A previous post introduced the Patients as Partners Health Literacy Prototype (PAP) sponsored by the British Columbia Ministry of Health Service, Primary Care Division; Legacies 2010; and Impact BC with support of the British Columbia Medical Association.
Four health care teams from four different communities participated in the PAP Health Literacy Collaborative. They were from Vancouver/Burnaby, the TriCities, Victoria and Hazelton/Gitsegukla. Each participating team was made up of a physician’s office practice and an adult literacy program. The teams made changes in order to improve health literacy with gratifying results which they reported during the Get Real: Partnerships for Moving Health Literacy Forward event on December 10 2009. The presentation is available here.
The Hazelton team
- This unique team brought together Gitsegukla Health Center, Storytellers Foundation, University of Northern British Columbia and the Northern Health Authority – a remarkable partnership. Student nurses provided education and support to community members with high blood pressure.
- The team wanted to address a unique problem in Gitsegukla. The area is served by newly graduated health practitioners who lack an understanding of the Gitsegukla First Nations culture. To address this problem, they created a cultural primer for health professionals who come to practice in the area so that they can be more sensitive to the cultural needs of the patients. The video will be a valuable tool in the recruitment of physicians.
To “take patient values and preferences into account,” Dr. Hii’s practice implemented a number of changes with the remarkable results below :
- assessing and documenting patient’s health literacy on intake by asking questions on formal education, preferred language, English fluency and daily reading habits.
- use of patient education materials for diabetes self management to ensure patients understand the concepts of ABC (Hemoglobin A1c, BP and Cholesterol) control. They also use the teach-back and “close-the-loop” strategy to enhance understanding although this is very time consuming. More diabetes patients have their blood pressure and cholesterol under control.
- proportion of patients answering “strongly agree” to
- My doctor asked about my ideas, beliefs & what I wanted when we planned my care went up from 30% to 60%. The goal is 80%.
- My doctor explained things to me in a way that was easy to understand went up from 40% to 70%
- I felt comfortable asking questions went up from 50% to 70%
- It was easy for me to tell the doctor when there was something I did not understand went up from 40% to 70%
- proportion of patients that explained medications and doses as prescribed; did not miss more than one dose in the last 7 days; did not start or stop any medications on their own went up from 70% to 90%.
Literacy learners at Douglas College:
- learned about H1N1 (at least 10/12 learners could explain what H1N1 is, how it is spread, how to avoid spreading it and what to do if they thought they had it
- participated in a pedometer challenge to increase their walking as part of a healthy lifestyle
- learned that nurses were approachable from 3 nursing students who spoke to their class to about the nursing profession
To encourage clear patient-physican dialogue, the Tri-Cities team surveyed literacy (English-as-Second-Language) learners on how they would describe their relationship with their doctor:
- 17/24 reported that they had a good-okay relationship;
- 4/24 reported difficulty in talking to their doctor;
- 16/24 reported having little to no confidence in asking their doctor questions.
The literacy learners suggested that they could improve the relationship with their physician by bringing a family member to an appointment and preparing questions that they would ask the doctor.
The Tri-Cities team assessed the literacy learners’ knowledge and use of the BC provincial non-emergency health information resource (811).
- 21/28 were unaware of the resource while 7/28 had heard of it but did not know much
- 26/28 had never used the resource while 2/28 had used the service and found it very beneficial
- on learning about the resource, 18/25 reported feeling comfortable about using it
- learners were particularly pleased to know that translation is available into over 100 languages.
The Victoria team
- created a prompt card (adapting the It’s Safe To Ask materials) to help their literacy learners communicate with their physicians, ask questions and seek clarification when something was not understood. The proportion of patients with confidence to speak up when there was something they did not understand increased from 3/8 to 7/8.
- surveyed their patients and found that 28/30 of them did not know which internet sites can give me helpful and reliable information about my health. In response, the practice set up a computer with recommended plain language websites in the reception area. A tracking system was put in place to track use and request feedback on this resource. 90% of the patients used the selected resources. This intervention was in response to the high proportion of patients who brought in flawed information printed off the internet.
- created a video to help literacy learners navigate their way to the practice location.
The results generated by these teams demonstrate that small changes can lead to significant improvement with far reaching impact on patients’ well being. The 8 month pilot project has ended but all the teams are determined to find ways to continue the partnerships. Certainly, the participating medical practices will profoundly changed their approach to dealing with patients as they move forward. Their accomplishments can inspire other health professionals to find meaningful changes that could improve their patients’ health literacy. Only a few months ago, in an earlier post, I wrote ” We are a long way from having a robust health literacy strategy like that of Iowa …” so I am thrilled to be proved wrong because the Primary Health Care Charter provides a framework which has been translated into the 3 pronged change package strategy (build relationships, ensure understanding, partner).
Some questions remain: what are the characteristics of the practices that volunteered to participate in this project? How can this awareness diffuse from these early adopters to others? How can the Victoria initiative to provide access to reliable online health information be further developed through partnerships with libraries across the province? How can technology be harnessed to empower patients (see my earlier post on e-patients)? How can the barriers to a wider adoption of patient-centred care be addressed? Many physicians cite time constraints as the biggest barrier to more patient-friendly practice. The physicians at the event suggested these approaches to addressing these problems:
- organize patient group sessions – for example to teach diabetes self management
- partner with pharmacists to enhance medication compliance and safety
- use of volunteer coaches to work with the patient
- refer patients to libraries for consumer health information (the partnership between Vancouver Coastal Health and Richmond Public Library is an excellent example in this regard)
- place computers in doctors’ offices to support access to reliable online health information (as in the example by the Victoria practice above)
- support sharing of tools such as forms and patient resources to avoid reinventing the wheel. A good example is a medical clinic walk-about check-list.
- involve medical office assistants and other office staff
The common thread in the above suggestions is the involvement of as many players as possible outside the traditional medical community to extend the physician’s reach in optimizing physician-patient communication. This is a pragmatic approach that seeks to address the reality of overworked physicians in BC. As the awareness is now in place, the next step is identifying creative ways to incorporate these suggestions and other “low-hanging fruit” in physician practices using the available resources. The ultimate progress will be accomplished when health literacy is considered important enough to merit ongoing and sustainable support across the province.
More information is available from the ImpactBC site or from the Collaborative Co-Directors: Connie Davis, ImpactBC, firstname.lastname@example.org or Kelly McQuillen, Ministry of Health Services, email@example.com