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Why aren't patients in compliance? Top issue may be misunderstanding
Low health literacy leads to poor outcomes
When patients don't follow their discharge plan and end up back in the hospital or fail to keep their chronic disease under control, resulting in complications, it could be that they simply don't understand what they're expected to do.
Patients have to understand what their health care providers are telling them. If case managers can't communicate effectively, it doesn't matter how much time you spend teaching patients about their condition and how to manage it. They're not going to follow their treatment plan if they don't understand it, says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, a Natick, MA, firm.
"There's often a big gap between what the healthcare professional thinks was explained and what the patient and family members understand. Healthcare can be complicated with so many diagnoses, medications taken many different ways, and so many levels of care that people who are literate, savvy, and interested may still be confused," Osborne adds.
Low health literacy is a problem that leads to poor medical outcomes for millions of Americans and adds millions of dollars in costs to the healthcare system. People with low functional health literacy have higher rates of healthcare utilization and $50 billion to $73 billion in additional healthcare expenditures, according to the Partnership for Clear Health Communications at the National Patient Safety Foundation.
A new report by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) found that low health literacy in older Americans is linked to poorer health status and a greater risk of death. The report also found an association between low health literacy in all adults and more frequent use of hospital emergency rooms and inpatient care, compared with other adults. The report updated a 2004 literature review and included findings from more than 100 new studies.
The inability of many Americans to read, combined with the use of medical jargon that even people who can read have difficulty understanding, creates a tremendous healthcare literacy problem, adds b, RN, EdD, chief executive officer for the Institute for Healthcare Advancement based in LaHabra, CA.
"When patients aren't familiar with the terminology the case manager uses, they miss the message and they don't understand what they need to do so that translates into non-adherence," she says. About 90 million adults Americans can't read above the fifth grade reading level, Mayer says, pointing out that most health education materials are written between the eighth grade and college level.
Don't confuse health literacy and literacy, Osborne warns. "Being a struggling reader is just one reason why some people have trouble understanding healthcare instructions," she says. There's no way to determine a patient's healthcare literacy just by looking at them or talking to them. "Somebody may be well educated and have a good job but doesn't understand medical terminology," Mayer adds.
As people age, health literacy levels often decline just at the time they may be experiencing more chronic conditions, taking multiple medications, and dealing with the stresses of life. "Older people may also have diminished hearing, vision, or memory, making it even harder for them to understand," Osborne says. "When people are in pain, afraid, or sick, they're often overwhelmed and at least for a while, nothing they are told sinks in," she says.
Understanding medical terms and instructions can be particularly difficult for people for whom English is not their first language, Osborne says. "A person may have the words to talk about the weather or food but they may not have the fluency needed to understand their health conditions and ask questions," she says.
Be aware of the subtle differences in languages, Osborne says. For example, when native English speakers are told to take medication once a day, they take it one time. But in Spanish, the world "once" means 11 times. "People may be taking 11 times the right amount of medication because of the word choice," she says.
"When patients transition from the emergency department or the inpatient hospital to home, or the hospital to a post-acute facility, the patients and caregivers assume a great deal of responsibility for seeing that the patient follows the treatment plan and avoids readmissions," Osborne says. "Often, it involves mastering new concepts, learning unfamiliar terms, and having expectations placed on them that are hard to meet."
Mayer advises healthcare professionals to speak in 'living room language' and avoid medical jargon when talking to patients. Instead of using terms such as "myocardial infarction" use "heart attack." Substitute "pee" for "urine," and use "X-ray" instead of "radiology," Mayer suggests.
Remember that patients can absorb only two or three things at the time. Even if you have 20 items on their chart that need discussing, break it into small portions. "If people are sick, they are even less likely to understand everything you are telling them," Mayer adds.
Instead of telling patients to take medication with food, be more specific: Advise them to take it after a meal or with a cracker, depending on the medication, she says. If you tell patients to take a medication twice a day, they may take it an hour apart. "Instead, say take one pill at breakfast and one at dinner," Mayer recommends.
Know your audience, Osborne advises. Look at where they are along the continuum of care, and gear your educational efforts to that. "Someone who is newly diagnosed with a serious illness looks at things very differently from someone who has been living with the condition for years," she says.
"Case managers who work with patients over the telephone have an added challenge because they can't see the other person's expression or know if they are distracted," Osborne says. "If you're not communicating face-to-face, ask the patient if now is a good time to talk, and listen carefully for cues that they may not understand."
Mayer says, "Make sure that any written materials you give patients are in simple language. Avoid giving patients brochures from pharmaceutical companies because they tend to use medical jargon." Instead, rewrite the information on the brochures using easy-to-understand language.
Materials you give your patients should be written on a fifth grade level. If the material is describing how to do something, like giving yourself an insulin injection, pictures can be invaluable.
"Some people argue that college-educated patients would be insulted by easy-to-read materials but in fact, nobody ever complains that something is too easy to understand. That's why we should make it easy for everyone to read, regardless of their literacy level," she says.
Make sure patients understand what you say
Ask them to repeat what they should do
As a case manager, your job isn't done just because you told a patient something. Your job is done when the other person understands it, says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, a Natick, MA, firm.
"As you talk to patients, take a moment after teaching a key point to confirm that the patient understands," Osborne suggests. Use the "teach-back method," and ask the patient to tell you in his or her own words what you just discussed. This helps demonstrate understanding in functional ways. "But don't just ask patients if they understand. They may say yes because they want to be agreeable, or they may be embarrassed to say they don't understand," she says. When you use the "teach-back method," put the responsibility for clear communication on yourself by saying something like, "I want to make sure I explained this clearly. Tell me again which medication you will be taking and when." Also, "don't pause after every sentence. That is repetitive, and the patient will get bored. Pause only after the key points," she says.
"If the other person doesn't quite get it right, try to communicate in a different way rather than just saying the same thing louder or slower," Osborne says. If you still don't think the patient understands, ask to meet with a family member or have someone else on the team talk to the patient.
The Partnership for Clear Health Communication suggests using its "Ask Me 3" program to improve communication with patients.
Providers should promote patient understanding of three essential questions:
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