Navigating the Health Care System
Slide 1. Navigating the Health Care System
A Health Literacy Perspective Through the Eyes of Patients
Ashley B. Hink
UNC Sheps Center for Health Services Research
NC Program on Healthy Literacy
Slide 2. Health Literacy
"The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."
—Healthy People 2010.
Slide 3. Purpose and Process
- To gain patients' perspectives on...
- Navigating health care services.
- Interacting with medical providers and staff.
- Understanding health information.
- Understanding their perspective helps us improve our practices.
- Document and describe the process of scheduling and attending a primary care visit.
- UNC Internal Medicine Enhanced Care Clinic.
- New patient: Ashley Hink.
- Returning patient: Larry Holt.
Slide 4. Patients
- Ashley Hink:
- 25 years-old.
- MPH Student.
- Researcher, health educator.
- Has difficulty sleeping.
- For the purpose of the visit, she claims to have high blood pressure and no insurance.
- Larry Holt:
- 58 years-old.
- School Custodian, father and grandfather.
- Has diabetes, hypertension and chronic shoulder pain.
- Insured through BCBS State Health Plan.
Images: Photographs of Ashley Hink and Larry Holt.
Slide 5. First steps
I referred to a pamphlet about the Internal Medicine phone system to help me schedule my appointment. It was easy to understand, and I knew exactly which option to select.
Image: Photograph of a pamphlet featuring phone numbers in bold text and a cell phone dialing the first phone number.
Slide 6. Scheduling confusion
It took a total of 2 calls, 4 selected options, 2 connections, 1 voicemail message, 1 call-back and a final conversation with an Enhanced Care staff member to get my appointment. Fortunately, I was able to see Dr. Malone within one week.
Image: Photograph of Ashley Hink talking on the phone.
Slide 7. Paperwork, and lots of it
As a new patient, I am required to fill out a seven-page personal health summary—most of which is very straight-forward and easy to fill out.
Image: Photograph of Ashley Hink filling out a form.
Slide 8. Health History Form
- Seven pages inquiring about social and medical history.
- Generally easy to follow and read.
- Some medical terms have common names in parenthesis:
- Anemia (low blood).
- Some medical terms have common names in parenthesis:
- Some of the answer options are not appropriate for the question (multiple choice vs. fill-in).
- Often resort to qualifying answers.
Images: A filled-in form and a detailed section of the form listing medical conditions. "VD" is highlighted and a note reads "VD - not spelled out, examples are hard to read for those with low literacy."
Speaker's Note: No one asked for the form when I brought it to my appointment.
Slide 9. Release of Medical Information
- No explanation or guidance.
- Technical/legal language, written at a high grade level.
- Must infer what information is needed:
- I authorize _____ to release to _____ the medical records of _____.
- I decided to leave this blank for now, and will fill it out if requested by the provider.
Image: The Release of Medical Information form.
Slide 10. Reminders and homework
In addition to my appointment reminder in the mail and over the phone, I receive an explanation of my upcoming appointment to the blood pressure clinic. It asks me to bring all of my medicine and to take my blood pressure before coming in.
Images: The Appointment Reminder and information regarding the Blood Pressure Clinic.
Slide 11. Requested BP Check
- 1/10/09 - Before giving blood: 108/74.
- 1/11/09 - With home monitor: 120/83.
Image: Photograph of Ashley Hink sitting on a sofa using a home blood-pressure monitor. The numbers 120/83 appear superimposed at the top of the photograph.
Slide 12. Made it
The UNC Ambulatory Care Center is home to 8 separate clinics. While the sign is hard to read from the road, it lets me know I'm in the right place.
Images: Photograph of the front of the UNC Ambulatory Care Center; inset photograph of the sign listing the medical centers within the building.
Speaker's Note: Before arriving, I receive a message inquiring about my health insurance... I don't respond.
Slide 13. Direction and assistance
While looking at the sign that directs patients to the correct floor, a security guard greets me from the information desks and asks if I need help.
Image: Photograph of the information desk at the UNC Ambulatory Care Center.
Slide 14. Check-in
A staff member checks me in and I'm pleasantly surprised to find out that I have no additional paperwork to fill out, nor do I have to wait. I was asked if I had health insurance—I turned around after saying ‘no' only to see people listening to my conversation.
Images: Photograph of the reception area for Enhanced Care/Same Day Clinic/Point of Care Lab and and inset photograph of a sign that says "Please Wait Here."
Slide 15. Waiting...
I paused at the door in attempt to follow directions. After waiting a while a staff member told me to walk to the end of the hall.
Images: Photograph of the door to the Point of Care Lab; a sign on the door says "Clinical Area: Please wait for a nurse to accompany you." Photograph of a long hallway with doors on either side and a nurse standing at the far end.
Slide 16. Weight and vitals
A cheerful nurse quickly gets my weight, heart rate and blood pressure.
Images: Photographs of Ashley Hink standing on a scale and having her blood pressure taken.
Slide 17. Excellent physiological acting
My first blood pressure reading was 150/99. I blame it on taking the stairs and drinking 3 cups of coffee. The nurse tells me to relax. Five minutes later it was 148/92.
Image: Photograph of Ashley Hink having her blood pressure taken; the monitor display shows 150/99. The numbers 150/99 appear superimposed at the top of the photograph. An inset photograph shows the home blood-pressure monitor displaying 148/92.
Slide 18. Reading material?
I like to read the pamphlets and health magazines while waiting. Hoping to find something relevant to my personal health, I find only 5 options, 3 of which are in Spanish.
Image: Photograph of a rack for displaying pamphlets; most of the slots are empty.
Slide 19. The visit
Dr. Malone asks me why I'm here and about my personal and family medical history. I discuss my sleeping problems, and tell him my family physician was considering starting me on a medication for high blood pressure. We discuss sleep hygiene, sodium in my diet, and treatment options for both issues.
Images: Photograph of a prescription pill container and medical forms on a table next to a computer keyboard; inset photograph shows Dr. Malone reading information on the computer screen.
Slide 20. Shared decision-making, future steps
Dr. Malone suggests re-starting my sleeping medication and possibly increasing it in the future. He says I don't need to start an anti-hypertensive medication yet, so we discuss how I might change my diet.
Image: Photograph of Ashley Hink and Dr. Malone discussing her options.
Slide 21. Goals, changes and more homework...
The blood pressure visit summary sheet provides a good overview of our visit and what I need to do at home...
- Decrease sodium intake.
- Re-start Trazodone.
- Check BP three times in the next week.
Image: A Patient Blood Pressure Sheet is filled out with information and recommendations for Ashley Hink.
Slide 22. Pharmacy cold shoulder
After waiting about 15 minutes, I sit down to a seemingly half-interested counselor. I told her I'd be getting my medicine here soon and wanted to start the paperwork. She said she wouldn't give it to me until I had a prescription" so much for being proactive.
Images: Photograph of the pharmacy area; inset photograph shows a service machine to select next-day service pick-up or an assistance from a counselor.
Slide 23. 45 minutes later...
Overall, my visit was an excellent experience. The process was relatively easy, the health care provider communicated clearly and included me in the decision-making process, and the staff were friendly.
Image: A point-of-view photograph shows Ashley Hink in her car, parking-lot ticket in hand, as she drives toward the exit gate.
Slide 24. Number of Steps?
- Call to make the appointment.
- Fill-out necessary paperwork.
- Take my blood pressure twice before the visit (pharmacy and blood drive).
- Prepare for appointment: get papers, medicine, directions.
- Drive from Raleigh to Chapel Hill, find the clinic.
- Follow the signs to the General Internal Medicine Clinic.
- Check-in at front desk.
- Nurse takes my weight, blood pressure.
- Review medical history and reason for visit with provider.
- Agree on treatment plan and verify understanding.
- Check-out at front desk.
- Attempt to speak with pharmacy benefits counselor.
- Re-fill prescription at the pharmacy medicine and check BP.
- Have friend check BP, send BP values to Dr. Malone.
- Examine food labels for sodium content, attempt to change diet.
Slide 25. Notable Points
- Specify directions on the Enhanced Care phone system.
- Make forms and pamphlets easy-to-read (language and design).
- Sensitivity toward uninsured.
- More pamphlets/health information in rooms.
- More signs in Spanish.
- Multiple appointment reminders and directions.
- Friendliness of staff (most).
- Short wait time to schedule and see provider.
- Provider communication, visit summary forms.
- Signage in English was clear and helpful.
Slide 26. Established Enhanced Care Patient
Followed for over 7 years at UNC, Mr. Holt is more than familiar with the appointment process. He arrives 30 minutes early for his 9:00 a.m. appointment and is happily greeted by two front desk staff that know him by name. In less than 5 minutes, he is called back to see Dr. Malone.
Image: Photograph of Larry Holt at the UNC reception desk.
Slide 27. How did you feel when you were first diagnosed with diabetes?
How did you feel when you were first diagnosed with diabetes?
"I had been on about 8 different pills a day. Sometimes, you just forget it."
"It frightened me—I was scared to death. I had 4 doctors. It was overwhelming."
Did the medical providers clearly explain what diabetes is and how to take care of it?
"It was easy to understand. They told me what to eat, what not to eat, and they explained my medicine to me."
Slide 28. Blood pressure check
Mr. Holt is here for a regularly scheduled diabetes and blood pressure follow-up. Dr. Malone intends to simplify his medication regimen so he can take all of his pills once a day.
Image: Photograph of Larry Holt having his blood pressure taken. The numbers 120/76 appear superimposed at the top of the photograph.
Slide 29. Medication review
Mr. Holt takes two medications twice a day, and admits that he sometimes forgets the second dose.
Mr. Holt takes 5 medicines a day—he takes them out one by one, explaining what they are for, how many he takes and how much they cost.
- Metformin B.I.D..
- Enalapril/HCTZ B.I.D..
- Lantus Q.D.
- Baby Aspirin Q.D.
- Simvastatin Q.D.
He checks his blood sugar at least once a day, often before work at 5 a.m.
Image: Photograph of Larry Holt taking his medication containers out of a bag and placing them in a row on the table.
Speaker's Note: He doesn't identify the medication by reading the labels—he examines the exterior of the bottle.
Slide 30. Review of Warning Labels
Image: Photograph of five medication containers.
Image: White label reads "Take with Food!"
"Take it when you eat food."
Image: Red label reads "Do Not Drink Alcoholic Beverages When Taking this Medication."
"It looks like a glass... I don't know what it means.""
Image: Green label reads "Medication Should Be Taken with Plenty of Water."
"It looks like they are showing you how to run your water."
Speaker's Note: All of Mr. Holt's medications have warning labels on them. One in particular has 4 colored labels on them. I ask him to look at the pictures and tell me what they mean.
Slide 31. How do you remember to take all of these medicines?
"If I go out of town, I take what I need. I put the pills in aluminum foil, and I keep my insulin on ice."
"Sometimes if I miss one, I'll take 2 later."
"I've used a pill box before."
"I set my bag of medicine at the table where I eat. I have to keep it where I see it."
Slide 32. Review meds, create a plan
Dr. Malone reviewed each of Mr. Holt's medications and interrogated his glucometer. He made sure Mr. Holt was up-to-date on lab work and discussed options to simplify his medication regimen.
Image: Photograph of Dr. Malone and Larry Holt discussing his options.
Speaker's Note: Dr. Malone thanks Mr. Holt for bringing his medication and glucometer. Dr. Malone points to each of the medications, says what they are for, and asks Mr. Holt to explain when and how many he takes in order to verify his adherence.
Slide 33. Teach-back
Dr. Malone says, "Tell me what you are going to do." Mr. Holt repeats each of the changes one by one, and Dr. Malone clarifies the directions if needed. At the end of the visit Dr. Malone asks, "Are we good? Any other questions I need to answer?"
- Check BS before breakfast and dinner.
- Increase insulin to 19 units.
- Start Metformin ER 500mg, 4 pills in the morning.
- Start Lisinopril/HCTZ 20/25mg, 1 pill in the morning.
- Stop Metformin and Enalapril/HCTZ.
Limits visit to 5 main points or changes.
Image: Photograph of Dr. Malone and Larry Holt discussing changes to his medication.
Speaker's Note: The visit was limited to 5 main changes/points. It is recommended to focus on 3 to 5 points per visit to avoid information overload and confusion.
Slide 34. Adherence Reinforcement
- Visit summary sheet.
- Threw away discontinued medications to avoid confusion.
- Patient can now get all medicines at one pharmacy.
- Prescriptions faxed in and ready for pick-up in the afternoon.
- Requested follow-up to review changes and BS.
Image: A visit summary sheet is filled out with Larry Holt's information.
Speaker's Note: Took steps to help Mr. Holt avoid medication confusion: threw away old medications he won't be taking anymore, and called in his new prescriptions to the pharmacy so they will be ready for pick-up later.
Slide 35. Health Literacy Best Practices
Image: Figure shows 7 boxes in a circle. The boxes are captioned:
- Appointment Reminders.
- Phone Follow-Up.
- Confirm Understanding (Teach-Back Method).
- Treatment Simplification.
- Shared Decision-Making.
- Medication Review (Brown Bag).
- Kind, Supportive Staff.
Slide 36. Patient Advice
If you had any advice to people that work in the clinic to make information they give you easier to understand, what would you tell them to do?
"I would tell them that they need to write it—not in cursive, in print, and to use small words so I can read it. You see, I can hardly understand those real big words. You have to break down the syllables to understand the big words."
Slide 37. Patient Advice
What about they way they talk to you? Do they explain things in a respectful way? Do they look at you when speaking with you? Do they explain things clearly?
"They explain it very well. They all know me! I come in and say good morning to everyone and they say hello. Everybody is fantastic out there. The nurses are fantastic, too. Since I've been coming here I really enjoy myself with the doctors and nurses and staff. They look out for me, so if I make a mistake it will be mine, not theirs, because they really explain things to me."
Slide 38. Acknowledgements
Last updated 3.26.09.
Thanks to Dr. Robb Malone and Mr. Larry Holt for their participation. All personal information was used with permission.