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					Addressing Health Literacy in a
    Multilingual Population:
  A community health center
            approach

            Andrea Anderson, MD, FAAFP

            Luis Padilla, MD, FAAFP
                    Outline
   Brief History of Unity Health Care
   Upper Cardozo Health Center
   Definition of Health Literacy
   Impact of Health Literacy
   How Our Patients Obtain, Process, and
    Understand our Health Information
   Current and Future Initiatives
   Challenges
        Unity Health Care, Inc
MISSION
 Unity Health Care, Inc. offers a citywide network of
 quality health and human services to the medically
 underserved regardless of race, ethnic background
 or ability to pay.
VISION
 Unity Health Care, Inc. will become the preeminent
 health care delivery system for the medically
 underserved of Washington, DC and recognized by
 them as the provider of choice.
www.unityhealthcare.org
Unity as a Community Health Center
   More than 20 years experience in Washington, DC
   Initially a health care for the homeless model
   Now a “medical home” model of care
   Present in all 8 Wards of the District of Columbia
   Mobile Medical Units
   Currently 32 service sites throughout DC
   321,000 visits in 2007
   Healthcare for DC inmates began October 1, 2006
        Unity Health Care 2006

Total Users   70,749    Total Visits   321,803
Working       59,096    Working        271,889
Poor,         (83.5%)   Poor,
Uninsured,              Uninsured,
Immigrants              Immigrants
Homeless      11,653    Homeless       49,914
              (16.5%)
                  Unity Health Care’s
                Upper Cardozo Health Center
   Ward one Northwest DC
       One of DC’s most diverse wards ethnically and
        economically
   Over 17, 000 patients enrolled in the center
   Over 76,000 visits in 2007
   Most diverse center in Unity Health Care’s network
   Predominately non-English speaking clients
   Low Literacy and Low English Proficiency (LEP) with
    average estimated reading level at third to fourth grade
Upper Cardozo: Services Offered
 Primary and        OB/GYN
  Preventive Care    Mental Health
 Dental
                     Laboratory
 Social Services
                     Specialty Care (HIV,
 Pharmacy
                      Pulmonary, Cardiology,
 WIC
                      Ophthalmology,
                      Endocrinology,
                      Podiatry)
Where do our patients come from?
             The Americas

 Canada        Paraguay      Haiti
 Mexico        Peru          Honduras
 USA           Uruguay       Jamaica
 Argentina     Venezuela     Nicaragua
 Bolivia       Costa Rica    Panama
 Brazil        Cuba          Trinidad
 Chile         Dominican
 Columbia      Republic
 Ecuador       El Salvador
 Guyana        Guatemala
Where do our patients come from?
             Africa

  Benin             Ivory Coast    Sierra Leone
  Burkina Faso      Kenya         Somalia
  Cameroon          Liberia       South Africa
  Central African   Malawi        Sudan
  Republic          Mali          Tanzania
  Chad              Mauritania    Togo
  Congo             Morocco       Tunisia
  Egypt             Mozambique    Uganda
  Eritrea           Nigeria
  Ethiopia          Niger
  Gabon             Republic of
  Gambia            Guinea
  Ghana             Senegal
Where do our patients come from?
 Asia, Europe , South Pacific, Middle East

 Bangladesh    Albania       Jordan
 China         England       Iraq
 India         France        Israel
 Korea         Greece        Syria
 Laos          Ireland       Iran
 Mongolia      Italy
 Nepal         Poland
 Russia        Spain
 Sri Lanka     Australia
 Thailand      New Zeeland
 Turkey        Polynesia
 Vietnam
Upper Cardozo: Ethnic Background

     Upper Cardozo Health Center User Profile

         0% 11%
    1%                                    Hispanic
   2%                                     African-Ameircan
                       57%                Caucasian
   29%                                    Asian
                                          Native American
                                          Other
 Upper Cardozo: Insurance Status
                                Insurance Status

             60
                   48.41
             50
Percentage




             40
             30                25.15         23.02
             20
             10                                              2.17       1.25
             0
                  Uninsured   Self Pay      Medicaid       Medicare     Private
                                                                      Insurance
                                         Insurance Class
  Upper Cardozo- Income Level by
     Percent of Poverty Level

          70
          60
          50

Percent   40
          30
          20
          10
           0
               <100   100-200   >200   Unknown
             Federal Poverty Income
                 Requirements
Group Size    Annual FPL   100% FPL    150% FPL    200% FPL
                           Monthly     Monthly     Monthly
1             $ 9800       $816.67     $1,225.00   $1633.33
2             $13200       $1,100.00   $1,650.00   $2,200.00
3             $16,600      $1,383.33   $2.075.00   $2,766.67
4             $20,000      $1,666.67 $2,500.00 $3,333.33

5             $23,400      $1,950.00   $2,925.00   $3,900.00
6             $26,800      $2,233.33   $3,350.00   $4,466.67
7             $30,200      $2516.67    $3,775.00   $5,033.33
8             $33,600      $2,800.00   $4,200.00   $5,600.00
9             $37,000      $3,083.33   $4,625.00   $6,166.67
10            $40,400      $3,366.67   $5,050.00   $6,733.33
      Health Literacy Definition

"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
    Impact of Low Health Literacy
   36 % of the adult U.S. population has basic or
    below basic health literacy level
   Major source of economic inefficiency in the
    U.S. healthcare system.
   Cost of low health literacy to the U.S. economy
    is in the range of $106 billion to $238 billion
    annually
   About 7 and 17 % of all personal healthcare
    expenditures
    Impact of Low Health Literacy
   Potential Savings - $106 billion to $238
    billion annually
   This would translate into enough funds to insure
    every one of the more than 47 million persons
    who lacked health care coverage in the United
    States in 2006
   Real day present costs of $1.6 trillion to $3.6
    trillion, accounting for the future costs of low
    health literacy that result from current actions
    (or lack of action).
           Impact of Low Health Literacy
   Women with inadequate literacy had significantly greater odds of
    never having had a Pap smear or no mammogram in the past 2 years

   black patients were significantly more likely than white patients to
    present with late-stage cancer; after adjusting for literacy, the
    researchers reported a smaller odds ratio that was no longer
    statistically significant

   lower S-TOFHLA scores were related to worse glycosylated
    hemoglobin (HbA1c) levels and reports of retinopathy and
    cerebrovascular disease
“Agency for Healthcare Research and Quality. January 2004. Literacy and Health Outcomes. Evidence
    Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina
    Evidence-based Practice Center under Contract No. 290-02-0016). Berkman ND, DeWalt DA, Pignone MP,
    Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. AHRQ Publication No. 04-E007-2.
    Rockville, MD”
                       Assessment Tools
   TOFHLA/sTOFHLA
       sTOFHLA version in English available at:
     http://www.peppercornbooks.com/catalog/product_info.php?products_id=2
        765&osCsid=
     Cost $10.00

       sTOFHLA version in Spanish available at:
     http://www.peppercornbooks.com/catalog/product_info.php?products_id=2
        766&osCsid=
     Cost $10.00

   Validation article
     Baker D, Williams M, Parker R, Grazmararian J, Nurss J. Development of a brief test
        to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.

Source: Health Literacy Assessment Tools Paul D. Smith,
   MDpaul.smith@fammed.wisc.edu5/7/07
                      Assessment Tools
   Newest Vital Sign
       English and Spanish versions available. Scoring sheets and
        patient sheets available at:
         http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-
           sign.html
         Cost: Free!
   Validation article
    Quick Assessment of Literacy in Primary Care: The Newest Vital
      Sign. Weiss B, Mays M, Martz W, Castro K, DeWalt D,
      Pignone M, Mockbee J, Hale F. Ann Fam Med 2005;3:514-552.
    Available to download at:
    http://www.pfizerhealthliteracy.com/physicians
      providers/newest-vital-sign.html

    Source: Health Literacy Assessment Tools Paul D. Smith,
      MDpaul.smith@fammed.wisc.edu5/7/07
  Healthy Literacy and Ethnic
          Minorities
While ethnic minority groups are
disproportionately affected by low health
literacy, the majority of those with low
health literacy skills in the United States are
white, native-born Americans, as the latter
group represents the largest segment of the
population.
       Health Literacy and Latino
              Populations
   May be more pronounced in Latino populations
   Low literacy and language barrier
   Decreased access to insurance
   Decreased educational attainment
   Increased difficulty managing medicines
   Metric versus English measurement system
   Difficulty in understanding specialist
    instructions
How Our Patients Obtain Information

 Flyers   and Brochures

 Web   based educational materials

 Point    of care internet access

 Language     Line
        How Our Patients Obtain
             Information
   Oral instructions from bilingual staff

   Medline-Plus tutorials in Spanish

   Community Partnerships
     Reach Out and Read


   Clinic Color Guide
               Forms and Signs
   Written at a third to
    fourth grade level
   Distributed multiple
    times by providers and
    staff
   Color coded
   Double sided bilingual
   Printed also in Amharic
    when applicable
    Point of Care Computer Access
 Internet Access in
  each exam room made
  possible through a
  NLM grant
 Web image searches

 MedlinePlus Tutorials

 Demonstration of
  medications, dosing,
  etc
    Web-based Patient Information
   www.boystownpediatrics.org
   www.familydoctor.org
   www.mdconsult.com
   www.medlineplus.gov
   https://secure.medactionplan.com
   www.epocrates.com
            Preliminary Data from Upper
                 Cardozo NLM Study
                      Initial and Final HGBA1c Mean

                 10
Hemoglobin A1c




                 9
                                                        Initial
                 8
                                                        Final
                 7

                 6
                       Control           Intervention
                                 Group
Preliminary Data from Upper
     Cardozo NLM Study
                    Initial and Final Systolic Mean

              130
Systolic bp




              120
                                                        Initial
                                                        Final
              110


              100
                      Control            Intervention
                                Group
    Phone Interpretation Services
   Language Line
   Over 100 major
    languages and dialects
    available
   Speaker phones
    available in each exam
    room
                Multilingual Staff
   17 out of 19 primary care providers speak Spanish

   Over 90% of support staff are bilingual or multilingual

   Languages Spoken By Upper Cardozo Staff
    Spanish        Tagalog
    French         Farsi
    Amharic        Tigrinya
    Chinese        Vietnamese
    Reach Out and Read Program
   National Program
    designed to promote
    early childhood
    literacy
   Literacy Promotion
    and books are
    encouraged at well-
    child visits ages
    6months-5 years
    Reach Out and Read Program
 Millions of books distributed nationwide
 Over 3,000 bilingual and culturally diverse
  books shared by providers in well child
  visits
 Reading is encouraged as a factor of health

 Introducing early childhood literacy
  encourages the discussion of adult literacy
 Adults can be referred to adult literacy
  programs, family literacy is encouraged
       Literacy Rich Environment
   Printed Material      Donated Books
        Community Partnerships
   Books for America

   Unity Wide Book Drive

   Read Out Loud Program

   Reading is Fundamental (RIF)
Clinic Color Guide
              Future Initiatives
   Computer Lab
     English Second Language skills building
     Computer skills development
   Health System Access Education
     Understanding health benefits
     Disability claims
     Patient language access rights
        DC 2004 Language Act
     Patient Directed Web Searches
   Computer Lab
    sponsored by a NLM
    grant
   Patients can research
    new diagnoses and
    online medical
    information
http://www.nlm.nih.gov/m
   edlineplus/spanish/tutori
   al.html
           Future Initiatives
 Heath   Literacy Assessment Tool

 Community      Education Days

 Shared   Decision Making

 Pictorial   Prescriptions
       Continued Challenges
 Mental  Illness
   No mental health benefit under
    current Alliance safety net
 Resources needed to expand and
  provide language services
 Resources and staff to assess how
  patients process and degree they
  understand information
       Continued Challenges
 Resources    to track changes and
 outcomes

 Bilingual   providers

 Bilingual   nurses and case managers

 Cultural   barriers to shared decision
 making
          Email Contacts
lpadilla@unityhealthcare.org

aanderson@unityhealthcare.org

				
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