Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud. These podcasts are a way to listen in about all aspects of health literacy including what it is, why it matters and ways to help improve health understanding.

Today, I’m talking with Dr. Darren DeWalt. He is a practicing physician and an associate professor in the Division of General Internal Medicine at the University of North Carolina at Chapel Hill.

Dr. DeWalt is a researcher looking at ways that patients with low literacy can self-manage chronic diseases such as diabetes, heart failure, COPD and asthma. His research often focuses on achieving better outcomes through patient-physician communication and health system design.

Among Dr. DeWalt’s many accomplishments is that he is the lead author of the AHRQ, (Agency for Healthcare Research and Quality) Health Literacy Universal Precautions Toolkit.

I have known Darren for many years and recently had the pleasure of hearing him give a presentation about this universal precautions toolkit. I thought this was a topic that you would want to hear about too. Welcome, Darren.

Dr. DeWalt: Thank you, Helen. It is good to be with you.

Helen: I know about health literacy. I used to work in hospitals. I know the term universal precautions. What is this about putting them together?

Dr. DeWalt: Health literacy has been in the press and medical literature for many years now. What it has led to is a lot of discussion about how we change the way we provide care to patients with limited health literacy.

What we have really been learning is that many patients have trouble understanding health information. In fact, most or all patients will have trouble at one point or another.

Helen: Do you mean everybody like you and me? I know I have had trouble.

Dr. DeWalt: Absolutely. I talk to my colleagues that are doctors. They have trouble when they go into a medical situation, particularly if it is not their specialty.

Rather than trying to pick out patients that we think have low reading abilities or low literacy skills in general, what we are proposing with universal precautions is to assume that all patients may have difficulty understanding health information and to start to communicate and design our practice in a way that we make sure everybody understands.

Helen: Are you looking at the individual, which traditionally had been where health literacy was going, or are you looking more at practices and what they can do on this bigger, consistent scale?

Dr. DeWalt: This toolkit is really designed for practices to think about how they are delivering healthcare, communicating with their patients and designing their systems. This is the side of the health literacy equation that we often refer to as the demands and complexity.

One side is the skills and abilities of the patient and what they bring to the encounter with their healthcare system. The other side are the demands in complexity that we as a healthcare system may place on that encounter or for that patient relative to their specific concerns that day, whether it’s treating a condition or prevention.

Helen: I know that you are a practicing physician. When you are talking about practices, are you talking about that acute care of what happens in an office or about a broader way of how we are communicating about health in any setting?

Dr. DeWalt: That is a great question, Helen. These principles apply across all settings of health. It could apply in public health settings or any sort of medical practice, whether you are a primary care doctor, sub-specialist, surgeon, nurse-practitioner or pharmacist. It could be anybody.

All of these situations could take into account these principles of universal precautions to try to design their care system so that everybody understands. In every specific encounter, don’t assume that your patient understands. Check with them and have this dialog until you have confirmed understanding.

Helen: You are figuring out the problem. I have your toolkit here. It is vast and filled with a tremendous amount of resources. Let’s get to those in a minute.

I am still stuck on how you know there is a problem. Aren’t people saying, “Not me”? How does a practice know that there is even a problem before they go about fixing it for everybody?

Dr. DeWalt: That is a great question. There are a couple of ways. One is to have a conversation at your practice and start to talk about things like, “Has anyone had an experience where our patients didn’t quite understand?”

In my experience, every practice can identify a lot of occasions when that happened. Just starting that conversation is one way to decide whether you have a problem. The second way is that you can assess your practice.

Helen: Is it like a real assessment?

Dr. DeWalt: It is a real assessment. In the toolkit, Tool 2 is assess your practice. There are several questions that you can ask yourself about your practice. Are you able to provide care in these ways that would be a universal precautions approach? You might decide after doing that assessment that, “We have some areas of our practice that might be confusing for our patients.”

Helen: Do you mean to assess it globally or different parts of it?

Dr. DeWalt: This assessment is designed for an outpatient ambulatory care practice, although many of them might apply to hospitals and health systems as well. It asks about several facets of a practice, such as the ability of a patient to navigate through the practice and find where they need to go.

Helen: Physically navigate?

Dr. DeWalt: Yes, physically navigate the practice. Then it goes all the way down to very specific elements of the patient-nurse or patient-doctor communication and what is going on in that interaction, such as what is happening with billing and what sort of supportive systems we have in our practice to help the patient best care for themselves. It asks about all aspects of care for the patient.

Helen: That is interesting. When I go see the doctor and go in with some vague complaint, the doctor does some tests and usually tells me I have this or that, or I don’t have this or that. Is that what this assessment does? Is it a way to diagnose your practice?

Dr. DeWalt: Yes. This is a way to diagnose your practice. It is just like a doctor may provide a test for a patient. This is a test for your practice.

Helen: That is neat. Do groups really do this?

Dr. DeWalt: Absolutely. Hundreds of practices around the country have applied this assessment, and many hospital systems have taken this assessment and adapted it to their hospital. What we hear from people is that this assessment is very eye-opening because it raises issues that they hadn’t thought about in much detail before.

Helen: Like what?

Dr. DeWalt: They are things like, “Are our staff adequately trained to provide clear health communication?” That often isn’t part of the training of many staff members in a clinical practice.

They are simple things like how to encourage questions for our patients. Are we asking, “What questions do you have?” and making sure that patients feel comfortable asking us questions? The other thing is, “Are we using the teachback regularly in our practice?”

Helen: Is it a checklist that people go through and answer yes, no or maybe?

Dr. DeWalt: That’s right. The responses are, “We’re doing this well,” “We need some improvement,” or, “We’re not doing it at all.”

Helen: I know health literacy is becoming a part of accreditation and standards. Is this voluntary, like some organization or practice can just decide, “We want to do it,” or is anyone telling you that you have to do this?

Dr. DeWalt: Right now I don’t know of any regulation that says you have to do this. This is voluntary.

Helen: This tool is also widely and freely available, correct?

Dr. DeWalt: That is correct. Anyone can access it on the AHRQ website or on the NC health literacy website.

Helen: We will have those URLs on the Health Literacy Out Loud web page for this podcast.

I don’t know why, but I just like that term “diagnosing your practice.” Maybe that is not the best term to use, but somehow it resonates with me. Once you know that there is a problem in certain aspects in your practice, then what?

Dr. DeWalt: Then you need to decide whether you are ready to do something about it. This toolkit is designed to help you make those decisions.

In this assessment, you have gone through this test and tried to make a diagnosis of what areas you think would help your patients the most. We have even given you some indications in the assessment on which items the experts think are the most important for patients. That can help you prioritize.

Most practices choose one, two or three elements that they think are most important for their patients. Then that assessment links you directly to a two or three-page tool on what you can do in your practice and start working on today to make a difference for your patients.

Helen: We are talking about tools and toolkits. Can you give an example of what a tool might be?

Dr. DeWalt: Sure. This toolkit is comprised of about 20 tools. A tool could be anything from how to use the teachback to how to welcome patients to your practice. Another one is how to deal with medication reviews for your patients. We call that the brown bag review of medication.

Helen: It is really detailed and specific, like “This is how to do it.”

Dr. DeWalt: Yes. It is very much a how-to guide. It walks you through very briefly, “These are the steps you ought to consider doing.”

We even tried to give you some measures to assess your progress so that you can view this as a quality-improvement activity. Go into the practice, try to make some changes, see how it is working on a small scale and then decide, “Can we do this throughout our entire practice?”

Helen: That is so neat. It is right out there for people to use. What are you hearing about practices’ experiences with this process?

Dr. DeWalt: I’m hearing a couple of things. One big thing is that they really like the assessment. Because it has 49 questions, most of them when they first see the assessment think, “Oh my gosh! This is too long.”

Then they sit down and do it. They have three, four or five people in their practice do this independently. They sit down and have a conversation for half an hour or an hour. They find it so eye opening.

Perhaps the most eye-opening thing is that they have different impressions of how the practice is doing. It starts a dialog. Everyone has come back and said, “That assessment is critical. People really should do the assessment if they are serious about understanding what is going on in their practice.”

The next thing that people say is that the toolkit can be overwhelming. When they go the website, sometimes they download the whole toolkit.

Helen: I did that. It is a big binder. It is well over 200 pages.

Dr. DeWalt: It is well over 200 pages if you download it.

Helen: I have it all right here. It is big. That is a problem. Help me through this.

Dr. DeWalt: It is a problem. We tried to design it to overcome that, but it is a big problem. We wanted to put all of these resources together where someone could find them in one place, but many of those pages are appendices or resources that you can use if you choose.

Each individual tool is only about three or four pages. Once someone decides what they want to work on, they can go to those three or four pages, pull them out and work on that tool.

Helen: When I heard you talk, that was the aha for me. I had this big, fat binder on my bookshelf, and I was like everybody else. I thought, “Oh my goodness! There is so much there.”

When you were talking about it, breaking it down and saying, “You could do this or this,” and, “Here’s a good place to get started,” that really changed it for me. That is what I wanted you to share with all of our listeners. It helps prioritize and manage this overwhelming sense of, “What are we going to do?”

Dr. DeWalt: We really tried to get at that with the design, but we haven’t figured out a way to stop the sticker shock of the 200-page binder. We don’t encourage people to print the whole thing out. You can just print out one tool at a time.

There is another thing that we did that we think could be helpful for a lot of folks if they just want to jump into this and start working on a small scale. It can be much less intimidating. In the toolkit, there is something called the quickstart guide.

Helen: What is that?

Dr. DeWalt: That is where we tried to break this down into a very small chunk. We said, “If you just want to get started and see how this works, don’t go through the whole assessment and all of that right now. Jump in and watch a short video so that you and some other members of your practice can get a sense for the importance of this.”

As you have seen, many of these videos are very powerful in helping us understand what patients go through. Then we say, “Here are three of the most popular tools we have seen.” The three tools that people choose over and over again are the teachback method, tips for communicating clearly, and the brown bag medication review.

Helen: That’s neat. You have prioritized them.

Dr. DeWalt: Those are the top three that practices choose to work on. They find the most interest in those tools. We said, “Just pick a tool. You can click on a link and it will take you to that three to four-page tool. Read through those three to four pages and try it out in your practice tomorrow.”

These are the types of things you can try out tomorrow. This doesn’t require a huge amount of resources and planning for months to make a change. These are things you can try the next day.

Helen: I love that because that is what I hear from professionals all of the time. They say, “This is too much. We don’t have any time. We don’t have any extra money.” That really helps prioritize it.

Dr. DeWalt: That’s right. Behavioral theory applies to all of us. We often talk about it in terms of our patients, but it applies to us as healthcare professionals, as well as the rest of our professional and personal lives. When change is big, it is really hard.

One of the things that makes change easier for us is to shrink the change. Make a small change first. Most of us can accept trying something out on a small scale because it doesn’t disrupt our entire lives.

That is what we are advocating here. We have seen that when practices or physicians try out one of these tools, they start to realize this is working pretty well, it is not that disruptive, and they can work through this at a pace that works with their schedule.

Helen: This reminds me. I did a podcast a while ago with Dr. Terry Davis, who you know. She is another health literacy researcher. It was about baby steps and helping patients make changes in their lives in small, manageable ways. It sounds like you have applied this to the practice side of it.

Dr. DeWalt: I appreciate that, Helen. This is a passion of mine. In own medical practice, my patients often have difficulty understanding health information and navigating my practice. We try to do a lot of this work.

I think that a big part of improving our healthcare system is helping patients navigate it better and giving patients the power to manage their own illnesses.

Helen: This toolkit helps to do that. Are there any other resources, or is this toolkit the primary resource that you want our listeners to know about?

Dr. DeWalt: The toolkit is the primary resource. Of course, this toolkit takes advantage of work that has been done over the past couple of decades, so there are links throughout this toolkit to other resources that can be found on the internet.

Starting with the toolkit is a great place to find many resources if you are trying to make changes in your practice.

Helen: Darren, thank you so much for helping us navigate the demand complexity side of health literacy, and thank you so much for being a guest on Health Literacy Out Loud.

Dr. DeWalt: Thank you, Helen.

Helen: Wow! I learned so much from Dr. Darren DeWalt, and I hope that you did too, but health literacy isn’t always easy. For help communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, please sign up for the free enewsletter, What’s New in Health Literacy Consulting.

NewHealth Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, on the mobile app Stitcher Radio and the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.com.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and your friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.