Massachusetts Community Health Center Improves Communication With Health Literacy Toolkit
Edward M. Kennedy Community Health Center (CHC) of Worcester and Framingham, MA, which serves over 24,000 patients who speak 93 languages, is committed to meeting the health care needs of its diverse population. To that end, the Kennedy CHC began using AHRQ's "Health Literacy Universal Precautions Toolkit" in 2010 as a guide to improve health literacy.
Kennedy CHC's Health Equity/Cultural Competency Team first used the toolkit's organizational assessment to assess how the center was performing in key areas that affect patient understanding. The findings were used to develop an action plan to increase health literacy. Addressing health literacy of patients has been explicitly recognized as a principal element in delivering culturally and linguistically appropriate services by the federal National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
"In order to be culturally responsive, we needed to address health literacy," says Sue Schlotterbeck, Director of Cultural and Language Services at the center. More than one third of patients in the United States have limited health literacy, which results in their not understanding what they need to do to take care of their health. The proportion is even larger for minority group members and individuals for whom English is not their first language. Limited health literacy is associated with poor management of chronic diseases, poor ability to understand and adhere to medication regimens, increased hospitalizations, and poor health outcomes.
AHRQ's toolkit helps provider organizations take "universal precautions"—because health care providers do not always know which patients have limited health literacy—to minimize risk for all patients. This approach "helped us to make sure the patient and provider understood each other," Schlotterbeck says.
After assessing its practice, Kennedy CHC established priorities. "Verbal communication became our top priority," she says. The center set out to increase staff awareness, improve the environment around spoken and written communication, integrate health literacy into policies and procedures, and then measure its success.
The center implemented health literacy training—incorporating it into annual and new hire training—and used the "teach back" method to tackle spoken communication shortfalls. The teach back method confirms patients' understanding of what their provider has explained, in a nonshaming way, by asking patients to repeat in their own words what they need to know or do. In addition to providing an opportunity to check for understanding, the method allows providers to reteach the patient, if necessary.
Kennedy CHC leaders made sure there was regular dialogue with clinical staff about teach back and the importance of health literacy. The center's newsletter regularly included articles about the initiative and progress updates. Stickers were affixed to staff members' computer screens to remind and prompt them to use the intervention, and "Teach Back Tuesdays" were instituted to supplement the initial and formal training sessions. "Once people started using teach back, many were hooked," Schlotterbeck says. "It's not that hard, and it makes sense."
In October 2011, nearly a year after implementing teach back, a survey of clinical staff found that 61 percent were using the method, with 78 percent reporting that it had changed the way they communicated with patients.
In May 2012, more than 100 staff members were surveyed again, with 91 percent reporting they were using teach back. Of those, 88 percent reported that it had increased patients' participation in their care.
"The teach back [method] helped me to know what the patient heard, and realize that repetition and clarification is needed," observes Donna Raymond, RN, a Kennedy CHC family nurse practitioner.
Tina King, dental practice manager and dental hygienist at Kennedy CHC, adds that teach back "helps start a dialogue with the patient, making it easier for patients to become engaged in asking questions, which in turn will help them to start making informed decisions and become a partner with their provider to reach their health care goals."
"I think AHRQ's toolkit made it easy for us to go down the path to address health literacy," concludes Schlotterbeck. "It sets standards and has a good set of resources. The guide was very helpful, along with the tools. It made us better."
To learn more about the toolkit, visit http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html.