Addressing Health Literacy in a Multilingual Population: A community health center approach Andrea Anderson, MD, FAAFP Luis Padilla, MD, FAAFP.

Addressing Health Addressing Health Literacy in a Multilingual Literacy in a Multilingual

Population: Population: A community health A community health

center approachcenter approach

Andrea Anderson, MD, FAAFP Andrea Anderson, MD, FAAFP

Luis Padilla, MD, FAAFPLuis Padilla, MD, FAAFP

OutlineOutline Brief History of Unity Health Care Brief History of Unity Health Care Upper Cardozo Health CenterUpper Cardozo Health Center Definition of Health LiteracyDefinition of Health Literacy Impact of Health Literacy Impact of Health Literacy How Our Patients Obtain, Process, and How Our Patients Obtain, Process, and

Understand our Health InformationUnderstand our Health Information Current and Future InitiativesCurrent and Future Initiatives ChallengesChallenges

Unity Health Care, Inc

MISSIONUnity Health Care, Inc. offers a citywide network of quality health and human services to the medically underserved regardless of race, ethnic background or ability to pay.

VISIONUnity Health Care, Inc. will become the preeminent health care delivery system for the medically underserved of Washington, DC and recognized by them as the provider of choice.

www.unityhealthcare.org

Unity as a Community Unity as a Community Health CenterHealth Center

More than More than 2020 years experience in Washington, years experience in Washington, DCDC

Initially a health care for the homeless modelInitially a health care for the homeless model Now a “medical home” model of careNow a “medical home” model of care Present in all 8 Wards of the District of

Columbia Mobile Medical Units Currently Currently 3232 service sites throughout DC service sites throughout DC 321,000321,000 visits in 2007 visits in 2007 Healthcare for DC inmates began October 1, Healthcare for DC inmates began October 1,

20062006

Unity Health Care 2006

Total Users

70,749 Total Visits

321,803

Working Poor, Uninsured, Immigrants

59,096(83.5%)

Working Poor, Uninsured, Immigrants

271,889

Homeless 11,653(16.5%)

Homeless 49,914

Unity Health Care’sUnity Health Care’sUpper Cardozo Health CenterUpper Cardozo Health Center

Ward one Northwest DCWard one Northwest DC One of DC’s most diverse wards ethnically and One of DC’s most diverse wards ethnically and

economicallyeconomically Over 17, 000 patients enrolled in the center Over 17, 000 patients enrolled in the center Over Over 76,00076,000 visits in 2007 visits in 2007 Most diverse center in Unity Health Care’s Most diverse center in Unity Health Care’s

networknetwork Predominately non-English speaking clientsPredominately non-English speaking clients Low Literacy and Low English Proficiency Low Literacy and Low English Proficiency

(LEP) with average estimated reading level at (LEP) with average estimated reading level at third to fourth gradethird to fourth grade

Upper Cardozo: Services Offered

Primary and Preventive Care

Dental Social

Services Pharmacy WIC

OB/GYN Mental Health Laboratory Specialty Care (HIV,

Pulmonary, Cardiology, Ophthalmology, Endocrinology, Podiatry)

Where do our patients come from?

The Americas

Where do our patients come from?

Africa

Where do our patients come from?

Asia, Europe , South Pacific, Middle East

Upper Cardozo: Ethnic Background

Upper Cardozo Health Center User Profile

57%

29%

2%

1%11%0%

Hispanic

African-Ameircan

Caucasian

Asian

Native American

Other

Upper Cardozo: Insurance Status

Insurance Status

48.41

25.15 23.02

2.17 1.250

10

20

30

40

50

60

Uninsured Self Pay Medicaid Medicare PrivateInsurance

Insurance Class

Per

cen

tag

e

Upper Cardozo- Income Upper Cardozo- Income Level by Percent of Poverty Level by Percent of Poverty

LevelLevel

0

10

20

30

40

50

60

70

<100 100-200 >200 Unknown

Percent

Federal Poverty Income Federal Poverty Income RequirementsRequirements

Group Size Annual FPL

100% FPL Monthly

150% FPLMonthly

200% FPLMonthly

1 $ 9800 $816.67 $1,225.00 $1633.33

2 $13200 $1,100.00 $1,650.00 $2,200.00

3 $16,600 $1,383.33 $2.075.00 $2,766.67

4 $20,000

$1,666.67

$2,500.00

$3,333.33

5 $23,400 $1,950.00 $2,925.00 $3,900.00

6 $26,800 $2,233.33 $3,350.00 $4,466.67

7 $30,200 $2516.67 $3,775.00 $5,033.33

8 $33,600 $2,800.00 $4,200.00 $5,600.00

9 $37,000 $3,083.33 $4,625.00 $6,166.67

10 $40,400 $3,366.67 $5,050.00 $6,733.33

Health Literacy Health Literacy DefinitionDefinition

"The degree to which individuals have "The degree to which individuals have the capacity to obtain, process, and the capacity to obtain, process, and understand basic health information understand basic health information and services needed to make and services needed to make appropriate health decisions". appropriate health decisions".

-Healthy People 2010-Healthy People 2010

Impact of Low Health Impact of Low Health LiteracyLiteracy

36 %36 % of the adult U.S. population has of the adult U.S. population has basic or below basic health literacy levelbasic or below basic health literacy level

Major source of economic inefficiency in Major source of economic inefficiency in the U.S. healthcare system. the U.S. healthcare system.

Cost of low health literacy to the U.S. Cost of low health literacy to the U.S. economy is in the range of economy is in the range of $106 billion$106 billion to to $238 billion$238 billion annually annually

About 7 and 17 % of all personal About 7 and 17 % of all personal healthcare expenditureshealthcare expenditures

Impact of Low Health Impact of Low Health LiteracyLiteracy

Potential Savings Potential Savings - - $106 billion $106 billion to to $238 billion$238 billion annuallyannually

This would translate into enough funds to This would translate into enough funds to insure insure every one of the more than 47 every one of the more than 47 millionmillion persons who lacked health care persons who lacked health care coverage in the United States in 2006coverage in the United States in 2006

Real day present costs of Real day present costs of $1.6 trillion $1.6 trillion to $3.6 trillionto $3.6 trillion, , accounting for the future accounting for the future costs of low health literacy that result costs of low health literacy that result from current actions (or lack of action).from current actions (or lack of action).

Impact of Low Health Impact of Low Health LiteracyLiteracy

Women with inadequate literacy had significantly greater odds of never having had a Pap smear or no mammogram in the past 2 years

black patients were significantly more likely than white patients to present with late-stage cancer; after adjusting for literacy, the researchers reported a smaller odds ratio that was no longer statistically significant

lower S-TOFHLA scores were related to worse glycosylated hemoglobin (HbA1c) levels and reports of retinopathy and cerebrovascular disease

“Agency for Healthcare Research and Quality. January 2004. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. AHRQ Publication No. 04-E007-2. Rockville, MD”

Assessment Tools TOFHLA/sTOFHLA

sTOFHLA version in English available at:http://www.peppercornbooks.com/catalog/product_info.php?

products_id=2765&osCsid=Cost $10.00

sTOFHLA version in Spanish available at:http://www.peppercornbooks.com/catalog/product_info.php?

products_id=2766&osCsid=Cost $10.00

Validation articleBaker D, Williams M, Parker R, Grazmararian J, Nurss J.

Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.

Source: Health Literacy Assessment Tools Paul D. Smith, [email protected]/7/07

Assessment Tools Newest Vital Sign

English and Spanish versions available. Scoring sheets and patient sheets available at:http://www.pfizerhealthliteracy.com/physicians-

providers/newest-vital-sign.html Cost: Free!

Validation articleQuick Assessment of Literacy in Primary Care:

The Newest Vital Sign. Weiss B, Mays M, Martz W, Castro K, DeWalt D, Pignone M, Mockbee J, Hale F. Ann Fam Med 2005;3:514-552.

Available to download at:http://www.pfizerhealthliteracy.com/physicians

providers/newest-vital-sign.html

Source: Health Literacy Assessment Tools Paul D. Smith, [email protected]/7/07

Healthy Literacy and Healthy Literacy and Ethnic MinoritiesEthnic Minorities

While ethnic minority groups are While ethnic minority groups are disproportionately affected by disproportionately affected by low health literacy, the majority low health literacy, the majority of those with low health literacy of those with low health literacy skills in the United States are skills in the United States are white, native-born Americans, as white, native-born Americans, as the latter group represents the the latter group represents the largest segment of the largest segment of the population.population.

Health Literacy and Health Literacy and Latino PopulationsLatino Populations

May be more pronounced in Latino May be more pronounced in Latino populationspopulations

Low literacy and language barrierLow literacy and language barrier Decreased access to insuranceDecreased access to insurance Decreased educational attainmentDecreased educational attainment Increased difficulty managing medicinesIncreased difficulty managing medicines Metric versus English measurement systemMetric versus English measurement system Difficulty in understanding specialist Difficulty in understanding specialist

instructionsinstructions

How Our Patients Obtain How Our Patients Obtain InformationInformation

Flyers and Brochures Flyers and Brochures

Web based educational materialsWeb based educational materials

Point of care internet accessPoint of care internet access

Language LineLanguage Line

How Our Patients Obtain How Our Patients Obtain InformationInformation

Oral instructions from bilingual staffOral instructions from bilingual staff

Medline-Plus tutorials in SpanishMedline-Plus tutorials in Spanish

Community PartnershipsCommunity Partnerships Reach Out and ReadReach Out and Read

Clinic Color GuideClinic Color Guide

Forms and SignsForms and Signs

Written at a third to Written at a third to fourth grade levelfourth grade level

Distributed multiple Distributed multiple times by providers times by providers and staffand staff

Color codedColor coded Double sided Double sided

bilingualbilingual Printed also in Printed also in

Amharic when Amharic when applicableapplicable

Point of Care Computer Point of Care Computer AccessAccess

Internet Access inInternet Access in

each exam room each exam room made possible made possible through a NLM through a NLM grantgrant

Web image searchesWeb image searches MedlinePlus MedlinePlus

TutorialsTutorials Demonstration of Demonstration of

medications, dosing, medications, dosing, etcetc

Web-based Patient Web-based Patient InformationInformation

www.boystownpediatrics.orgwww.boystownpediatrics.org www.familydoctor.orgwww.familydoctor.org www.mdconsult.comwww.mdconsult.com www.medlineplus.govwww.medlineplus.gov https://secure.medactionplan.comhttps://secure.medactionplan.com www.epocrates.comwww.epocrates.com

Preliminary Data from Upper Cardozo NLM Study

Initial and Final HGBA1c Mean

6

7

8

9

10

Control Intervention

Group

Hem

og

lob

in A

1c

Initial

Final

Preliminary Data from Upper Cardozo NLM Study

Initial and Final Systolic Mean

100

110

120

130

Control Intervention

Group

Systo

lic b

p

Initial

Final

Phone Interpretation Phone Interpretation ServicesServices

Language LineLanguage Line Over Over 100100 major major

languages and languages and dialects dialects availableavailable

Speaker phones Speaker phones available in each available in each exam roomexam room

Multilingual StaffMultilingual Staff 1717 out of 19 primary care providers speak out of 19 primary care providers speak

SpanishSpanish

Over Over 90%90% of support staff are bilingual or of support staff are bilingual or multilingualmultilingual

Languages Spoken By Upper Cardozo StaffLanguages Spoken By Upper Cardozo StaffSpanishSpanish TagalogTagalogFrenchFrench FarsiFarsiAmharicAmharic TigrinyaTigrinyaChineseChinese VietnameseVietnamese

Reach Out and Read Reach Out and Read ProgramProgram

National Program National Program designed to designed to promote early promote early childhood literacychildhood literacy

Literacy Promotion Literacy Promotion and books are and books are encouraged at well-encouraged at well-child visits ages child visits ages 6months-5 years6months-5 years

Reach Out and Read Reach Out and Read ProgramProgram

Millions of books distributed nationwideMillions of books distributed nationwide Over Over 3,0003,000 bilingual and culturally diverse bilingual and culturally diverse

books shared by providers in well child books shared by providers in well child visitsvisits

Reading is encouraged as a factor of healthReading is encouraged as a factor of health Introducing early childhood literacy Introducing early childhood literacy

encourages the discussion of adult literacyencourages the discussion of adult literacy Adults can be referred to adult literacy Adults can be referred to adult literacy

programs, family literacy is encouragedprograms, family literacy is encouraged

Literacy Rich Literacy Rich EnvironmentEnvironment

Printed MaterialPrinted Material Donated BooksDonated Books

Community PartnershipsCommunity Partnerships

Books for AmericaBooks for America

Unity Wide Book DriveUnity Wide Book Drive

Read Out Loud ProgramRead Out Loud Program

Reading is Fundamental (RIF) Reading is Fundamental (RIF)

Clinic Color GuideClinic Color Guide

Future InitiativesFuture Initiatives Computer LabComputer Lab

English Second Language skills English Second Language skills buildingbuilding

Computer skills development Computer skills development Health System Access EducationHealth System Access Education

Understanding health benefitsUnderstanding health benefits Disability claimsDisability claims Patient language access rightsPatient language access rights

DC 2004 Language ActDC 2004 Language Act

Patient Directed Web Patient Directed Web SearchesSearches

Computer Lab Computer Lab sponsored by a sponsored by a NLM grantNLM grant

Patients can Patients can research new research new diagnoses and diagnoses and online medical online medical information information

http://http://www.nlm.nih.gov/www.nlm.nih.gov/medlineplus/spanish/medlineplus/spanish/tutorial.htmltutorial.html

Future InitiativesFuture InitiativesHeath Literacy Assessment ToolHeath Literacy Assessment Tool

Community Education DaysCommunity Education Days

Shared Decision MakingShared Decision Making

Pictorial PrescriptionsPictorial Prescriptions

Continued ChallengesContinued Challenges Mental IllnessMental Illness

No mental health benefit under No mental health benefit under current Alliance safety netcurrent Alliance safety net

Resources needed to expand and Resources needed to expand and provide language servicesprovide language services

Resources and staff to assess Resources and staff to assess how patients process and degree how patients process and degree they understand informationthey understand information

Continued ChallengesContinued Challenges Resources to track changes and Resources to track changes and

outcomesoutcomes

Bilingual providersBilingual providers

Bilingual nurses and case Bilingual nurses and case managersmanagers

Cultural barriers to shared Cultural barriers to shared decision makingdecision making

Email Contacts

[email protected]

[email protected]