addressing health literacy in a multilingual population: a community health center approach andrea...
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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
