CCHAP Home > Newsletter Articles > Newsletter Thirteen, November 2007

CCHAP Newsletter Thirteen

November 2007

 

Hidden Health Disparity for Children, Parental Health Literacy

Primary Care Learning Center

Parent Advisory Group

Integrating Developmental Screening In A Pediatric Practice

Counseling For Uninsured Children And Families


 

 

 

A Very Important Hidden Health Disparity
Health Literacy


CASE: You are seeing a new patient for an illness visit. The mother is given a registration form and a medical history form to fill out. Fifteen minutes later, she and her 2 year-old son are directed into a patient room where the nurse reviews the forms and notices that they are incomplete and contain many spelling errors. She helps the mother fill in the blanks. After the history and physical exam and after you discuss the treatment, you ask, “Do you have any questions?”   The mother says, “no” and takes a written handout without further comment. When the nurse returns and again asks if she has any questions, the mother again replies, “no” and says she is late for another appointment and asks if she can leave. The nurse discharges her.

Health Literacy
According to the 2003 National Adult Literacy Survey, there are approximately 89 million adults with significant literacy deficits that affect what they understand at a health visit or what they understand from a healthcare handout. The survey estimates that 21% of our population is functionally illiterate with another 27% having marginal health literacy skills.

Health literacy dramatically influences health outcomes. For example:  Hemoglobin A1C levels in a diabetic child are directly correlated to how well the parent and child understand the instructions given to them by their healthcare provider. The Hemoglobin A1C levels are 1.5 times higher when the patient/parent has  low health literacy skills, and the cost for care can be 3 to 4 times higher.

Malpractice case law makes it clear: the responsibility for making sure patients understand their instructions rests with the clinician.

Who is at risk?
 African American adults are two times more likely than White non-Hispanics to have difficulty understanding instructions at health care visits or in handouts.   Hispanic adults are 3 times more likely and Asian Americans are 1.5 times more likely than White non-Hispanics to have health literacy problems. However, in absolute numbers, more white non-Hispanic adults are considered to be functionally health illiterate than minority populations.  And, of course, highly educated, highly literate adults often report that they do not understand instructions given by their healthcare provider.

Key Steps to reduce the effect of limited health literacy
  • Recognize parent/patients with limited health literacy
  • Create a “shame-free” environment
  • Develop a communication style that promotes good understanding in all parents and patients
  • Confirm the parent’s / patient’s understanding
  • Use patient-friendly materials
Recognize families with limited health literacy
The majority of parents (patients) with limited health literacy do not tell anyone about their limitations, especially people in the health care system.  The group at highest risk for limited health literacy is, of course, families where English is their second language.   Other signs that may be a clue for limited health literacy include:
  • Incomplete or inaccurate forms
  • Poor adherence (compliance) with treatment
  • Lack of follow-through on appointments, testing and referrals
  • Parents who do not ask questions
  • Parents who ask many more questions than most parents
  • Parents who cannot name medications or describe how to correctly give them
  • Parents who say “I forgot my glasses” or “I will read it later.”
How can clinicians ask about health literacy in a way that enables parents to comfortably acknowledge their difficulty in understanding or reading?   The four best validated questions are:
  • “Do you feel I have explained this well enough for you?”
  • “How often do you need someone to help you when you read instructions?”
  • “How confident are you filling out medical forms by yourself?”
  • “How do you best learn new material? By talking or from a handout or by a demonstration (hands on)?”

Create a “Shame-Free” Environment
Ask the staff in your practice to read this article, so that each staff member can see they have an important role in recognizing and assisting parents or patients with limited health literacy.  Everyone can be on the look out for potential signs of limited health literacy. 

Front desk personnel can routinely offer assistance to families in completing the forms. Everyone in the practice should be willing to stop what they are doing to assist with forms or to answer questions. All staff should be approachable regarding referrals, insurance questions, appointment scheduling and testing.    Clinicians can ask if the families have questions, if they feel the instructions have been explained well enough, and whether they can be of more help.  All staff should provide help by imagining what a parent would need if they had limited literacy or limited medical understanding.

Helpful Communication Methods
  • Slow down and speak slowly. Sit rather than stand.  Convey with your body language and tone of voice that you will be patient and spend the time needed by the parent / patient.
  • Use plain and simple language, using lay terms instead of medical terminology.  A rule of thumb is to explain it as you would to your grandmother.
  • Focus on 3 key issues:
      • The main problem(s)
      • What they need to do
      • Why it is important
  • Summarize the key issues at the end
  • Draw pictures or write simple lists
  • Avoid acronyms, initials and medical jargon. Avoid words like “unremarkable”, “may”, “might”, and “suggests”. Be careful with homonyms like “stool”, “gait”, and “dressing”.
Confirm The Parent's/Patient's Understanding
Use the “Teach Back” method. When you want to confirm their understanding, ask them to say or show you what they are going to do, rather than asking if they understand. “Let me see if I have explained this well enough. When you get home, how are you going to give the medication?” Or ask them to demonstrate how they will do things.
  • Allow time for questions. Convey with your tone of voice and body language that you will devote enough time to answer their questions.
  • Enlist the help of other staff. The medical assistant, nurse or check-out staff can ask “do you have any more questions?” “Do you feel you will need any help?”
  • When a staff member or provider suspects limited understanding, make a follow-up phone call in a day or two.
Use Patient-Friendly Materials
  • Forms should be simple and collect only essential information. They should also be offered in the family's preferred language. 
  • Written materials should be understandable by a 5th grader (10 to 11 year old)
  • Written materials are more effective if they are read to the parent and patient by the staff or provider. They are even more effective if a staff member or provider underlines or circles the most important points
  • Limit content to one or two objectives
  • Use words that non-medical people know
  • Use one and two syllable words, short paragraphs, large fonts (minimum 12 point). Do not use UPPER CASE  FONT – it is difficult to read.
  • Don’t clutter the page. Have a lot of empty space
  • Use headings. Bullets are better than paragraphs
  • Most Internet material is too difficult for the average person to understand
  • CD’s or videos are more effective than audiotapes, because most people learn better by seeing rather than hearing. Neither should be longer than 3-4 minutes

Health Literacy Websites
http://www.healthliteracy.com/ The article section is very good
http://healthliteracy.worlded.org/ Some great examples and tools
http://www.hsph.harvard.edu/healthliteracy/asthma/asthma3.pdf Asthma Info. for patients
http://www.hsph.harvard.edu/healthliteracy/doak.html
http://www.cmc-dayton.org/PDF_Files/For_physicians_sitelet/PedClipsForbiJanfinal.pdf

 
  

CCHAP is Creating
A Primary Care Learning Community


What is a Primary Care Learning Community?
A primary care learning community (PCLC) is a group of primary care practices that strive to improve the care they are providing by sharing what they have learned with the other practices in the learning community.
  
A PCLC brings clinicians (practices) together to (1) identify the problems (questions) that need to be addressed in order to improve primary care, (2) identify potential solutions suggested by the practices and (3) implement solutions and observe the effects in their practice.
   
A PCLC answers clinical questions and solves clinical problems faster than traditional research, and shares those solutions quickly with clinicians.
   
Which Practices Should Participate?
      Any practices that want to improve the health outcomes of their patients and are willing to collaborate with other practices and organizations.
 
What are the requirements for participation?
      The only requirement is that you share your ideas on what the problems are and how they should be addressed.  When additional funding or resources are needed, CCHAP will work with the practice, governmental agencies and community organizations to find the  resources.
  
Stay tuned
Future newsletters will describe our learning community in more detail and will invite you to participate in developing our PCLC.
   
One Question For You
What is the most important clinical problem (not reimbursement related) that should be addressed to improve the health outcomes for low income or minority children in your practice?
[email poole.steven@tchden.org to send your answer]
  

   
CCHAP announces the formation of a
Parent Advisory Group (PAG)


As part of CCHAP’s ongoing commitment to pediatric practices and Medicaid/CHP+ families in Colorado, we are forming a PAG to assist us with identifying unmet needs, barriers to care, areas for program growth, and ideas for  improving the  cultural responsiveness of  the services we provide.   The PAG will be available to CCHAP practices if they have questions they would like to ask parents.
  
Soon, we will be asking each practice to give us the names of 2 families from your practice for participation in our PAG.  We are looking for families that have Medicaid or CHP+ and/or who represent a minority.  We hope they will provide valuable insight about the challenges Medicaid/CHP+ and uninsured families and minority families face when seeking health care in Colorado.  If you know the names now of the families you recommend, please send their contact information to  poole.steven@tchden.org.  Thank you.
   

   
Integrating Developmental Screening
Into a Pediatric Practice

 

  • The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool at well child visits for infants/toddlers birth to five.
  • The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
  • Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
  • The Colorado Chapter of the AAP supports the ABCD project.
  • Early detection and intervention improves outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
  • The most time-efficient tool is one in which the parent completes a questionnaire.
  • To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
  • What are providers saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
      • It takes 1-2 minutes for an MA, LPN or RN to score.
      • It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
      • In many instances, it reduces the length of the visit.
      • It helps providers concentrate on the concerns/priorities of the parents.
      • It reduces the number of concerns that come up as you are walking out the door at a well care visit.
      • It improves patient satisfaction.
      • It promotes positive parenting practices.
      • It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
  • Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices to implement a standardized tool such as the ASQ or PEDS. Support will also be given to office staff on how toincorporate a standardized developmental screening tool into the current office work flow.

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com

 

The Ages & Stages Questionnaire (ASQ)
 

The Ages & Stages Questionnaire (ASQ) is a well respected screening tool.  It has the best sensitivity and specificity.  It is standardized across various common minorities.   Health care providers have identified the following advantages:

  • Parent completed—Parents are partners in their child’s
    assessment and intervention activities.
  • Serves as a talking guide with parents identifying a
    child’s strengths as well as things the child is not
    doing yet.
  • Practical—Scoring takes 1-2 minutes and can be done
    by paraprofessionals.
  • Cost-efficient—May be photocopied repeatedly.
  • Scoring is simple—Only three responses:
    1. Sometimes, occasional or emerging response from
      child = 5 points
    2. Yes, child performs specified behavior = 10 points
    3. Not Yet = 0 points
  • If the child’s total score falls in a shaded area of the bar
    graph for any developmental area, further diagnostic
    assessment is recommended.
Visit www.brookespublishing.com to view and order the ASQ tool online.

The Parents’ Evaluation of Developmental Status (PEDS)

PEDS is another tool commonly used by practices involved in
a pediatric surveillance program. Provider feedback has
been positive. “The PEDS is nice because physicians value
knowing the issues parents want to address before going
into the room.”
 
Below are other advantages outlined in an article by
Frances Glascoe, PhD, Associate Professor, Division of
Child Development, Vanderbilt University School of
Medicine:
  • Developed out of four cross-validation studies on a
    nationally representative sample of families.
  • Uses parent concerns or judgments about the child’s
    development and behavioral status.
  • Easy to score—two minutes to elicit and interpret.
  • Enables health care providers to determine the need to
    refer and where.

Visit www.pedstest.com to view and order the PEDS tool online.
 


Counseling for Uninsured Children and Families
 
CENTUS for Kids


 
For over a quarter of a century CENTUS (formerly Samaritan Counseling Center) has provided professional mental health care services to the working poor, disadvantaged, uninsured and underinsured children, individuals and families throughout the greater Denver area.
  
CENTUS is accredited by the Samaritan Institute (a national network of counseling centers) and supported by client fees and contributions.  In our quarter century of service we have always accepted clients regardless of their ability to pay. 
  
CENTUS for Kids is a group of child-centered CENTUS therapists specializing in mental health care for children ages 3 – 18 and their families, providing services to at-risk children and youth who have no resources for quality early identification and therapy/counseling to address psychological needs and to start on the road to a healthy character in adulthood.  CENTUS for Kids counselors provide life-changing counseling to achieve stability and healing as well as develop life skills necessary to become healthy, happy adults and contributors to our community.
Counseling services for children and youth are provided out of five locations throughout the greater Denver area.  We also provide children’s mental health educational opportunities, classes, workshops and group sessions at any of our eleven satellites or our central office, in schools, other medical offices, or at agencies serving children.  Parents, schools and child-centered organizations come to us for assessment of a child’s behavioral, emotional, intellectual or learning difficulties. Counselors also provide play therapy, cognitive-behavioral therapy, group and individual filial therapy, parenting coaching, psychodynamic therapy, early childhood intervention, ADHD identification and therapy, plus a host of other childhood, youth and family related services.
  
For more information, please visit www.centus.org or call 303-639-5240.