For the Love of Health

Understanding Health Literacy with Greg O'Neill and Dr. Himani Divatia

• ChristianaCare • Season 2 • Episode 5

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Sometimes hearing medical news and information can be difficult to wrap your head around. But understanding that information can be the difference between a good outcome and a poor outcome.

Low health literacy is associated with more hospitalizations, greater use of emergency care, and higher mortality. Greg O'Neill, ChristianaCare's Patient and Family Health Education Director, and Dr. Himani Divatia, ChristianaCare's Associate Designated Institutional Official, join us to discuss the critical need for clear communication in healthcare, share examples of the Teach-Back method of understanding health instructions, and offer advice on how to better receive health information yourself.

Greg O'Neill, MSN, APRN, AGCNS-BC, leads the strategic plan for patient education and health literacy initiatives at ChristianCare as Director of Patient & Family Health Education. In this role, O'Neill has developed a team of Nursing Professional Development Specialists who champion health literacy best practices systemwide and support all manner of patient education initiatives and vendor relationships.

Himani R. Divatia, DO, is an experienced internist, pediatrician, and hospitalist.  She has been with ChristianaCare since her residency in 2015.

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Speaker 1

You can just ask a friend or a family member about the last time that they had difficulty understanding their health.

Speaker 2

You're listening to For the Love of Health, a podcast about delivering care and creating health, brought to you by Christiana Care. And now here are your hosts.

Speaker 3

Hello everyone, I'm Megan McGerman.

Speaker 2

And I'm Jason Tokarski. Welcome to another episode of For the Love of Health brought to you by Christiana Care.

Speaker 3

Sometimes hearing medical news and information can be difficult to wrap your head around, but understanding that information can be the difference between a good outcome and a poor outcome.

Speaker 2

Low health literacy is associated with more hospitalizations, greater use of emergency care and higher mortality. Here to talk to us about the importance of health literacy are Greg O'Neill, christiana Care's patient and family health education director, and Dr Hemani Devaitia, christiana Care's associate. Designated institutional official.

Speaker 3

Greg and Hemani, thank you both so much for your time today.

Speaker 1

Yeah, thanks for having us Great to be here.

Speaker 3

Let's lay the groundwork. What is health literacy and why is it important?

Speaker 1

When most people hear the word literacy, they're thinking of reading and writing, and that's true, but it can be so much more For health literacy. We're talking about how people receive health information, understand it and then take action on it so to improve their health or manage their care. If this does not happen, then you open up the door for the possibility of confusion, mistakes, complications, all kinds of things like this, and ultimately, that person may not be able to follow the recommendations of their healthcare team.

Speaker 2

Give us an idea of what this looks like nationally and regionally? Are there any statistics you can give us relating to health literacy and what patients are dealing with?

Speaker 1

So if you haven't seen the research, you can just ask a friend or a family member about the last time that they had difficulty understanding their health, and you'll soon find out that this is a widespread problem. The studies show us that at least one third, but really the majority of people probably struggle with health information, either finding what they need or understanding the complex nature of the health information they're confronted with.

Speaker 4

It's interesting actually, the literature does show, specifically for understanding of that information and being able to remember it and being able to remember it about 40 to 80 percent of people incorrectly remember the information that is given to them at a health care encounter, and what they do remember only half of that. So about 50 percent of what they do remember is accurately remembered, and so it's critical for us to engage with our patients and ask for the clarification of that understanding and reclarify what we're intending to share with them in order to make sure that patients feel that that communication is effectively received and that they can take action on those recommendations.

Speaker 1

So some of the work we've done. In Delaware we did a landscape analysis where we held focus groups and we sent out surveys to our community and we found that the local data really did match the more historical data nationally. So you're going to find about one third of people struggle with the most basic health information and then you're going to find about two thirds about 66 percent, maybe a little higher than that are going to struggle with even sort of moderate health information. So this is following your discharge instructions or navigating the medication label on your prescription, so things like that. It was very interesting to us to see that our data matched what had been found before. So we do think that not much has changed since the original data came out some years ago and we're looking to update that data soon with more research.

Speaker 3

So what are your teams doing here at ChristianaCare to make sure that our patients can properly follow through on those actions?

Speaker 4

So it's interesting, you know, for physicians specifically, medicine is truly that blend of art and science. Specifically, medicine is truly that blend of art and science and as we work to deliver great quality outcomes and experiences, we know that that's embedded in high quality care and that high quality communication. We have some tools that are embedded within our electronic medical record that allow us to share information in various forms that our patients can understand, take home, share with family members and caregivers. We also have a communication tool which is really powerful, called TeachBack, which allows the patient to share back what they've understood and the providers can clarify if there are any discrepancies. It's important also to know that we have a work group ongoing that brings together some clinical experts and physicians and advanced practice clinicians to think about new tools, new technologies and new trainings that we can use to seamlessly make the communication more successful.

Speaker 1

Yeah, I think the most important thing for our system of health is to make sure that we're consistent. We need to provide information in plain language, and that's going to help us ensure that no one leaves a visit or an encounter without a firm understanding of their health. So we are making big strides in this area, using the best tools available to us to provide information in an easy-to-understand format and to do that consistently. I also think, as Hamani said, it's important for us to provide our caregivers with the skills that they need to confirm understanding. So something simple like asking a patient to explain back what they think the plan is or what their diagnosis means in their own words. That's the only way to truly know that we're all on the same page and that we're understanding each other in the clearest way possible.

Speaker 3

Talk to me, hemani, about what teach-back really looks like in real time, when you're in a session with a patient or you're working with your fellow clinicians on hammering home the importance of this teach-back concept. Walk us through this kind of interaction.

Speaker 4

So teach-back is really a framework of communication and it's composed of three core elements. The first step is really explaining the information to the patient in plain language, avoiding medical jargon and being respectful in the tone and delivery of that communication. The second piece is asking the patient to confirm back in their own words what they've understood. And the third piece is re-clarifying if there's any discrepancies or if the patient has further questions, or perhaps if what you were intending to say was not captured in the appropriate way.

Speaker 2

Could we role play that a little bit? Could you give me a little bit of what it would be like if I were your patient and you were trying to get me some of this information that you're referring to?

Speaker 4

That's a great idea, sure. So, jason, let's imagine that you are a patient in the hospital that is getting ready for discharge after a recent procedure that you've had. I might come to you and say Hi, jason, my name is Dr Devaitia, it's great to meet you today. Hi, jason, my name is Dr Devaitia, it's great to meet you today. I'd like to take the next two minutes to share with you your discharge plan before we get ready to get you home. So you've been started on a new medication for pain. You'll be expected to take two pills three times a day for the next couple of days, and you might notice some constipation as a side effect. If you experience these symptoms, please call your doctor's office. So I'd like to make sure I explain that clearly to you. Can you, jason, repeat back to me in your own words the management plan for your pain?

Speaker 2

Sure, so I'm getting two pills three times a day. Next several days that I'll be on these medications, constipation is probably the main thing I'll be looking for and if I have any issues, get back in touch with my my medical provider.

Speaker 4

And that's great, but that's not how it usually goes.

Speaker 2

So good job. So that's an example of effective teach back.

Health Literacy Strategies and Equity

Speaker 3

So that is an example of effective teach-back.

Speaker 4

We know that sometimes, while our intentions are absolutely pure in explaining the information correctly, the reception of that understanding does not always work out.

Speaker 3

And is that really because you know, jason is in this very controlled setting, listening to you very intentionally setting up this example, but certainly if he were an inpatient in the hospital right now, his head would be in 75 other places.

Speaker 4

That's absolutely true. Due to the complexity of the healthcare system at large, due to a variety of sources of information that patients can have at their fingertips at any given time, and due to rapidly evolving diagnostics and therapeutics, there is a lot of information to convey, and we want to make sure that we're able to convey the right information at the right time.

Speaker 1

Can I ask, amani, what would you have done if Jason said something that you didn't expect? What if he said he was supposed to take those pills, you know, three times a day for two weeks, three pills a day, twice a day.

Speaker 4

That is a great point and often comes up, and so it's the responsibility of the healthcare team to then be able to stop, re-clarify and ask again through teach-back for the patient to clarify their understanding. It might take a couple of times to get to that right information transfer, but at the end of the day those extra few minutes are worth a lot more in the long run.

Speaker 3

I would assume as well that health literacy depends on age. How do you work in the different age groups, from you know, the parents who are worried about their youngest kids to then the parents who are attending appointments with their elderly parents? There must be ways. You have to adjust there.

Speaker 1

There are. However, the strategies are universal. So talking to someone in plain language, using tools that are designed to be easy to understand, getting them to explain back their understanding that works for anyone. Getting them to explain back their understanding that works for anyone. So I think you're right in highlighting that we have populations that we need to make sure we're really looking and addressing the needs. So if we have an aging population, if we have certain groups within our communities who may be a little bit more disconnected or have different challenges, let's lean into that and make sure we're meeting their need. But the tools are really the same. If we do them consistently, we're going to find out that there's a need and we're going to figure out a way to address it.

Speaker 4

I think it's so wonderful that you brought that up, because, personally, I trained in both internal medicine and pediatrics and the one thing among many that is similar across the age spectrum is how you communicate. It is through that training that we were really able to share how to consistently communicate with young individuals and individuals of all ages. Health literacy we can make no assumptions about it, but we really should have some standard tools, processes and understanding of how to deliver it unanimously.

Speaker 2

And obviously age is only one factor that has to be considered here. We've mentioned the language barrier that can be there. Let's talk about the health equity angle of making sure we're talking to people in the manner that they can.

Speaker 1

Yeah, we have a really strong partnership with the folks in our organization that strive to improve the equity of care. Can you imagine going to a healthcare encounter and not receiving any information in the language that you need it in? I mean that is a terrible position to be in. So we try to find and use tools that provide information in as many languages as possible to meet people where they are. That is a critical need and really the lowest hanging fruit in terms of meeting those equity goals right out of the gate.

Speaker 3

And what can a patient do who is listening to this, who may have just seen that example and thought the same thing? If I'm in a real patient experience and you've just shared some hard news with me and then expected me to remember all of that, I'm not going to remember that. What can people do? What tactics do you share with patients to help them remember things as clearly as Jason just did?

Speaker 4

So we really encourage our patients to write down their questions for the next time that they see their provider, that way that they can clarify any questions that they have. We also encourage our patients to use various forms of information, various modes of information, such as verbal, visual and written information, and we want them to express if they have a preferred language, because we recognize that the gaps in health literacy are even greater for those who don't have English as their first language. Lastly, we want our patients to collaborate with their entire healthcare team so that they can seek clarity with each interaction that they have.

Speaker 1

Yeah, I would encourage anyone to take the opportunity the next time they're in a visit or an encounter to ask those questions and then go ahead and explain back what your understanding is in your own words and see how it goes. There might be some opportunity to clear things up.

Speaker 3

Have either of you gotten feedback directly from patients who say you know, I came in here and my head was spinning and the way that I was able to take this information has really helped?

Speaker 1

Yeah, absolutely. We hear directly from our patients and our providers that this process of getting people to explain their understanding in their own words it really makes the entire healthcare encounter better for everyone. So it might seem like a simple task to try and accomplish that, but it's so worth it.

Speaker 4

I think it's also important for our patients to understand that they may be asked to confirm their understanding, and that is not to test a patient or to make it more complex. It's actually to ensure that we're identifying those health literacy gaps and addressing those at the point in time.

Speaker 1

Let's not forget that it is the responsibility of our care teams to communicate in the way that the patient needs. So this is just one way, with these techniques and the tools that we have, to try and make sure we're meeting them there.

Speaker 3

There's certainly more than Teach Back in the entire realm of health literacy. So what else are you working on, Greg?

Speaker 1

We're trying to use technology as best we can, and that's certainly going to play a part in reaching people where they are, but for me, ultimately, it comes down to our relationships with our patients and our families.

Speaker 1

That's going to be the best way to make sure that we're communicating in a way that works for everyone. We're communicating in a way that works for everyone, and the newly formed Health Literacy Council of Delaware is pulling together all the health systems, public health agencies, community partners from around the state to make sure that we're all using the same strategies to meet this need. So that may end up resulting in us agreeing around certain technology strategies, maybe even using similar partners to try and reach people, because the important part is that people feel like they're being communicated with in a consistent fashion and in a way that works for them. It's a real dance sort of meeting that need with what's available from a technology standpoint. So we'll keep bringing those ideas forward as a state and anybody that wants to check it out can go to healthliteracydeorg to learn more about the council and the work that we're doing. But we think that in Delaware we can really move together to make sure we're reaching our community in the same fashion.

Speaker 3

Greg and Hamani. Thank you both so much for your time today.

Speaker 4

Thank you so much for having us.

Speaker 2

We'll have more information on health literacy in the show notes for this episode.

Speaker 3

And don't forget to subscribe to For the Love of Health on Apple Podcasts or Spotify. And you can watch the video versions of For the Love of Health on Christiana Cares YouTube channel.

Speaker 2

We'll be back in two weeks with another great conversation.

Speaker 3

Until then, thanks for joining us for the Love of. Health.

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