Perfecting the Dismount: Improving the Handoff to the Patient

Darren A. DeWalt, MD, MPHUniversity of North Carolina School of Medicine

Disconfirming Evidence

Patients remember 17%-60% of information told by a physician

McGuire LC. Exp Aging Res. 22:4, 403-428. 1996.

National Assessment of Adult Literacy (NAAL)

n = 19,714

● Most up to date portrait of literacy in U.S.

● Scored on 4 levels

● Lowest 2 levels cannot:

◦ Use a bus schedule or bar graph

◦ Explain the difference in two types of employee benefits

◦ Write a simple letter explaining an error on a bill

National Center for Education Statistics, U.S. Department of Education

2003 National Assessment of Adult Literacy

Intermediate

Basic

Below Basic

Proficient

14%13%

44%

29%

93 Million Adults have Basic or Below Basic Literacy

Basic or Below Basic

52% of H.S. Grads

61% of Adults ≥ 65

Williams et al. Chest 1998, 114(4):1008-1015.

Asthma Patients with Low Literacy have Poorer Metered Dose Inhaler (MDI) Skills

Mean MDIScore0 - 4

0.7

1.21.5

1.7

0

1

2

3

4

< 3rd 4th-6th 7th-8th >9th

Can Patients Comprehend Rx Drug Warning Labels?

Davis et al. JGIM 2006; 21: 847-851

Simple Familiar Wording Understood by Most Patients

84%

(1st grade.)

Slide by Terry Davis

More Complex Message Limited Comprehension

59%

(7th - 8th grade.)

Slide by Terry Davis

Unfamiliar Multi-step Instructions Rarely Understood

8%

(12th-13th grade)

Slide by Terry Davis

• “Someone swallowed a nickel”• “Indigestion”• “Bladder”• “Looks like a ghost- Casper”

What does this picture mean?

Slide by Terry Davis

“Show Me How Many Pills You Would Take in 1 Day”

John Smith Dr. Red

Take two tablets by mouth twice daily.

Humibid LA 600MG1 refill

Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth Twice Daily”

71

8089

63

84

35

Figure 2. Inconsistencies Between Listed Doses and Markings on Measuring Device

Yin, H. S. et al. JAMA 2010;304:2595-2602

Copyright restrictions may apply.

Figure 3. Use of Atypical Unit Markings on Measuring Device and Inconsistency With Listed Doses

Yin, H. S. et al. JAMA 2010;304:2595-2602

Copyright restrictions may apply.

Figure 4. Presence of a Listed Dose Not Shown on Measuring Device, Resulting in Need to Measure More Than 1 Instrument Full of Medicine

Yin, H. S. et al. JAMA 2010;304:2595-2602

Copyright restrictions may apply.

The single biggest problem in communication is the illusion that it has taken place.

-- George Bernard Shaw

How do we perfect the dismount?

Very carefully!

Improve Skills and Reduce Complexity

Skills/Ability

Demands/Complexity

Health Literacy

Slide by Ruth Parker, MD

21www.nchealthliteracy.org

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Care Model

Key Drivers For Improving Outcomes

• Improve written communication

• Improve spoken communication

• Improve self-management and empowerment

• Improve supportive systems

Improving Written Health Information

• Most materials written well above the average literacy of the population

• Guidelines available for better clear written health information

• We know better materials can improve knowledge and help start behavior change

• Materials rarely stand alone

Yin HS, et al. Arch Ped Adol Med. 162: 814-822; 2008.

P<0.001

Improving Spoken Communication

13

Understanding

Clarify

Assess

Explain

Teach-back

12

Teach to Goal

• Ensure mastery of content before stopping the teaching

• Build in reinforcement over time (we all forget or have drift in our understanding)

• Know what you want the patient to master!

11

Mean self-care scores (95% CI) at Baseline (•) and 1-month follow-up ( ) ■

J Card Fail. 2011 Oct;17(10):789-96.10

Mean heart failure symptom score (95% CI) at baseline (•) and 1-month follow-up ( ) ■

J Card Fail. 2011 Oct;17(10):789-96.9

Improving Self Management and Empowerment

8

Brown Bag Medication Review

7

Brown Bag Medication Review

• Verify what the patient is taking• Identify and/or avoid medication errors and

drug interactions• Assist the patient to take medications

correctly• Answer the patient's questions

6

Brown Bag Medication Review

• Success to Brown Bag Review1. Patient is asked to bring in their medicines. Set

expectations.2. Patient brings medicines to appointment.3. Provider/staff reviews the medicines with the

patient. Reinforce adherence.

5

Biggest Barriers

• Getting patients to bring in their medicines

• Practices would set up a system but would not stick with it or modify it if it was not working

4

What have we learned about implementation?

• Gotta have a team

• Win hearts and minds

• Start with practice assessment

• Take the long view (still haven’t seen Pop-Tart® results)

3

You Can’t make a REAL Patient Centered Medical Home without Health Literacy

• Culturally and linguistically appropriate services• Training care teams to coordinate care, provide support in self-

management, and in communication skills• Treatment goals reviewed and updated • Follow up with no-shows• Assess patient/family understanding of medications• Assesses barriers to adherence• Develops and documents self-management plans• Maintain resource list• Offers health education and peer support• Obtains feedback on patient experience• Sets goals that address disparities in care 2

Perfecting the Dismount

• Like a gymnast, takes lots of work• Practice until the system is reliable• Keep the end in mind (productive

interactions!)• Everyone is accountable (this isn’t just

for some members of the practice, it is a team sport)