D='  = @B +  0^N0 p Z(   ~  s *  HU     s *Į  Hv   *Pk;KH  0޽h ? 'ay___PPT10Y+D='  = @B +  0^N0 `X (  X x X c $$  HU    X c $  H0<$@0   ". X ZH|k  ??Fo PKripalani et al 2006. Gazmararian et al 1999. Fang et al 2006. Davis et al 2006.$Q n<Q  8XH X 0޽h ? 33332*___PPT10 .sb/+ED'  = @B D' = @BA?%,( < +O%,( < +Dd' =%(D ' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X ,%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X ,C%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X Do%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X o%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X %(Dd' =%(D ' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X %(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X %(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X M%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X N{%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*X {%(+1: 0^N0 |#t#p3U] #(  \ P| . T]  #"." .; !]  Z,  ??y  aUse extreme caution in how you take it Medicine will make you feel dizzy Take only if you need itbb @`  ]  Zd  ??. y P  @`P ]  ZP  ??y   vDon t take when wet Don t need water Don t drink hot water<< @` ]  Z  ??. y  P  @` ]  Z  ??y&   If allergic to dairy, don't take medicine Don t eat for 1 hour after taking medicineUU @` ]  ZT  ??.& y  P  @`n ]  ZP  ??ye&  Don't drink and drive Don t drink alcohol. It s poison, and it ll kill youKK @` ]  Z|#  ??.ey&  P  @` ]  Zt,  ??ye gDon't leave medicine in the sun   @` ]  Z@5  ??.ye P  @` ]  Z?  ??y "Chew pill and crush before swallowing Chew it up so it will dissolve. Don t swallow whole or you might chokenn @` ]  ZG  ??.y P  @` ]  ZP  ??y XDon't take food  @` ]  ZY  ??.y P  @`B $]  Zo ??.B %]  T1 ??.B &]  T1 ??.B ']  T1 ??.eeB (]  T1 ??.& & B )]  T1 ??.  B *]  T1 ??.  B ,]  Zo ??.B -]  Zo ??..B .]  T1 ??yyB /]  Zo ?? 2] T@^  ??"5 [#Misinterpretation of Warning Labels$ 2$$F  \ 3 A  ?10-xn@R  \ 3 *A ?1-57G_COLORAD  \ 3 A  ?5-xN% i D \ 3 A ?8-xN H \ 3 A?1-11GN *F \ 3 A ?11-xN Z \ 3 2A! ?Label%2011-editk  | \ T ??Qt Q| \ T ??Qt Q| \ T ??Qt Q| \ T ??Qt Q| "\ T ??Qt Q| '\ T ??Qt Q| ,\ T ??Qt Q| 1\ T ??Qt Q F] Z??"`8U G] Z??"`6 H] Z??"`6? I] Z??"`/  J] Z??"`G (  K] Z??"` /}  L] Z??"` 6 U] Zj  ??Fo {'Davis et al 2006. 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Howard et al 2005.$< n<<  8XH ( 0޽h ? 3333___PPT10i.sb/+D='  = @B +  |0^N0 L(  x  c $  HP     s *,k  HIa   "8 @H  0޽h ? ̙33y___PPT10Y+D='  = @B +!0^N0   (   x  c $  LpP   H  0޽h ? 3333___PPT10i.~]C+D='  = @B +  0^N0 4 Z(  4 ~ 4 s *  HU    4 s *k  Hv   *Pk;KH 4 0޽h ? 'ay___PPT10Y+D='  = @B +  0^N0 \%(  \~ \ s *  H`    \ c $`  H@`   (tp \ TDk  ??  < 2  \ Z  ??Fo y%Weiss 2003. Kripalani and Weiss 2006.$& n<&  8XH \ 0޽h ? 'a___PPT10e.+D='  = @B +  0^N0 d6(  d~ d s *  HU   x d c $T  H&   H d 0޽h ? ̙33___PPT10e.+D='  = @B +  0^N0 $pD(  D~ D s *  HU   ~ D s *  H    pz   D  ,$D 0 D  `  ?? v 0  P20 2( D 63k  9  TSide effect Low sugar When you need it Pill that goes in your bottom/behind On skin UZUH D 0޽h ? 'a91___PPT10+tD'  = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D7' =4@BBBB%(D' =1:Bvisible*o3>+#.<*D%(D' =-s6Bwipe(left)*<3<*D+  0^N0 l6(  l~ l s *<  HU   x l c $  H    H l 0޽h ? ̙33___PPT10e.+D='  = @B +  0^N0 0t.(  t~ t s *  HU   Z t C 2Aioi10753f1 ' t Z  ??Fo Schillinger et al 2003$ n<    8XH t 0޽h ? fp=y___PPT10Y+D='  = @B +  0^N0 P|<(  |~ | s *&  HU   ~ | s *d'  H    H | 0޽h ? fp=y___PPT10Y+D='  = @B +  0^N0 ph(  ~  s *@5  HU     s *@6  H <$0   H  0޽h ? fp=d\___PPT10<+FD'  = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*6C%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*Db%(+8+0+0 +  0^N0   $(   r  S P@  HU   r  S (A  H   H  0޽h ? 3333___PPT10i.\@+D='  = @B +   0^N0  (  ~  s *,J  HU     s *P  H<$0   ,C gTH  0޽h ? 'Xf33f3j b ___PPT10B + D '  = @B D ' = @BA?%,( < +O%,( < +D' =%(D' =%(D@' =A@BB BB0B%(D' =1:Bvisible*o3>+#.<*7%(D' =-o6Bdissolve*<3<*7D' =%(D' =%(D@' =A@BB BB0B%(D' =1:Bvisible*o3>+#.<*8%(D' =-o6Bdissolve*<3<*8D' =%(D' =%(D@' =A@BB BB0B%(D' =1:Bvisible*o3>+#.<*%(D' =-o6Bdissolve*<3<*+8+0+0 +!0^N0   p(  px p c $b  LpP   H p 0޽h ? 3333___PPT10i.~]C+D='  = @B +  0^N0 < Z(  < ~ < s *h  HU    < s *hNm  Hv   *Pk;KH < 0޽h ? 'ay___PPT10Y+D='  = @B +  0^N0  H(   r  S 8u  HU     S k  H[   0=.vv>NH  0޽h ? 3333___PPT10u..o[+D='  = @B +  0^N0   $(   r  S   HU   r  S d  H~0   H  0޽h ? 3333___PPT10i.X%)+D='  = @B +  0^N0   $(   r  S   HU   r  S Ќ  H    H  0޽h ? 3333___PPT10i.[{+D='  = @B +  0^N0  :(   r  S ԓ  HU     S   H"   "p`PpH  0޽h ? 3333___PPT10i.ZT0Tc+D='  = @B +0 JB0(  0d 0c $RE   6 03 r jeje#" 0e~ u   hLet me share with you what we ll be covering in our training today. When you leave here today, I want you to able to& [State learning objectives here] Define health literacy, Describe the health care experiences of low-literacy patients, Discuss health literacy and medication use, Review techniques to improve communication with low-literacy patients, and Have an opportunity for Hands-on practice! Adult learners learn best by doing. This is where our hands-on activity comes into play.d@-ZC2!YH 0 0j ? ̙339=0 ` <(  <d < c $QE   s  < 3 r4s gg T  s  +[Introductions: Please have participants introduce themselves. During their introduction, ask them to share an experience during which a patient had difficulty understanding something about their medications, or made an error due to misunderstanding].H < 0j ? ̙33SO0  (  d  c $RE     3 r gg ~ u   EEveryone is probably familiar with the definition of literacy- the ability to read and write, but what about Health Literacy? Health Literacy refers to a constellation of reading and numeracy skills required to function in the health care environment. These include: Reading prescription bottles Figuring out appointment slips Understanding informed consent documents Understanding discharge instructions Following diagnostic test instructions Reading health education materials Completing health insurance applications Health literacy is context specific. Someone who has excellent reading and writing skills, and who functions very well in another environment (for example, an accountant), may still have low health literacy.D  d H  0j ? ̙33B Q0  (  d  c $RE     3 r| gg ~ u   4Greater demands are being placed on our patients as consumers of health care. The health care system is increasingly complex and demanding of patients  from direct-to-consumer advertising to shorter hospitalizations with greater self-care requirements after discharge. At times, physicians may actually place greater burdens on patients, such as in the process of informed decision-making for prostate cancer screening. Most patient instructions are written. There is a consistent gap between the reading demands of the health care setting and the actual skills of many Americans. For example, the average American has an 8th grade reading level, while the average medical/health information is written at at least a 12th grade level. Verbal instructions are often complex, rushed, and given at a time when patients and their families are stressed by illness.Z`[}[H  0j ? ̙33 a0 \ T ` (  `d ` c $RE   H  ` 3 r7 gg y ul  TL___PPT9.& 2 f All patients, not just those with low health literacy, will benefit from these 5 recommended strategies for patient-centered visits: Using plain language is not easy for us as clinicians. Make a conscious effort to avoid medical jargon and vague instructions. Keep it short and simple. Only tell patients what they need to know, not what is nice to know. There is a growing body of research suggesting that asking patients to  teach back what they have learned improves medical outcomes. This was recently listed as one of the top 11 patient safety practices for reducing medical errors (National Quality Forum 2003, Shojania et al 2001). Most pharmacists probably feel that they give patients a chance to ask questions, but some simple techniques can enhance patients comfort level in asking questions. Because everyone has different learning styles, verbal messages should be reinforced with written information and pictures whenever possible. Everyone learns better if information is reinforced in multiple ways. Provide easy-to-understand information for ALL patients. Together, these strategies and others will help ensure the environment is patient-friendly and shame-free for ALL patients. --|-[[.l@KH ` 0j ? ̙33b0 ~vh(  hd h c $RE   j h 3 rC ggy u   lThink about how much easier it is for you to understand new information if it is presented a little more slowly. Concrete examples or analogies can help give a sense of reality to abstract concepts or things that patients can t see in their own body. Also pay attention to the patients own terminology and use those terms yourself in the discussion. Be careful about vague things that you are accustomed to saying in your counseling. Just what exactly does it mean to take a medication on an empty stomach. Be as specific as possible when providing instructions.(7   p H h 0j ? ̙33v c0 6 . p (  pd p c $RE   "  p 3 r_ gg \ Q   hLimit information There s a tendency to try to explain everything to a patient at one visit. In most cases, the patient will actually be better off if you select just a few key points, reinforcing and repeating them during the discussion. Less is more. In choosing the points to address, try asking the patient to identify the 1 or 2 most important things to them. Patients are far more likely to remember the answers to their own questions and concerns. This strategy will also reduce the  by the way&  questions as you are wrapping up your patient counseling. You could combine the patient s 1-2 priority items with your top 1-2 things to develop a manageable list of just a few things to discuss. The patient s concerns might be the same as yours, or they could be totally different. Develop short explanations for common conditions- how can you explain a diabetes medicine in 2 or 3 brief sentences? Focus on behaviors- what do you want the patient to do? Review each point at the end- summarize and reinforce RiH p 0j ? ̙33L d0   @x (  xd x c $QE     x 3 r[ gg    > How many of you know the teach back principle? Well, teach back is used to assess patient understanding. Asking patients to repeat something in their own words is a far better way to gauge comprehension than simply asking,  Do you understand? Let me walk you through this diagram. After explaining a new concept, we should assess the patient s recall and understanding, clarify our explanation as needed, reassess comprehension, and continue to clarify until the patient expresses satisfactory understanding. Most of us who have performed a teach back assess patient recall and comprehension the first time, but if we need to clarify or tailor the information, rarely we re-assess patient comprehension. This is the most common mistake made when attempting to apply the teach back model. In one study, physicians who used the teach-back technique with their diabetic patients achieved better glycemic control. Teach back works. *Note: the process shown in this diagram may be modified as needed in each patient encounter. The cycle may repeat as many times as is necessary for sufficient patient recall and comprehension.(/te~KH x 0j ? ̙33e0 ~`(  d  c $QE   r  3 rx gg    lWhen asking patients to  teach back , it helps to put them at ease by placing the burden on yourself. You want to know what information the patient understood. You also need to focus the teach back on 1 or 2 points. If I asked you right now to tell me what I have shared with you in the last hour, you might recall 1 or 2 concepts, but this is not effective for assessing your knowledge. It would be more effective for me to assess your understanding of the impact of health literacy. I might say, for example,  We have covered a lot of information today. In order for me to be sure that I explained health literacy correctly (placing the burden on myself), tell me two things you can do to improve communications with patients (focuses the teach back on 1 point). What are some other ways you can ask for a teach back?07[7H  0j ? ̙336f0 (  d  c $QE     3 rL gg L   (As pharmacists wrap up a patient encounter, they often solicit questions from the patient, in part to check patient s comprehension of the information that has been covered. Unfortunately, we often do this in a closed-ended way with a yes/no prompt such as:  Do you have any questions? or  Any questions? Remember, patients are often hesitant to admit that they don t understand something or they re afraid to ask what might be considered a  stupid question. This is most true for patients with low health literacy. Open the door for them by effectively soliciting patient questions. Ask,  What questions do you have? (2=sH  0j ? ̙33~0 bZH(  Hd H c $PD   N H s *Է     Let s practice a few simple alternatives to common jargon that may come up in medication counseling.H H 0j ? 33d0 $0(  d  c $NQ     3 r,k aa C0   VBLet s try our own teach-back now& H  0j ? ̙330 @ 2(   d  c $PD     s *h     Some excuses you may hear from patients with low health literacy include:  I forgot my glasses. I ll read this when I get home.  I forgot my glasses. Can you read this to me?  Let me bring this home so I can discuss it with my children. Other possible red flags for low health literacy are: Lack of follow-through - incomplete forms/ missed appointments Patients cannot describe how to take their medications, have difficulty explaining medical concerns, or seldom have any questions.)iH  0j ? 330 ` F(   d  c $RE     3 r0 jeje~ u   Now, let s talk about how it might feel to be a patient who has trouble understanding medical information.H  0j ? ̙330  8(   d  c $RE     3 r jeje~ u   Now, let s transition to what is known about health literacy and medication use.QO[H  0j ? ̙330 xp8 (  8 d 8 c $RE   d 8 3 r jeje~ u   Now let s shift gears to discuss techniques that you can use in your day-to-day interactions with patients that will improve communication, especially for those patients who have limited literacy skills.H 8 0j ? ̙33,0 @ |(  @ d @ c $RE    @ 3 r jeje~ u    H @ 0j ? ̙33hA0 ` x(  ` ^ ` S PD    ` c $     n6Certain groups are more likely to have limited health literacy. These groups include& However, it is important to remember that low health literacy is a problem that touches all groups and segments of society. In terms of raw numbers, most people with low health literacy are White.H ` 0j ? 3380___PPT10.s4]}B0 d (  d ^ d S PD    d c $     IHere are some figures from another national study which looked at general literacy skills. Of those aged 65 or greater, 81% have low literacy Blacks and Hispanics are more likely to have low literacy: 77% and 78% compared to 41% of Whites Those with the least amount of education have the highest prevalence of limited literacy.\JH d 0j ? 3380___PPT10.]t0 ^Vh (  h ^ h S PD   P h c $42     You can t tell by looking. Patients are very savvy in masking the signs of limited health literacy, as there is a great deal of shame associated with this. In fact, one study found that 24% of individuals who suffered from limited health literacy had never informed their spouse (Parikh et al 1995). Patients with limited health literacy skills may be very articulate, and smart enough to navigate through life and the health care environment with these limitations. Tell me, when do you suspect a patient has low health literacy? What are some of your experiences with low-literacy patients?$SjH h 0j ? 3380___PPT10.`_0 F>l (  l ^ l S PD   8 l c $A     Because we can t tell by looking who is affected by low health literacy, we advocate using a Universal Precautions approach - that is, simplify information for everyone, independent of their perceived health literacy abilities. By simplifying information for all and assuming that most patients may have difficulty in understanding the information, we are paving the way for improved communications and, hopefully, improved adherence and health outcomes.$H l 0j ? 3380___PPT10. J_J0 p Z(  p ^ p S PD    p c $P     PSeveral studies have assessed patients understanding of their medications. In these studies, researchers found that individuals with limited health literacy demonstrated& 12 to 18 times the odds of being unable to identify their own medications and distinguish one from the other Common difficulty understanding simple instructions such as taking a medication every 6 hours or on an empty stomach Worse understanding of common drug mechanisms and side effects, such as how warfarin works (despite being on warfarin and having attended educational classes on its use) Greater misinterpretation of drug warning labels ,-k,gH p 0j ? 3380___PPT10.p,`0 t ,(  t ^ t S PD    t c $pc     "Now, let s review some important health communication messages about drug warnings and patient safety. First, we find that warning labels are not regulated, and many have not been updated since the 1960s. Dr. Terry Davis and colleagues conducted a study where she identified concerning misunderstandings of warning labels by patients. Let me share a few of these with you.vuH t 0j ? 3380___PPT10.p`z0 &x (  x ^ x S PD    x c $(n     Other research studies have found that patients with low health literacy had& Greater difficulty understanding numerical information, such as INR levels for monitoring warfarin use. Lower medication adherence, though not all studies have shown this. One study showed that the majority of patients were non-adherent because they didn t understand their medication regimens. Anecdotal evidence of making mistakes with their medications and experiencing more adverse drug events (though this, too, is not consistently supported in research) Higher health care costs, due in part to greater use of Emergency Departments and higher hospitalization rates. VNh--H x 0j ? 3380___PPT10.a0 p (   ^  S PD     c $     Let s pause to check in and find out what questions you have so far& H  0j ? 3380___PPT10. fm0  ((   ^  S PD     c $      H  0j ? 3380___PPT10.$q0 ld (   X  C PD   d  S      [This training program was originally developed by researchers at Emory University in Atlanta, GA. The PILL study - Pharmacy Intervention for Limited Literacy - was funded by APP and the Robert Wood Johnson Foundation. The training program is part of a larger study addressing health literacy systems-based interventions. We are using this program to identify ways in which we can better communicate with our patients.] H  0j ? 3380___PPT10.Yup+v0  (   X  C PD     S      ,This last section of the training allows you to practice the techniques we ve discussed. [For this section you will need the included handouts.] Directions: Split your participants into groups of three. Each group will get one copy of each handout (instructions for pharmacist, patient, and observer roles). This is a role-play exercise in which everyone with the  pharmacist role will practice counseling the  patient using the clear health communication techniques covered in the presentation. The  observer will provide feedback to the  pharmacist after he or she is done  counseling. After each round, members of each group should switch roles. All three people in each group should have a chance to act as the pharmacist. This exercise will require about 15 minutes total.w"3H  0j ? 3380___PPT10.YuP_0 1)  (   X  C PD   )  S      Finally, I want to point out that included in your handouts is a list of references you can consult if you want to learn more about health literacy. H  0j ? 3380___PPT10.Yu .0 `  >(   X  C PD     S      @,The National Assessment of Adult Literacy (NAAL) provided the first measure of our country s health literacy. This household survey found that 14% of American adults function at the below basic level, 22% function at the basic level, 53% have an intermediate level of health literacy, and 12% have proficient health literacy. Note that interpreting medication labels requires intermediate skill. This means that 36% of adult Americans have levels of health literacy BELOW what is required to understand typical medication information.H  0j ? 3380___PPT10.IAY"0   (   X  C PD     S $     zWhen you were the pharmacist, did you do anything different than you usually do when counseling a patient? Was explaining things using clear plain language hard? Was thinking of a way to clarify something the patient didn t understand the first time hard? Was it easier for the third pharmacist than the first? What did you notice when it was your turn to observe? How might you counsel patients differently when you get back to your pharmacy? H  0j ? 3380___PPT10.X_0 SK  (   X  C PD   K  S      Written materials are easy-to-read if they use: Few messages, with no assumptions that patients know about how the body works, diseases, or medications Short, simple, and familiar words Easy-to-understand phrasing of numeric information Large, sans serif fonts Short, simple, and familiar words Short lines and lots of white space Simple illustrations that are directly applicable to the text 0ZH  0j ? 3380___PPT10.\0 D<  (   X  C PD   <  S      fIn sum, we need to adopt Universal Precautions since we do not know which patients have low health literacy. In fact, research shows that all patients, even those with high health literacy, benefit from clear communication. Today we ve gone over some of the strategies to improve communication. It will take practice to incorporate these strategies into your daily routine. What might prevent you from implementing the strategies we ve been discussing? How might you overcome those barriers? 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Jacobson, MPH, CHES.-Root EntrydO)ִ6PicturesCurrent User,SummaryInformation(3Graph Chart/ 0DAriale SortsLL Ԗ-a0ԖDTahomae SortsLL Ԗ-a0Ԗ DWingdingsortsLL Ԗ-a0Ԗ0DTimes New RomanLL Ԗ-a0Ԗ@DMonotype SortsLL Ԗ-a0ԖPDSymbole SortsLL Ԗ-a0Ԗ A .  @n?" dd@  @@`` <40 yF5..   5 45%     ' 'x    9՜.+,0d    On-screen Show!! )ArialTahoma WingdingsTimes New RomanMonotype SortsSymbolcolored boxesMicrosoft Graph ChartEStrategies to Improve Communication Between Pharmacists References  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles! Slide Titles!4_nDHHSDHHS _cDHHSDHHSCorey.Mackison  ////5O and Patients'Training Curriculum for Pharmacy Staff Overview Definition2Health Literacy in America: Results from the NAALHigh Risk Groups-Functional Literacy of High Risk Populations OverviewHealth Care Experiences+Possible Indicators of Low Health LiteracyUniversal Precautions Overview Low Literacy and Medication Use Slide 14#Health Literacy and Medication Use,Some Challenges in Trying to Improve ThingsWhat questions do you have? Over_  xxview0Recommended Strategies to Improve Communication,1. Explain Things Clearly in Plain Language4Using Plain Language: What could we say instead of$2. Focus on Key Messages and Repeat-3. Use a Teach Back to Check UnderstandingTeach Back Scripts!4. Effectively Solicit Questions5. Patient-Friendly Materials8Help me make sure Ive explained things clearly so farWhat questions do you have? OverviewHands on Practice!Role Play DiscussionWrap Up x| v    x !"#$%&'(E PWXb   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~rs222V     b$reb:/fSXb$SQnR$+c*K[iK!b$&`&?wXb$k.sDc:tb$D.n3D_{}$$b$p/^hpe}6|q"$>$ ߬$R$F-] ۃ%q[ 0e0e A@A5%8c8c     ?1d0u0@Ty2 NP'p<'p@A)BCD|E? [@8 g4KdKd -a0Tppp@  <4!d!dK*0L<4ddddK*0Lg4PdPd| -a0nxph pB( ʚ;y.ʚ;<4dddd)0,^___PPT10> .&kmcmorr.___PPT9O(a(?  %O  =U=DStrategies to Improve Communication Between Pharmacists and PatientsED0`[Presenters Names Here] Developed by Sunil Kripalani, MD, MSc and Kara L. Jacobson, MPH, CHES 4aP($F$;#PowerPoint Document(DocumentSummaryInformation8&Training Curriculum for Pharmacy Staff''(Developed and used by the PILL Study (Pharmacy Intervention for Limited Literacy) Emory Center on Health Outcomes and Quality Rollins School of Public Health, Emory University Grady Memorial Hospital Atlanta, GA ~S07,R f >vOverview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!@nO Definition   zHealth Literacy:  The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Pl2PP " dP" 4      1Health Literacy in America: Results from the NAALAHigh Risk Groups "Elderly Minorities Immigrants Poor## 2Homeless Prisoners Persons with limited education  23 B,Functional Literacy of High Risk Populations--(Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@n>TtHealth Care ExperiencesLow-l      !"#$iteracy patients commonly hide their difficulty Many feel ashamed Avoidant behaviors When do you suspect low literacy? Your experiences?(Z4*Possible Indicators of Low Health Literacy+*3Excuses:  I forgot my glasses. Lots of papers folded up in purse/pocket Lack of follow-through with tests/appts. Seldom ask questions Questions are basic in nature Difficulty explaining medical concerns or how to take medsUniversal PrecautionsCan t tell by looking Communicate clearly with everyone Confirm understanding with everyone Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@nU+YLow Literacy and Medication Use (> Ability to identify their own medications 12-18 x greater odds Understanding of how to take medications Take med every 6 hrs 52% correct Take med on empty stomach 46% correct Understanding of drug mechanisms and side effects Warfarin works by thinning blood 70% correct Bleeding/bruising most common SE 49% correct Misinterpretation of common warning labels 3-4 x more likely to misinterpret P3+3*M35---$]z"Health Literacy and Medication Use##& Understanding of numerical information If your blood test result for warfarin is just right when it is between 2.0 and 3.0, which of the following results would be  just right ? 29% correct Medication adherence Adverse drug events (?) Health care costs ZZ3(3 33   IQ+Some Challenges in Trying to Improve Things,+RIncreasingly complex health system Greater self-care requirements More medications for chronic conditions Formulary and manufacturer changes Medication reconciliation Most patient instructions are written Low-literacy pts have trouble understanding Verbal instructions Often complex Delivered rapidly Easy to forget in stressful situation#ZZ&Z,ZZFZ#e&,F  What questions do you have? Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!8@nF-a/Recommended Strategies to Improve Communication"0/$3 0  Explain things clearly in plain language Focus on key messages and repeat Use a  teach back or  show me technique to check understanding Effectively solicit questions Use patient-friendly educational materials to enhance interactionn (    .b+1. Explain Things Clearly in Plain Language,+(Slow down the pace of your speech Use plain, non-medical language  Blood pressure pill instead of  antihypertensive Pay attention to patient s own terms and use them back Avoid vague terms  Take 1 hour before you eat breakfast instead of  Take on an empty stomach CkM-  36Md~fUsing Plain Language: What could we say instead of& *4$$37Adverse reaction Hypoglycemia PRN Suppository Topical $7ZZ8/c#2. Focus on Key Messages and Repeat$#(Limit information Focus on 1-3 key points Develop short explanations for common medical conditions and side effects Discuss specific behaviors rather than general concepts What the patient needs to do Review each point at the end`0dX3. Use a  Teach Back to Check Understanding-*  1eTeach Back Scripts   VI want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, what would you say? Let s review the main side effects of this new medicine. What are the 2 things that I asked you to watch out for? Show me how you would use this inhaler. 0+ZZ+" 2f 4. Effectively Solicit Questions!! Don t say: Do you have any questions? Any questions? Instead say: What questions do you have?  * *  "  5. Patient-Friendly Materials8Appropriate Content Plain Language Layout IllustrationsxnHelp me make sure I ve explained things clearly so far&  87(0 How do you know if a patient has low health literacy? Name at least 2 techniques to improve communication with low-literacy patients. Provide an example of the teach-back.V7ZZPZZ&ZoWhat questions do you have? Overview Define health literacy Describe the health care experiences of low-literacy patients Discuss health literacy and medication use Review techniques to improve communication with low-literacy patients Hands-on practice!*@nHands on Practice!In this section, you will divide into groups of 3. Each person in the group will have a role to play: Pharmacist Patient Observer Refer to the handouts for instructions for each role. After each round, the  observer will provide feedback to the  pharmacist. Switch roles after each round. Each person should have a chance to play the pharmacist.PfnA3$3fRole Play Discussion7What was different? Was it hard? What did you learn? Wrap UpAdopt Universal Precautions Implement Strategies to Improve Communication, e.g., Plain Language Focus on Key Messages Teach Back What questions do you have? `Q0Q0 ReferencesvDavis TC, Wolf MS, Bass, PF III, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S, Parker RM. Low Literacy Impairs Comprehension of Prescription Drug Warning Labels. Journal of General Internal Medicine. 2006;21(8):847 851. Fang MC, Machtinger EL, Wang F, Schillinger D. Health Literacy and Anticoagulation-related Outcomes Among Patients Taking Warfarin. Journal of General Internal Medicine. 2006;21(8):841-846. Freidland RB. Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy. Washington, DC: National Academy on an Aging Society; 1998. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP. Health Literacy Among Medicare Enrollees in a Managed Care Organization. JAMA. 1999;281:545-551. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors Associated with Medication Refill Adherence in Cardiovascular-related Diseases: A Focus on Health Literacy. Journal of General Internal Medicine. 2006;21(12):1215-C15. Howard DH, Gazmararian J, Parker RM. The Impact of Low Health Literacy on the Medical Costs of Medicare Managed Care Enrollees. The American Journal of Medicine. 2005;118(4):371-377. Katz MG, Jacobson TA, Veledar E, 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. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education; September 1993. 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. Kripalani S, Weiss BD. Teaching About Health Literacy and Clear Communication. Journal of General Internal Medicine. 2006;21(8):888-890. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006. National Quality Forum. Safe Practices for Better Healthcare, 2003; Washington, D.C. Parikh N, Parker R, Nurss J. Shame and health literacy: the unspoken connection. Patient Education and Counseling. 1995;25:109 199. 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. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report No. 43 from the Agency for Healthcare Research and Quality. AHRQ Publication No. 01-E058; 2001. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000. 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. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003.: nP $  $ i   $    % A \  $ f $ ? t   /   ( R  !    O<   "  M  j    /1jz|?@ABCDe~r)c=c1