The AAFP defines health literacy in terms of a patient's ability to "obtain, process and understand basic health information" and act on it appropriately. Failure in any one of these areas can lead to confusion, lack of follow-through or even a deadly mix of medications. That's why promoting health literacy in the family medicine practice setting is critical to effective care.
To help physicians make simple changes in their offices to better communicate with their patients about health information, the AAFP National Research Network (AAFP NRN) and the University of Colorado School of Medicine worked together to upgrade the Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit.(www.ahrq.gov)
Researchers worked with 12 primary care practices, each of which implemented four of the tools during a six-month period. They collected data through surveys, as well as via qualitative interviews during visits to each practice before and after implementation of the toolkit. These data were then used to guide changes to the toolkit.
Natty Mabachi, Ph.D., M.P.H., AAFP NRN research project manager for this project, told AAFP News that in the current health care environment, in which many practices are seeking patient-centered medical home (PCMH) certification, focusing on health literacy is one of the hoops these offices have to jump through anyway.
- To help physicians better communicate with their patients about health information, the AAFP National Research Network helped upgrade the Agency for Healthcare Research and Quality's Health Literacy Universal Precautions Toolkit.
- The toolkit comes with a user guide that provides best-practice tips.
- The project involved 12 primary care practices, each of which implemented four of the tools during a six-month period.
"Linking the health literacy toolkit to some of the bigger concerns of these practices helped the project resonate with participants and staff; helping them understand it was part of becoming a better practice overall," she said.
Mabachi added that the toolkit is flexible enough that any type of practice can use it.
"It is written in an accessible way with the primary care (health professional) in mind and can be used not only by the practice but also by a practice's quality improvement facilitator, when available," she said.
The toolkit comes with a user guide(www.ahrq.gov) that provides best-practice tips.
"If you get stuck, the guide can help you troubleshoot and get 'unstuck,'" Mabachi said. "We recommend using the toolkit and guide hand-in-hand to best navigate the toolkit."
The AHRQ Health Literacy Universal Precautions Toolkit was first published in 2010 and was piloted in only a few small practices at the time, according to Mabachi.
In 2012, the AHRQ sponsored a study by the University of Colorado and the AAFP NRN to examine the process of implementing the toolkit in a diverse group of 12 practices across the country. In addition to looking at implementation, the demonstration project also sought to determine how the toolkit could be adjusted based on participants' feedback to make it better.
List of 12 Participating Practices
The following primary care practices participating in testing the second edition of the Agency for Healthcare Research and Quality's Health Literacy Universal Precautions Toolkit:
- Annville Family Medicine in Annville, Pa.
- Chula Vista Medical Plaza in Chula Vista, Calif.
- Complete Family Medicine in Kirksville, Mo.
- Fairview Clinics - Lakeville in Lakeville, Minn.
- Family Medical Care Center in Granite Falls, N.C.
- Georgetown University/Providence Hospital Family Medicine Residency Program at Fort Lincoln Family Medicine Center in Colmar Manor, Md.
- Legacy Medical Group - Emanuel in Portland, Ore.
- Namaste Health Care in Ashland, Mo.
- Omar Khan, M.D., and Javed Gilani, M.D., in Wilmington, Del.
- Providence Medical Center - South Lyon in South Lyon, Mich.
- RST Medical Group Inc. in Decatur, Ga.
- Stony Brook Internal Medicine - Primary Care Center in East Setauket, N.Y.
Mabachi and her counterpart at the University of Colorado School of Medicine, Juliana Barnard, M.A., oversaw the project to rethink the toolkit and worked with the practices by collecting data, conducting site visits and organizing the data analysis. The sample of practices spanned small offices to larger residency-accommodating practices and included locations in both rural and urban settings.
Before implementing the toolkit, practices had to go through an orientation that included an on-site visit from the research team members. During the six-month implementation period, the researchers conducted regular check-ins with the practices to troubleshoot challenges. This was followed up with post-implementation site visits to collect additional data and stage more interviews.
The group officially completed the project on Sept. 21, 2014, and its findings will be published this year in the Journal of Ambulatory Care Management. Additional publications based on findings from the project are expected to follow.
One of the recurring comments the researchers heard about the original toolkit was that -- at 227 pages -- it was just too long and needed to be streamlined. But on the other end of the spectrum, many practice staff members were asking for more direction and details on some of the tools and said some of the information was too general. So the research team worked to refine the toolkit.
"Practices were either not going through the whole toolkit (because we recommended reading it from start to finish) or they were picking and choosing what they felt they had the resources to do, while leaving things out that were important," Mabachi said. "For example, many weren't evaluating their implementation."
Still, the researchers found that quite a few of the practices were able to develop a plan and follow it, allowing them to make changes that were impactful.
For example, practices that implemented tool No. 8 in the toolkit -- "Conduct Brown Bag Medicine Reviews"(www.ahrq.gov) -- saw great feedback from patients. The "brown bag review" of medication is a common practice used to encourage patients to bring all of their prescriptions in during their visit to have them reviewed by the physician, who can then identify any potentially dangerous interactions and misunderstandings of use.
"Patients really liked this medication reconciliation and found it useful," Mabachi said, "and practices were able to catch things that they weren't catching before, like patients continuing to take pills that they shouldn’t have continued to take."
A practice also reported that because some of its patients saw several doctors, some medication was contraindicated by prescriptions from other physicians, which could have led to dire patient outcomes.
Exit interviews with staff at each participating practice showed that staff members varied in the degree to which they implemented the tools, but they all found the tools generally helpful.
Some of the smaller practices that didn't have the resources or quality improvement know-how to fully utilize the toolkit ended up implementing the tools in a narrow fashion -- as a "bare minimum" version, Mabachi said. "For them, it was helpful but less impactful on their patients," she noted.
Bigger practices were more easily able to make the tools part of their everyday practice processes.
"We encourage practices to connect the health literacy toolkit to other quality improvement efforts -- to meaningful use efforts, to (patient-centered medical home) efforts," she said. "If it is incorporated into those other goals, then buy-in among your staff will be easier and it will help you achieve your current goals. For many practices, this was an 'ah-ha' moment."