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pdfHealth Literacy
Universal Precautions
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Health Literacy Universal Precautions Toolkit
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Contract No: HHSA290200710014
Prepared by:
North Carolina Network Consortium
The Cecil G. Sheps Center for Health Services Research
The University of North Carolina at Chapel Hill
Chapel Hill, NC
Authors:
The Cecil G. Sheps Center for Health Services Research
Darren A. DeWalt, M.D., M.P.H.
Leigh F. Callahan, Ph.D.
Victoria H. Hawk, M.P.H., R.D.
Kimberly A. Broucksou, M.S.W., M.P.A.
Ashley Hink, M.P.H.
Harvard School of Public Health
Rima Rudd, Sc.D.
Agency for Healthcare Research and Quality
Cindy Brach, M.P.P.
AHRQ Publication No. 10-0046-EF
February 2010
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
This document is in the public domain and may be used and reprinted without permission
except those copyrighted materials noted for which further reproduction is prohibited
without the specific permission of copyright holders.
The findings and conclusions in this toolkit are those of the authors, who are responsible
for its contents; the findings and conclusions do not necessarily represent the views of the
Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health
and Human Services (HHS). Therefore, no statement in this toolkit should be construed
as an official position of AHRQ or HHS.
Suggested Citation:
DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, 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. February
2010.
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
Acknowledgements
We thank the representatives of the North Carolina Network Consortium, The
Cecil G. Sheps Center for Health Services Research, and the Harvard School of Public
Health.
Our thanks go to our Expert Advisory Panel members:
Ed Wagner, M.D., M.P.H.
The MacColl Institute for Healthcare
Innovation
Group Health Center for Health Studies
Seattle, WA
Michael Barr, M.D., M.B.A., F.A.C.P.
American College of Physicians
Washington, DC
Michael Paasche-Orlow, M.D., M.P.H.
Boston University School of Medicine
Boston, MA
Toni Cordell
Patient Advocate
Charlotte, NC
Gail Neilsen, R.T.R., B.S.H.C.A., S.A.H.R.A.
Iowa Health Systems
Des Moines, IA
Special thanks to Sue Stableford, M.P.H., M.S.B., Director of the Health Literacy
Institute in Portland, Maine.
We acknowledge the following practices for helping to test the toolkit.
Matthews Health Clinic
Matthews, NC
HealthServe Community Health
Clinic
Greensboro, NC
Biddle Point Family Medical Center
Charlotte, NC
Cornerstone Medical Center
Burlington, NC
Dayspring Family Medicine
Eden, NC
Myers Park Pediatrics
Charlotte, NC
Siler City Community Health Center
Siler City, NC
UNC Family Medicine
Chapel Hill, NC
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
Table of Contents
About this Toolkit
i
Quick Start Guide
ii
Overview of Health Literacy Universal Precautions
1
Path To Improvement
10
References
12
List of Tools
14
Tools to Start on the Path to Improvement
Tool 1: Form a Team
15
Tool 2: Assess Your Practice
18
Tool 3: Raise Awareness
22
Tools to Improve Spoken Communication
Tool 4: Tips for Communicating Clearly
25
Tool 5: The Teach-Back Method
28
Tool 6: Followup with Patients
31
Tool 7: Telephone Considerations
34
Tool 8: Brown Bag Medication Review
37
Tool 9: How to Address Language Differences
41
Tool 10: Culture and Other Considerations
46
Tools to Improve Written Communication
Tool 11: Design Easy-to-Read Material
49
Tool 12: Use Health Education Material Effectively
53
Tool 13: Welcome Patients: Helpful Attitude, Signs, and More
57
Tools to Improve Self-Management and Empowerment
Tool 14: Encourage Questions
60
Tool 15: Make Action Plans
63
Tool 16: Improve Medication Adherence and Accuracy
66
Tool 17: Get Patient Feedback
69
Tools to Improve Supportive Systems
Tool 18: Link Patients to Non-Medical Support
73
Tool 19: Medication Resources
77
Tool 20: Use Health and Literacy Resources in the Community
79
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AHRQ Pub. No. 10-0046-EF
Table of Contents
Appendix Items
83
Plan-Do-Study-Act (PDSA) Directions and Examples
84
Plan-Do-Study-Act (PDSA) Worksheet
93
PowerPoint Presentation—Health Literacy: Barriers and Strategies
95
Health Literacy Assessment Questions
123
Questions for Discussion
130
Moderator’s Guide
132
Communication Self-Assessment
134
Key Communication Strategies Poster
136
PowerPoint Presentation-Teach-Back: A Health Literacy
Tool to Ensure Patient Understanding
138
Teach-Back Self-Assessment Evaluation and Tracking Log
159
Followup Instruction Form
161
Sample Automated Telephone System Menu
163
Brown Bag Medication Review Poster
165
Adult Initial Health History Form
167
Young Child Health History Form
177
Adult Return Visit Update Form
187
Consent to Treat Form
189
Release of Medical Information
191
Lab Results Letter
194
Appointment Reminder
196
The Action Plan Form and Example
198
Medication Aid Poster
201
Sample Cover Letter
203
Community Referral Form and Example
205
List of Internet Resources
208
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
About this Toolkit
The Agency for Healthcare Research and Quality (AHRQ) commissioned The University of North Carolina at Chapel Hill to develop and test this Health Literacy Universal Precautions Toolkit. It provides step-by-step guidance and tools for assessing
your practice and making changes so you connect with patients of all literacy levels.
Toolkit Key
Throughout the toolkit we have used a number of icons and symbols to help you
quickly identify different forms of tools and documents.
Tools for practice change
Resources on the Internet
Video
Testimonials from a practice
Document in the appendix
Tips or key points
All blue underlined words are links to other toolkit documents or Internet resources
(e.g. Web sites, videos, publications, articles.) Click on the words to connect to the
link. We also have a list of Internet resources along with their URLs.
Toolkit Design
This toolkit is designed to be used by all levels of staff in a practice providing primary care for adults and/or pediatric patients. (Please note that references to patients
also includes caregivers and parents.) This toolkit is divided into manageable
chunks so that its implementation can fit into the busy day of a practice. It contains:
Quick Start Guide If you want to jump right in and try something, this
is a one page guide that will get you started.
Overview This section provides some important background about
health literacy universal precautions and how this toolkit is designed to
address them (9 pages).
Path to Improvement This two-page document outlines the six steps to
take to fully implement this toolkit into your practice.
Tools The toolkit contains 20 tools (2-5 pages long) to help you identify and address areas that need improvement. These tools often reference resources on the Internet as well as appendix items.
Appendix The appendix contains over 25 resources such as forms,
PowerPoint presentations, worksheets, and posters that support the implementation of the tools. It also contains a list of Internet-based resources that are referenced throughout the toolkit.
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i
Quick Start Guide
Watch a short video.
This 6-minute health literacy video is sponsored by the American
College of Physicians (ACP) Foundation and has some vivid examples
of why addressing health literacy is so important.
Pick a tool and try it.
Link to one of these tools and review it. Pick a day and try it out on a
few patients.
I want to be confident my patients
are taking their medications
correctly.
Brown Bag Medication Review
I want to be confident that I am
speaking clearly to my patients.
Tips for Communicating Clearly
I want to be confident that my
patients understand what they
need to do regarding their health
when they get home.
The Teach-Back Method
Assess your results.
How did it go? Do you need to make some adjustments? Do you want to
address another statement from the list above and try another tool?
Or, you may want to take this to the next step by going to the Overview
and learning about health literacy universal precautions and this toolkit.
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ii
Overview of Health Literacy Universal
Precautions
Medical care is complicated, and many people struggle with understanding
medications, self care, instructions, and followup plans. The way we organize our
practice and communicate with patients can help to minimize confusion and lead
to better health outcomes. This toolkit is designed to help practices take a
systematic approach to reducing the complexity of medical care and ensure that
patients can succeed in the health care environment.
Testimonials
“Before reviewing this toolkit, we had never heard the term health literacy. As we assessed our practice and reviewed the tools, we realized
that the concerns addressed in this toolkit are things we see and struggle
with every day. This toolkit made us more aware of the challenges that
our patients face and guided us to make meaningful changes throughout
our practice.”
-office manager, rural family practice clinic
“When we introduced this toolkit to our staff, they thought ‘oh great,
more responsibilities for us to cram in to our busy day.’ But what we
quickly realized is that it is not adding more, it is about learning how to
do things differently. After implementing some of these tools, we really
felt like we were more able to connect with our parents about the health
of their child. ”
-MD, urban pediatric practice
What is health literacy?
Seeking medical care, taking medications correctly, and following prescribed
treatments requires that people understand how to access and apply health
information. Health literacy is the ability to obtain, process, and understand health
information to make informed decisions about health care. It involves using
literacy as well as other skills (e.g., listening) to perform health-related tasks.
According to a national survey, over one-third of the adult population has limited
health literacy, meaning that they have basic or below basic health literacy levels.1
Limited health literacy is associated with medication errors, increased health care
costs, and inadequate knowledge and care for chronic health conditions.2,3,4
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What are universal precautions?
Universal precautions refers to taking specific actions that minimize risk for
everyone when it is unclear which patients may be affected. For example, health
care staff take universal precautions when they minimize the risk of spreading
bloodborne disease by using gloves and proper disposal techniques. This toolkit
offers practices a means to structure their services and their patient interactions to
minimize the risk that any one of their patients will not understand the health
information they are given, thus allowing patients to make informed decisions
about their health care.
Why take universal precautions when it comes to health
literacy?
Providers don’t always know which patients have limited health literacy. Some
patients with limited health literacy:
Have completed high school or college.
Are well spoken.
Look over written materials and say they understand.
Hold white collar or health care jobs.
Function well when not under stress.
Experts recommend assuming that everyone may have difficulty understanding
and creating an environment where patients of all literacy levels can thrive. In the
case of health literacy universal precautions, primary care practices should ensure
that systems are in place to promote better understanding for all patients, not just
those you think need extra assistance. Improving patient understanding is
beneficial for the patient and health care provider. Research suggests that clear
communication practices and removing literacy-related barriers will improve care
for all patients regardless of their level of health literacy.
If you are wondering how many of your patients may have limited health literacy,
you can use the prevalence calculator to produce an estimate.
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What are the tasks a patient needs to accomplish in a health care
visit?
When we consider the tasks that a patient has to perform for a routine visit, we
start to see how complex it is and understand the many points where things can go
wrong. Let’s consider a couple different types of visits. (See Figure 1.)
Figure 1. Patient Tasks for Diabetes and Asthma Followup Visit
Diabetes patient
Schedule an appointment.
Organize and bring blood glucose
values and medications requested
by the clinician.
Get transportation to the medical
office.
Pre-Visit
Visit
Check in and fill out paperwork.
Update medical history and answer
clinician’s questions.
Report blood glucose values.
Review treatment plan and listen to
education about diet and exercise.
Receive prescription and referral to
an eye doctor.
Check out, pay bill and make
followup appointment.
Parent of child with asthma
Schedule an appointment.
Organize and bring the asthma
symptom and medication record.
Make arrangement to get child and
parent transportation to appointment (possibly pull out of school).
Go to the pharmacy and have
prescription filled.
Make an appointment with the
ophthalmologist.
Get transportation to and find
ophthalmologist’s office.
Post-Visit
Adhere to medication regimen.
Check and record daily blood
glucose values.
Make diet and exercise changes.
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Check in and fill out paperwork.
Update medical history and answer
clinician’s questions.
Report asthma symptoms and
medication taken.
Review treatment action plan and
learn about how to use medication.
Learn about precipitants and how
to avoid them.
Receive prescription.
Check out, pay bill, and make
followup appointment.
Go to the pharmacy and have
prescription filled.
Educate school teachers and others
about treatment plan.
Adhere to medication regimen.
Check and record symptoms and
adjust medicines.
Know when to contact the doctor.
3
How will promoting health literacy improve health outcomes?
To obtain optimal health outcomes, people need health care access, health knowledge, and behavior change. (See Figure 2.) To help patients and their care givers
accomplish these goals, the practice needs a structured approach. We have identified four change areas that are important for promoting health literacy in your practice:
1. Improve spoken communication.
2. Improve written communication.
3. Improve self-management and empowerment.
4. Improve supportive systems.
We include tools to address topics in each area. All areas are important and should
be addressed over time as you make changes in your practice.
Figure 2. Factors Necessary to Improve Health Outcomes and Tools to Help
Access
Knowledge
Behavior
Transportation
Medical Information
Self-efficacy
Insurance
Communication
Adherence
Scheduling
Understanding
Self-care
Support Systems
Language/Culture
Social Reinforcement
Tools to Improve
Supportive
Systems
Tools to Improve
Spoken and Written
Communication
Tools to Improve
Self-management
and Empowerment
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Improved
Health
Outcomes
4
Key Change 1: Improve Spoken Communication
Studies indicate that patients have difficulty understanding health information that
is communicated orally during the patient-clinician interaction. Patients
understand and retain about 50 percent of the information discussed by their
physicians.14, 15 This can have an enormous impact on patient safety and
adherence.
Studies show that those with limited literacy are less likely to:
Ask questions during the medical encounter. 16
Seek health information from print resources. 17
Understand medical terminology and jargon. 15
In addition, increased pressures on primary care physicians limit the time they are
able to spend with patients, causing many to move rapidly through multiple points
during the encounter. These factors lend to the problem of misunderstanding and
poor retention of information. Studies show that patients often leave visits with a
very different understanding of what they are supposed to do than their
clinicians.18
There are multiple places in the patient care process where oral exchanges occur,
from scheduling medical visits to communicating health information and
treatment options. Each point where verbal communication occurs is an
opportunity to improve the clarity and quality of the exchanges between practice
staff and patients of all literacy levels and languages.
Tools to Improve Spoken Communication
Tool 4: Tips for Communicating Clearly
Tool 5: The Teach-Back Method
Tool 6: Followup with Patients
Tool 7: Telephone Considerations
Tool 8: Brown Bag Medication Review
Tool 9: How to Address Language Differences
Tool 10: Culture and Other Considerations
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Key Change 2: Improve Written Communication
Health care providers rely heavily on print materials to communicate with
patients. Many health-related documents are written at a college level and contain
a large amount of text in small print and complex terminology. What are the
implications of this for the majority of Americans, who read at the 8th grade level
or below? A number of studies have shown that those with limited literacy skills
have difficulty understanding written information, including medication dosage
instructions and warning labels;19,20 discharge instructions;21 consent forms for
treatment and participation in research studies;22 and basic health information
about diseases, nutrition, prevention, and health services.23 The inability to read
and comprehend such things can prevent clinicians from obtaining an accurate
medical history. It can also impact your patients’ ability to understand medical
advice, take medication correctly and safely, engage in self-care behaviors, and
make informed decisions about their health care. These things contribute to
patient outcomes and practice liability.
Tools to Improve Written Communication
Tool 11: Design Easy-to-Read Material
Tool 12: Use Health Education Material Effectively
Tool 13: Welcome Patients: Helpful Attitudes, Signs, and More
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Key Change 3: Improve Self-Management and Empowerment
An important part of patient-centered medical care is enabling patients to share
responsibility for their health and health care. Ultimately, it is the patients who
have to adopt a healthy lifestyle and manage their chronic condition.
Limited literacy has been associated with poor adherence, self-care behaviors, and
understanding of health information. It is therefore not surprising that some
studies show that patients with limited literacy skills have poorer control of
chronic conditions such as diabetes, HIV, and asthma compared to those with
adequate or above average literacy.2 Studies also show that children of caregivers
with low literacy have poorer control of their asthma and diabetes compared to
children of caregivers with adequate or above average literacy.23,24 In addition,
patients with limited literacy are less likely to ask questions or participate in the
medical decisionmaking process than those with adequate or above average
literacy.16
Fortunately, there are several health literacy tools that primary care practices can
use to help patients manage their chronic conditions and otherwise empower
patients to take care of themselves and their families.
Tools to Improve Self-Management and Empowerment
Tool 14: Encourage Questions
Tool 15: Make Action Plans
Tool 16: Improve Medication Adherence and Accuracy
Tool 17: Get Patient Feedback
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Key Change 4: Improve Supportive Systems
All patients need support outside the primary care setting to make healthy choices
and adhere to treatment plans. Literacy can affect many aspects of patients’ lives,
and those with limited literacy are more likely to have additional risk factors for
poor health and social and economic well-being. Adults over age 65, some
minority groups, low-income individuals, and those with lower educational
attainment are more likely to have limited health literacy than others.1 These
individuals may face a host of barriers to achieving optimal health outcomes,
many of which cannot be overcome within the walls of a primary care office.
However, primary care practitioners and staff can link patients to community
organizations and government agencies. These organizations can assist patients
with issues like obtaining insurance coverage, medication assistance, case
management, mental health services, basic adult education, and support services
for specific health needs (e.g., diabetes education, HIV/AIDS support groups,
family planning services). Some patients, especially those with limited literacy,
are not going to achieve their health goals unless you go the extra mile to help
them access and obtain such services.
Tools to Improve Supportive Systems
Tool 18: Link Patients to Non-Medical Support
Tool 19: Medication Resources
Tool 20: Use Health and Literacy Resources in the Community
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Does paying attention to health literacy work?
A number of studies have shown that health literacy practices improve health
outcomes.5 Below are a few research studies as well as case studies from practices
that have used this toolkit, showing how health literacy practices can identify
potentially dangerous situations and improve specific health behaviors and
outcomes.
Research Studies
Colon Cancer Screening: This study shows how easy-to-read brochures
can increase participation in colon cancer screening.6
Depression Management: This study shows that when patients who were
low literate and depressed were referred to literacy programs, their depression
symptoms significantly improved compared to the control group.7
Diabetes and Heart Failure Management:
These studies show that when
provided self-management education with good health literacy practices,
patients can successfully control their diabetes and heart failure.8,9,10
Automated Telephone Self-Management Support System: This study
showed that with good self-management education and the use of automated
telephone calls, patient were able to achieve better diabetes-related care, better
communication with their provider, and greater functional status.11
Case Studies
Medication Review: Several practices implemented Tool 8: Brown Bag
Medication Review in their practice. They found medication errors in 80
percent of 15 reviews conducted, such as:
Patients that had stopped taking medication without provider knowledge.
Patients taking discontinued medications.
Patients having two prescriptions for the same medication and taking both.
Patients taking medications or supplements without the doctor’s
knowledge.
Action Plans: When one practice implemented Tool 15: Make Action Plans
clinicians found that it was easy to do, focused the discussion, and most of all
was very well received by the patients. The patients felt they had a
prescription to address their problems and they felt empowered and energized.
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Path to Improvement
Ready to get started! By following these 6 steps and working through the tools,
you should be on your way to implementing health literacy universal precautions
in your practice.
Watch a Health Literacy Video.
This 6 minute health literacy video from the ACP Foundation lets you
hear from real patients and medical staff.
Form Your Team.
Establishing a team of people committed to health literacy universal
precautions is an essential step in the process. Getting support and buy-in
from all levels of practice staff will be necessary for successfully making
changes. The team should include at least one staff member from each
area of your practice. Detailed guidance on creating your health literacy
team is outlined in Tool 1: Form a Team .
Assess Your Practice.
How do you know where to get started making changes in your practice?
In order to identify areas of your practice that are in need of improvement,
your health literacy team should conduct a health literacy assessment of
your practice.12 Tool 2: Assess your Practice will guide your team
through this process.
Choose Tools.
After completing the assessment and discussing the results, you will be
able to identify strengths, barriers, and opportunities for improvement.
Tool 2: Assess your Practice offers guidance in choosing tools to
implement. For a complete list of tools click on Tools .
Raise Staff Awareness About Health Literacy.
Generating awareness of the issue is necessary any time you want to
promote change. If the clinicians and staff in your practice are not aware
of how health literacy issues affect your patients, they will not be as
receptive to implementing new ideas. Tool 3: Raise Awareness
includes guidance and links to several resources that can be used to inform
your practice staff about health literacy.
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Plan Your Changes.
Once your health literacy team has assessed your practice, identified priority areas
for improvement, and provided health literacy awareness training, your team will
lead the practice in implementing health literacy tools. It is important to have a
practice improvement strategy to test changes and assess whether they are
achieving desired goals. The Model for Improvement13 is a commonly used method
to guide health care organizations and practices on making changes. It outlines
four steps to work through before making widespread changes.
1. Set Aims.
What are you trying to accomplish?
Your health literacy team should define what you want to achieve by implementing
health literacy changes in your practice. The aims should be time-specific, realistic,
and measureable. For example, an aim to promote medication adherence may be:
“Over the next 6 months, the practice will put systems in place to remind all
patients to bring medicines to every visit.”
2. Establish Measures.
How will you know that a change is an improvement?
Your team will select specific measures that will be used to assess whether or not
your aims are being achieved. These can be measures of reach, process, or
outcomes. What percentage of patients brought their medications to their visit?
What percentage of visits included a teach-back? What percentage of patients with
diabetes have their glucose levels at their goal? Measures can also be qualitative,
such as an assessment of whether the practice flow was interrupted by a change.
3. Select Changes.
What changes can you make that will result in improvement?
This toolkit contains numerous potential changes to help your practice. Start with
the Tools that are most closely associated with your aim.
4. Test Changes.
How can you test your selected changes and implementation strategy?
Once you have selected a tool, you need a plan for implementing it into your
practice. One suggested way for making changes in your practice is by doing small
PDSA (plan-do-study-act) cycles for each change you wish to make. We have an
explanation and directions for this type of change model along with a PDSA
worksheet that you can use to help you in this process. For more information on
using the Model for Improvement, see the Institute for Healthcare Improvement
Web site .
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References
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the literature. Pediatrics. 2009;124 Suppl 3:S265-74.
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21. Yates K, Pena A. Comprehension of discharge information for minor head injury: a
randomized controlled trial in New Zealand. N Z Med J. 2006;119(1239):U2101.
22. Sudore RL, Landefeld CS, Williams BA, et al. Use of a modified informed consent
process among vulnerable patients: a descriptive study. J Gen Intern Med. 2006;21
(8):867-73.
23. Rothman RL, Housam R, Weiss H, et al. Patient understanding of food labels: the role
of literacy and numeracy. Am J Prev Med. 2006;31(5):391-8.
24. DeWalt DA, Dilling MH, Rosenthal, MS, Pignone MP. Low parental literacy is
associated with worse asthma care measures in children. Ambul Pediatr.2007;7(1):2531.
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Tools
Tool Number and Name
Tools to Start on the Path to Improvement
Tool 1: Form a Team
Tool 2: Assess Your Practice
Tool 3: Raise Awareness
Tools to Improve Spoken Communication
Tool 4: Tips for Communicating Clearly
Tool 5: The Teach-Back Method
Tool 6: Followup with Patients
Tool 7: Telephone Considerations
Tool 8: Brown Bag Medication Review
Tool 9: How to Address Language Differences
Tool 10: Culture & Other Considerations
Tools to Improve Written Communication
Tool 11: Design Easy-to-Read Material
Tool 12: Use Health Education Material Effectively
Tool 13: Welcome Patients: Helpful Attitudes, Signs, and More
Tools to Improve Self-Management and Empowerment
Tool 14: Encourage Questions
Tool 15: Make Action Plans
Tool 16: Improve Medication Adherence and Accuracy
Tool 17: Get Patient Feedback
Tools to Improve Supportive Systems
Tool 18: Link Patients to Non-Medical Support
Tool 19: Medication Resources
Tool 20: Use Health and Literacy Resources in the Community
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Form a Team
Tool 1
Form a Team
Overview
Initiating and sustaining health literacy universal precautions in a practice requires
strong, effective leadership and a clear strategy. The most effective teams include
at least three categories of members: senior leadership, clinical leaders, and dayto-day leaders. If any layer of the team is not committed to this effort, you won’t
get the results you want. The health literacy team can increase awareness and
provide education about health literacy. More importantly, they will lead changes
in the practice to address the needs of patients at all literacy levels. Commitment
by all three levels of staff is important to successfully implement health literacy
universal precautions.
Purpose
To help your practice assemble a health literacy team and identify a leader who
will champion health literacy universal precautions.
Tip
Goals for Your Team
Raise awareness about health literacy.
Conduct a practice assessment.
Identify health literacy priorities.
Establish aims and goals.
Action
Identify members.
Thoughtful selection of the health literacy team will help to bring lasting
change. The members should reflect major roles in your practice.
Chair or Champion: This person will possess the passion to see
success in the team and the ability to help facilitate and oversee
changes that are needed.
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Form a Team
Tool 1
Employees from each department: Representatives from each
department can offer assistance on how to assimilate changes into that
department as well as take the changes back to their department.
These will include the following:
Clinicians
Nurses
Practice manager
Front desk/receptionist
Senior leadership: Top management can help make decisions with the
ability to direct and provide resources as needed. They can also help
the team break down barriers to making improvements.
Patient and/or caregiver of a patient: Having a patient and/or
caregiver of a pediatric patient on the team can be extremely eyeopening and provide an invaluable perspective on your practice.
Although this is often overlooked, we strongly encourage you to think
about recruiting someone for your team, either as a full-fledged or an
ad hoc member. They provide clinicians and staff with first-hand
insight on what patients experience and how systems and
communication can be improved.
Tip
Patient and/or Caregiver Representative
Ask staff to identify and suggest patients or caregivers who are typical of your patient population.
Include this member as needed on special projects.
Consider providing this member a meal or a small
gift of appreciation for their participation.
Establish team.
Size of team: The number of people on the health literacy team will
vary based on the number of clinicians and staff employed by your
practice, but keep it manageable. A team with more than 8 members
can make it hard to get things done.
Meetings: The team should meet regularly to manage the process of
implementing tools, evaluating the results, and ensuring transformation
of the practice. Many of these tools have short implementation cycles,
and more frequent meetings (bi-monthly) may be beneficial at first.
Less frequent meetings may be adequate as more changes are in place.
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Form a Team
Tool 1
Ad hoc members: Members such as senior leadership or patients can
be added as ad hoc members and called to work on special projects.
For example, you may involve a patient or caregiver to review the
written materials used with patients.
Quality improvement team: If your practice has a quality
improvement team established, rather than forming a separate health
literacy team, you may want to incorporate health literacy into this
team’s activities.
Train members.
Members of the team will need to learn about health literacy before initiating
any changes. Once the team is educated and motivated to make changes, then
they can work through this toolkit. The following is a list of training aids to
help with team education, and for more in-depth explanation look at Tool 3:
Raise Awareness ,which discusses education of the whole practice.
The Health Literacy Video (6 minutes) from The American College
of Physicians Foundation.
Health Literacy and Patient Safety: Help Patients Understand (23
minutes) a video from the American Medical Association
Health Literacy: Barriers and Strategies PowerPoint presentation.
Prevalence Calculator estimates the percentage of patients in your
practice who may have particular difficulty understanding medical
information.
Track Your Progress
Is your team meeting on a regular basis?
Are meetings productive with clear plans for action?
Are members of your team coming to meetings prepared to discuss progress
made since the last meeting?
Resources
The Institute for Healthcare Improvement Web site outlines how to create a
health improvement team and practice improvement methods.
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Assess Your Practice
Tool 2
Assess Your Practice
Overview
Effectively serving your patients involves considering health literacy in all areas
of your practice. Patients of all literacy levels must interact with schedulers,
nurses, and doctors, as well as understand how to manage their health. We have
developed the Health Literacy Assessment Questions to help you assess how
your practice is performing in several key areas that affect patient understanding
and satisfaction. Completing this assessment process may help to identify
opportunities to improve the experience and outcomes of your patients.
For each assessment question, we have assigned a level of importance based on
the perceived benefit to improve patient understanding. The assigned levels are as
follows:
* Beneficial
** More Beneficial
*** Most Beneficia1
Purpose
To provide your practice with a method of assessing how you are meeting the
needs of your patients. This tool may help you to identify strengths, barriers, and
opportunities for improvement.
Testimonials
All of the practices that tested the toolkit found the health literacy assessment beneficial. Here are some comments:
“The assessment increased our attention to areas not previously
identified as concerns, like the signs in our practice. We just
don’t think of those things every day.”
“Before doing the assessment, we had an idea about what tool
we wanted to try. But after discussing our assessment questions,
we completely changed our selection.”
“We liked the assessment process, and when we looked at our
answers, our priorities just lit up.”
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Assess Your Practice
Tool 2
Action
1. Answer the Health Literacy Assessment Questions.
The assessment has 49 questions and can be completed in less than 30
minutes. We suggest you have several people complete the assessment
questions on their own, and then come together for a group discussion to
review the results.
Identify several people to complete the assessment questions.
Choose clinical and administration staff members. Aim to include at
least one person from each area of your practice.
Print a copy of the Health Literacy Assessment Questions
for
each person.
Have each person answer the Health Literacy Assessment
Questions for your practice. One or more people may consider doing
a “practice walk-through” when a practice member acts like a patient
and experiences the practice from the patient’s perspective while
answering the questions.
2. Discuss the assessment questions and choose a tool.
After everyone has completed the assessment questions, use the results to set
your aims and choose tools to implement.
Review and discuss the assessment results.
Organize a meeting with those staff who completed the assessment
questions, as well as the members of your health literacy team. You
may consider focusing on the areas that you notice questions answered
“Needs Improvement” or “Not Doing,” as these represent potential
opportunities for improvement.
Set one or more aims.
Now that you have an idea what areas you want to improve, it is
helpful to set one or more aims for your practice. An aim is a specific
statement summarizing what your organization hopes to achieve. Your
aim should be specific and time measurable. An aim is important to
help everyone in the practice understand the goal and to facilitate
communication about the ideas for change. For example:
“The practice will improve telephone communication
with patients over the next quarter.”
“Over the next 6 months, the practice will put systems in place
to promote patient medication adherence.”
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Assess Your Practice
Tool 2
Choose a tool.
Review your assessment questions in the area addressed by your aim.
If you see several areas that are important to you, consider starting
with questions rated *** or ** in the importance level. These practice
areas are most important for improving patient outcomes, but you may
choose to modify the level of importance based on the workings of
your practice. For each question selected, review the items in the
Tools to Help column to identify the specific tools to use. We suggest
that you focus your efforts by implementing one, or possibly two,
tools at a time. Refer to Tools for a comprehensive list of tools.
Plan and start your implementation.
Read the tool and develop a plan for making changes. First, test some
small changes. Try something with one clinician and/or a few patients
to see how the new ideas change the flow in the practice. Remember
that even the best laid plans may not lead to the results you want.
Work out the kinks on a small scale before spreading it to the rest of
the practice. For more information about the improvement strategies
go to the Overview section.
Establish Health Literacy Universal Precautions in your practice.
Health Literacy Universal Precautions require that your practice have
systems in place to address each of the four key change areas. Stay
focused on your aims, but continue to add new aims and implement
tools until your practice has addressed all four of the key change areas:
1. Improve Spoken Communication.
2. Improve Written Communication.
3. Improve Self-Management and Empowerment.
4. Improve Supportive Systems.
Track Your Progress
After implementing one or more tools, you should consider the following:
Confirm that any tools implemented are now a regular part of care
throughout the practice.
Verify that all four key change areas have been addressed in your
practice.
Develop a plan to re-assess your practice at regular intervals.
Continue to monitor progress and update your health literacy priorities
as needed.
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Assess Your Practice
Tool 2
Resources
Sources for developing this assessment tool include:
Rudd RE, Anderson JE. The Health Literacy Environment of Hospitals and
Health Centers. Partners for Action: Making Your Healthcare Facility
Literacy-Friendly. Cambridge MA: National Center for the Study of Adult
Learning and Literacy. 2007.
Jacobsen KL, Gazmararian JA, Kripalani S, McMorris KJ, Blake SC, Brach
C. Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy
Assessment Tool User’s Guide. 2007. (Prepared under contract No. 290-000011T07.) AHRQ Pub No. 07-0051. Rockville, MD: Agency for Healthcare
Research and Quality. October 2007.
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Raise Awareness
Tool 3
Raise Awareness
Overview
Health literacy affects a patient's ability to access health care services, understand
health-related information, and follow health care instructions. Therefore, limited health
literacy should be an issue of concern for all clinical and administrative staff in your
practice. Implementing health literacy universal precautions in your practice requires
that all of your staff are aware of the problem, know how it affects your patients and
consistently work to improve communication.
This tool provides you with several options for educating your staff including:
Short sessions during a staff meeting.
Lunch and learn sessions.
Self-study for continuing education credit.
When planning for your education session, it is important to include time for group
discussion so that practice staff can reflect on how health literacy issues impact patients.
Purpose
To provide options and consideration for raising your staff’s awareness about health
literacy.
Testimonial
“We had a lunch meeting to discuss health literacy and introduce this topic
to the staff, most of whom had never heard the term before. I gave no formal introduction but rather told them we were going to watch a short video.
I showed the 6-minute Health Literacy video, and as soon as it ended I was
amazed at the reaction. The staff started talking about similar experiences
they have had with our patients.
“I knew that ‘Sally’ did not understand the changes that Dr. Dean made
to her medicines; when she left the practice, she looked so bewildered.”
“I once had a man get very angry and storm out of the office after I gave
him our health history form. I later learned that he could not read.”
This video created such momentum. It was very easy to get the staff to work
on these tools after watching it.”
-office manager, rural family practice
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Raise Awareness
Tool 3
Action
Education Options.
Video: These videos include candid patient interviews about their
experience and understanding of health-related information.
Health Literacy Video (6 minutes)
Help Patients Understand (23 minutes)
PowerPoint presentation: Health Literacy: Barriers and Strategies
This presentation includes 26 slides with speaker’s notes that can be
delivered in 30-40 minutes to a group or as a self-study program.
Group discussion.
When planning your group education session, allow a few
minutes at the end for group discussion on the topic. Refer to
attached Questions for Discussion and Moderator’s Guide.
Self-study for continuing education credit.
Unified Health Communication 101—Addressing Health
Literacy, Cultural Competency, and Limited English
Proficiency is a 5-hour online learning course by the
Department of Health and Human Services.
Health Literacy and Public Health: Communicate to Make a
Difference Series from the New York/New Jersey Public
Health Training Center has 2 modules, each 1-2 hours long.
Tips
Suggestions for Education
Schedule sessions at times that are convenient to most staff.
Group sessions may create enthusiasm and motivate your staff better
than individual self-study programs.
Develop a plan for ongoing health literacy education that includes updates from your staff and health literacy team.
Continue education.
Make sure to have a plan for revisiting the topic periodically
and training new staff.
Other tools for raising awareness.
Share results from the Prevalence Calculator, which
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Raise Awareness
Tool 3
estimates the percentage of patients in your practice who may
have difficulty understanding medical information.
Track Your Progress
Assess your education plans.
Document the number of staff completing the health literacy training.
Confirm that health literacy education is offered to staff on an ongoing
basis.
Resources
Manual: Health Literacy and Patient Safety: Help Patients Understand
manual for clinicians from the American Medical Association.
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Tips for Communicating Clearly
Tool 4
Tips for Communicating Clearly
Overview
Patients often need to remember several things when they leave a primary care
practice. Communicating effectively with patients is important to ensure:
Patient safety.
Patient self-management.
Efficient use of time.
All levels of communication are important, whether it be for diagnostic purposes,
taking medication correctly, preparing for lab work, home care, followup, or
scheduling appointments. Clear oral communication strategies help patients feel
more involved in their health care and increase their likelihood of accepting
recommendations.
Purpose
To introduce effective oral communication strategies and offer suggestions on
how to increase staff awareness as they interact with patients. This tool is for the
entire health care team.
Testimonial
“Our practice implemented this tool by giving the Communication Self Assessment worksheet to 11 physicians and asking them to complete it and rate
their communication skills. It was interesting to note that 80 percent recorded that they had good communication skills with their patients, yet over
one-third of them reported that they did not verify that patients understood
the directions before leaving the office (e.g., teach-back). We then asked
them to fill out the assessment after each of the next few patient visits. The
results improved, but what was even more important was that several commented that they liked the tool because it reminded them about skills to use
for good communication and consequently they were more aware of them
when they went in to see their next patient.”
-MD, family practice teaching facility
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Tips for Communicating Clearly
Tool 4
Action
Key communication strategies.
Warm greeting: Greet patients with a smile and a welcoming attitude.
Eye contact: Make appropriate eye contact throughout the interaction.
Plain, non-medical language: Use common words when speaking to
patients. Take note of what words they use to describe their illness and
use them in your conversation.
Slow down: Speak clearly and at a moderate pace.
Limit content: Prioritize what needs to be discussed and limit
information to 3-5 key points.
Repeat key points: Be specific and concrete in your conversation and
repeat key points.
Graphics: Draw pictures, use illustrations, or demonstrate with 3-D
models.
Patient participation: Encourage patients to ask questions and be
involved in the conversation during visits and to be proactive in their
health care.
Refer to Tool 14: Encourage Questions for guidance on how
to encourage your patients to ask questions.
Teach-back: Confirm patients understand what they need to know and
do by asking them to teach back directions.
Refer to Tool 5: The Teach-Back Method for more guidance
on how to use the teach-back method.
Tips
Strategies to Remind Staff About Communication Skills
Key communication strategies poster.
Hang poster in various locations.
Staff bulletin board messages.
Include key points and update regularly.
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Tips for Communicating Clearly
Tool 4
Clear communication strategies in practice.
Assessments
Staff self-assessment: Have all staff complete the brief
Communication Self-Assessment after one patient encounter
a day during the week and reflect on their interaction. This will
help them see if they are using the strategies and where they
might need to improve.
Patient assessment: Devise a short patient survey using some
suggestions from Tool 17: Get Patient Feedback or from the
communication self-assessment form to ask patients how staff
are communicating.
Track Your Progress
Assess personal improvement.
Examine your staff’s completed Communication Self-Assessment
sheets after a week. After a few weeks have passed, complete another
round of self-assessments and look for changes. If your staff are
actively adopting these strategies, you should see improvements.
Obtain patient feedback.
Collect patient feedback before implementing the tool. Then
administer the questions again 2 or 3 months later to assess for
improvement.
Resources
Manual: “Health Literacy and Patient Safety: Help Patients Understand”
by the American Medical Association offers suggestions for improving oral
communication and alternatives to complex medical words (pages 31-34).
“Plain Language Thesaurus for Health Communication” by the Centers for
Disease Control and Prevention can give you tips on avoiding medical jargon
when you communicate with patients.
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The Teach-Back Method
Tool 5
The Teach-Back Method
Overview
Studies have shown that 40-80 percent of the medical information patients receive
is forgotten immediately1 and nearly half of the information retained is incorrect.2
One of the easiest ways to close the gap of communication between clinician and
patient is to employ the “teach-back” method, also known as the “show-me”
method or “closing the loop.”3 Teach-back is a way to confirm that you have
explained to the patient what they need to know in a manner that the patient
understands. Patient understanding is confirmed when they explain it back to
you. It can also help the clinic staff members identify explanations and
communication strategies that are most commonly understood by patients.
Purpose
To provide your practice with examples and helpful advice on performing the
teach-back method.
Action
1. Learn the teach-back method.
Teach-Back Video : View a 5-minute video that gives two examples
of using teach-back with medication changes.
Testimonial
“I decided to do teach-back on five patients. With one mother and her
child, I concluded the visit by saying ‘So tell me what you are going to do
when you get home.’ The mother just looked at me without a reply. She
could not tell me what instructions I had just given her. I explained the
instructions again and then she was able to teach them back to me. The
most amazing thing about this “ah ha” moment was that I had no idea she
did not understand until I asked her to teach it back to me. I was so
wrapped up in delivering the message that I did not realize that it wasn’t
being received.”
-resident physician, pediatric office
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The Teach-Back Method
Tool 5
Teach-Back: A Health Literacy Tool to Ensure Patient
Understanding: This PowerPoint presentation can be used in a
group setting or as a stand-alone self-study. It contains 20 slides
developed by clinicians at the Iowa Health System.
AMA video: View a video entitled “Health Literacy and Patient
Safety: Help Patients Understand.” The last 5 minutes of the 23-minute
video includes an example of a clinician using teach-back.
Keep in mind:
This is not a test of the patient's knowledge: This is a test of
how well you explained the concept.
Use with everyone: Use teach-back when you think the person
understands and when you think someone is struggling with
your directions.
Teach to all staff: All members of the practice staff can use it
to make sure their communication is clear.
Tips
Suggested Approaches When Using Teach-back.
“I want to be sure that I explained your medication correctly. Can you
tell me how you are going to take this medicine?”
“We covered a lot today about your diabetes, and I want to make sure
that I explained things clearly. So let’s review what we discussed. What
are three strategies that will help you control your diabetes?”
“What are you going to do when you get home?”
2. Try the teach-back method.
Start Slowly. Initially, you may want to try it with the last patient of
the day.
Plan your approach. Think about how you will ask your patient to
teach-back information based on the topic you are reviewing. Keep in
mind that some situations will not be appropriate for using the teachback method.
Use handouts. Reviewing written materials to reinforce the teaching
points can be very helpful for patient understanding. Refer to Tool
12: Use Health Education Materials Effectively.
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The Teach-Back Method
Tool 5
Clarify. If patients cannot remember or accurately repeat what you
asked them, clarify your information or directions and allow them to
teach it back again. Do this until the patient is able to correctly
describe in their own words what they are going to do, without
parroting back what you said.
Practice. It may take some getting used to, but studies show that once
established as part of a routine, it does not take longer to perform.
Track Your Progress
Assess results of the teach-back method with staff and patients.
The Teach-Back Self-Evaluation and Tracking Log provides a
method for staff to document their experience using the teach-back
method. Encourage staff to use the logs, and hold a discussion about
their experience. This will allow people to share teach-back strategies
that worked best. In addition, it is helpful to ask patients if they find
the teach-back interaction positive and helpful during the patient
encounter.
Assess how often the teach-back is used.
A few weeks after first trying the teach-back, track how many
clinicians or staff members are using it. Have each individual keep a
log of when and how it was used over the course of a few days.
References
1.
2.
3.
Kessels RP. Patients' memory for medical information. J R Soc Med. May 2003;96(5):219-22.
Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a
rheumatology clinic. Rheumatology. 1979;18(1):18-22.
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with
diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
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Followup with Patients
Tool 6
Followup with Patients
Overview
Followup, in terms of a primary care setting, is the act of making contact with a
patient or caregiver of a patient at a later, specified date to check on their progress
regarding a change or action that took place at their last appointment or contact.
You can use followup for:
Monitoring health such as checking blood pressure values.
Reinforcing knowledge and action plans.
Confirming medication adherence.
Scheduling appointments.
Verifying follow-through on referrals.
Reporting lab results.
Contact with patients between office visits can enhance patients’ sense of being
cared for by your practice. Studies show that patients appreciate and respond well
to followup contact. Establishing a system to followup with patients is also
beneficial for the clinic staff. The additional contact with patients can give staff
reassurance that the patients understand what they need to know and do.
Purpose
To outline different followup options and how to use them.
Action
1. Identify ways to initiate and track followup.
Your record-keeping system will largely determine how followup
contacts are initiated. Electronic systems often have built-in
mechanisms to signal such actions. Many registries can alert the staff
that a planned followup is needed. If you do not have an electronic
system, think of the other ways you systematically do things, like order
blood tests or record immunization reminders. You may be able to use
a similar system to keep track of who needs a followup and when.
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Followup with Patients
Tool 6
2. Determine methods to provide followup.
The method by which you followup with a patient depends on what
you need to followup on and your practice’s capacity.
Visit: If a physician needs to physically examine the patient, a
visit is the only means to do this.
Phone call: A phone call can save both the physician and the
patient time. A phone call conversation can also be used to
reinforce information provided to patients at their visits. Some
insurance companies (and some patients) will pay directly for
care provided over the phone.
Automated call system: Some practices may benefit from an
automated system that enables patients to call in or receive
calls to report health-related information (e.g., blood pressure,
blood glucose), and get laboratory results.
These automated systems are often costly to implement,
but large practices or practice networks may have the
resources to purchase them.
For more information, refer to Automated Telephone
Reminders: A Tool to Help Refill Medicines On Time.
Followup forms: Patients can be taught to record information
at home and bring that record in at their next appointment. This
is an example of a Followup instruction sheet for a diabetes
patient. It is given to patients after a visit, and asks them to
record blood glucose and call/fax/e-mail in their values by a
specified date. This can be done for many different conditions.
E-mail: This can be a very efficient means of communicating
to patients because it does not require that the patient and
clinician are available at the same time. It is important to keep
the following things in mind when using e-mail with patients:
Make sure patients know when or how often you return
your e-mail, and stress that any life-threatening
emergencies are not appropriate for e-mail.
E-mail communication may not be appropriate for
relaying sensitive health and personal information. It
may not be the most confidential means of
communication.
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Followup with Patients
Tool 6
For more information on using e-mail see Enhancing
Doctor-Patient Communication Using E-mail: A Pilot
Study.
Mail: Mailing normal lab results and reminders can be efficient
for the office staff, and patients may appreciate knowing that
their lab results were within normal limits.
Use everyday language in written communications.
Refer to Lab results letter.
3. Identify who will do the followup.
Clinician: If the followup is complex or sensitive, the clinician may
prefer to provide followup over the phone. Consider a system for
someone else on the staff to coordinate and perform the followup
based on the needs determined by the patient or physician.
Nurse: Oftentimes nurses are in excellent positions to followup with
patients. They have the training and expertise to review things like
blood pressure and blood glucose values with patients, discuss and
encourage specific health behaviors, and review medication adherence.
Other office staff: There may be opportunities for front desk staff or
volunteers to contact patients for followup. Such followup could
include scheduling appointments, confirming that patients followed
through with referrals, and providing patients with information on
community resources.
Track Your Progress
Assess need for followup.
Have clinicians track how many patients would benefit from a
followup contact and for what reason within a given week. This may
help to identify demand for a followup system and what type of system
is needed to address your needs.
Track the use of followup and its outcomes after a system is implemented.
Assess the number of followup actions (phone calls, e-mails, letters,
automated calls, etc.) performed by your practice within a week.
Note what is achieved by the followup contacts: medication changes,
referrals made, clarification of medication regimens.
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Telephone Considerations
Tool 7
Telephone Considerations
Overview
Telephone contact plays an important role in health care, and the efficiency of a
telephone contact will shape a patient’s impression of your practice. If you have
not evaluated your phone system and procedures recently, it may be time to assess
how your practice is managing incoming and outgoing calls. Efficient and
courteous call management may save your practice time and money and should
benefit your patients as well. It is important to consider health literacy when
assessing your telephone communications.
Purpose
To help practices manage their telephone system and develop staff procedures for
telephone contact.
Testimonial
“When our practice staff tried to answer all phone calls, many patients complained about getting a busy signal. Therefore, we installed an automated
system with menu options for the most common requests. As a result of the
menu options, our staff is able to answer more calls. In addition, we observed our rate of rescheduled appointments increased, which decreased our
no show rate. We felt this was all a result of a more efficient phone system.”
- internal medicine practice
Action
One way to assess your current telephone system is to call and evaluate it
yourself, remembering to call during and after business hours. In addition, you
should ask your patients and staff what they like and do not like about your
system. Keep the following points in mind when assessing and improving your
system.
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Telephone Considerations
Tool 7
Automated system for incoming calls.
Create messages for your automated system.
Use a voice that sounds friendly.
Use a conversational tone of voice.
Speak clearly, using everyday words.
If you provide a phone number, repeat it.
Create the menu for your automated system.
Consider the following sequence of choices on the main menu:
Provide a choice of language (if applicable).
Provide instructions for medical emergencies.
Do not have more than 5 choices within a menu option.
Possible menu options:
Option 1: Appointments: schedule, reschedule, confirm or
cancel.
Option 2: Prescription refills or to request a referral.
Option 3: Directions to your office.
Offer options for different forms of transportation,
including public transportation.
Reference familiar landmarks.
Option 4: Speak to a staff person and/or leave a message for
clinical staff.
Option 5: Repeat menu.
Further options include:
Nurse advice line.
Billing or insurance questions.
For an example of possible menu options refer to the Sample
Automated Telephone System Menu.
Record after hours message.
Assess the automated message and menu options used when the
practice is closed.
Educate your patients about using the phone system.
Talk with them at check-in or during their visit.
Put up posters in the waiting area.
Review the phone number to call when the practice is closed (after
hours).
Telephone etiquette.
Clinicians and staff members should keep the following things in mind when
speaking with patients:
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Telephone Considerations
Tool 7
Use a friendly, conversational tone of voice.
Speak clearly, at a comfortable pace.
Refer to the caller by name when possible.
Give callers your undivided attention, and try to avoid interruptions
during the call.
Use teach-back when appropriate, see Tool 5: The Teach Back
Method.
Encourage questions.
Use everyday words, and avoid medical jargon.
Use scripts when applicable for clear answers to common questions,
such as directions to your practice or preparation instructions.
Provide guidance to staff for answering questions when a script is not
provided.
Toll-free phone number.
Consider adding a toll-free number for your office to encourage patients to
call with questions.
Track Your Progress
Count the number of complaints about accessing your practice by phone and
wait time while on hold. Compare complaints before and after changes to
your system.
Resources
For additional information refer to “How Does Your Practice Sound on the
Phone?”.
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Brown Bag Medication Review
Tool 8
Brown Bag Medication Review
Overview
The “Brown Bag Review” of medications is a common practice that encourages
patients to bring all of their medications and supplements to medical
appointments. This provides clinical staff with an opportunity to review and
discuss the medications that the patient is taking. Reviewing medications with
your patient may help you to:
Answer the patient’s questions.
Verify what the patient is taking.
Identify and/or avoid medication errors and drug interactions.
Assist the patient to take medications correctly.
Purpose
To help practices develop a process to improve communication about medications
between patients and clinical staff.
Testimonials
We tested the tools in this toolkit with 9 different practices. Practices that
tested this tool were shocked at what they found.
“On the day we did the brown bag review, we had a patient experiencing
unexplained symptoms. It wasn’t until we looked at his medicine bottles
that we realized he was taking a double dose of beta blocker. This explained his symptoms perfectly. Had we not had the medicine bottles to
identify the problem, we would have sent him to the hospital.”
“Out of 10-15 brown bag reviews, only 2 were accurate.”
“Out of five brown bag reviews, we found three that had duplicate medicine bottles resulting in double dosing and one discontinued medicine
that was still being taken.”
“We found errors in every review, including one where a patient stopped
his medicine on his own, another where a patient was taking a supplement the provider did not know about, and others where the medicines
did not match what was in the chart.”
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Brown Bag Medication Review
Tool 8
Action
1. Get patients to bring in their medicines. Conducting brown bag reviews has
been VERY eye-opening for many practices, and most feel it is a worthwhile
thing to do. The challenge is getting the patient to bring in their medications.
It helps to have a full-scale campaign whereby everyone in the practice is
stressing its importance and many different tactics are employed. Here are a
few suggestions:
What to bring: Review with patients what to bring.
All prescription medicines (including pills and creams).
All over-the-counter medicine they take regularly.
All vitamins and supplements.
All herbal medicines.
Ways to remind:
On the appointment card.
During the appointment reminder call.
During the visit: discuss as a part of their visit.
Hang posters in the exam rooms and the waiting room.
Bulletin board: Display a bulletin board with anonymous case
studies and persuasive reasons for bringing in their medicines.
Emphasize medication reduction: A brown bag review may
result in the physician stopping some medications, which is
often appealing to patients.
Provide a carrier: Consider providing your patients with a
small sack (canvas, paper, or plastic) to carry their medications.
The sack may have a printed reminder on one side and your
practice name on the other.
2. Set out the medications.
The nurse should place all of the patient’s medications on the counter
in the exam room to remind the clinician to perform a medication
review.
3. Offer praise to the patient for bringing medications.
Thank the patient for bringing his or her medications and stress the
importance of bringing them to every visit.
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Brown Bag Medication Review
Tool 8
4. Review the medications.
Introduce the review process: Ask the patient if they have any
questions about their medications, and acknowledge the purpose of
reviewing medications.
Some helpful questions to ask:
“Are you taking any new medications since your last visit?”
“Have you stopped taking any medications since your last
visit?”
“Please show me what you take for your ?”
“How many of these pills do you take each day?”
“When do you take this pill?”
“What do you take this medication for?”
5. Clarify medication instructions.
Clearly review with the patient what medications they should be
taking and how to take them. Refer to Tool 5: The Teach-Back Method
to confirm understanding.
6. Update the medications in the patient’s chart.
Clearly document medication inconsistencies and what the patient is
directed to take.
Note in the chart when full medication reviews are done and when
partial or updated ones are done to help track the process for the
practice.
7. Provide patient with updated list of medications.
Refer to Tool 16: Improve Medication Adherence and Accuracy
ways to document medications for patients and assist them with
remembering and correctly taking them.
for
8. Bill for medication review.
Select the ICD-9 V58.69 to bill the patient’s insurance for the review.
Track Your Progress
Document in the patient medical record whether or not a medication review
occurred at the visit. At the end of a day or week, identify the percentage of
patients who had a medication review completed.
During a week, count the number of medication reviews that identified a
problem.
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Brown Bag Medication Review
Tool 8
Strive to have 9 percent of patients with a review in the past 12 months.
Resources
The American Medical Association manual “Health Literacy and Patient
Safety: Help Patients Understand” offers information on medication
reviews.
Brown Bag Toolkit is a toolkit from the Ohio Patient Safety Institute that
contains information for practices with pharmacies to plan a brown bag event.
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How to Address Language Differences
Tool 9
How to Address Language Differences
Overview
Delivering good health care and changing health behaviors is hard enough without
the added complication of language differences between a patient and health care
provider. Speakers of languages other than English often do not get the health
information they need.
Addressing language differences is an important part of addressing health literacy
universal precautions and is also a requirement by law. As part of the Civil Rights
Act of 1964 and subsequent Federal and State laws and policies, a practice
participating in Medicare or Medicaid is legally required to provide equal access
to services for patients who do not speak or understand English well.
Purpose
To help practices consider multi-language issues and offer suggestions on how to
address them. This tool includes a list of resources that practices can access to
assist in developing their plan to address language barriers.
Action
Assess and document language preferences and language assistance
needed.
“I Speak” cards: These are cards that read “Mark this box if you
read or speak [a specific language]” and are written in that particular
language. Copies of these cards can be displayed or readily accessible
at the reception desk or welcome area to help patients identify which
language they speak.
Determine patient’s language assistance needs. Ask all new patients
(especially if someone else is making the appointment for them):
“What language do you feel most comfortable speaking with
your doctor or nurse?” If they answer American Sign
Language, ask whether they have TDD capabilities
(Telecommunication Devices for the Deaf).
“Would you like an interpreter?”
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How to Address Language Differences
Tool 9
“In which language would you feel most comfortable reading
medical or health care instructions?”
Record patients’ language assistance needs. Once assessed,
preferred language and language assistance needs should be noted in
the chart. If electronic charts are used, this information can easily be
tracked over time to help practices appropriately plan language
services.
Display patients’ rights. At the receptionist desk or welcoming
area, display a sign explaining patients’ right to language services and
how to access those services at your practice.
Acceptable language assistance services.
On-site trained interpreters: Often times an interpreter is well
educated and uses medical terms. Training should include attention to
plain language and other health literacy issues. To find a local
interpreter you can go to:
American Translators Association
Pro Z
Telephone medical interpreter services: This will require special
equipment such as dual handset or speaker phones in examining
rooms.
Bilingual clinicians and staff trained as interpreters.
Other emerging technologies to look for (but not yet tested):
Video conferencing (especially for American Sign Language).
Voice activated software that recognizes and translates phrases
from one language to another, also known as a “phraselator.”
Tips
Planning for Interpretation Services
Tell patients that interpreters will be provided for free. If patients
say they will bring their own interpreters, tell them untrained interpreters often make mistakes, and in particular children should not
be asked to interpret.
Consider training your staff on how to work with interpreters.
If many of your patients speak a particular language, consider
hiring bilingual staff.
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How to Address Language Differences
Tool 9
Unacceptable interpreter services.
Untrained staff: Using untrained staff to interpret has been shown to
lead to clinically significant medical errors.
Family and friends: Practices must keep in mind that family or
friends are considered untrained interpreters. Using family or friends
poses a problem with patient privacy. In addition, family may impose
their view of the patient and their health. Patients may insist that staff
communicate with bilingual family or friends and that request should
be respected, but a trained interpreter should be in the room to assure
that the information is accurately relayed.
Minor children of patient: Minor children should never be used as
interpreters. Using minor children to interpret puts the child in a very
vulnerable position and puts the practice at risk for liability if
something were to go wrong. Patients may be less likely to discuss
more personal health topics when using children as interpreters.
Translated written material.
What will need translating?
Forms, signs, posters, pamphlets, etc.
Health education material: The following Web sites have a
large selection of easy-to-read health education material in
several languages.
MedlinePlus by the National Institutes of Health.
Healthy Roads Media provides materials in handout
form, audio, Web video, and mobile video for a variety
of different opportunities for practitioners to get them to
patients.
Health Information Translations provides
materials in 18 different languages, including American
Sign Language video for patients that are deaf.
Things to keep in mind about translating words into another
language.
Direct, word-for-word translations do not always work because
nuances of culture are thereby ignored.
Translators must apply plain language guidelines. Dense
materials in English are often difficult to understand. The same
material in another language will also be difficult to
understand.
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How to Address Language Differences
Tool 9
Organizing languages services.
Office visits: For small populations of diverse patients, consider
scheduling appointments at times when appropriate interpretation
services are available.
Phone calls: Plan designated times that patients can call when
interpreters are available.
Unscheduled communications: Have a plan for when a patient who
you did not know needed language assistance comes in or calls (e.g.,
contract with medical telephone interpreters).
How to pay for language assistance services.
Paying for these services is by far the most challenging part, especially if there
are no trained bilingual staff at the practice. Although these services are
mandated for most practices, funding them may take some creative thinking.
Investigate whether Medicaid and other insurance plans will pay for
interpreters or have negotiated discounts. (Medicaid reimbursement is
available in 13 States.)
Coordinate with other practices to develop contracts with language
assistance vendors.
Contact community organizations for possible volunteer trained
interpreters.
Consider separate flexible funding sources such as grants or
fundraisers to help subsidize these services.
Track Your Progress
After implementation, take 1 week and ask staff to make note of all the
language assistance needs that they encountered and how they were dealt with.
Collect the comments, and discuss them at the next Health Literacy Team
meeting. Explore new approaches to address the weaknesses, and do another
evaluation in another 2 months.
Compile a list of the most common languages spoken by your patients.
Compare that list with the languages used for the written materials you
distribute. Repeat after 2 months to see whether more non-English materials
are available.
Resources
“Addressing Language and Culture” is a booklet by The California
Academy of Family Physicians Foundation that helps practices gauge how
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How to Address Language Differences
Tool 9
well they are doing at providing services sensitive to language and culture.
The Health Care Language Services Implementation Guide is a Web
site sponsored by the Department of Health and Human Services’ Office of
Minority Health that provides a comprehensive guide to addressing language
access services in health care settings. It offers case study audios that
skillfully illustrate the issues around the need for language access services. It
also provides a comprehensive list of resources such as laws and regulations,
telephone translation services, testing and training for interpreters, funding
options, etc.
“Office Guide to Communicating with Limited English Proficient
Patients” is a booklet by the American Medical Association that offers
practical advice.
Hablamos Juntos has a number of resources for language services, one
being a toolkit on improving the quality of health care translations.
“Unified Health Communication 101: Addressing Health Literacy,
Cultural Competency, and Limited English Proficiency” is a free online
learning course broken down into five, 1-hour modules and offering
continuing education credits.
References
1. Flores,G. Language barriers to health care in the United States. New Engl Med, 2006;355
(3):229-31.
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Culture and Other Considerations
Tool 10
Culture and Other Considerations
Overview
The fact that patients are complex and dynamic is not a new notion to any
clinician. Such things as religion, culture, and employment can play a part in their
health and be an important component in understanding why they make certain
choices. But in the hustle and bustle of the day, a clinician can sometimes deliver
medical advice without fully understanding how health beliefs and cultural
practices may influence how that advice is received. Learning about patients’
ethnic backgrounds, cultures, and religions should not lead to stereotyping or
assumptions, but should help clinicians deliver good patient-centered care.
Purpose
To outline a perspective and offer resources to help clinicians avoid
miscommunication in cross-cultural situations and foster more patient-centered
relationships.
Action
Learn about your patients’ health beliefs and cultural practices.
The best way to learn about patients’ health beliefs is to ask them.
Tips
How to Ask Your Patients About Their Health Beliefs and Customs
“I am not familiar with your cultures and beliefs. Can you teach
me what I might need to know so I can better treat you?”
“What do you call your illness? What do you think caused your
illness? How do you think it should be treated?”
“Do any traditional healers advise you about your health?”
Improve cross–cultural communication skills.
Continuing education courses can be helpful.
“Think Cultural Health: Bridging the Health Care Gap through
Cultural Competency” has several options and is sponsored by
Department of Health and Human Services.
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Culture and Other Considerations
Tool 10
“Unified Health Communication 101: Addressing Health Literacy,
Cultural Competency, and Limited English Proficiency” is a free online learning course broken down into five, 1-hour modules and
offering continuing education credits.
Considerations.
If your practice includes a concentration of patients from a particular cultural
background, it can be helpful to learn about their customs and beliefs.
Health beliefs and customs: Some patients have different beliefs
about the causes of and treatment of specific diseases. For instance, in
the Hispanic culture, some believe the cure for empacho (indigestion)
is massage of the abdomen or pinching the skin until it pops.
Ethnic customs: Customs like fasting at particular times or the
treatment of women by men are things that clinicians need to be aware
of.
Religious beliefs: Practices based on religious beliefs, such as refusing
contraception or blood transfusions, can be very important in treatment
decisions.
Dietary customs: Food and diet are very important in helping people
maintain a healthy lifestyle, and having knowledge of typical diets
helps practitioners advise patients.
Interpersonal customs: Having knowledge of interpersonal customs
can help develop a trusting and working relationship with patients. For
instance, in some cultures it is impolite to make eye contact or touch a
person casually during conversation.
Expectations: People develop expectations (high or low) based on
experiences. For instance, imagine treating a middle-aged man whose
parents did not live past age 50, or a woman who knows she carries the
genes for breast cancer.
Web sites: The following Web sites have specific information about
different cultures and beliefs.
EthnoMed is a Web site containing information about
cultural beliefs, medical issues, and other related issues
pertinent to the health care of recent immigrants, many of
whom are refugees fleeing war-torn parts of the world.
Culture Clues are one-page tip sheets that offer insight into
the health care preferences and perceptions of patients from 10
different cultures and special needs groups (including the deaf
and hard-of-hearing). It also covers end-of-life issues.
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Culture and Other Considerations
Tool 10
The “Cultural Competence Resources for Health Care
Providers” Web site provides an exhaustive list of resources
regarding cultural competence issues for specific ethnicities,
religions, and special populations.
Avoid stereotyping.
Understand that each person is an individual and may or may not take on
certain cultural beliefs or practices. For example, it would be inappropriate to
assume that just because a person exhibits one cultural characteristic, like
wearing a piece of religious jewelry or clothing, that they also adhere to the
dietary customs of that religion. Yet, ignorance of that potential connection
between such practices can lead to ineffective medical care.
Track Your Progress
Count how many employees have completed a cultural competency training
session.
Add a page to patients’ charts to note health beliefs and customs, then
randomly select some charts and see what percentage have notes on the
patient’s health beliefs and customs.
Conduct patient surveys and ask how often the doctor showed respect for what
the patient had to say. See if responses vary by race or ethnicity, and whether
they change over time. Refer to Tool 17: Get Patient Feedback for more
information.
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Design Easy-to-Read Material
Tool 11
Design Easy-to-Read Material
Overview
A patient is often asked to read something in their doctor’s office. They may be
asked to fill out a form or may be given written material on how to manage their
disease. A patient’s reading abilities are often below the readability of this
material. In addition, patients who are ill can sometimes find it hard to answer
complex questions accurately. Practices that are conscientious about developing
and using written materials that are easier to read may increase the chance that
patients will use it correctly, thereby saving staff time and improving patient
outcomes.
Purpose
To provide strategies for developing well-written patient material, including forms
and education materials.
Action
Train one person on how to evaluate and create written material.
Have one person take responsibility for learning how to design simple, easyto-read written materials for your practice that will be appropriate for
everyone, including people who have limited health literacy.
Tools that will help: The following Internet sites are useful resources for
anyone wanting to evaluate or create well-written material.
Formatting: The following sites offer good advice on formatting.
Clear Doc Index by the Literacy partners of Manitoba.
Clear and to the Point: Guidelines for Using Plain Language at
NIH from the Harvard School of Public Health.
Assessing reading level: Readability formulas assess text for
complexity, grade level, and multi-syllable words. You can assess any
text by cutting and pasting it into these programs. These formulas can
be helpful but should not be your only evaluation tool because reading
level is only one aspect of readability, and readability formulas are not
always accurate with forms that have short sentences or phrases.
Readability Formulas.com has three different readability calculators.
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Design Easy-to-Read Material
Tool 11
Common Words.
Listen: To get a common word explanation of something, try
explaining it verbally to a lower literate patient and having
them explain it back, taking note of what words were used.
Reference list: The Plain Language Thesaurus for Health
Communications is available from the Centers for Disease
Control and Prevention.
Tips
Words Patients May Not Understand
hypertension benign
oral
enlarge
lateral
terminal
monitor
referral
When explaining things like test results, be cautious about using
words such as “negative” and “positive.” These words have general connotations that are sometimes different than the medical jargon. For example, a negative test result is often good for the patient but may be perceived as a bad outcome.
Patient feedback.
Ask a variety of patients to evaluate your forms or other written
materials (also evaluate material that you did not develop). Consider
asking the following questions:
Is the information clear and easy to understand?
Is it confusing in any way?
Are any parts/words hard to read or understand?
Is there anything offensive?
What is helpful and what isn’t?
In Other Words…Can They Understand? Testing Patient
Education Materials With Intended Readers has some great
tips on using patients to test material.
Health education material.
Content: Clearly state how to prevent or manage disease without a lot
of extra information. This element seems to be the most
challenging, as most material is written by educators who feel
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Design Easy-to-Read Material
Tool 11
compelled to explain more than the patient needs to know to manage
their disease. When evaluating material ask “Is this information
something the patient needs to know or do to stay healthy?”
Chunk the information. Include clearly defined headings and
divisions between sections of information allowing for a lot of white
space on the page.
Sentence structure.
Use short, simple sentences.
Write at a reading level of 6th grade or below.
Word choice.
Limit the use of medical jargon, and define any terms you use.
Limit the use of multi-syllable words.
Graphics. Visuals and graphics can help relay a message and enhance
the understanding of your message.
Patient forms.
Format considerations.
Check boxes: Low literate patients often avoid writing answers
because of poor spelling, so offering check boxes of common
answers is helpful.
“Don't know” options: Give patients the option of checking a
“don't know” box so they don't feel compelled to check
inaccurate information.
Bold key words: This helps draw attention to the main point of
the questions.
Use common medical words such as “mammogram” and
“allergic reaction” first in the questions with a common word
definition in parentheses after it (see example forms).
Example Forms: The example forms listed below are written with
the above guidelines in mind and were tested using cognitive
interviews with patients with low literacy skills. There are a wide
range of questions from asking about a person’s reading skills to
asking about cultural beliefs. The longest form does not take more then
30 minutes for a lower literate patient to fill out. They are constructed
in Microsoft ® Word format to allow practices to edit and use the parts
they feel would be useful to their own specific needs. NOTE: Any
practice that chooses to use a form for any legally binding purpose
should confer with their attorney for legal advice.
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Design Easy-to-Read Material
Tool 11
Adult Initial Health History Form
Young Child Health History Form
Adult Return Visit Update Form
(1 page)
Consent to Treat Form
Release of Medical Information
Lab Results Letter
Appointment Reminder
Help patients fill out forms.
Keep in mind that some patients will need help reading, understanding, and
completing the material they are given. A practice needs to have a system in
place to offer ALL patients help with forms. Here are some friendly, nonstigmatizing ways to let patients know that help is available.
“I am going to give these forms to you right now. You can choose to
fill them out now or you can wait until you get to the room and the
nurse will be happy to go over them with you.”
“Sometimes items in these forms are not clear. We are happy to go
over them with you, or you can fill them out on your own.”
“Thank you for filling out the form. Can we go over it to make sure we
got everything? Some items are not always clear, and we want to
make sure we have all the information correct.”
Track Your Progress
Every 4 months do a tally of what written material has been reviewed and
revised using the plain language guidelines. See if the percentage goes up
over time.
Every 4 months tally how many forms or other material have been reviewed
by a patient or patients for readability.
Are forms more complete when they reach the chart? Before implementation
take one week and tally the percentage of questions that were not answered on
forms that were filled out by patients. In 2 months, do it again and see if the
percentage of unanswered questions has gone down.
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Use Health Education Material Effectively
Tool 12
Use Health Education Material Effectively
Overview
Health materials are effective only when used as a part of an overall patient
education strategy. Simply handing your patient a pamphlet is not enough to
promote understanding or behavior change. Patients have various levels of
literacy and speak different languages. Your selection of well-designed
educational materials and how you use them when educating your patients will
determine how effective you are at helping them manage their health care.
Purpose
To offer strategies on how to use educational materials effectively to promote
better patient understanding.
Action
Use educational materials.
Use in conjunction with spoken instruction.
Educational material should be used to facilitate discussion, not
replace it. Do not assume that patients read the materials you give
them. Just handing a pamphlet to a patient has been shown ineffective
at changing behavior. Educational material should be used when a
clinician is focusing on a specific point of care that needs further
reinforcement.
Review the material with the patient.
Make note of important information by circling or highlighting it in the
material, and discuss how it relates to the patient’s care. Consider
personalizing the materials by adding the patient’s name, medications,
or specific care instructions. Make sure the patient understands the
written material and verbal instruction by asking them to restate the
main points.
Refer to Tool 5: The Teach-Back Method.
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Use Health Education Material Effectively
Tool 12
Repeat and followup.
Reinforcing information is essential for a patient to learn skills and
change behavior. Providing followup phone contact and referring to
the educational material again in future visits can improve
understanding and adherence. You may need to give the material to
the patient more than once, and you may focus on different topics at
subsequent visits.
Refer to Tool 6: Followup with Patients.
Use video.
Incorporating a video presentation into patient education can be
effective if the practice identifies good videos and has the capacity to
show them to patients. Videos that review the causes and treatment of
a specific disease can be especially helpful for patients who are newly
diagnosed with an illness. Videos should follow similar principles to
good educational materials, including use of simple graphics and plain
language. They should review material at a moderate pace and with
clear pronunciation. Remember that video presentations are not a
substitute for reviewing and discussing the information with the
patient, but they can be helpful to introduce and/or reinforce the topics
discussed.
Manage educational materials.
Effectively using educational materials in your practice requires that you have
a supply that is easy to find and available when needed. Consider identifying
a staff person to monitor and manage your educational materials. Some things
to consider include:
Location: Identify a storage location that is accessible to staff.
Organization: Keep materials arranged so you can easily find what
you need.
Supply: Monitor inventory regularly and re-order before you run out.
Keep materials updated: Review and identify new materials as
needed.
Training: Confirm that at least one member of your staff knows how
to develop and evaluate educational materials.
Refer to Tool 11: Design Easy-to-Read Material
for more
information on material design and review.
Education: Teach your staff how to use any new materials developed
or obtained for patient use.
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Use Health Education Material Effectively
Tool 12
Print materials from the Internet.
When printing material from Web sites, look for a portable document format
(PDF) version rather than printing the Web page. A PDF file will allow the
document to print in a format that incorporates layout, font, and pictures.
Different types of health education material.
Brief materials: These are shorter in length and can be useful for
basic education during patient visits. We have listed a few examples
of short, easy-to-read health education materials below:
Dusty the Asthma Goldfish and His Asthma Triggers Fun Book
Environmental Protection Agency (English & Spanish).
Attention Deficit/Hyperactivity Disorder (ADHD) The
National Institute of Mental Health.
Managing Chemotherapy Side Effects National Cancer
Institute.
Using the Chemotherapy Side Effects Fact Sheets National
Cancer Institute.
Diabetes: Know the Signs Learning about Diabetes (English
& Spanish).
Prevent and Control High Blood Pressure: Mission Possible
The National High Blood Pressure Education Program (English
& Spanish).
Take Steps—Prevent High Blood Pressure The National
Institutes of Health (English & Spanish).
Your Guide to Preventing and Treating Blood Clots Agency
for Healthcare Research and Quality (AHRQ).
Help for Smokers and Other Tobacco Users AHRQ (English
and Spanish).
Comprehensive disease management materials: Some health
education materials are comprehensive in content and are designed to
be used during patient encounters addressing more detailed disease
management topics. Often these materials can be customized for
patients’ specific needs or interests. Clinicians that use the
comprehensive materials should be familiar with their layout and how
to review them with patients. They are longer than the brief materials
listed above and can be printed on-site or ordered from the Web sites.
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Use Health Education Material Effectively
Help Your Child Gain Control Over Asthma
Tool 12
Environmental
Protection Agency (English).
Caring for Your Heart: Living Well with Heart Failure North
Carolina Program on Health Literacy (English & Spanish).
Diabetes Literacy and Numeracy Education Toolkit
Vanderbilt University. Note: Register on the Web site to
obtain free copies.
Track Your Progress
Assess your review of materials and their organization.
Are you running out of materials? Are you able to find the materials
you need? Every quarter, assess your system for managing your
educational materials.
Assess staff awareness and use of materials.
Do your clinicians know what materials are available and how to use
them? After identifying and organizing your materials, have the
materials reviewer discuss them during a staff meeting. Review what
materials are available, where they are, and how to use any
comprehensive materials.
Periodically check in with clinicians, and ask them if they are using the
materials and if additional materials are needed.
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Welcome Patients: Helpful Attitude, Signs, and More
Tool 13
Welcome Patients: Helpful Attitude,
Signs, and More
Overview
Do your patients feel welcome when they enter your practice? Have you clearly
identified where to go for assistance?
While some patients may feel anxious or intimidated when locating and entering a
health care practice, this may be more problematic for patients that are new to
your practice and for those with limited literacy. Creating a friendly environment
that is easy to navigate may help your patients feel a sense of welcome and
encourage their participation in the health care experience.
Purpose
To offer suggestions for creating a welcoming atmosphere by addressing your
front desk, waiting room, and signs.
Action
Evaluation.
Patient walkthrough: Have a person who is unfamiliar with your
practice walk through it and give you feedback on the feel and
navigation. For more information see pages 99-115 of The Health
Literacy Environment of Hospitals and Health Care Centers.
Staff walkthrough: Have one or two staff members do a walkthrough
of your practice and assess the front desk area, waiting room, and
signs.
Front Desk.
Helpful atmosphere: First impressions count. The first person a
patient meets in your practice is very important at setting the tone.
This person should be helpful and cheerful.
Help with forms: If a patient is handed a form, offer them assistance
filling out that form. (For more information see Tool 11: Design Easyto-Read Material.)
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Welcome Patients: Helpful Attitude, Signs, and More
Tool 13
Collect only essential information: Don’t ask questions that will be
asked again later in the visit.
Assess language preferences: Have “I speak” cards at the front
desk so staff can identify language preferences from the beginning of
the visit and can obtain the appropriate language services.
Practice brochure: Develop an easy-to-read brochure using tips from
Tool 11: Design Easy-to-Read Material that highlight the elements
of your practice. Include the following:
Contact Information, including after-hours and emergency.
Services provided.
Address and directions to your office.
What to bring to appointments.
Waiting Room.
Bulletin boards: These can be focal points of your lobby that arouse
interest, stimulate thought, and encourage action.
Target audience: Your patient population.
Central theme: Have no more than four points of interest.
Easy-to-read and colorful.
Update regularly: Assign different staff to maintain and
update content on a regular basis.
Television: Many services are available to provide health information
via a closed circuit television in your waiting room. When evaluating
them, take note of any complicated medical terms or language that
may be difficult to understand.
AHRQ Questions Are the Answer: a video that encourages
patients to ask questions and become more involved in their
health care.
Signs. Making signs easy to read and clearly visible will help to avoid
confusion and reduce the amount of time staff spend directing patients from
place to place.
Identify locations. Your practice should have signs to identify or
direct patients to each of the following areas:
From the front of the building to your practice entrance.
Waiting room/Checkin/out.
Billing department.
Laboratory.
Nursing area or station.
Exam rooms.
Restrooms.
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Welcome Patients: Helpful Attitude, Signs, and More
Tool 13
Identify process or procedure. Your practice should have a limited
number of signs that give basic instructions such as “Please sign in” or
“If you have been waiting more than 20 minutes, please tell the front
desk staff.”
Use simple, universal words. Make sure signs are in the languages of
your patient population.
Use graphics when appropriate. Hablamos Juntos (“We speak
Together”) is an initiative that has created graphic symbols for
common medical services, some which may be applicable in the
practice setting.
Use color coding, lines, or symbols. These may be another way for
you to guide patients through your practice.
Make signs clear and visible. The signs should be easily visible by
patients.
Track Your Progress
Employ the patient walkthrough technique by having someone initially
evaluate your practice on many of these points. After making the changes and
offering employee education, conduct another patient walkthrough and
compare the results.
Over the course of a week, count how many times staff have reviewed the
patient information brochure with new patients.
Resources
The American Medical Association manual “Health Literacy and Patient
Safety: Help Patients Understand” provides guidance on using health
literacy best practices for patient checkin and registration.
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Encourage Questions
Tool 14
Encourage Questions
Overview
An essential part of achieving good health outcomes is helping patients to
understand that their role in their health care is important. But patients can
sometimes be ashamed to ask questions, fearing that they will seem foolish. In
some cultures, deference to authority figures stifles questions. Creating a shamefree environment that encourages patients to ask questions and gives them the
confidence to take ownership of their health is crucial in this effort.
There are several strategies designed to change the dynamic of the patient/
clinician interaction. These approaches, when used over time, are aimed at
teaching patients to become more involved, but they will also help a practice to:
Decrease the number of call backs or questions after a patient leaves.
Increase patient satisfaction.
Increase patient safety.
Purpose
To give strategies for eliciting questions from patients.
Testimonial
“We decided to implement the ‘Ask Me 3’ program for 2 weeks for some of the
afternoon patients in clinic A. As part of the responsibilities of the front desk
those 2 weeks, I made copies of the brochures. As one of these patients came
in, I would give them a brochure and say, ‘Every time you see your provider
you should leave knowing the answers to these three questions. What questions
do you have for your doctor today? You can write them here…’ I point to
their brochure and hand them a pencil. I then flagged the chart with a green
sticky note, and when the nurse would take them back she would reinforce the
pamphlet and encourage them to talk about their questions. When that patient
was ready to check out I would ask them, ‘Did you get your questions answered
today?’ Most of the responses were positive, but the more amazing thing was
that fewer patients from this clinic were stopping to ask questions or calling
back in after their visit compared to clinic B.”
-community medical clinic
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Tool 14
Action
The following programs encourage questions. They contain brochures, posters,
and videos along with directions on how to implement them in a practice.
Although true patient activation takes much work to achieve, many practices
found these programs easy to implement and very helpful in focusing the
conversation, especially when used with Tool 5: The Teach-Back Method.
Ask Me 3: This program, designed by the National Patient Safety
Foundation, encourages patients to know three things before leaving the
encounter:
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
Questions Are the Answer: This campaign, created by AHRQ, encourages
patients to get more involved in their health care. It contains videos,
handouts, and an online question builder.
Tip
Clinicians can use the questions and strategies in these
programs to help structure patient visits.
Other considerations.
Invite questions using body language.
Sitting: Sit at the same level as your patient.
Look and listen: Look at patients when talking and listening,
as opposed to the chart or computer.
I have the time: Be conscious about presenting yourself as
having time and wanting to listen to their questions. Try not to
interrupt.
Solicit questions.
“What questions do you still have?”
“That was a lot of information. What do I need to go over
again?”
Avoid asking, “Do you have any questions?” This often leads
to a quick “no,” even if they do have questions.
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Tool 14
Involve the entire staff in soliciting questions.
Checkin: Have the clinical staff talk to patients while taking
vitals or checking them in about questions they want to ask the
doctor.
Ancillary staff: Use nurses, health educators, and other staff to
encourage questions.
Checkout: Ask each patient on their way out whether their
questions were answered.
Expand the scope.
Other health settings: Encourage patients to ask questions of
other physicians, pharmacists, etc.
Family and friends: Encourage patients to bring a relative or
friend to the next visit to help them remember information, and
include these people in the conversation.
Managing questions: If patients have many questions,
prioritize them with your patient and defer some to a future
visit.
Track Your Progress
Count the number of questions from patients before and after implementation.
This will provide good measurement for how well the strategies are
implemented.
Measure whether patients know the answers to the three questions as they exit.
For example, ask one patient a day at checkout if they know their main
problem, what they need to do, and why. See whether the responses change
over the course of 2 weeks. Check again after 2 months
Have all members of your team measure the number of patients that brought
or asked questions. Include questions asked by family or friends
accompanying the patient. Measure for 2 days before making changes, 2 days
after a month, and 2 days after 6 months.
Ask as patients exit, “Did you get a chance to ask all your questions?” If
patients answer no, ask whether the doctor/nurse said they would address
some questions later. Record the number of patients who answered “no” to
both questions over time.
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Make Action Plans
Tool 15
Make Action Plans
Overview
Many patients have trouble taking the actions they need to maintain their health
and manage their health conditions. An action plan, created by the patient and
clinician, outlines a step the patient can take to attain a larger health goal such as
quitting smoking or losing weight. Action plans help patients integrate these steps
or health behavior changes into their daily lives to achieve the goal, and they
allow for patients to be actively involved in their own care. Research has shown
that such plans are instrumental in bringing about behavior changes in patients. In
a recent study of more than 200 patients, 5 percent reported a behavior change in a
followup phone call 3 weeks after their visit with a physician when an action plan
was made.1
Purpose
To guide clinicians through the process of creating and using action plans in their
practice.
Tips
Opportunities to Use Action Plans
Making diet changes.
Smoking cessation.
Increasing physical activity.
Reducing stress.
Improving sleep habits.
Action
Action plan video.
Watch this 6-minute American College of Physicians Foundation
Video to see three examples of patients and providers creating an
action plan. (Scroll to the bottom of the Web page, and click on the
blue box “Ready, Set, Action Plans.”)
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Tool 15
Action plan forms.
Below are two options for action plan forms:
Action Plan Project
by the University of California at San
Francisco Department of Family and Community Medicine has
action plans in English, Spanish, and Chinese.
The Action Plan Form in this toolkit can be modified to fit
your needs.
Create action plans with patients.
Motivation: If a patient does not express the motivation to change,
then the patient is not ready for an action plan. The goal must be
important to the patient for the plan to be successful.
Created by the patient: The patient must determine the goal with the
provider’s guidance.
Small and realistic: Brainstorm small, specific, and realistic steps the
patient can take to achieve the goal that can be re-revaluated over a
short time period, like a week.
One step at a time: Have the patient pick one specific step that he or
she is likely to implement.
Fill out the form: Outline what, how much, when, and how often
they will do the step.
Assess confidence: Assess the patient’s confidence by asking, “How
confident are you that you can follow this action plan?” A patient
should feel confident, stating a 7 or higher on a scale of 0-10 on
confidence. If they are not, revise the goal so the patient feels
confident they can achieve it.
Ask the patient, “What might stop you from following this
action plan?” Problem solve about how to overcome barriers.
Make a copy of the action plan: Give a copy to the patient, and place
a copy in the patient’s chart.
Followup.
Followup is very important; it lets the patient know that you are
interested in helping them achieve behavior changes. Options for
followup include a phone call or meeting during an office visit.
If the goal was not achieved, the followup can help to redefine a goal
that can be achieved and result in recognized progress for the patient.
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Tool 15
If goals were achieved, celebration and praise are in order! Work with
the patient to make the next goal. Each small step gets the patient closer
to the ultimate goal of eating healthier, quitting smoking, losing weight,
etc.
Track progress. Action plans can help clinicians track patients’
progress over time and improve the likelihood that health goals will be
discussed in followup visits.
Refer to Tool 6: Followup with Patients for more information on
followup.
Help providers to remember to use an action plan.
Accessible: Copy the form and determine how it will be accessible to
physicians when they are seeing patients:
Place them in an accessible folder or drawer in the exam rooms.
Make it available in the electronic medical record.
Have the physicians carry their own supply.
Put them in patients’ charts.
Copy the action plans on colored paper so they stand out.
Track Your Progress
Assess frequency of use.
Have clinicians record in the chart whether an action plan was created or
reviewed. At the end of the first week, identify the percent of patients
who had an action plan created with their clinician. Check again in 2
months, 6 months, and 12 months to see how many action plans are
created or reviewed. Aim to create action plans for 90 percent of
patients that have chronic health problems or with specific unhealthy
behaviors within 12 months.
Resources
“Helping Patients Adopt Healthier Behaviors” is a four-page journal article
about actions plans that gives example dialogue on how to use them.
“What are Action Plans?” is a two-page document on action plans from the
University of California at San Francisco School of Medicine.
References
1
Handley M, MacGregor K, Schillinger D, et al. Using action plans to help primary care patients
adopt healthy behaviors: a descriptive study. J Am Board Fam Med. 2006;19(3):224-31.
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Improve Medication Adherence and Accuracy
Tool 16
Improve Medication Adherence and
Accuracy
Overview
Medication errors resulting in death have risen from 1,040 in 1983 to 8,634 in
2004.1 Medication errors such as taking the wrong dose or at the wrong time of
day are extremely common. Research has shown that patients with limited health
literacy are less likely to know how to take their medicine (e.g., how to use an
inhaler) and have more difficulty following complex medication regimens.2
Helping patients understand medications and how to take them can reduce the
number of medication errors. That knowledge can also help patients increase
their ability to care for their illnesses, especially chronic illnesses.
Purpose
To outline some approaches practices can use to help patients manage their
medication and improve medication adherence.
Action
Helping patients organize their medications provides an excellent opportunity to
educate them on the medications and their purpose.
Ask patients how they remember to take their medicines.
“Do you have a way to remember to take your medicines?”
“Everyone forgets to take their medicine from time to time. When was
the last time you forgot to take any of your medicine?”
Tips
When you prescribe medicine, write precise instructions for taking the
medicine. For example, write, “Take 1 pill in the morning and 1 pill at
bedtime.”
When a patient switches from a brand name to a generic medicine, tell
them that the color, shape, and size of the pill may change. If you are
using visuals, make sure you show the correct pill.
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Tool 16
Different methods of managing medications.
The following methods of medication organization and management
offer very different approaches. After talking with your patient, you can
determine which level of assistance would be most beneficial.
MedCard
Iowa Health Collaborative developed a “Know it, Show it, Tell
it” program for medications. The Web site provides a printable
two-sided form for listing medications and other health
information that can be folded and carried in a wallet (also in
Spanish). The site also has a poster for promoting it and
specific instructions.
Pill Chart
This pill chart is simple and easy to read, breaking the patient
medicines down into only what they need to know like “Brand
Name,” “Generic Name,” size (mg), and then the number of
pills of each medicine they take at what times.
Pill Cards
A pill card uses pictures and simple phrases to show each
medicine, its purpose, how much to take, and when to take it.
Patients or family members can also use the template to make
their own pill cards.
Pill Boxes
Obtaining pill boxes: Pill boxes are easily accessible on the
Internet, fairly inexpensive, and can be customized with a
sticker with your practice’s logo and phone number.
Filling pill boxes: Introducing patients to pill boxes and
teaching them how to fill their own boxes can be invaluable for
some patients and a strategy they use for many years. Show
patients, and then use Tool 5: The Teach-Back Method to
assure they understand. Encourage patients to bring their pill
boxes as well as their pill bottles, and refresh the teaching when
new medications are added.
Family members: Sometimes family members are capable of
filling and monitoring the pill boxes. Encourage your patients
to bring family members to appointments.
Home health agencies: Ask local home health agencies what
services they may have for filling pill boxes on a regular basis.
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Tool 16
Testimonial
“I was really drawn to the MedCard in Tool 16 and implemented this in the
clinic on a small scale. Although I quickly realized that it took the staff a lot of
time to fill out the information, I was struck by how much the patients appreciated it when we handed it to them. What I realized is that our Electronic Medical Record could be set up to supply the same information in a fairly efficient
way, so I set forth to make a few changes so we could offer this information to
our patients and easily keep our records and theirs updated.”
-family medicine practice
Find time to help patients manage their medicines. Some of these options take
a lot of time for the staff to do. Here are some suggestions to help with that.
Volunteer: Have a volunteer fill out MedCards, pill charts, or pill cards
prior to or after the visit, and mail them to the patient.
Electronic medical record: Look at your current electronic medical
record system and see if it can be adapted to create a medicine list that
would be easily read and understood by patients.
Family member or case manager: Pass the task on to a family member or
case manager and verify its accuracy when they bring it to their next
appointment.
Advertise the service. Display this Medication Aid Poster that outlines the
different options to help introduce patients to the service.
Record in chart. Note in patients’ charts what method they use to remember how
to take their medicine.
Track Your Progress
At the end of the first week, identify the percentage of patients who take medicine
that had a reminder strategy noted in their chart. Check again in 2, 6, and 12
months. Aim to have notes on reminder strategies for 90 percent of patients within
12 months.
Reference
1.
Phillips,DP. A steep increase in domestic fatal medication errors with use of alcohol and/or street
drugs. Arch Intern Med 2008;168(14):1561-6.
2. Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and Health Outcomes. Evidence Report/
Technology Assessment No. 87 (Prepared by RTI International-University of North Carolina
Evidenced-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04E007-2. Rockville, MD: Agency of Healthcare Research and Quality. January 2004.
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Get Patient Feedback
Tool 17
Get Patient Feedback
Overview
Patients are in the best position to judge if a medical office poses health literacy
challenges. Patients interact with a variety of office staff and clinicians while
they:
Fill out forms.
Discuss health concerns with clinicians.
Undergo diagnostic tests and treatment procedures.
Receive medication and self-care instructions.
Each step presents a risk for misunderstanding and confusion. Frequently,
practices are unaware of the level of difficulty patients encounter in completing
routine forms and navigating the health care system. Obtaining patient feedback
allows patients to play an active role in identifying areas of improvement for
health literacy.
Purpose
To provide guidance to practices on how to obtain and use patient feedback
regarding health literacy issues. This tool acquaints practices with the Consumer
Assessment of Healthcare Providers and Systems (CAHPS®) Clinician & Group
Survey—Item Set for Addressing Health Literacy. This tool also introduces other
means of obtaining feedback, such as shadowing patients, patient walkthroughs,
and getting patient feedback on written material.
Action
Select patients to provide feedback.
When identifying patients to provide feedback, be sure to select a
group of patients that are representative of your practice in terms of
age, gender, race/ethnicity, and health issues.
Survey: CAHPS® Clinician & Group Survey—Item Set for Addressing
Health Literacy.
Background: The CAHPS® Item Set for Addressing Health Literacy
consists of 29 items that aim to assesses the performance of practices
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Tool 17
regarding health literacy issues. These items are a supplement to the
CAHPS® Clinician & Group Survey (24 items). It is available in both
English and Spanish. If you already have a patient survey, you may
add CAHPS® items to your existing survey.
CAHPS® health literacy survey items: are on pages 8-14 of the
survey; the core set of questions is on pages 1-5. These items ask
patients to choose 1 of 4 responses to questions; Always, Usually,
Sometimes, Never. You can also go to CAHPS® Survey and
Reporting Kits for a version of items that includes 6 possible
responses.
Using the survey: Fielding the CAHPS® Clinician & Group Survey
provides guidance on using the CAHPS®. It provides instructions on:
Constructing the sampling frame.
Choosing the sample.
Maintaining confidentiality.
Collecting data.
Methods of data collection (i.e., mail only, telephone only, or
mixed mode: mail and telephone).
Tracking returned questionnaires.
Methods of administration: Because patients with limited literacy are
unlikely to respond to a mail survey, we suggest that you administer
the survey by phone or have a phone followup to a mail survey. We
have also included a Sample Cover Letter that can be mailed to
patients with the survey.
Analyze the results. After collecting the completed questionnaires,
have a member of your health literacy team examine the results and
identify which items received the lowest scores.
Identify improvement strategies. Have the health literacy team
prioritize which health literacy practice weaknesses to address first.
Identify and implement health literacy tools that can address these
areas. For more information see the About the CAHPS® Item Set for
Addressing Health Literacy.
Patient shadowing.
Process of shadowing: Shadow several patients over the course of a
week. When a patient makes an appointment, ask if you can
accompany them during the visit and do the following:
Stay with the patient from the moment they check in, while
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they are filling out forms, being taken to the exam room, etc.
At the end of the visit, discuss what went well and what was
difficult about the visit. Also ask them about their
communication with the office before the visit.
Note what health literacy practices were used (e.g., confirming
understanding through teach-back, avoiding medical jargon,
encouraging questions).
Navigating the Health Care System: A Health Literacy
Perspective Through the Eyes of Patients is a PowerPoint
presentation on a shadowing and walkthrough experience.
Review feedback. Bring the feedback to the Health Literacy Team and
identify improvement strategies.
Patient walkthrough.
One way to evaluate your practice is to have a person that is unfamiliar
with it walk through it and give you feedback on the feel and
navigation.
For more information, see pages 99-115 of The Health Literacy
Environment of Hospitals and Health Care Centers.
Patient feedback of written material.
Ask a variety of patients at the end of their visit or while they are
waiting to evaluate one or two of your forms or other written material
(also evaluate material that you did not develop). Think about asking
them the following questions:
Is the information clear and easy to understand?
Is it confusing in any way?
Are any parts/words hard to read or understand?
Is there anything offensive?
What is helpful and what isn’t?
In Other Words…Can They Understand? Testing Patient
Education Materials With Intended Readers has some great
tips on using patients to test material.
Track Your Progress
Assess for improvement.
Administer the CAHPS® Clinician & Group Survey—Item Set for
Addressing Health Literacy once a year. Compare results to determine
changes.
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Tool 17
Shadow several patients before and 6 months after initiating quality
improvement strategies based on your initial patient shadowing efforts.
Assess whether the same issues surface.
Three months after obtaining patient review of written materials, go
over the list of materials that were identified as needing revision or
replacement. Check whether these materials have been revised or
replaced or whether they are still being distributed.
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Link Patients to Non-Medical Support
Tool 18
Link Patients to Non-Medical Support
Overview
It is important to realize that limited literacy not only affects the patient’s health
care but all aspects of their life. Primary care practices think they don’t have time
to provide patients with extra support to help with things like understanding health
benefits, obtaining medication, housing, or transportation issues. They may feel
that they are wasting their time on petty issues. This assistance, however, is
critical to achieving optimal health.
It is not a matter of merely having a list of support services and making referrals.
Often we make a referral, but a breakdown occurs and the connection is not made.
Practices need to anticipate such breakdowns and build into their system of care a
commitment to make sure patients connect with needed services in a timely
manner. Making sure this happens involves assigning responsibility for support
activities, allocating staff time, and tracking outcomes.
Purpose
To suggest:
Approaches to assess patients’ needs for additional services.
Ideas for developing a list of community services.
Ways to create a system for helping patients with non-medical needs.
Action
Assess the problem.
Take time to listen to patients about the other things that may inadvertently
be affecting their health and take some ownership at trying to help them
overcome these challenges. Keep track of these issues in the chart.
Involve current support systems.
Most patients will have a support system in place, either formal or
informal. Asking patients how they get certain needs met may reveal
that they have a case manger or local social service agency that helps
them. They may mention a friend or family member that provides
support.
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Link Patients to Non-Medical Support
Tool 18
This support system may be very helpful at assisting the patient with
achieving medical goals, but you may also want to make a direct
connection. Ask the patient if you can invite them to clinic
appointments, e-mail them, or call them.
Develop a community resources list.
Information and Referral (I &R): There are various ways to identify
and obtain contact information for agencies and non-profits in your
community.
In many parts of the country The United Way and AIRS
(Alliance of Information and Referral Systems) 2-1-1–
Information & Referral Search can provide you with a phone
number to call for information about the social services in your
area, or simply dial 2-1-1 on your phone.
Many States have centers for non-profits that list various nonprofit agencies by county and service area.
Contact your local Chamber of Commerce, or city or county
government agencies for a list of services and programs in the
area.
Ask these agencies to send pamphlets or to give a presentation
to your practice so you understand their services, referral
process, and know a contact person.
Tips
Common Community Resources Patients May Need
Food pantries and goodwill locations
Transportation services
Domestic violence shelters
Youth mentoring programs
Budget management programs
Teen pregnancy programs
Support groups
Services for the hearing or visually impaired
Aging and caregiver services
Employment assistance program
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Link Patients to Non-Medical Support
Tool 18
Organize resources. Have one person in your practice gather
information and document the referral process. Make sure it is
updated regularly. Train everyone on how to use the resource guide,
or centralize the process and have one person do the referrals.
Internal referral form: Have a standard, simple Community Referral
Form that is used to give patients referral information with agency
name, phone number, and contact person if available. Understand that
some may not call when simply given a phone number of an agency.
Some patients may need the practice to be more proactive and actually
make the connection and appointment for them.
Personal contacts: Develop relationships with frequently used social
service agencies, case management agencies, and local social workers;
include them in care plans and when working with their clients.
Followup: Find out if the referral was completed. Followup with the
patient and the service provider. Document the results in the patient’s
chart.
Refer to Tool 6: Followup with Patients.
Create an environment for supporting patients.
Create a supportive atmosphere. The first step is greeting patients
with a smile. Make it an obvious priority to support patients in all
kinds of ways so they can achieve the best possible health. Understand
that it can sometimes be the patient that interferes with success. But
clearly presenting to the patients and the staff that the practice is
willing to support them in a variety of ways may create an atmosphere
where patients start to trust in at least one system—the practice.
Adjust office responsibilities. Consider rearranging responsibilities
within the practice so a staff person can take on the role of helping
patients with various non-health related problems.
Locate a social worker or community psychiatrist. Some assistance
provided by these individuals may be reimbursable through some
insurance plans, while others may work on a sliding scale. Meeting
with these individuals and getting to know them and their services can
be invaluable.
Think creatively and resourcefully.
Networking: Cultivate community networks by joining such
organizations as the Chamber of Commerce. For non-profit
organizations, recruiting influential board members like local
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Link Patients to Non-Medical Support
Tool 18
hospital executives can help to open doors for beneficial
relationships.
Collaboration: Think about collaborating with other area
practices to contract with an area professional for assistance
with more challenging patients.
Local resources: Think about services that other entities might
offer like a local hospital or university.
Other services you can offer: Certify one person in the
practice as a Notary Public. This can help expedite certain
forms and eliminate an additional step for patients. Locate a
Notary Public training course in your area.
Track Your Progress
Test whether your resource book is up to date. Call four randomly chosen
service providers, and verify their information.
Conduct a spot check of your charts. Choose 10 charts at random, and see if
they record patients’ non-medical challenges, the patient’s support systems,
and how the practice interfaces with them. Repeat again in 3 months, and see
if charts are more complete.
Track how many referrals are made in a month and then again after a few
months of implementation.
Make note of five referrals you have made. Check the patients’ charts 1 month
later to see if the outcome of the referral is documented.
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Medication Resources
Tool 19
Medication Resources
Overview
Medicine is often a vital ingredient to maintain health. Unfortunately, some
patients may try to save money by going without their medicines or reducing the
amount they take. Some larger pharmacies have recently helped the low-income
consumer by offering many generic medicines at a lower price. But these
programs do not always cover every medicine, and sometimes generic
prescriptions are not appropriate for the situation.
Purpose
To give practices some resources for helping patients with their medicine costs.
Action
Ask patients directly if they are having trouble getting their medicines.
“In these times, it is sometimes hard to afford all the things we need.
Are you having any trouble paying for your medicines?”
“Medicines can be expensive. Have you ever had any trouble paying
for your medicines?”
Inform patients that you can help.
Talk with patients about how important it is to take their medicines.
Let them know you want to help and have options for obtaining
medicines.
“Taking your medicines is important. If you ever have
problems affording your pills, please let me know BEFORE
you run out, and we can try to help you get them.”
Discuss medication assistance.
Insurance coverage: Find out if your patients know whether they
have prescription medication coverage under their health insurance
plan. If they do, make sure they understand they don’t have to pay the
full price for their medicines and that they should bring their insurance
card to the pharmacy. If your patient is uninsured, make a referral to an
agency that can help them apply for Medicaid or other subsidized
insurance. Likewise, if your patient is covered by Medicare but not by
Part D, make a referral to an agency that can counsel your patient
about the plan options.
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Medication Resources
Tool 19
Patient Assistance Programs.
Select Care Benefits Network is a patient advocate agency
working with low income patients to help them receive their
medications from pharmaceutical companies. This is not a free
service. It does charge a monthly fee, but they will let the
patient know over the phone if they qualify to receive the
medications from the pharmaceutical company prior to any
financial commitment.
RXAssist offers a comprehensive database of patient
assistance programs, as well as practical tools, news, and
articles, so that health care professionals and patients can find
the information they need.
Local funds. There may be some local agencies that would give
financial assistance for medications. Refer to Tool 18: Link Patients to
Non-Medical Support for more guidance on identifying local
medication assistance agencies.
Mail order. Some insurance plans offer patients the option of
receiving prescription medications by mail. Using this service may
save money and make it easier for your patient to get their
medications. Patients should contact their insurance plan for more
information.
Track Your Progress
Track over time how many patients need assistance paying for their
medicines, and note the services the practice provided.
Ask each patient seen during 1 week if they went without medicine or did not
take their full dose because of trouble paying for it in the last month. Repeat
after 6 months. Note whether there has been a decrease.
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Health and Literacy Resources
Tool 20
Use Health and Literacy Resources in the
Community
Overview
Your patients’ health outcomes may be improved through their participation in a
variety of health and literacy programs. Since it is unlikely that your practice is
able to offer all of the resources and services that your patients need, your ability
to help them connect to the appropriate organizations in your community is an
important part of your practice. Therefore, your practice staff should be prepared
and willing to do the following:
Identify resources available in your community.
Contact resources to discuss available programs and services.
Approach patients about the services available.
Assist patients in linking with these services and resources.
Purpose
To offer a method of identifying available health and literacy resources in your
community. In addition, it suggests ways to approach your patients and help them
connect with these resources.
Testimonial
“Through this toolkit our eyes were really opened up by the literacy resources in our community and how easy it is to talk to people about them.
We looked at Tool 20 and decided to contact the Literacy Directory for a local resource that would provide help for reading, math, GED, and English as
a second language (ESL). We were surprised at how quickly we were connected to a resource. We then called that program, which is run out of the
local community college, and they sent a representative over to the clinic
within an hour with brochures about the program. That all took no more
than 5 minutes of our time! The next step was to actually talk to patients in
the visit about these local services. I was very surprised that patients were
overwhelmingly receptive to questions like: “Are you interested in improving your reading skills?” Many were very interested in more information
about local programs, so I gave them a brochure, making sure to review it
with them and circling the number they are to call.”
-rural community health center
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Health and Literacy Resources
Tool 20
Action
1. Identify health and literacy resources.
MedlinePlus Go Local is a Web site that will enable you to search
and identify local health resources for specific areas of interest such as
diabetes management, weight loss, or smoking cessation. (Note: If no
results are visible on screen, scroll down.)
The Literacy Directory is a site that identifies local resources to
provide help with reading, math, GED, and English for speakers of
other languages (ESOL).
2. Contact the resource.
Call them to discuss the following:
Information about their program(s) or service(s).
How to make referrals.
How to contact them and where they are located.
Contact person’s name.
How to know if your patient enrolls or gets a service.
Tip
Examples of Community Health Resources and Programs
Diabetes Education
Weight Management Programs
Smoking Cessation Programs
Exercise/Fitness Programs
Support Groups
Stress Management Programs
3. Assist patients.
Be prepared to connect your patient with the appropriate health-or
literacy-related service.
Obtain or develop an easy-to-read handout such as this
Community Referral Form, for health, literacy or other
referrals information you give your patients. Include the
following information:
Name of the program.
Phone number.
Location and directions to get there.
Information to help the patient know what to expect from
each service.
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Health and Literacy Resources
Tool 20
Make it routine. During visits, think about community
resources that the patient may benefit from.
Review the handout, including the name of the person to
contact.
Help with the referral. Ask staff to help the patient by making
the initial phone call.
4. Followup.
By following up with a patient regarding a referral, a practice can:
Confirm that the patient actually successfully connected with
the resource.
Check the quality of the resource as a helpful service.
Reaffirm that you feel the patient could benefit from the
resource and that you care enough about the patient to see it
through.
Tip
Patients may be more likely to connect with a community resource or
service if they have a recommendation from their clinician.
5. Approach patients about literacy issues.
Because talking to patients about literacy issues may feel awkward,
the DIRECT tool1 offers suggestions about how to go about it.
D—Ask about difficulty reading.
“Have you ever had a problem with reading?”
I—Ask if they have an interest in improving.
“Would you be interested in a program to help you improve
your reading?”
R—Have referral information for ready for patients.
E—Ask everyone about their literacy skills.
C—Emphasize that low literacy is a common problem.
“Half of Americans have some difficulty with reading.”
T—Take down barriers to joining literacy classes:
Help with initial phone call.
Have informational sessions at the clinic.
Make followup contact with patients to see if they were
able to find the right class.
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Health and Literacy Resources
Tool 20
Track Your Progress
Test whether your resource book is updated. Call four service providers and
verify their contact information.
Track how many referrals are made in a month and then again after a few
months of implementation.
Note five literacy referrals you made and check the chart after 1 month to see
if the outcome is documented.
References
1. American Medical Association. “Health literacy and patient safety: Help patients understand.
Reducing the risk by designing a safer, shame-free health care environment.” 2007
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Appendix Items
Tool Name and Appendix Items
Overview
Plan-Do-Study-Act (PDSA) Directions and Examples
Plan-Do-Study-Act (PDSA) Worksheet
Tool 1: Form a Team
PowerPoint Presentation—Health Literacy, Barriers, and Strategies
Tool 2: Assess Your Practice
Health Literacy Assessment Questions
Tool 3: Raise Awareness
PowerPoint Presentation—Health Literacy, Barriers, and Strategies
Questions for Discussion
Moderator’s Guide
Tool 4: Tips for Communicating Clearly
Communication Self-Assessment
Key Communications Strategies Poster
Tool 5: The Teach-Back Method
PowerPoint Presentation- Teach-Back: A Health Literacy Tool to Ensure Patients
Understand
Teach-Back Self-Evaluation and Tracking Log
Tool 6: Followup with Patients
Followup Instruction Form
Tool 7: Telephone Considerations
Sample Automated Telephone System Menu
Tool 8: Brown Bag Medication Review
Brown Bag Medication Review Poster
Tool 11: Design Easy-to-Read Material
Adult Initial Health History Form
Young Child Health History Form
Adult Return Visit Update Form
Consent to Treat Form
Release of Medical Information
Lab Results Letter
Appointment Reminder
Tool 15: Make Action Plans
The Action Plan Form and Example
Tool 16: Improve Medication Adherence and Accuracy
Medication Aid Poster
Tool 17: Get Patient Feedback
Sample Cover Letter
Tool 18: Link Patients to Non-Medical Support
Community Referral Form and Example
Tool 20: Use Health and Literacy Resources in the Community
Community Referral Form and Example
Additional Items
List of Internet Resources
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PDSA Directions and Examples
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/introB.doc
To view in pdf, scroll to next page.
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PDSA Directions and Examples
The Plan-Do-Study-Act method is a way to test a change that is
implemented. By going through the prescribed four steps, it guides the
thinking process into breaking down the task into steps and then
evaluating the outcome, improving on it, and testing again. Most of us
go through some or all of these steps when we implement change in
our lives, and we don’t even think about it. Having them written down
often helps people focus and learn more.
For more information on the Plan-Do-Study-Act, go to the IHI (Institute
for Healthcare Improvement) Web site or this PowerPoint presentation
on Model for Improvement.
Keep the following in mind when using the PDSA cycles to implement
the health literacy tools:
Single Step - Each PDSA often contains only a segment or
single step of the entire tool implementation.
Short Duration - Each PDSA cycle should be as brief as
possible for you to gain knowledge that it is working or not
(some can be as short as 1 hour).
Small Sample Size - A PDSA will likely involve only a portion of
the practice (maybe 1 or 2 doctors). Once that feedback is
obtained and the process refined, the implementation can be
broadened to include the whole practice.
Filling out the worksheet
Tool: Fill in the tool name you are implementing.
Step: Fill in the smaller step within that tool you are trying to implement.
Cycle: Fill in the cycle number of this PDSA. As you work though a strategy for implementation,
you will often go back and adjust something and want to test if the change you made is better or
not. Each time you make an adjustment and test it again, you will do another cycle.
PLAN
I plan to: Here you will write a concise statement of what you plan to do in this testing. This will be
much more focused and smaller than the implementation of the tool. It will be a small portion of the
implementation of the tool.
I hope this produces: Here you can put a measurement or an outcome that you hope to achieve.
You may have quantitative data like a certain number of doctors performed teach-back, or
qualitative data such as nurses noticed less congestion in the lobby.
Steps to execute: Here is where you will write the steps that you are going to take in this cycle.
You will want to include the following:
The population you are working with – are you going to study the doctors’ behavior or the
patients’ or the nurses’?
The time limit that you are going to do this study – remember, it does not have to be long,
just long enough to get your results. And, you may set a time limit of 1 week but find out
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after 4 hours that it doesn’t work. You can terminate the cycle at that point because you got
your results.
DO
After you have your plan, you will execute it or set it in motion. During this implementation, you will
be keen to watch what happens once you do this.
What did you observe? Here you will write down observations you have during your
implementation. This may include how the patients react, how the doctors react, how the nurses
react, how it fit in with your system or flow of the patient visit. You will ask, “Did everything go as
planned?” “Did I have to modify the plan?”
STUDY
After implementation you will study the results.
What did you learn? Did you meet your measurement goal? Here you will record how well it
worked, if you meet your goal.
ACT
What did you conclude from this cycle? Here you will write what you came away with for this
implementation, if it worked or not. And if it did not work, what can you do differently in your next
cycle to address that. If it did work, are you ready to spread it across your entire practice?
Examples
Below are 2 examples of how to fill out the PDSA worksheet for 2 different tools, Tool 17: Get
Patient Feedback and Tool 5: The Teach-Back Method. Each contain 3 PDSA cycles. Each one
has short cycles and works through a different option on how to disseminate the survey to patient
(Tool 17: Patient Feedback) and how to introduce teach-back and have providers try it. (Tool 5:
The Teach-Back Method).
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PDSA (plan-do-study-act) worksheet
TOOL: Patient Feedback
STEP: Dissemination of surveys
CYCLE: 1st Try
PLAN
I plan to: We are going to test a process of giving out satisfaction surveys and getting
them filled out and back to us.
I hope this produces: We hope to get at least 25 completed surveys per week during this
campaign.
Steps to execute:
1. We will display the surveys at the checkout desk.
2. The checkout attendant will encourage the patient to fill out a survey and put it in
the box next to the surveys.
3. We will try this for 1 week.
DO
What did you observe?
We noticed that patients often had other things to attend to at this time, like making
an appointment or paying for services and did not feel they could take on another
task at this time.
The checkout area can get busy and backed up at times.
The checkout attendant often remembered to ask the patient if they would like to fill
out a survey.
STUDY
What did you learn? Did you meet your measurement goal?
We only had 8 surveys returned at the end of the week. This process did not work well.
ACT
What did you conclude from this cycle?
Patients did not want to stay to fill out the survey once their visit was over. We need to
give patients a way to fill out the survey when they have time.
We will encourage them to fill it out when they get home and offer a stamped envelope to
mail the survey back to us.
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PDSA (plan-do-study-act) worksheet
TOOL: Patient Feedback
STEP: Dissemination of surveys
CYCLE: 2nd Try
PLAN
I plan to: We are going to test a process of giving out satisfaction surveys and getting
them filled out and back to us.
I hope this produces: We hope to get at least 25 completed surveys per week during this
campaign.
Steps to execute:
1. We will display the surveys at the checkout desk.
2. The checkout attendant will encourage the patient to take a survey and an envelope.
They will be asked to fill the survey out at home and mail it back to us.
3. We will try this for 2 weeks.
DO
What did you observe?
The checkout attendant successfully worked the request of the survey into the
checkout procedure.
We noticed that the patient had other papers to manage at this time as well.
Per Checkout attendant only about 30% actually took a survey and envelope.
STUDY
What did you learn? Did you meet your measurement goal?
We only had 3 surveys returned at the end of 2 weeks. This process did not work well.
ACT
What did you conclude from this cycle?
Some patients did not want to be bothered at this point in the visit – they were more
interested in getting checked out and on their way.
Once the patient steps out of the building they will likely not remember to do the survey.
We need to approach them at a different point in their visit when they are still with us –
maybe at a point where they are waiting for the doctor and have nothing to do.
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PDSA (plan-do-study-act) worksheet
TOOL: Patient Feedback
STEP: Dissemination of surveys
CYCLE: 3rd Try
PLAN
I plan to: We are going to test a process of giving out satisfaction surveys and getting
them filled out and back to us.
I hope this produces: We hope to get at least 25 completed surveys per week during this
campaign.
Steps to execute:
1. We will leave the surveys in the exam room next to a survey box with pens/pencils.
2. We will ask the nurse to point the surveys out/hand then out after vitals and
suggest that while they are waiting they could fill out our survey and put it in box.
3. We will see after 1 week how many surveys we collected.
DO
What did you observe?
Upon self report, most nurses reported they were good with pointing out or handing
the patient the survey.
Some patients may need help reading survey but nurses are too busy to help.
On a few occasions the doctor came in while patient filling out survey so survey was
not complete.
STUDY
What did you learn? Did you meet your measurement goal?
We had 24 surveys in the boxes at the end of 1 week. This process worked better.
ACT
What did you conclude from this cycle?
Approaching patients while they are still in the clinic was more successful.
Most patients had time while waiting for the doctor to fill out the survey.
We need to figure out how to help people who may need help reading the survey.
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PDSA (plan-do-study-act) worksheet
TOOL: Teach-back
STEP: MDs initially performing Teach-back
CYCLE: 1st Try
PLAN
I plan to: We will ask the physicians in Wednesday PM to perform teach-back with the
last person they see that day.
I hope this produces: We hope that all the physicians will perform teach-back and find
that it was useful, did not take that much more time, and they will continue the practice.
Steps to execute:
1. We will ask the 5 physicians who hold clinic on Wednesday PM to perform teachback with their last patient of the day.
2. We will show these physicians the teach-back video.
3. After their last patient checks out, we will ask the physicians if they felt
a. it was useful?
b. it was time consuming?
c. they will do it again?
DO
What did you observe?
All physicians found the teach-back video informative and seemed eager to try this
new tool.
STUDY
What did you learn? Did you meet your measurement goal?
4 out of 5 physicians performed teach-back on at least one patient in the afternoon. The 1
physician who did not indicated she did not quite know how to integrate it into her visit.
ACT
What did you conclude from this cycle?
4 out of 5 felt comfortable with it and said they would continue using it.
For the 1 who was not sure how to integrate it, we will look for other teach-back resources to
help address this.
Ready to introduce to entire clinical staff.
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PDSA (plan-do-study-act) worksheet
TOOL: Teach-back
STEP: MDs continuing to perform Teach-back CYCLE: modified
2nd try
PLAN
I plan to: We will see if the physicians in Wednesday PM clinic are still performing
teach-back by asking them after their last patient leaves. (3 weeks have gone by since
initial introduction.)
I hope this produces: We hope that each of the physicians will have performed teach-back
on at least 3 of their afternoon patients.
Steps to execute:
1. We will approach the 5 physicians on Wednesday PM after their last patient leaves
and ask them to count the number of patients they performed teach-back on this
afternoon.
2. We will ask the physicians if they still feel
a. it was useful?
b. it was time consuming?
c. they will do it again?
DO
What did you observe?
Some physicians could not find appropriate situations for teach-back.
All still felt it was a worthy tool during their patient visits but feel they need to
remember it and practice it more.
STUDY
What did you learn? Did you meet your measurement goal?
3 out of 5 physicians said they did perform teach-back on 3 of their patients.
1 performed it in one instance.
1 did not perform it at all (same one as before).
ACT
What did you conclude from this cycle?
Teach-back is being used, maybe not as readily as I had anticipated.
Maybe the goals of ‘3 out of 6 patient encounters should contain teach-back’ is
unrealistic. We may put a sign in the clinic rooms, in view of the physicians, to remind
them about teach-back.
Will measure again in 6 months.
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PDSA (plan-do-study-act) worksheet
TOOL: Teach-back
STEP: MDs continuing performing Teach-back
CYCLE: 3rd Try
PLAN
I plan to: We want to see if the signs put up in the exam rooms help physicians remember
to do teach-back and increased its utilization.
I hope this produces: We hope that all the physicians will perform teach-back 3 out of 6
times.
Steps to execute:
1. We will put signs reading “Teach it Back” taped on the exam room desk/work area
to remind physicians to use the technique.
2. We will ask physicians if they notice the signs and if they reminded them to
perform teach-back.
3. We will see if Wednesday PM clinic had increased use of teach-back.
DO
What did you observe?
Nurses felt the sign will get in the way.
STUDY
What did you learn? Did you meet your measurement goal?
4 out of 5 physicians did teach-back on 3 patients Wednesday afternoon. 1 did it on 1
patient.
4 out of 5 said they did see the sign and that it was a reminder to do teach-back.
ACT
What did you conclude from this cycle?
That a reminder is needed (especially initially) to help physicians use this tool in their
visit.
No further intervention needed at this point.
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PDSA Worksheet
MS Word version available on the Internet at
http://www.nchealthliteracy.org/toolkit/introA.doc
To view in pdf, scroll to next page.
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PDSA (plan-do-study-act) worksheet
TOOL:
STEP:
CYCLE:
PLAN
I plan to:
I hope this produces:
Steps to execute:
DO
What did you observe?:
STUDY
What did you learn? Did you meet your measurement goal?
ACT
What did you conclude from this cycle?
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Health Literacy, Barriers and Strategies
The PowerPoint presentation is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool1A.ppt
To view slides in pdf, scroll to next page.
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Health Literacy:
Hidden Barriers
and
Practical Strategies
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Hidden Barriers to Communicating
with Patients
Clients/Patients:
Education/ Literacy/ Language
Health Literacy:
Capacity to
• Obtain, process, understand basic health
information and services
• Make appropriate healthcare decisions (act on
information)
• Access/ navigate healthcare system
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IOM Report on Health Literacy
•
90 million adults have trouble understanding
and acting on health information
•
Health information is unnecessarily complex
•
Providers need health literacy training
Healthy People 2010
•
Improve health communication/health literacy
Joint Commission (1993)
•
Patients must be given information they understand
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“As a former nurse,
trauma surgeon, and
public health director [I
realized] there was a
wall between us and the
people we were trying to
serve.
Health care professionals
do not recognize that
patients do not
understand the health
information we are
trying to communicate.
We must close the gap
between what health care
professionals know and
what the rest of America
understands.”
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Dr. Richard Carmona,
Former U.S. Surgeon General
mentioned health literacy in
200 of last 260 speeches
99
U.S. high school dropout rate is 30%
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EPE Research Center (2008). “Cities in Crisis”
Red Flags for Low Literacy
Frequently missed appointments
Incomplete registration forms
Non-compliance with medication
Unable to name medications, explain purpose or
dosing
Identifies pills by looking at them, not reading label
Unable to give coherent, sequential history
Ask fewer questions
Lack of follow-through on tests or referrals
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Mismatched Communication
Provider Process: Giving information
Patient Process: Understanding, remembering, and acting on
information
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Our Expectations of
Patients are Increasing…
Prevention (eating, exercise, sunscreen, dental)
Immunization
Self Assessment of Health Status
• Peak flow meter
• Glucose testing
Self-treatment
• Insulin adjustments
Health Care Use
• When to go to clinic/ ER
• Referrals and follow-up
• Insurance/ Medicare
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And the Process is Becoming
More Complex
PP – Prior to seeing physician
ED – Emergency Department
F/U – Follow up
HCP – Health care professional
Health Literacy and Patient Safety:
AMA Foundation, 2007
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“
Patient Safety: Medication
Errors
“How would you take this medicine?”
395 primary care patients in 3 states
• 46% did not understand instructions ≥ 1 labels
• 38% with adequate literacy missed at least 1 label
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Davis TC , et al. Annals
Int Med 2006
105
“Show Me How Many Pills You
Would Take in 1 Day”
John Smith
Dr. Red
Take two tablets by
mouth twice daily.
Humibid LA
600MG
1 refill
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Slide by Terry Davis
Rates of Correct Understanding vs. Demonstration
“Take Two Tablets by Mouth Twice Daily”
89
84
71
80
63
35
Davis TC , et al.
Annals Int Med 2006
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Lessons Learned From Patients
•
Tell me what’s wrong (briefly)
•
What do I need to DO & why
•
Emphasize benefits (for me)
If meds, break it down for me:
1.
What it is for
2. How to take (concretely)
3. Why (benefit)
4. What to expect
Remember: what’s clear to you is clear to you!
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Strategies to Improve Patient
Understanding
Focus on ‘need-to-know’ & ‘need-to-do’
Use “Teach Back”
Demonstrate/ draw pictures
Use clearly written education materials
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Focus on “Need-to-know”
& “Need-to-do”
What do patients need to know/do…?
• When they leave the exam room
• When they check out
• What do they need to know about?
• Taking medicines
• Self-care
• Referrals and follow-ups
• Filling out forms
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“Teach-back”
Ensuring agreement and understanding about
the care plan is essential to achieving
adherence
“I want to make sure I explained it correctly.
Can you tell me in your words how you
understand the plan?”
Some evidence that use of “teach-back” is
associated with better diabetes control
Schillinger, D. Archives of Internal Med, 2003
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‘Teach-back’ Improves Outcomes
Diabetic Patients with Low Literacy
Audio taped visits – 74 patients, 38 physicians
Patients recalled < 50% of new concepts
Physicians assessed recall 13% of time
When physicians used “teach back” the
patient was more likely to have HbA1c levels
below the mean
Visits that assessed recall were not longer
Schillinger, D. Archives of Internal Med, 2003
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Teach-back
Explain
Assess
Clarify
Understanding
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Confirm patient understanding
“Tell me what you’ve understood”
“I want to make sure I explained
your medicine clearly. Can you tell
me how you will take your
Do you
medicine?”
understand?
Do you have any
questions?
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Patient Education: What We Know
•
•
Written materials, when used alone, will not
adequately inform
Patients prefer receiving key messages from
their clinician with accompanying
pamphlets
•
•
Focus needs to be “need-to-know” & “need-to do”
Patients with low literacy tend to
ask fewer questions
•
Bring a family member and
medication to appointment
IOM: Report on Health Literacy 2004
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Berkman et al. AHRQ Report 2004
115
Visuals Improve Understanding/
Recall
Pictures/demonstrations most helpful
to patient with low literacy & visual
learners
Most health drawings too complicated
Physician drawings often very good (not
too complex)
Patients say “show me” & “I can do it”
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7 Tips for Clinicians
Use plain language
Limit information (3-5 key points)
Be specific and concrete, not general
Demonstrate, draw pictures, use models
Repeat/Summarize
Teach-Back (Confirm Understanding)
Be positive, hopeful, empowering
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Use Plain Language
20 complicated and commonly used words
• Screening
• Mental Health
• Dermatologist
• Annually
• Immunization
• Depression
• Contraception
• Respiratory problems
• Hypertension
• Oral
• Community Resources
• Monitor
• Diabetes
• Cardiovascular
• Diet
• Referral
• Hygiene
• Eligible
• Prevention
• Arthritis
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Examples of Plain Language
Plain Language
Annually
Arthritis
Cardiovascular
Dermatologist
Diabetes
Hypertension
Yearly or every year
Pain in joints
Having to do with the heart
Skin doctor
Elevated sugar in the blood
High blood pressure
The Plain Language Thesaurus for Health Communications
http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf
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Is your Clinic/ Site Patient-centered?
What is the ‘tone,’ 1st impression?
A welcoming, calm environment
An attitude of helpfulness by all
staff
Patients treated as if your family
Patient-centered check-in &
scheduling
Easy to follow instructions/
directions
Patient-centered handouts
Brief telephone followup
Case management
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Discussion Questions
Looking back, have there been instances when
you suspected, or now suspect, that a patient
might have low literacy? What were the signs?
Do we do things in our practice that make it
easier for patients with low literacy to
understand services and information?
Consider the entire process of patient visits, from
scheduling an appointment to check-out
What strategies could all of us adopt to minimize
barriers and misunderstanding for low literacy
patients?
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Acknowledgements
Most slides and material were created by
•
Terry Davis, PhD
With additions by
• Darren DeWalt, MD, MPH
• Ashley Hink, MPH
• Victoria Hawk, RD, MPH
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Health Literacy Assessment Questions
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool2A.doc
To view in pdf, scroll to next page.
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Health Literacy Assessment Questions
Have several staff members complete the questions on their own, and then
come together for a group discussion to review the results. Please refer to
Tool 2: Assess Your Practice for more information.
Please select one answer that most accurately describes your practice:
Doing Well
Needs Improvement
Not Doing
Not Sure
N/A
Our practice is doing this well
Our practice is doing this, but could do it better
Our practice is not doing this
I don’t know the answer to this question
This is not applicable to our practice
Importance:
* Beneficial ** More Beneficial *** Most Beneficial
1. Improve Spoken Communication
Doing
Well
1. Staff members have received awareness
and sensitivity training about health
literacy issues.
2. All levels of practice staff have agreed
to support changes to improve patient
understanding.
3. Staff offers everyone help regardless of
appearance (e.g., filling out forms,
giving directions).
4. Staff members who have patient contact
can identify behaviors that may indicate
literacy problems.
5. Staff uses clear oral communication
techniques (e.g., uses plain, everyday
words, limit to 3-5 main points, and
information is specific and concrete).
6. Staff does not use medical jargon when
communicating with patients (e.g., not
using words like anticoagulant,
hypertension, NPO).
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Needs
Improvement
Not
Doing
Not
Sure
or
N/A
Importance
Tools to
Help
***
1-Form
Team
3-Raise
Awareness
***
1-Form
Team
3-Raise
Awareness
***
3-Raise
Awareness
11-Design
Material
*
3-Raise
Awareness
***
3-Raise
Awareness
4-Commun.
Clearly
***
3-Raise
Awareness
4-Commun.
Clearly
124
1. Improve Spoken Communication
Doing
Well
Needs
Improvement
Not
Doing
Not
Sure
or
N/A
7. Staff does not talk too fast when
communicating with patients.
8. Staff uses audio/video materials and/or
visual aids to promote better
understanding and enhance
communication with patients (e.g., food
models for portion sizes, model of body
part, and instructional health videos).
9. Clinical staff talks with patients about
any education materials they receive
during the visit and emphasizes the
important information.
10. Staff asks patients to state key points in
their own words (i.e., teach-back
method) to assess understanding of care
instructions.
11. Staff encourages patients to ask
questions by using these words: “What
questions do you have?” instead of “Do
you have any questions?”
12. Staff uses trained interpreters or
language services with patients who do
not speak English well.
13. When staff gives directions for finding
the office, they refer to familiar
landmarks and public transportation
routes as needed.
14. If there is an automated phone system,
one option is to speak with a person.
15. If there is an automated phone system,
one option is to repeat menu items.
16. When a phone call is answered (either
by person or an automated phone
system), there is an option to hear
information in a language other than
English (if appropriate to the needs of
your community).
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Importance
Tools to
Help
**
4-Commun.
Clearly
**
4-Commun.
Clearly
12-Use
Health Ed.
Material
***
12-Use
Health Ed.
Material
***
5-Teach
Back
Method
**
5-Teach
Back
Method
14-Enc.
Questions
***
9-Language
Differences
*
7-Telephone
**
7-Telephone
*
7-Telephone
**
7-Telephone
125
Please select one answer that most accurately describes your practice:
Doing Well
Needs Improvement
Not Doing
Not Sure or
N/A
Our practice is doing this well
Our practice is doing this, but could do it better
Our practice is not doing this
I don’t ’know the answer to this question
This is not applicable to our practice
Importance:
* Beneficial ** More Beneficial *** Most Beneficial
2. Improve Written Communication
Doing
Well
Needs
Improvement
Not
Doing
Not
Sure
or
N/A
17. A sign identifies the location where
patients checkin.
18. At least 1 staff member knows how to
identify, prepare and simplify written
materials so they are easier to read.
Importance
Tools to
Help
**
13-Welcome
Patients
11-Design
Material
12-Use
Health Ed.
Material
11-Design
Material
12-Use
Health Ed.
Material
11-Design
Material
12-Use
Health Ed.
Material
***
19. Staff pilot test new written materials for
appeal and comprehension with a few
patients.
***
20. Staff have reviewed all of our written
materials to check how easy they are to
read using a readability formula.
**
***
12-Use
Health Ed.
Material
21. Patient education materials are concise,
limit jargon, and are designed using
standard techniques to make them easy
to read.
22. If appropriate, our written materials are
available in languages other than
English.
23. All clinic forms intended for patient
use/data collection are concise, limit
jargon, and are designed using standard
techniques to make them easy to read.
24. Lab and test results letters are concise,
limit jargon, and are designed using
standard techniques to make them easy
to read (e.g., avoid the use of “positive”
or “negative” results).
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**
12-Use
Health Ed.
Material
9-Language
Differences
***
11-Design
Material
***
11-Design
Material
126
2. Improve Written Communication
Doing
Well
Needs
Improvement
Not
Doing
Not
Sure
or
N/A
***
11-Design
Material
*
13-Welcome
Patients
*
13-Welcome
Patients
*
13-Welcome
Patients
*
13-Welcome
Patients
*
13-Welcome
Patients
*
13-Welcome
Patients
*
13-Welcome
Patients
9-Language
Differences
25. Appointment slips are clear and
concise. They provide contact
information for patients with questions
and, when needed, include preparation
instructions that are easy to understand.
26. The name of the practice is clearly
displayed on the outside of the building
and front door.
27. Office signs use large, clearly visible
lettering.
28. Signs are posted throughout the office
to direct patients to find appropriate
locations (e.g., restrooms, checkout, lab
work, etc.).
29. The walls and bulletin boards are not
covered with many printed notices. It is
easy for anyone to pick out the
important information.
30. Office signs use plain, everyday words
such as “Walk‐In” and “Health Center”
rather than formal words such as
“Ambulatory Care” or “Primary Care
Practice.”
31. Consistent symbols/graphics are used
on signs throughout the facility.
32. Office signs are written in English and
in the primary languages of the
populations being served (e.g., if most
of the patients speak English and
Spanish, signs are written in English
and Spanish).
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Importance
Tools to
Help
127
Please select one answer that most accurately describes your practice:
Doing Well
Needs Improvement
Not Doing
Not Sure or
N/A
Our practice is doing this well
Our practice is doing this, but could do it better
Our practice is not doing this
I don’t know the answer to this question
This is not applicable to our practice
Importance:
* Beneficial ** More Beneficial *** Most Beneficial
3. Improve Self-Management and Empowerment
Doing
Well
Needs
Improvement
Not
Doing
Not
Sure
or
N/A
***
14 – Enc.
Questions
*
14– Enc.
Questions
***
15-Make
Action Plans
***
12-Use
Health Ed.
Material
***
8-Brown Bag
Review
***
16Medication
Adherence
***
6-Followup
***
1-FormTeam
17-Patient
Feedback
33. Staff creates an environment that
encourages our patients to ask questions
and get involved with their care.
34. Staff encourages patients to write down
questions while waiting for their
appointment.
35. Clinicians work with patients to discuss
health care priorities and develop action
plans to promote behavior change.
36. Clinicians and staff have clear roles and
responsibilities about teaching patients
self-management skills (e.g., dietary
advice, using a glucometer or inhaler).
37. Our staff reviews medications with
patients at least annually, and after any
significant medical event to ensure
concordance between patient and
clinical recommendations.
38. Our staff discusses different methods
for taking medications correctly and
offers patients assistance setting up a
system (e.g., pill box, pill chart).
39. Our staff contacts our patients between
office visits to ensure understanding or
to follow up on plans made during the
visit.
40. Our practice requests feedback from
patients.
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Importance
Tools to
Help
128
Please select one answer that most accurately describes your practice:
Doing Well
Needs Improvement
Not Doing
Not Sure or
N/A
Our practice is doing this well
Our practice is doing this, but could do it better
Our practice is not doing this
I don’t know the answer to this question
This is not applicable to our practice
Importance:
* Beneficial ** More Beneficial *** Most Beneficial
4. Improve Supportive Systems
41. Staff assesses patient’s language
preference.
42. Staff assists patients to find affordable
medications and fill out applications as
needed.
43. Staff asks patients if they would like
help understanding their medical bills or
insurance forms.
44. Staff asks patients if they need extra
support and offers to work together with
them.
45. Staff assesses patient’s non-medical
barriers and takes initiative to address
them and provide appropriate referrals
or extra support as needed.
46. Staff confirms (by mail or phone)
patient followthrough after a referral is
made.
47. Staff maintains an updated list of
community resources and refers patients
as needed.
48. Staff helps patients to access
community-based programs (e.g., adult
literacy, English for speakers of other
languages, stop smoking, weight loss).
49. Staff demonstrates knowledge and
sensitivity to patients’ cultural beliefs
and customs.
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Doing
Well
Needs
Improvement
Not
Doing
Not
Sure
or
N/A
Importance
Tools to
Help
***
13-Welcome
Patients
9-Language
Differences
***
20-Health &
Literacy
Resources
**
18-NonMedical
Support
**
18-NonMedical
Support
**
18-NonMedical
Support
**
6-Followup
**
20-Health &
Literacy
Resources
18-NonMedical
Support
**
20-Health &
Literacy
Resources
**
10-Culture
& Other
Consider.
129
Questions for Discussion
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool3B.doc
To view in pdf, scroll to next page.
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Health Literacy Video
Questions for Discussion
1. Now that you realize “you can’t tell someone’s health literacy
status just by looking,” what are some things that you have noticed
that would suggest your patients may have a difficult time
understanding?
2. Consider the patients featured in this video. What surprised you
about their attitudes, concerns, or questions?
3. What have you learned that you will use to improve your
communication with patients?
4. What is the most important thing that your practice needs to
change to promote better communication?
5. What ideas do you have for changes that would improve your
patients’ understanding?
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Moderator’s Guide
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool3C.doc
To view in pdf, scroll to next page.
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Health Literacy Video
Moderator’s Guide
What should your practice do to improve your patients’ understanding of
health related information and self-care instructions? This guide is for the
moderator of the discussion following the presentation of the health
literacy video.
Discussion Guidance
To promote a productive discussion, please review the following
information with the participants before you begin. Stress that there is
work to do to move forward with implementing health literacy universal
precautions in your practice and ideas and support from all staff is
essential.
Remind participants that:
Everyone is encouraged to speak.
No one or two individuals should dominate the discussion.
All ideas will be considered.
Participants should listen to each other.
Other suggestions for the facilitator:
Identify one person to take notes.
Review each question.
Summarize key ideas.
Identify the next steps for your practice.
Allow at least 30 minutes for discussion.
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Communication Self-Assessment
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool4A.doc
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Communication Self-Assessment
Directions: After a patient encounter, rate your level of agreement to the statements in the table.
Your self-assessment is subjective, but it allows you to examine your oral communication with
patients honestly. After completing the assessment, think about how you may enhance areas in
need of improvement.
Disagree
Neutral
Agree
I greeted the patient with a kind, welcoming attitude.
I maintained appropriate eye contact while speaking with the
patient.
I encouraged the patient to voice his or her concerns throughout
the visit.
I spoke clearly and at a moderate pace.
I explained things using non-medical language.
I limited the discussion to fewer than 5 major points or topics.
I gave specific, concrete explanations and instructions.
I repeated key points.
I used a visual aid such as a picture, diagram, or model to help
explain something to my patient (if applicable).
I asked the patient what questions he or she had.
I verified that the patient understood the instructions I gave him
or her.
What are areas can you improve on? What strategies can you use to improve them?
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Key Communication Strategies Poster
MS Word version available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool4B.doc
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Key Communication Strategies
Warm Greeting
Eye Contact
Slow Down
Limit Content
Teach-Back
Repeat Key Points
Patient Participation
Plain, Non-medical Language
Use Graphics When Explaining
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Teach-Back: A Health Literacy Tool to Ensure
Patient Understanding
The PowerPoint presentation is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool5A.ppt
To view slides in pdf, scroll to next page.
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Teach-back:
A Health Literacy Tool to
Ensure Patient Understanding
Presentation created by The Iowa Health System Health
Literacy Collaborative
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Objectives - After completing this
module, you will be able to:
Define teach-back and its purpose
• Describe the key elements for using
teach-back correctly
• Use teach-back in the clinical setting
•
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Health Literacy
•
...the capacity to obtain, process, and
understand basic health information
and services needed to make
appropriate health decisions.
Ratzan & Parker, 2000
•
…the ability to read, understand, and
use health information to make
appropriate healthcare decisions and
follow instructions for treatment.
AMA & AMA Foundation, 2003
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How Patients Feel
●
Patients may have negative feelings and
emotions related to their limited reading ability or
limited understanding.
Institute of Medicine, 2004
●
The health care environment can make it hard for
patients to tell us they don’t read well or do not
understand.
●
They hide this with a variety of coping
techniques.
Parikh N Pt Educ and Counseling 1996
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The Right to Understand
●
Patients have the right to understand healthcare
information that is necessary for them to safely
care for themselves, and to choose among
available alternatives.
●
Healthcare providers have a duty to provide
information in simple, clear, and plain language
and to check that patients have understood the
information before ending the conversation.
The 2005 White House Conference on Aging;
Mini-Conference on Health Literacy and Health Disparities.
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The Challenge
●
Research shows that patients remember
and understand less than half of what
clinicians explain to them.
Ley, Communicating with patients: improving communication
satisfaction, and compliance 1988
Rost, Predictors of recall of medication regimens and recommendations
for lifestyle change in elderly patients 1987.
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Universal Communication Principles
●
Everyone benefits from clear information.
●
Many patients are at risk of misunderstanding,
but it is hard to identify them.
●
Testing general reading levels does not ensure
patient understanding in the clinical setting.
Adapted from: Reducing the Risk by Designing a Safer, Shame-Free Health
Care Environment. AMA, 2007
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Talking with Patients & Families
Always:
●
Use Plain Language.
●
Slow down.
●
Break it down into short statements.
●
Focus on the 2 or 3 most important
concepts.
●
Check for understanding using teach-back.
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Teach-back
Why do I use it?
• What is it?
• How do I use it?
• When do I use it?
•
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Teach-back is…
●
Asking patients to repeat in their own
words what they need to know or do, in a
non-shaming way.
●
NOT a test of the patient, but of how well
you explained a concept.
●
A chance to check for understanding and, if
necessary, re-teach the information.
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Teach-back is Supported by Research
● “Asking that patients recall and restate what they
have been told” is one of 11 top patient safety
practices based on the strength of scientific
evidence.”
AHRQ, 2001 Report, Making Health Care Safer
● “Physicians’ application of interactive
communication to assess recall or comprehension
was associated with better glycemic control for
diabetic patients.”
Schillinger, Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”
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Asking for a Teach-back - Examples
Ask patients to demonstrate understanding,
using their own words:
● “I want to be sure I explained everything clearly. Can
you please explain it back to me so I can be sure I
did?”
● “What will you tell your husband about the changes
we made to your blood pressure medicines today?”
● “We’ve gone over a lot of information, a lot of things
you can do to get more exercise in your day. In your
own words, please review what we talked about. How
will you make it work at home?”
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Teach-back…
● Creates an opportunity for dialogue in which the
provider gives information, then asks the patient
to respond and confirm understanding before
adding any new information.
● Re-phrase if a patient is not able to repeat the
information accurately.
● Ask the patient to teach back the information again,
using their own words, until you are comfortable they
really understand it.
● If they still do not understand, consider other
strategies.
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Teach-Back: Closing the Loop
Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop
Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003
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Teach-back – Additional Points
●
Do not ask yes/no questions like:
o
o
●
“Do you understand?”
“Do you have any questions?”
For more than one concept:
o
“Chunk and Check”
Teach the 2-3 main points for the first
concept & check for understanding using
teach-back…
Then go to the next concept
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Teach-back – Using it Well:
Elements of Competence
●
●
●
●
●
●
Responsibility is on the provider.
Use a caring tone of voice & attitude.
Use Plain Language.
Ask patient to explain using their own words
(not yes/no).
Use for all important patient education, specific
to the condition.
Document use of & response to teach-back.
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Patient Rights
It is neither just, nor fair, to expect a
patient to make appropriate health
decisions and safely manage his/her
care without first understanding the
information needed to do so.
Reducing the Risk by Designing a Safer, Shame-Free
Health Care Environment. AMA, 2007
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IHS Ankeny Clinic
Physician Experience
●
“In the absence of teach-back, the only
indicator of misunderstanding may be a
medication mistake or patient error,
which could be harmful.”
●
There were “surprising misconceptions
of patients’ understanding of
instructions. Nonverbal cues do not
seem reliable.”
Dr. Fred Marsh, 2004
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Questions to Consider
What are specific topics or directions you
commonly discuss with your patients that you
can use the teach-back method with?
Ideas: Insulin injections, inhalers, medication
changes, chronic disease self-care, colonoscopy
prep
How can you phrase your teach-back
questions? Brainstorm and discuss how you
can ask questions for the scenarios above.
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Acknowledgements
●
●
●
●
●
●
Iowa Health System
o
Health Literacy Teams
o
Mary Ann Abrams, MD, MPH
o
Bob Dickerson, MSHSA, RRT
o
Barb Earles, RN, MHA, CPHRM
o
Gail A. Nielsen, BSHCA, IHI Fellow
o
Barb Savage, MT (ASCP)
American Medical Association
American Medical Association Foundation
New Readers of Iowa
Audrey Riffenburgh, MA, Riffenburgh & Associates
Ashley Hink, MPH
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Teach-Back Self-Evaluation and Tracking Log
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool5B.doc
To view in pdf, scroll to next page.
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Teach-Back Self-Evaluation and Tracking Log
Name: ___________________________________ Start/end date:_____/_____
Patient
ID
# Items
to do or
remember
1. Increase
evening
insulin dose
to 26 units.
2. Start
Enalapril 5
mg, take 1
pill every
morning.
Teachback
used?
Yes No
X
Results – Clarification needed? Patient perceptions?
Your assessment?
What to do
differently next time
I asked the patient to tell me his medication changes. He understood
the addition of Enalapril and the dose, but he forgot how much I
asked him to increase his insulin dose by. I clarified, and he actually
expressed his appreciation for my confirmation.
If I find that many patients
can’t recall their
medication changes, I may
use a form to write them
down for all patients.
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Followup Instruction Form
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool6A.doc
To view in pdf, scroll to next page.
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Followup Instruction Form
For a Diabetes Patient
Patient Name:
Date:
Provider:
Educator:
Goals:
1.
2.
Medicine Changes:
1.
2.
3.
4.
5.
Blood Sugar Testing:
Date
Before
Breakfast
After
Breakfast
Before
Lunch
After
Lunch
Before
Dinner
After
Dinner
Bedtime
Call (clinic phone number) or fax (clinic fax number) your blood sugars on
2 to 3 AM
(date)
When you fax or phone in blood sugars, please give us a phone number we can call you at.
Phone number
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Sample Automated Telephone System Menu
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool7A.doc
To view in pdf, scroll to next page.
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Sample Automated Telephone System Menu
Introduction
You have reached the
Family Practice
Language Choice
o For choices in English
press 1
o For choices in Spanish
press 2 (recorded in
Spanish)
Medical Emergency
o If this is a medical
emergency, hang up and
call 911
Appointments
For appointments
press 1
o To make or
change an
appointment
press 1
o To cancel o
confirm an
appointment
press 2
Refill or Referral
Directions
Speak with Staff
For refills or
referrals press 2
For directions to
our office press 3
To speak with a
staff member press
0
o For refills press
1
o For referrals
press 2
o For driving
directions press
1
o For bus
information
press 2
o To speak with a
staff member
press 1
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Repeat
To repeat these
choices press 4
164
Brown Bag Medication Review Poster
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool8A.doc
To view in pdf, scroll to next page.
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Bring ALL Your Medicines to
EVERY Appointment!
This includes:
Prescription medicines.
Over-the-counter medicines.
Herbal medicines.
Vitamins and supplements.
Your doctor will go over them with you to:
Review what you are taking.
Make sure you are taking them right.
See if you can take fewer medicines.
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Adult Initial Health History Form
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11A.doc
To view in pdf, scroll to next page.
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Adult Initial Health History
Name
First
Middle
Last
Today's Date
Date of Birth
Address
Telephone Number
(home)(
(cell) (
(work) (
)
)
)
Filling out this form
Answering these questions will help your doctor understand
your health and how best to treat you.
If you need help filling out this form:
o Bring this form with you to your appointment and a nurse will help you.
OR
o Call the clinic at [555-1212 ext. 123] before your appointment and
someone can help you over the phone.
Bring to your appointment:
1. This Initial Health History Form
and any other important
medical records
2. Your insurance information
3. All your medicines (prescription,
herbal, over-the-counter pills and creams)
We look forward to working with you!
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GENERAL HEALTH
1. Why did you make this appointment? (Check all that apply.)
regular checkup
first appointment to start care with a new doctor
switching doctors (from whom:
have a specific health problem (if so, explain
)
)
2. In general, what do you consider to be your main health problem(s)? (Check all that
apply.)
heart problems
diabetes
stomach problems
depression/emotional problems
ear, nose, or throat problems
joint problems
high blood pressure
Other(s) – please explain
3. How would you describe your health?
Excellent
Very Good
Good
Fair
Poor
4. Are you taking any prescription medicines?
Yes. Please list your medicines below OR
I brought my pill bottles or a list.
No, I do not take any prescription medicines. (If no, go to question #5.)
Name of medicine
Amount / How many pills or doses do you take at
size of pill
Example:
dinner
morning
noon
dinner
morning
noon
dinner
morning
noon
dinner
morning
noon
dinner
morning
noon
dinner
morning
noon
dinner
(Please use the back of this form if you have more prescription medicines.)
Furosemide
20 mg
2 morning
2 noon
_ bed
bed
bed
bed
bed
bed
bed
5. What over-the-counter medicines, do you take regularly?
Pain reliever (for example: Tylenol, Advil, Motrin, Aleve, aspirin)
Vitamins
Antacid (for example: Tums, Prilosec)
Herbal medicine (please list)
Other (please list)
None - I do not take any over-the-counter medicines regularly.
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6. Have you ever had any allergic reaction (bad effects) to a medicine or a shot?
Yes. (Please write the name of the medicine and the effect you had.)
No, I am not allergic to any medicines.
Medicine I am allergic to What happens when I take that medicine
Example:
Atenolol
I get a rash
7. Do you get an allergic reaction (bad effect) from any of the following? (Check all
that apply)
latex (rubber gloves)
grass or pollen
eggs
shellfish
Other (please describe)
No - I have no allergies that I know of.
8. Have you ever been a patient in a hospital overnight?
Yes. (If yes, explain EACH reason and when.)
No, I have never been a patient in a hospital. (If no, go to question #9)
I was in the hospital because:
When
Example:
Heart Attack
6 years ago
9. Have you ever had a colonoscopy (a test to look at your insides by sending a camera
through your bottom)?........... ……………………..................................... Yes
No
When
10. Have you ever received a blood transfusion (when you are given extra
blood)? …………………………………………………………………… Yes
When
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FOR WOMEN ONLY
11. Have you ever been pregnant? ……………………………………
How many times?
How many children have you given birth to?
Yes
No
12. Have you had a PAP smear? ………………………………………
Date of last one
Yes
No
13. Have you ever had a PAP smear that was not normal? …………
Yes
No
14. Have you had a mammogram (breast x-ray)?...................................
Date of last one
Yes
No
SHOTS
15. When was your last Tetanus shot?..............Year
never
don’t know
16. When was your last Pneumonia shot?........ Year
never
don’t know
17. When was your last Flu shot?..................... Year
never
don’t know
SOCIAL HISTORY
18. Circle the highest grade you finished in school?
1 2 3 4 5 6 7 8
9 10 11 12
GED
1 2 3
Grade School
High School
Vocational School
19. What language do you prefer to speak?
English
Spanish
1 2 3 4+
College
Other
20. How well can you read?
Very well
Well
Not well
I can not read
21. What do you do during the day?
Work full-time
Work part-time
Attend school
Take care of children at home
Go out most days (shop, visit, appointments)
Stay home most days
Other
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22. Have you ever smoked cigarettes, cigars, used snuff, or chewed tobacco?
No (if no, go to question #23.)
Yes
a. When did you start?
b. How much per week?
c. Have you quit?............................. No
Yes, when
_
d. Do you want to quit?.................... No
Yes
Already Quit
23. Do you drink alcohol?
No (if no, go to question #24.)
Yes
a. Have you ever felt you ought to cut down on your drinking?
b. Have people ever annoyed you by criticizing your drinking?
c. Have you ever felt bad or guilty about your drinking? ……...
d. Have you ever had a drink first thing in the morning? ……...
24. Are you
Single
Married
Partnered
Yes
Yes
Yes
Yes
Divorced or Separated
No
No
No
No
Widowed?
25. Who lives in your house?
26. Do you have sex with
men
women
both
neither
27. Do you have any beliefs or practices from your religion, culture, or otherwise that
your doctor should know? For example:
I am a Jehovah’s Witness and do not accept blood/blood products.
I do not use birth control because of personal or religious beliefs.
I fast (go without food) for periods of time for personal or religious reasons.
I am a vegetarian (do not eat meat.)
I am a vegan (do not eat anything that comes from an animal.)
Other special diets or eating habits. (Please describe.)
I use traditional medicines or treatments, such as acupuncture or herbs.
Other beliefs
No, I have no beliefs or practices that need to be included in my care.
28. Check any of the following things you use to help you walk.
Cane
Walker
Wheelchair
Other
I do not need any help walking
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29. Check any of the following types of help at home you receive (paid help or family
and friends).
Help with cleaning/laundry.
Help with shopping.
Help with personal care (bathing, dressing).
Help with taking my medications.
I do not use any help at home.
30. In the past year, have you been emotionally or physically abused by your partner or
someone important to you?.........................................................................
Yes
No
31. In the past year have you been hit, pushed, shoved, kicked or threatened
by a partner or someone important to you?.……………………………... Yes
32. EXERCISE
Describe what kind of
How many days per week
exercise you do. (Check all do you exercise?
that apply.)
walking
once per week
biking
twice per week
swimming
3 times a week
weight training
4 times a week
yoga
5 times a week
other
6 times a week
I do not exercise
7 times a week or more
No
For how long do you
exercise each day?
less than 15 minutes
15-30 minutes
30 – 45 minutes
45 minutes – 1 hour
over 1 hour
Comments:
FAMILY HISTORY
What medical problems do people in your family have?
Family Member
Medical Problems
Mother:
Diabetes (sugar)
High blood pressure
Cancer
other:
Father:
Diabetes (sugar)
High blood pressure
Cancer
other:
Sisters:
Diabetes (sugar)
High blood pressure
Cancer
other:
Brothers:
Diabetes (sugar)
High blood pressure
Cancer
other:
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Heart problems
Heart problems
Heart problems
Heart problems
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HISTORY OF MEDICAL CONDITIONS
Have you ever had any of the following conditions? (Check all that apply)
Anemia (low iron blood)
Asthma (wheezing)
Diabetes (sugar)
Heart Trouble
Hemorrhoids (piles)
Cancer
Hepatitis (yellow jaundice)
Tuberculosis (TB)
Liver Trouble
Pneumonia
Rheumatic fever
Ulcers
Stroke
High Blood Pressure
Skin problems
Depression (feeling down or blue)
Epilepsy (fits, seizures)
Anxiety (nerves, panic attacks)
VD, STD (syphilis, gonorrhea, chlamydia, HIV)
Other
REVIEW OF SYMPTOMS
YES
NO
Do you feel tired a lot?
yes
no
Do you have trouble falling or staying asleep?
yes
no
Do you have other problems with sleep?
Have you lost your appetite recently?
yes
yes
no
no
Have you lost weight in the last year without trying?
yes
no
Do you eat too much or have you gained weight
recently?
yes
no
Throat
Do you have other problems with eating?
Do you have sore throats a lot?
yes
yes
no
no
Ears
Do you have other problems with your throat?
Do you have trouble hearing?
yes
yes
no
no
Do you wear a hearing aid?
yes
no
Do you have constant ringing or noises in your ears?
yes
no
Do you have other problems with your ears?
Do you have back pain?
yes
yes
no
no
Do you have any other problems with your back?
yes
no
Sleeping
Eating
Back
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Eyes
Nose and
Sinuses
Teeth and
Mouth
Heart or
Breathing
Bowel
movements
Peeing and
Kidney Stones
Joints
Do you have trouble with your vision or seeing?
yes
no
Do you wear glasses or contacts?
yes
no
Do you have other problems with your eyes?
Do you have a runny or stopped up nose a lot?
yes
yes
no
no
Do you have other problems with your nose or
sinuses?
Do you have sore or bleeding gums?
yes
yes
no
no
Do you wear plates or false teeth?
yes
no
yes
no
yes
no
Do you wake up at night with trouble breathing?
yes
no
Do you have a racing or skipping heartbeat at
times?
yes
no
yes
no
yes
no
Do you have any other problems with your bowel
movements (poop)?
Do you have trouble passing your urine (peeing)?
yes
yes
no
no
Does it burn when you pass urine (pee)?
yes
no
Do you have to pee more than 2 times a night?
yes
no
Do you leak urine (pee)?
yes
no
Have you ever passed kidney stones?
yes
no
Do you have any other problems with your peeing?
Do you have swollen or painful joints?
yes
yes
no
no
Do you have any other problems with your joints?
yes
no
Do you have other problems with your teeth and
mouth?
Do you ever have pain/tightness in your chest when
working or exercising?
Do you have other heart or breathing problems?
Do you have bowel movements (poop) that are
black, like tar, or bloody?
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Head,
Do you have frequent or severe headaches?
yes
no
Balance, Fever
Have you ever fainted (passed out)?
yes
no
Have you lost your balance and fallen recently?
yes
no
Do you have weakness in any part of your body?
yes
no
Have you had a fever within the past month?
yes
no
Do you have any other problems with your head or
balance?
Do you get upset easily?
yes
yes
no
no
Do frightening thoughts keep coming into your
mind?
yes
no
Have you ever been hospitalized for nerves,
thoughts or moods?
yes
no
During the past 2 weeks, have you often been
bothered by having little interest or pleasure in
doing things?
yes
no
During the past 2 weeks, have you often been
bothered by feeling down, depressed, or hopeless?
yes
no
Men Only
Do you have any other problems with your
emotional health?
Have you ever had prostate trouble?
yes
yes
no
no
Women Only
Do you have any other male problems?
Do you have pain or lumps in your breast?
yes
yes
no
no
Do you have unusual vaginal discharge or itching?
yes
no
Do you or have you taken hormones (such as birth
control pills)?
yes
no
Do you have any other female problems?
yes
no
and Weakness
Emotional
Health
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Young Child Health History Form
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11B.doc
To view in pdf, scroll to next page.
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Young Child Health History Form
Child’s Name:__________________________________
First
Middle
Last
Child’s Address___________________________________________________________
Today’s Date_____________
Filling out this form
Answering these questions will help your doctor understand
your child’s health and how best to treat you.
If you need help filing out this form:
o Bring this form with you to your appointment and a nurse will help you.
OR
o Call the clinic at [555-1212 ext. 123] before your appointment and
someone can help you over the phone.
Bring to your appointment:
1. This Child Health History Form
and any other important
medical records.
2. A complete copy of the child’s
immunization records.
3. The child’s insurance information.
4. Any medicines the child takes
(prescription, herbal, over-the-counter
pills, and creams).
We look forward to working with you!
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GENERAL INFORMATION
Female
What is the child’s sex?
Male
Child’s Date of Birth_____________________________ current age
Is your child adopted?
No
Yes If yes, at what age?
Who is filling out this form?
Mother
Father
Other guardian (please explain relationship to child) __________________________
Other (please explain)
The child’s parents are:
Single
Married
Divorced
Separated but not divorced
Widowed
Living together but not married
unknown
Main adult contact for child
Alternate adult contact for child
Name:
Name:
Relation to child:
Mother
Father
Other: ________________________
Address:
Same as child’s
Street address: ____________________
Relation to child:
Mother
Father
Other: ________________________
Address:
Same as child’s
Street address: ____________________
City: ________________________
State: ________________________
Zip: ________________________
Home Phone:
Cell Phone:
Work Phone:
City: ________________________
State: ________________________
Zip: ________________________
Home Phone:
Cell phone:
Work Phone:
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TODAY’S HEALTH PROBLEMS
1. List your child’s main heath problems (or reasons for visiting the clinic).
Routine checkup
Immunizations (shots)
A health problem (please specify)
Switching doctors (last doctor
2. How well do you feel your child acts or behaves?
Poor
Fair
Good
Very Good
)
Excellent
MEDICAL HISTORY
3. Has your child ever been a patient in a hospital (other than a few days after birth)?
No (If no, go to question #9.)
Yes (If yes, explain why and when below.)
My child was in the hospital because:
Example:
Bike accident
When
5 years old
4. Is your child taking any prescription medicines?
Yes - Please list the child’s medicines below or
I brought my child’s medicines.
No. My child does not take any prescription medicines. (If no, go to question #5.)
Name of medicine
Amount / How many pills or doses does your child take at
size of pill
Example:
noon
dinner
morning
noon
dinner
morning
noon
dinner
morning
noon
dinner
(Please use the back of this form if you have more prescription medicine.)
Dexadrine
10 mg
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1 morning
1 bed
bed
bed
bed
180
5. What over-the-counter medicines, does your child take regularly?
Vitamins
Herbal medicine (please list)
Other (please list)
None, my child does not take any over-the-counter medicines regularly.
6. Does your child have any allergic reaction (bad effect) from any of the following?
(Check all that apply.)
Outside or Indoor allergies (for example: grass, pollen, cats …)
Food Allergies (for example: peanuts, milk, wheat …)
Medicine or shots (immunization). (Please list below.)
No, my child has no allergies that I know of.
Medicine child is allergic to
Example:
amoxicillian
What happens when the child take that medicine
Diarrhea (runny poop)
7. Has your child had any of the following diseases?
Measles
Yes
No
Don’t Know
Mumps
Yes
No
Don’t Know
Chicken Pox
Yes
No
Don’t Know
Whooping Cough
Yes
No
Don’t Know
Rubella
Yes
No
Don’t Know
Rheumatic Fever
Yes
No
Don’t Know
Scarlet Fever
Yes
No
Don’t Know
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8. Please check any of the following medical problems that your child has ever had.
Has your child ever had:
Ear infections
Yes
No
Nose problems (sinus infections, nose bleeds)
Yes
No
Eye problems (blurry vision, need to wear glasses)
Yes
No
Hearing problems
Yes
No
Mouth or throat problems (Strep throat, swallowing problems)
Yes
No
Diarrhea (having frequent and runny bowel movements)
Yes
No
Constipation (problems having a bowel movement (BM))
Yes
No
Throwing up (vomiting)
Yes
No
Problems peeing (bed wetting, pain when peeing)
Yes
No
Back problems (crooked back, back pain)
Yes
No
Growing pains (bone or body pains due to growing)
Yes
No
Muscle and bone problems (weak muscles, pain in joints)
Yes
No
Skin problems (acne, flaking skin, rashes, hives)
Yes
No
Seizures (shaking fits)
Yes
No
ADD/ADHD (problems paying attention, sitting still)
Yes
No
Sleeping problems (falling or staying asleep)
Yes
No
Breathing problems (cough, asthma)
Yes
No
Warts
Yes
No
Jaundice (yellow skin)
Yes
No
SHOTS
9. Has your child received immunizations (shots) in the past?
No (If no, go to question #10.)
Yes
If yes, have you given this office a copy of the immunization (shots) records?
Yes (If no, go to question #10.)
No
If not, please give us the name of the doctors’ offices or clinics where your child has
received these shots so we can get the records.
Doctor’s office/clinic name:
Doctor’s office/clinic phone number:
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ABOUT MOM WHEN PREGNANT
The following questions are about the mother of the child during pregnancy and birth.
and go to #17.
If you do not know about the pregnancy of the mother, check here
10. What was the general health of the mother during pregnancy?
Excellent
Good
Fair
Poor
Unknown
11. Were any of the following used during pregnancy?
Cigarettes
Alcohol
Illegal drugs (which ones? ___________________________________________)
Prescription drugs (which ones? ______________________________________)
None of the above
12. Did the mother have any of the following conditions or problems during pregnancy?
Preeclampsia (high blood pressure)
Diabetes (sugar)
Emotional stress
Injury or serious illness
Unexpected bleeding or spotting
Other
13. Was the birth:
On the due date
Before the due date (by how much
)
After the due date (by how much
14. Was the birth:
Vaginal
)
C-Section (surgical cut in the tummy?)
15. Were any of the following used?
Pain medicine during birth (epidural)
Tool to help pull baby out (forceps or vacuum)
None
16. Were there any problems during the birth?
Yes
No
If yes, please explain:
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ABOUT THE CHILD AS A BABY
17. Was/is the child breastfed?
Yes
No
If yes, how long
____________
18. In the first 2 months after birth, did the child have:
Jaundice (yellow skin)
Colic (upset stomach, crying)
Breathing problems
Other
None of the above
19. At what age did the child begin to crawl?
20. At what age did the child begin to sit up?
21. At what age did the child begin to walk?
22. At what age did the child get his/her first tooth?
23. At what age did the child began to say words (mama, dada)?
24. How would you rate your child’s health in his or her first year of life?
Excellent
Very Good
Good
Fair
Poor
Unknown
IN SCHOOL AND ATA HOME
25. Does the child go to school or daycare?
Yes
No If yes, what is its name?
________________________________________________________________________
26. If your child goes to school or daycare, describe how your child acts in school or
daycare.
Check all that apply.
Nervous, worried
Shy, withdrawn, keeps to self
Hyper, restless, can’t sit still
Gets angry easily
Pushy, bullies others
Scared, fearful
Relaxed, calm
Moody
Social, friendly
Happy
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27. How are your child’s grades in school?
Excellent
OK
Poor
Does not go to school
28. About how much exercise does your child get every day?
Less than 30 minutes
30 minutes to 1 hour
Over 1 hour
29. About how many hours of TV does your child watch every day?
Less than1 hour
1-3 hours
More than 3 hours
30. About how many hours is your child on a computer every day?
Less than 1 hour
1-3 hours
More than 3 hours
Does not have a computer
31. About how many hours does your child spend outside every day?
Less than1 hour
1-3 hours
More than 3 hours
32. About how many hours are spent reading with your child every day?
Less than 15 minutes
15-30 minutes
30 minutes to1 hour
More than 1 hour
33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc?
Yes
No
Does not do activities like that
34. Does your child get buckled in a car seat or wear a seat belt when riding in a car?
Yes
No
35. Do you have guns in the home? Yes
If yes, are they locked up? Yes
No
No
36. What activities is your child involved in:
Riding bike
T-ball/baseball
Dance/movement
Skate boarding
Karate
Video games
Girl Scouts/Boy Scouts
Soccer
Playing a musical instrument
Reading
Playing with friends
Other team sports
Other activity(s)
Too young to be involved in activities
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37. Please list what your child typically eats and drinks in a day for:
Breakfast
Lunch
______
Dinner
______
Snacks
______
FAMILY
38. Check all the people that the child lives with:
Mother
Father
Brothers (how many?
)
Sisters (how many?
)
Other family members (list
)
Friends or other people (list
)
Animals
Dogs (how many?
)
Cats (how many?
)
Other animals
39. What medical problems do people in the child’s family have?
Family Member
Medical Problems
Mother:
Depression
Anxiety (nerve) problems
Overweight
High blood pressure
Cancer
Heart problems
Other:
Father:
Depression
Anxiety (nerve) problems
Overweight
High blood pressure
Cancer
Heart problems
Other:
Sisters:
Depression
Anxiety (nerve) problems
Overweight
High blood pressure
Cancer
Heart problems
Other:
Brothers:
Depression
Anxiety (nerve) problems
Overweight
High blood pressure
Cancer
Heart problems
Other:
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Diabetes (sugar)
Learning disability
Diabetes (sugar)
Learning disability
Diabetes (sugar)
Learning disability
Diabetes (sugar)
186
Adult Return Visit Update Form
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11C.doc
To view in pdf, scroll to next page.
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Adult Return Visit Update
Patient Name
Date
1. What would you like to talk to the doctor about today?
1.
2.
3.
2. How would you describe your health since your last visit?
Excellent
Very Good
Good
Fair
Poor
3. Have you been hospitalized or been to the Emergency Room since your last visit?
Yes
No.
4. Have you seen any other doctors since your last visit?
Yes
No
5. Have your medicines changed since your last visit?
Yes
No
6. Have you been exercising?
Yes
No
7. Have you been hit, pushed shoved, kicked, or threatened by someone important to you?
Yes
No
8. During the past 2 weeks, have you often been bothered by having little interest or pleasure in
doing things?
Yes
No
9. During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless?
Yes
No
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Consent to Treat Form
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11D.doc
To view in pdf, scroll to next page.
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Consent to Treat
1. I
(patient name) give permission for
[practice name] to give me medical treatment.
2. I allow [practice name] to file for insurance benefits to pay for the
care I receive.
I understand that:
[practice name] will have to send my medical record information
to my insurance company.
I must pay my share of the costs.
I must pay for the cost of these services if my insurance does not
pay or I do not have insurance.
3. I understand:
I have the right to refuse any procedure or treatment.
I have the right to discuss all medical treatments with my provider.
Patient’s Signature
Date
Parent or Guardian Signature
(for children under 18)
Date
Print name
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Release of Medical Information
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11E.doc
To view in pdf, scroll to next page.
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Release of Medical Information
Permission to get records
I,
(patient
name)
(doctor’s or hospital name who has records)
(my doctor’s name)
,with a date of birth,
(patient’s DOB)
, give my permission for
to give my medical records (as described on p. 2) to
so that he/she can better understand my condition and help me.
Permission to get sensitive information
By putting my initials by each item below, I understand that I give permission for records to be sent
that may contain information about:
my mental health,
transmittable disease I may have like HIV/AIDS,
genetic records, and/or
drug and alcohol records.
I understand that:
I do not have to give my permission to share these records.
If I want to take away the permission for my doctor to get these records, I need to talk to
my doctor or a staff person and sign a paper.
This form is only good for 3 months from the date I sign it.
Patient’s Signature
Date
Authorized Representative’s Signature
Date
Relationship of Authorized Representative
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Page 2
Consent for release of medical records for
(patient
Date:
name)
Requesting records from:
Name of Practice:
Name of Physician:
Fax number:
Address:
Types of records we are requesting
Any and all types of records you have for this patient
Doctor visit notes
Emergency Room notes
Urgent care notes
History and physical
Hospital Progress Notes
Operation or procedure notes
Clinic notes
Pathology reports
Doctors orders
Nurses notes
Discharge Summary
Lab reports
Radiology Reports
Consultations
Other
Records within the following dates:
All records for this patient
Records dated between
and
Please send records to:
Attention:
At fax number:
Or mail to:
For any questions please call (phone number):
and ask for:
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Lab Results Letter
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11F.doc
To view in pdf, scroll to next page.
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Lab Results Letter
Dear Ms. Sally Doe,
You had a blood test to measure your cholesterol levels on June 25, 2009.
The test results show that your cholesterol is high and that we need to
work together to decrease it.
My office will call you to make an appointment so we can address this. If
you have questions before your appointment, please call my nurse,
Stephanie, at 555-8726.
Thank you and talk to you soon,
Dr. James Morris
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Appointment Reminder
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool11G.doc
To view in pdf, scroll to next page.
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This is a reminder that:
[Patient name] has an appointment
For:
A diabetes followup visit
With:
Dr. James Morris
Date:
Wednesday, July 29, 2009
Time:
10:00 AM
Where: At the UNC General Internal Medicine Clinic
located on the third floor of the
UNC Ambulatory Care Center
Address: UNC Ambulatory Care Center
101 Mason Farm Road
Chapel Hill, NC 27599
If you can not come to this appointment:
Call 555-1212.
When you hear the menu options,
press “1” to talk to someone who will
help you reschedule the appointment.
What to bring
Bring all your medicines (pills, creams, liquids), including
prescription and over-the-counter medicines that you are taking.
Bring your insurance information.
Special Instructions:
Do not eat for 12 hours before your visit.
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The Action Plan Form and Example
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool15A.doc
To view in pdf, scroll to next page.
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Action Plan Form
My visit with
Date
Things we talked about/Things I need to do:
Action Plan
One goal I want to achieve that will improve my health:
One specific step I can take to achieve this goal:
What:
How Much:
When:
How Often:
How sure am I that I can do this?
1
2
Not sure
3
4
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6
7
8
9
10
Very sure
199
Action Plan Form Example
My visit with: Dr. Thomas
Date: June 15, 2009
Things we talked about / Things I need to do:
Increase evening insulin dose from 20 to 25 units.
Make an appointment with the eye doctor. Call Main Street Ophthalmology at
555-9837.
Action Plan
One goal I want to achieve that will improve my health:
Lose 10 pounds with exercise and diet changes
One specific step I can take to achieve this goal:
Increase my exercise with regular walking.
What: Walking
How Much: 30 to 40 minutes
When: During my weekday lunch breaks; Sunday or Saturday morning in the
neighborhood with my wife.
How Often: Four times a week
How sure am I that I can do this?
1
2
Not sure
3
4
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6
7
8
9
10
Very sure
200
Medication Aid Poster
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool16A.doc
To view in pdf, scroll to next page.
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Do you have trouble remembering to
take your medications?
Ask us for help in setting up a system—we can provide:
1 MedCard— A simple 2-sided
card that fits in your wallet and lists your
health problems, medicines you take, and
other health information.
2 Pill Chart— A list of your
pills, when to take them, and why you take.
them.
3 Pill Card— A picture of your
pills and when to take them.
4 Pill Box— A plastic box with
sections to hold the pills you take in the
morning, noon, evening, and bedtime.
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Sample Cover Letter
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool17C.doc
To view in pdf, scroll to next page.
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SAMPLE COVER LETTER FOR PATIENT SURVEY
FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]
We at [NAME OF PROVIDER ORGANIZATION] need your help. We want to
improve the care we give you and other patients. We would like you to tell us about
your experiences with the care you receive from [DOCTOR’S NAME] and our office.
The information that you give us will stay private. Your answers will never be seen by
your doctor or anyone else involved with your care. Your doctor will not even know
you helped us by answering these questions. You do not have to answer the questions.
Your medical care will not change in any way if you say no.
If you are willing to help us, please answer these questions about the care you have
received from [DOCTOR’S NAME] and our office in the last 12 months. This
questionnaire should take about [TIME] minutes or less of your time.
Please return the completed survey in the enclosed postage-paid envelope by
[MONTH/DAY/YEAR].
If you have any questions about this survey, please call [CONTACT NAME] at
(XXX) [XXX-XXXX]. All calls to this number are free. Thank you for helping to
make health care at [NAME OF PROVIDER GROUP] better for everyone!
Sincerely,
[NAME OF PERSON REPRESENTING PROVIDER ORGANIZATION]
Nota: Si quiere una encuesta en español, por favor llame al (XXX) [XXX-XXXX].
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Community Referral Form and Example
MS Word version is available on the Internet at
http://www.nchealthliteracy.org/toolkit/tool18A.doc
To view in pdf, scroll to next page.
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[Practice Name]
Community Referral Form
Reason for Referral:
Name of Program:
Name of Contact Person:
Phone:
Location:
Details:
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Example Community Referral Form
City Family Practice
Community Referral Form
Reason for Referral: Improve your reading skills
Name of Program: Adult Reading Program
Name of Contact Person:
Phone:
Location:
Melanie Baker
(555) 555-5555
Spencer Adult Leaning Center
560 Blake Lane
Fauxcity, FS, 55555
Details:
Free reading classes
Call Melanie or stop by to sign up
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The Health Literacy Universal Precautions Toolkit
List of Internet Resources
The toolkit references a number of resources, including several that are available on the
Internet. This list identifies the addresses (URL’s) for each item on the Internet. Refer to
the section or tool to learn more about these and other resources.
Section or
Tool
Overview
Resource Name and Internet URL (universal resource locator)
Prevalence Calculator
Pfizer Clear Health Communication Initiative
Search for “Health Literacy Prevalence Calculator” for the exact URL.
Health Literacy Video
American College of Physicians Foundation
http://www.acpfoundation.org/hl/video/healthliteracy.wmv
Colon Cancer Screening
Health Care Provider-Directed Intervention to Increase Colorectal Cancer
Screening Among Veterans: Results of a Randomized Controlled Trial
http://www.jco.ascopubs.org/cgi/content/abstract/23/7/1548
Depression Management
Literacy Education as Treatment for Depression in Patients with Limited Literacy
and Depression
http://www.ncbi.nlm.nih.gov/pubmed/16881941
Diabetes and Heart Failure Management
Influence of Patient Literacy on Effectiveness of a Primary Care-Based Diabetes
Management Program
http://jama.ama-assn.org/cgi/content/abstract/292/14/1711
Automated Telephone Self-Management Support System:
Effects of Self-Management Support on Structure, Process, and Outcome Among
Vulnerable Patients with Diabetes: A Three-Arm Practical Clinical Trial
http://care.diabetesjournals.org/content/32/4/559.abstract
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Section or
Tool
Overview
(cont’d)
Tool 1: Form a
Team
Resource Name and Internet URL (universal resource locator)
Plan-Do-Study-Act Worksheet
Institute for Healthcare Improvement
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/PlanDo-Study-Act%20(PDSA)%20Worksheet
Health Literacy Video
American College of Physicians Foundation
http://www.acpfoundation.org/hl/video/healthliteracy.wmv
Health Literacy and Patient Safety: Help Patients Understand (video)
American Medical Association Foundation
http://classes.kumc.edu/general/amaliteracy/AMA_NEW3.swf
Prevalence Calculator
Pfizer Clear Health Communication Initiative
Search for “Health Literacy Prevalence Calculator” for the exact URL.
How to Improve
The Institute for Healthcare Improvement
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove
Tool 2: Assess
Your Practice
Tool 3: Raise
Awareness
The Health Literacy Environment of Hospitals and Health Centers.
Partners for Action: Making Your Health Care Facility Literacy-Friendly
Harvard University
http://www.hsph.harvard.edu/healthliteracy/HealthLiteracyEnvironment.pdf?id=1
163
Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy
Assessment Tool
Agency for Healthcare Research and Quality
http://www.ahrq.gov/qual/pharmlit/pharmlit.pdf
Health Literacy Video
American College of Physicians Foundation
http://www.acpfoundation.org/hl/video/healthliteracy.wmv
Health Literacy and Patient Safety: Help Patients Understand (video)
American Medical Association Foundation
http://classes.kumc.edu/general/amaliteracy/AMA_NEW3.swf
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Section or
Tool
Tool 3: Raise
Awareness
(cont’d)
Resource Name and Internet URL (universal resource locator)
Unified Health Communication 101 – Addressing Health Literacy, Cultural
Competency, and Limited English Proficiency (online training)
Health Resources and Services Administration
ftp://ftp.hrsa.gov/healthliteracy/training.pdf
Health Literacy and Public Health
New York New Jersey Public Health Training Center
http://nynj-phtc.org/phLit/Home/phlit-login.cfm
Prevalence Calculator
Pfizer Clear Health Communication Initiative
Search for “Health Literacy Prevalence Calculator” for the exact URL.
Tool 4: Tips
for Communicating
Clearly
Health Literacy and Patient Safety: Help Patients Understand (manual)
American Medical Association Foundation
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Health Literacy and Patient Safety: Help Patients Understand (manual)
American Medical Association Foundation
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Plain Language Thesaurus for Health Communication
Centers for Disease Control and Prevention
http://depts.washington.edu/respcare/public/info/Plain_Language_Thesauru
s_for_Health_Communications.pdf
Tool 5: The
Teach-Back
Method
Tool 6:
Followup with
Patients
Teach-Back Video
North Carolina Program on Health Literacy
Search for “Teach Back Video-a technique for teaching patients" for the URL.
Health Literacy and Patient Safety: Help Patients Understand (video)
American Medical Association Foundation
http://classes.kumc.edu/general/amaliteracy/AMA_NEW3.swf
Automated Telephone Reminders: A Tool to Help Refill Medicines On Time
Agency for Healthcare Research and Quality
http://www.ahrq.gov/qual/callscript.pdf
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Section or
Tool
Resource Name and Internet URL (universal resource locator)
Tool 6:
Followup with
Patients
(cont’d)
Enhancing Doctor-Patient Communication Using E-mail: A Pilot Study
American Board of Family Practice
http://www.jabfm.org/cgi/content/full/18/3/180
Tool 7:
Telephone
Considerations
Tool 8: Brown
Bag
Medication
Review
How Does Your Practice Sound on the Phone?
American Academy of Family Physicians
http://www.aafp.org/fpm/990100fm/45.html#x2
Health Literacy and Patient Safety: Help Patients Understand (manual)
American Medical Association Foundation
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Tool 9: How to
Address
Language
Differences
Brown Bag Toolkit
Ohio Patient Safety Institute
http://www.ohiopatientsafety.org/meds/default.htm
“I Speak” Cards
U.S. Department of Commerce – Language Identification Flashcard
http://www.lep.gov/ISpeakCards2004.pdf
Patient’s Rights
State of Florida – Agency for Workforce Innovation
http://www.floridajobs.org/PDG/PostersforEmployers/IS%20Poster%2011x17.pdf
Directory of Translation and Interpreting Services
American Translators Association
https://www.atanet.org/onlinedirectories/individuals.php
Translator and Interpreter Directory
ProZ
Search for “ProZ Translator and Interpreter Directory” for the exact URL.
MedlinePlus (health information in multiple languages)
National Library of Medicine
http://www.nlm.nih.gov/medlineplus/languages/languages.html
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Section or
Tool
Tool 9: How to
Address
Language
Differences
(cont’d)
Resource Name and Internet URL (universal resource locator)
Multi-lingual Educational Material
Healthy Roads Media
http://www.healthyroadsmedia.org/
Quality Translations in Multiple Languages
Health Information Translations
Search for “Health Information Translations” for the exact URL.
Addressing Language and Culture
California Academy of Family Physicians Foundation
http://www.familydocs.org/system/files/AddressingLanguageandCulture.pdf
The Health Care Language Services Implementation Guide
U.S. Department of Health and Human Services
https://hclsig.thinkculturalhealth.org/user/home.rails
Office Guide to Communicating with Limited English Proficient Patients
American Medical Association
http://www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf
More Than Words Toolkit
Hablamos Juntos
http://www.hablamosjuntos.org/mtw/default.toolkit.asp
Tool 10:
Culture &
Other
Considerations
Unified Health Communication 101 – Addressing Health Literacy, Cultural
Competency and Limited English Proficiency (online training)
Health Resources and Services Administration
ftp://ftp.hrsa.gov/healthliteracy/training.pdf
Think Cultural Health: Bridging the Healthcare Gap Through Cultural
Competency
U.S. Department of Health and Human Services
https://www.thinkculturalhealth.org/
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Section or
Tool
Tool 10:
Culture &
Other
Considerations
(cont’d)
Resource Name and Internet URL (universal resource locator)
Unified Health Communication 101 – Addressing Health Literacy, Cultural
Competency, and Limited English Proficiency (online training)
Health Resources and Services Administration
ftp://ftp.hrsa.gov/healthliteracy/training.pdf
EthnoMed (multi-cultural information)
Integrating Cultural Information into Clinical Practice
http://ethnomed.org/
Culture Clues (tip sheets)
University of Washington Medical Center
http://depts.washington.edu/pfes/CultureClues.htm
Tool 11:
Design Easyto-Read
Material
Cultural Competence Resources for Health Care Providers
Health Resources and Services Administration
http://www.hrsa.gov/culturalcompetence/
Clear Doc Index
Literacy Partners of Manitoba
http://www.plainlanguage.mb.literacy.ca/resources/ClearDoc2004.pdf
Clear and to the Point: Guidelines for Using Plain Language at NIH
Harvard School of Public Health
http://www.hsph.harvard.edu/healthliteracy/how_to/clear.html#top
Readability Formulas
ReadabilityFormulas.com
Search for “free readability assessment” for the exact URL.
Plain Language Thesaurus for Health Communications
Centers for Disease Control and Prevention
http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for
_Health_Communications.pdf
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Section or
Tool
Tool 11:
Design Easyto-Read
Material
(cont’d)
Tool 12: Use
Health
Education
Material
Effectively
Resource Name and Internet URL (universal resource locator)
In Other Words…Can They Understand? Testing Patient Education
Materials With Intended Readers
Health Literacy Consulting
Search for “testing patient education materials” for the exact URL.
Dusty the Asthma Goldfish and His Asthma Triggers Fun Book (English &
Spanish)
Environmental Protection Agency
http://www.epa.gov/asthma/publications.html#Dusty
Attention Deficit/Hyperactivity Disorder (ADHD)
National Institute of Mental Health
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivitydisorder-easy-to-read/complete.pdf
Managing Chemotherapy Side Effects
National Institutes of Health
http://www.cancer.gov/cancertopics/chemo-side-effects/constipation.pdf
Using the Chemotherapy Side Effects Fact Sheets
National Institutes of Health
http://www.cancer.gov/cancertopics/chemo-side-effects/using.pdf
Diabetes: Know the Signs
Learning about Diabetes
http://www.learningaboutdiabetes.org/downloads/KnowTheSignsEN100404.pdf
Prevent and Control High Blood Pressure: Mission Possible
National Institutes of Health
http://hp2010.nhlbihin.net/mission/partner/should_know.pdf
Take Steps-Prevent High Blood Pressure!
National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov/health/public/heart/other/sp_hbp.pdf
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
214
Section or
Tool
Tool 12: Use
Health
Education
Material
Effectively
(cont’d)
Resource Name and Internet URL (universal resource locator)
Your Guide to Preventing and Treating Blood Clots
Agency for Healthcare Research and Quality
http://www.ahrq.gov/consumer/bloodclots.pdf
Help for Smokers and Other Tobacco Users
Agency for Healthcare Research and Quality
http://www.ahrq.gov/consumer/tobacco/helpsmokers.pdf
Help Your Child Gain Control Over Asthma
Environmental Protection Agency
http://www.epa.gov/iaq/schools/pdfs/publications/ll_asthma_brochure.pdf
Caring for Your Heart: Living Well with Heart Failure
North Carolina Program on Health Literacy
http://www.nchealthliteracy.org/comm_aids/Heart%20Failure%20Intervention%
20Core,%20ver.%201.pdf
Tool 13:
Welcome
Patients:
Helpful
Attitudes,
Signs and
More
Diabetes Literacy and Numeracy Education Toolkit
Vanderbilt University
http://medicine.mc.vanderbilt.edu/Templates/TemplateDivision.aspx?qs=cElEP
Tc0NA
The Health Literacy Environment of Hospitals and Health Centers.
Partners for Action: Making Your Health Care Facility Literacy-Friendly
Harvard University
http://www.hsph.harvard.edu/healthliteracy/HealthLiteracyEnvironment.pdf?id=1
163
“I Speak” Cards
U.S. Department of Commerce – Language Identification Flashcard
http://www.lep.gov/ISpeakCards2004.pdf
AHRQ Questions Are the Answer
Agency for Healthcare Research and Quality
http://www.ahrq.gov/questionsaretheanswer/level2col_1.asp?nav=2colNav00&co
ntent=09_0_videos
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
215
Section or
Tool
Tool 13:
Welcome
Patients:
Helpful
Attitudes,
Signs and
More (cont’d)
Tool 14:
Encourage
Questions
Tool 15: Make
Action Plans
Resource Name and Internet URL (universal resource locator)
We Speak Together (graphic symbols)
Hablamos Juntos
http://www.hablamosjuntos.org/signage/symbols/default.using_symbols.asp#sa
Health Literacy and Patient Safety: Help Patients Understand (manual)
American Medical Association Foundation
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Ask Me 3
The Partnership for Clear Health Communication
http://www.npsf.org/askme3/PCHC/
Questions Are the Answer
Agency for Healthcare Research and Quality
http://www.ahrq.gov/questionsaretheanswer/level2col_1.asp?nav=2colNav00&co
ntent=09_0_videos
Ready. Set. Action Plan! How to Effectively Use the Diabetes Guide (video)
American College of Physicians Foundation
http://acpfoundation.org/hl/diabguide.htm
Action Plan Project
University of California at San Francisco School of Medicine
http://www.familymedicine.medschool.ucsf.edu/community_service/actionPlan.a
spx
Helping Patients Adopt Healthier Behaviors
Clinical Diabetes
http://clinical.diabetesjournals.org/content/25/2/66.full.pdf
Tool 16:
Improve
Medication
Adherence and
Accuracy
What are Action Plans?
University of California at San Francisco School of Medicine
http://www.familymedicine.medschool.ucsf.edu/pdf/actionPlan/WhatAreActionP
lans.pdf
MedCard
Iowa Healthcare Collaborative
http://www.ihconline.org/UserDocs/Pages/MedCard.pdf
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
216
Section or
Tool
Tool 16:
Improve
Medication
Adherence and
Accuracy
(cont’d)
Tool 17: Get
Patient
Feedback
Resource Name and Internet URL (universal resource locator)
Pill Chart
North Carolina Program on Health Literacy
http://www.nchealthliteracy.org/comm_aids/2c%20Daily%20Meds%20English.p
df
Pill Cards
Agency for Healthcare Research and Quality
http://www.ahrq.gov/qual/pillcard/pillcard.htm
CAHPS® Item Set to Address Health Literacy (in the CAHPS® Clinician
and Group Survey)
Agency for Healthcare Research and Quality
https://www.cahps.ahrq.gov/cahpskit/files/351a-4_AdultPrim_Eng_4pt_V1.pdf
CAHPS® Survey and Reporting Kits
Agency for Healthcare Research and Quality
https://www.cahps.ahrq.gov/cahpskit/CG/CGChooseQx4P.asp
Fielding the CAHPS® Clinician and Group Survey
Agency for Healthcare Research and Quality
https://www.cahps.ahrq.gov/cahpskit/files/33_CG_Fielding_the_Survey.pdf
About the CAHPS® Item Set for Addressing Health Literacy
Agency for Healthcare Research and Quality
http://www.cahps.ahrq.gov/CAHPSkit/files/1311_About_Health_Lit.pdf
Navigating the Healthcare System: A Health Literacy Perspective Through
the Eyes of Patients
North Carolina Program on Health Literacy
http://www.nchealthliteracy.org/presentations/Patient%20Experience.ppt
The Health Literacy Environment of Hospitals and Health Centers.
Partners for Action: Making Your Health Care Facility Literacy-Friendly
Harvard University
http://www.hsph.harvard.edu/healthliteracy/HealthLiteracyEnvironment.pdf?id=1
163
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
217
Section or
Tool
Resource Name and Internet URL (universal resource locator)
Tool 17: Get
Patient
Feedback
(cont’d)
In Other Words…Can They Understand? Testing Patient Education
Materials With Intended Readers
Health Literacy Consulting
http://www.healthliteracy.com/article.asp?PageID=3811
Tool 18: Link
Patients to
Non-Medical
Support
2-1-1-Information & Referral Search
The United Way and Alliance for Information Referral Systems
http://www.211.org/
Tool 19:
Medication
Resources
Notary Public Training Course Locator
Notary Rotary
Search for “Find a notary public” for the exact URL.
Select Care Benefits Network (discount medicines)
http://www.scbn.org/healthcare_professionals.html
Tool 20: Use
Health and
Literacy
Resources in
the
Community
RX Assist
AstraZeneca
http://www.rxassist.org/
MedlinePlus Go Local
National Library of Medicine
http://www.nlm.nih.gov/medlineplus/golocal/index.html
The Literacy Directory
National Institute of Literacy
http://literacydirectory.org/
Health Literacy Universal Precautions Toolkit
AHRQ Pub. No. 10-0046-EF
218
| File Type | application/pdf |
| Author | Ashley Bailey Hink |
| File Modified | 2011-04-25 |
| File Created | 2010-03-02 |