Adults with LHL experience shame and feel less empowered in their interactions with health care providers than patients with adequate health literacy, often leading to a breakdown in communication within clinical encounters. Clear health communication techniques are one way to ensure patients are more engaged and empowered.
Clear Verbal Communication
Clear verbal communication techniques are helpful for all patients (Table 69–2). Before offering a recommendation or providing teaching, it is important to tailor communication to the individual. First, assess what patients already know (eg, “What do you already know or believe about…?”). The answer to this question can help clinicians detect misunderstandings and focus their instructions. Next, attempt to learn and then to match instructions to the patient’s regular, day-to-day routine. This may help elicit barriers and enhance compliance.
Table 69–2.Clear health communication. ||Download (.pdf) Table 69–2. Clear health communication.
|Setting up the discussion: |
|Tailor communication: |
Ask, “What do you already know about...?”
Ask patients about their day-to-day routine to tailor instructions
|Clear communication techniques |
Avoid medical jargon; for example, say “not cancer” instead of “benign”
Keep number of points to ≤3
Attempt to provide information in patient’s native language
|Confirm understanding (teach-back) |
|Reinforce instructions |
When discussing health-related topics, providers should attempt to slow their speech, use lay language, and avoid jargon, for instance say “high blood pressure” instead of “hypertension.” It is also recommended that clinicians limit information to 3 topics or less, and to focus the discussion on concrete instructions about what the patient needs to do when they go home. To improve patient understanding and health outcomes, when possible, every effort should be made to provide information to patients in their native language and to offer interpreters.
Importantly, if a patient is known to be hearing impaired, before beginning a discussion, ensure the patient has working hearing aids or is using an assistive hearing device such as a Pocket Talker. With all patients, the clinician should face the patient to allow for lip reading, which may assist in understanding.
We recommend that all verbal communication be followed by a confirmation of understanding, often called the “teach-back” or “teach-to-goal strategy.” Asking, “Do you understand?” or “Do you have any questions?,” often conveys to the patient that they should understand. Instead, we recommend clinicians ask, “What questions do you have?” After questions are answered, clinicians can ask patients or caregivers to restate in their own words what was just discussed or to demonstrate what skill was just taught (eg, insulin dosing). We recommend placing the onus of clear communication on the clinician: “We have just talked about a lot things. To make sure I did a good job and explained things clearly, can you tell me in your own words/show me…?” Teach back has been associated with better chronic disease management and informed medical decision making, yet has not been shown to increase the length of a medical visit.
Reinforcing Verbal Communication
Verbal communication can be reinforced with written materials, pictures, or graphs. Using written materials to reinforce verbal instructions has been shown to increase knowledge and improve patient’s satisfaction with communication. In addition, literacy appropriate written materials can improve the completion rate of medical forms and can help with chronic disease management (see Table 69–1).
When looking for appropriate written information for older patients, the target grade level should be the fifth grade reading level or lower, and should include clear headings, bright contrasting colors, a font size of 14 points or larger, and a combination of both upper- and lowercase letters (ie, not all capital letters). Because of the high prevalence of ophthalmic-related conditions in older adults, non-serif (sans serif) fonts, such as Arial or Helvetica, and nonglossy, matte materials are recommended because they are easier to see. Sentences should contain 1 topic, be no more than 6–8 words in length, and be written in an active “how to” voice. Written materials should also have a high white-space-to-text ratio and include carefully chosen pictures that explain the text and put written material into context.
When creating health care materials, several resources can be used to ensure the materials are literacy appropriate. The Suitability Assessment of Materials uses criteria standards in 6 categories: content; literacy demand; graphics; layout and typography; learning stimulation/motivation; and cultural appropriateness to help assess if the literacy level is appropriate. The Lexile Framework and the Lexile Analyzer (http://www.lexile.com) can also be used to assess the readability of written materials based on sentence length and word frequency. It is important to include the target population in the design and pilot testing of materials to ensure proper understanding and to improve the material’s acceptability.
Strategies for Medically Complex Patients
Patients with multiple medical conditions can benefit from disease-management programs that incorporate strategies for LHL patients. Disease-management programs for heart failure and diabetes that include literacy-appropriate verbal communication, literacy-appropriate written materials with pictures, automated telephone calls, and/or nurse follow-up calls have been shown to improve disease management, decrease hospitalizations, and decrease mortality. New technology, such as tailored, computerized, discharge instructions from virtual nurses also show promise for older adults with LHL. These computer technologies allow patients to repeat the information as often as needed.
Creative use of multidisciplinary teams may improve medical care and patient understanding for all older adults with multimorbidity, and especially for older adults with LHL. Some examples include group medical visits, collaborating with pharmacists to help review medications and fill pill boxes, and asking social workers to help complete advance directive or informed consent forms. The use of health navigators and community health workers may also help patients navigate the health care system and manage their disease processes.