Welcome to the National Patient Safety Foundation’s · The costs of limited health literacy are sizeable. Limited health literacy is estimated to cost the U.S. economy between $106

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Welcome to the National Patient Safety Foundation’s Promoting Clear Health Communication with Ask Me 3 Educational Module.

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Over the course of this educational module, you will learn about the importance of health literacy. In particular, you’ll learn about the nature of limited health literacy, the prevalence and impact.

You will learn what to watch for in terms of identifying at-risk populations and red flag behaviors.

In addition, you will learn what health care professionals can do to help patients increase their understanding of health care information.

A key solution is the use of Ask Me 3, a program run by the National Patient Safety Foundation, which is meant to encourage clear health communication between patients and health care professionals.

You will also learn how to successfully implement Ask Me 3 in your organization.

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Please note that Ask Me 3 is a registered trademark licensed to National Patient Safety Foundation.

NPSF provides, through a non-exclusive, non-transferable license, this educational module and certain Ask Me 3 materials and resources for download and distribution free of charge to aid in the promotion of health communication, including health literacy, and increased patient safety.

Individuals wishing to download and distribute Ask Me 3 materials and resources, representing themselves or organizations, must register and agree to the official terms and conditions to obtain access to the materials.

For more information, please visit www.npsf.org/AskMe3

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This module was prepared by the following team at NPSF.

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NPSF would like to graciously acknowledge the following individuals for their expert assistance with this module.

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So, what do health care professionals need to know about limited health literacy?

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Health literacy has been defined “as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

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Limited health literacy is a serious issue facing our health system.

According to the National Action Plan to Improve Health Literacy released by the USDepartment of Health and Human Services, nearly 9 out of 10 adults have difficulty using every day information that is routinely available in our health care facilities, media and communities.

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While some health care professionals may assume that limited health literacy is confined to certain populations, it can affect anyone, regardless of age, race, education or income.

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The 2003 National Assessment of Adult Literacy is the only population-level study of health literacy conducted to date in the US.

While dated, this study provides the most accurate indication of the health literacy levels of adult Americans and has been widely cited in subsequent articles on the topic.

Results show that most adults struggle to understand health care information and may be confused about how to use prescription medications or adhere to care plan activities.

The degree of confusion varies based on individual health literacy levels.

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Individuals with proficient health literacy can use health information effectively, such as to consider the risks and benefits of a certain treatment.

These patients can “perform complex activities, such as integrating, synthesizing and analyzing multiple pieces of information.”

They also “might find the information required to define a medical term by searching through a document.”

However, only 12% of adults in the US meet the criteria for proficient health literacy.

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Over half of all US adults have only intermediate health literacy.

Individuals with intermediate health literacy are able to “perform moderately challenging activities, such as summarizing written text, determining cause and effect and making simple inferences.”

However, they may still “find it difficult to define a medical term from a complex document about an unfamiliar topic.”

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Even more challenging, over one third of US adults have below basic or basic health literacy. These are individuals that are of great concern for our health care system.

These patients “may fail to understand critically important warnings on the label of an over-the-counter medication.”

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Limited health literacy impacts patient comprehension.

It has been linked to misunderstanding prescription instructions, taking or providing medications incorrectly, poor comprehension of nutrition labels as well as poor understanding of preventative care information.

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While limited health literacy is a critical issue, the way that health care professionals communicate with patients can also hinder comprehension.

Here you see data showing the proportion of US adults who reported that their health care providers always explained things so they could understand.

As you can see, with the results hovering at 60% of the time, there is room for improvement.

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Limited health literacy can have a significant impact on patients, and has been consistently linked with poor health outcomes.

It is negatively associated with self-reported health and adults with below basic health literacy skills are more likely to report their health as poor.

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Limited health literacy can also have a psychological toll on patients.

Patients with limited health literacy are often embarrassed and feel a sense of shame.

Many have never shared their struggle with anyone, even family members.

And, they may go to great lengths to hide their lack of understanding.

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Limited health literacy also impacts resource utilization.

Patients with limited health literacy generally use health care resources more often.

They have higher rates of hospitalization and emergency care visits and lower rates of flu immunizations.

They also may experience more preventable hospital visits and admissions, and tend to have higher medical costs and use an inefficient mix of services.

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The costs of limited health literacy are sizeable.

Limited health literacy is estimated to cost the U.S. economy between $106 billion to $238 billion each year.

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Finally, limited health literacy inhibits shared decision making, which is a process wherein patients and their providers make health care decisions together.

It is a process that takes into account both clinical evidence as well as a patient‘spersonal values and preferences.

For shared decision making to occur, patients must be able to comprehend the health information shared with them.

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Patients may not know what they don’t know.

Research indicates that patients often have tests and surgeries that they would not

want if they knew all their options.

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Further, studies have shown that patients and health care professionals view trade-offs differently.

On this slide, you can see sizeable discrepancies between what physicians think patients would want to choose, and compared to what patients would actually choose.

It is critical for patients to be able to comprehend health information so that they can participate in shared decision making and make informed decisions about their care.

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So, what do health care professionals need to watch for to identify patients who might be struggling with limited health literacy, and what are some clues that patients may not have good understanding of their care?

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Identifying patients with limited health literacy is often difficult.

It helps to be aware of at-risk populations as well as red flag behaviors and responses.

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However, do keep in mind that, while certain populations are at greater risk, limited health literacy can impact anyone.

It is a state, not a trait.

Also, compounded with less than proficient health literacy, illness, pain and fear can affect patients’ abilities to understand and communicate effectively.

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Indeed, there are certain patient populations that may be at greatest risk for limited health literacy.

These populations include:- Elders or adults over age 65- Individuals with limited education or low incomes- Non-native speakers of English- Racial or ethnic groups- Recent refugees and immigrants- And adults with any type of disability, difficulty or illness.

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Limited health literacy disproportionately affects minority groups and lower socioeconomic groups.

On this slide, you can see varying levels of health care literacy across a range of ethnic groups.

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So how can health care professionals identify patients with limited health literacy? This is often not an easy task, particularly when patients may compensate with avoidance behaviors.

Patients with limited health literacy cope in different ways to avoid attracting attention, such as by making excuses to avoid reading health information or postponing decision making.

For instance, patients may say, “I forgot my glasses,” or “I will read this when I get home.”

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Other methods for recognizing patients with limited health literacy include watching for red flag behaviors, such as:

- Failure to complete or inaccurately completing registration forms

- Inability to describe their medication regimen

- “Difficulty in explaining medical concerns”

- And an inability to “articulate symptoms or time course of illness”

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Additional opportunities to detect limited health literacy may occur when patients are unable to name their medications, explain their purpose or explain when they are supposed to take them.

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As a reminder, while it can be helpful to have awareness of at-risk populations and red flag behaviors, it is also important to avoid stereotyping patients.

As discussed earlier, the National Assessment of Adult Literacy shows us that the majority of adults have difficulty understanding health care information, or do not have proficient levels of health literacy.

Further, it is also worthwhile to note most adults will struggle with limited health literacy at some point in their lives.

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So, what can health care professionals do to help patients increase their understanding of health care information?

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Clear health communication is key.

A provider’s communication skills can directly influence a patient’s health literacy and comprehension.

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Some tactics to promote clear health communication include:- Slowing down your conversation- Limiting and repeating information that the patient needs to know- Avoiding the use of medical jargon and explaining the terms they need to learn- Using easy to read patient decision aids- Referring to illustrations to explain important concepts

- And making visits interactive by using the Ask Me 3 questions and the “teach-back”technique

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Slowing down your conversation and speech can help encourage understanding.

Rapid speech may hinder patients’ comprehension of the information shared.

Keep in mind that patients with limited health literacy are less likely to ask health care professionals to slow down or repeat information than other patients.

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To help promote understanding, limit the amount of information shared and repeat it.

Patients have trouble remembering information shared during medical visits. Research indicates that there is an “inverse relationship” between the quantity of information shared and how much a patient is able to recall.

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To encourage retention of critical information, limit the amount shared and reinforce it, focusing on the top 1 or 2 key points that your patient needs to know.

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Medical jargon can be off-putting for patients of all health literacy levels.

Strive to use simple, non-medical terms when conversing with patients, such as those shown here.

For example “edema” may be more readily recognized and understood if a health care professional uses language such as “swelling” or “build up of fluid”

However, there may be terms that a patient needs to learn because they will hear them frequently. If this is the case, take care to explain what they mean.

Provide written materials, or patient decision aids, that are easy-to-read.

Whenever possible, provide materials that the patient can take home with them for ongoing reference.

All patients, not just patients with limited health literacy, favor simple, straightforward materials.

In designing written materials, strive to: - Use short sentences- Present information using bulleted lists- Focus on only a few key points, with the most important information listed first- Leverage headings and subheadings to separate blocks of information- Use simple terms; avoid medical jargon- And use active voice

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Also, consider referring to illustrations to explain important concepts and reinforce recommended actions.

Patients remember visual images better than words or letters.

The use of graphic illustrations can help patients understand and retain information.

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Research shows that use of patient decision aids can have a considerable impact in promoting patient comprehension.

According to a systematic review of 115 studies involving over 34,000 participants, the use of patient decision aids helped individuals - Improve their knowledge of care options- “Feel more informed and clear about what matters most to them.” - Increase the accuracy of their risk perceptions- And have greater participation in decision making

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Making visits interactive can also help increase understanding.

Invite patients to ask questions throughout the visit, rather than saving them for the end.

Ask Me 3 can help encourage patients to speak up and ask questions.

In addition, use “teach-back” to check comprehension

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Ask Me 3 is an educational program offered by the National Patient Safety Foundation that encourages patients to ask three simple but essential questions during every health care interaction.

These three questions include:

What is my main problem?

What do I need to do?

And why is important for me to do this?

These questions help focus conversations between patients and health care professionals around critical elements of diagnosis, treatment and context.

Ask Me 3 was created by health literacy experts as part of the Partnership for Clear Health Communication at the Pfizer pharmaceutical company.

NPSF offers the Ask Me 3 under a licensing agreement with Pfizer.

This agreement has been in place since 2007, and the program has been broadly used both within and outside of the US.

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Ask Me 3 helps patients become more involved in their health care, and it can also assist health care professionals organize their conversations with patients by focusing

attention on the information patients need to take care of their health.

NPSF provides a variety of free materials in both English and Spanish to help implement Ask Me 3, which we will discuss further in a moment.

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Finally, and as always, use “teach-back” to make visits more interactive and promote clear health communication.

This tactic asks patients to repeat – or “teach-back” – the information that has been shared with them to ensure comprehension.

If a patient cannot repeat or explain what they have been told, assume that you have not clearly communicated the information.

Try to explain the information again. Then, ask the patient to “teach-back” the information a second time.

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Instead of simply asking if something makes sense, consider asking a patient to “explain how you will take your medication” to gauge their comprehension of the information shared.

Estimates indicate that it only takes one minute to put “teach-back” into practice.

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Given the prevalence of low and limited health literacy, absence of cues or red flag behaviors should not be assumed to mean adequate comprehension.

NPSF encourages health care professionals to adopt universal precautions and strive to use these clear communication strategies with all patients regardless of their apparent health literacy skills.

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So, how can health care professionals implement Ask Me 3 to promote clear health communication in their organization?

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There are many ways to implement the Ask Me 3 concept and materials.

To get started, consider:- Educating your team- Posting Ask Me 3 information- Sharing Ask Me 3 materials- Showing the Ask Me 3 video - And discussing Ask Me 3 with patients

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To educate your team, consider convening an inter-professional group to discuss the prevalence of limited health literacy and what it may mean for your patients.

Discuss how Ask Me 3 might be a good fit for your organization.

If you decide to move forward, conduct a more detailed training for your team on health literacy and Ask Me 3 so that everyone will be prepared to field inquiries about the program and answer the questions during visits.

Role playing with your team can help assist them in gaining experience using the threequestions to frame conversations with patients.

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Post educational information to raise awareness and encourage patient questions.

The Ask Me 3 poster, which is available for complimentary download on the NPSF website, can be used to stimulate patient interest about the program.

Consider posting information in high-traffic areas, such as: - Entrances to your facility- Information and reception areas- Waiting rooms- Examination rooms - Bathrooms - And the cafeteria

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Share educational materials.

The informative and easy-to-read Ask Me 3 flier, which is available for complimentary download on the NPSF Ask Me 3 website, can help educate patients about the three questions and how to use them.

Consider sharing materials in the following ways: - Handing it out at check-in and reception areas- Putting it on tables in the waiting room- Sending a special mailing to patients - Or distributing information and talking about it at health fairs

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Consider adding the Ask Me 3 video to your internal patient television network.

Available in English, with Spanish captioning available, this video features a patient speaking to his provider using the Ask Me 3 questions to get the answers needed to better understand his health condition and how best to take care of himself.

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And finally, take advantage of opportunities to discuss Ask Me 3 with patients.

Encourage your team to refer to Ask Me 3 during patient visits and to consider using it to structure conversations with patients.

The Ask Me 3 program is most often used to assist patients in getting the information they need to take care of their health.

However, health care professionals can also use it to structure how they share information with patients to ensure that the answers to the three questions are provided in the course of the conversation.

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As a reminder, NPSF provides a variety of free materials - in both English and Spanish -to help implement Ask Me 3, including an implementation guide, printer friendly posters and fliers as well as a video of Ask Me 3 in action.

Visit www.npsf.org/AskMe3 to download.

Please note that registration and agreement with terms and conditions is required, and that these materials may not be co-branded without permission from NPSF.

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The Implementation Guide provides tips and strategies for implementing the Ask Me 3 concept and materials into your practice or organization as well as other steps you can take to encourage clear health communication.

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The Ask Me 3 poster can be used to introduce patients to the program.

The poster is available in both English and Spanish and can be printed on 11 x 17 paper.

The informative 2-page Ask Me 3 flier helps educate patients about the program and encourages them to ask health care professionals the three questions.

The flier is available in both English and Spanish and can printed on standard 8.5 x 11 paper.

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The Ask Me 3 video shows how to use the questions in action. It can be viewed on the NPSF Ask Me 3 webpage.

Please contact NPSF if you are interested in showing the video in your practice or organization.

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So, in conclusion, it is important to remember that limited health literacy can affect anyone and has been linked to poor health outcomes, high resource utilization, and poor comprehension.

Tactics to promote clear health

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communication include:- Slowing down yourconversation

- Limiting and repeating information at every visit

- Avoiding the use of medical jargon and explaining terms

- Using easy-to-read patient decision aids

- Referring to illustrations to explain important concepts

-And making visits interactive by using the Ask Me 3

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questions and the “teach-back”technique

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As a reminder, please note that Ask Me 3 is a registered trademark licensed to National Patient Safety Foundation.

NPSF provides, through a non-exclusive, non-transferable license, this educational module and certain Ask Me 3 materials and resources for download and distribution free of charge to aid in the promotion of health communication, including health literacy, and increased patient safety.

Individuals wishing to download and distribute Ask Me 3 materials and resources, representing themselves or organizations, must register and agree to the official terms and conditions to obtain access to the materials.

For more information, please visit www.npsf.org/AskMe3

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Thank you for taking the time to learn about how to promote clear health communication with Ask Me 3.

If you have any further questions, please contact the NPSF team by phone at 617-391-9900 or by email at [email protected].

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