NYS HIVQUAL Workshop:
Screening for Health Literacy
October 16, 2009
Nanette Brey Magnani breymagnan@aol.com
&
Meera Vohra mxv10@health.state.ny.us
NYSDOH AIDS Institute
1
National Quality Center (NQC)
Commemorating Health Literacy Month with
song http://www.healthrock.com/podcasts
October is Health Literacy Month (11th year!)
This a time for organizations and
individuals worldwide to promote the importance
of understandable health information.
Health Literacy month was started in 1999 by
Helen Osborne along with a team of health
literacy advocates.
http://www.healthliteracymonth.org/
2
National Quality Center (NQC)
“It makes me feel bad when I come in here
and somebody hand me something and I
can’t read it...”
“I’ve had a lot of illnesses, but I prefer to stay
home.”
Baker DW, et. al. The Health Care
Experience of Patients with Low
Literacy. Arch Fam Medicine 5, June 1996
3
National Quality Center (NQC)
Definitions: Health Literacy
‘ the degree to which individuals have the
capacity to obtain, process, and understand
basic health information and services needed
to make appropriate health decisions’
1.U.S. Department of Health and Human Services. Health Communication (Chapter 11). In: Healthy People 2010:
Understanding and Improving Health and Objectives for Improving Health. 2 nd ed. Washington, D.C.: U.S. Government
Printing Office; 2000.
2.“Health Literacy.” National Network of Libraries of Medicine. http://nnlm.gov/outreach/consumer/hlthlit.html
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National Quality Center (NQC)
Definitions: Health Literacy
“ the ability to read, understand and act upon
health-related information. It also refers to
the capacity of professionals and institutions
to communicate effectively so that community
members can make informed decisions and
take appropriate actions to protect and
promote their health.”
Office of the Mayor
5
National Quality Center (NQC)
How many have observed…
• Incomplete patient satisfaction forms or
registration forms
• Excuses to not fill out forms
• Family members brought in to speak for
patients
• Patients just nod their head in understanding
• Inability to name medications
• Medication non-adherence
• Frequently missed appointments
6
National Quality Center (NQC)
Does this Swiss Cheese Model reflect your clinic?
7
National
Quality Center (NQC)
Institute for Healthcare
Improvement
Consequences of Low Health Literacy
• Several studies found limited health literacy in people
living with HIV/AIDS to be associated with:
 Less preventive care
 Increase use of ER and hospitalizations
 poor health outcomes such as less HIV knowledge,
 lower CD4 cell counts,
 poor medication adherence, and
 more hospitalizations
than those with adequate levels of health literacy.
8
National Quality Center (NQC)
Low Literacy Rates in NY
New York State: 50%*
•
•
•
•
•
New York City: 63%
Albany: 45%
Syracuse: 51%
Buffalo: 61%
Rochester: 57%
Go to https://www.casas.org/lit/litcode/Search.cfm to find rates in your city or
county.
*Synthetic estimates of adult literacy proficiency presented here combine information from
the 1993 National Adult Literacy Survey (NALS) and the 1990 U.S. Census to estimate
adult literacy proficiencies in geographical areas not adequately sampled by NALS.
Portland State University, 1996. Permission granted to CASAS for internet delivery at
https://www.casas.org
9
National Quality Center (NQC)
HIVQUAL Indicator
“Enter the date of the most recent Health Literacy Screen (even if before
the review period).”
If the patient’s medical record documents the date of any health
literacy screening enter most recent date (continue to 1.1) Otherwise
click on “None documented (stop).”
1.1 “Was a need for Health Literacy intervention
indicated?”
 Yes (continue to 1.2)

No (stop)
1.2 “Did the patient receive a health literacy
intervention?”
 Yes (stop)
 No (stop)
10
National Quality Center (NQC)
Health Literacy – Common Terms
• Functional health literacy: basic reading and writing
skills to understand and follow simple health messages
• Interactive health literacy: more advanced skills to
manage health in partnership with Healthcare Provider
• Critical health literacy: the ability to critically analyze
information, increase awareness and participate in action
to address barriers
A and Saunders M. Health literacy revisited: what do we mean and why does it matter?
11
Health Promotion International. 2009
National Quality Center (NQC)
Types of Literacy, Knowledge and Skills
1. Prose: search, comprehend, use continuous text
Examples:
• pamphlets
• newspaper articles
NAAL research
12
National Quality Center (NQC)
Contd. Types of Literacy, Knowledge and Skills
2. Document: search, comprehend and use noncontinuous texts in various formats
Examples:
• train schedule
• food labels
• prescription labels
• appointment slips, HIPAA forms
NAAL research
13
National Quality Center (NQC)
Contd. Types of Literacy, Knowledge and Skills
3. Quantitative: identify and perform computations,
alone or sequentially, using numbers embedded in
printed materials
Examples:
• completing an order form
• balancing a checkbook
• understanding graphs
NAAL research
14
National Quality Center (NQC)
Purpose of Health Literacy Screen
To help the HIV program staff determine the degree to
which patients have the ability to understand:
 Oral communication such as:
•
•
•
•
Intake procedures
Doctor’s directions
Medical exam
Discharge instructions
Does this involve prose, document or quantitative literacy?
Functional? Interactive? Critical?
“Health Literacy.” National Network of Libraries of Medicine
http://nnlm.gov/outreach/consumer/hlthlit.html
15
National Quality Center (NQC)
Purpose of screening contd.
 Written communication such as:
•
•
•
•
•
Intake forms
Instructions on prescription drug bottles
Appointment slips
Medical education brochures
Consent forms
Does this involve prose, document or quantitative literacy?
Functional? Interactive? Critical?
“Health Literacy.” National Network of Libraries of Medicine http://nnlm.gov/outreach/consumer/hlthlit.html
16
National Quality Center (NQC)
Purpose of screening contd.
 How to negotiate complex health care systems –
how the health system works:
• Insurance forms
• Signage
• Phone system
Does this involve prose, document or quantitative literacy?
Functional? Interactive? Critical?
17
National Quality Center (NQC)
Purpose of screening contd.
• To identify potential barriers to effective
communication such as:
 congruence of the message with health values
and beliefs
 language
18
National Quality Center (NQC)
Purpose of screening contd.
…..so patients can make informed health
decisions, maintain and improve their health,
and self-manage their illness.
19
National Quality Center (NQC)
Criteria for Selection
• Brainstorm factors to consider when selecting
a tool to pilot
• Identify the top 3-4 factors
20
National Quality Center (NQC)
Standardized Screening Tools
•
•
•
•
•
REALM
REALM-R
TOFHLA
S-TOFHLA
NVS
• Strengths
 Assess reading ability, reading
comprehension and/or numeracy in a
health care context.
 Detect whether or not a patient has
limited functional health literacy.
 Used as proxy measures in health
literacy research.
• Limitations:
 Not designed to comprehensively test
health literacy.
 Results do not identify a health literacymedication adherence relationship,
etiologies or specific interventions.
Davis TC, Wolf MS, Arnold CL, Byrd RS, Long SW, Springer T, Kennen E, and Bocchini JA. Development and Validation of the Rapid Estimate of
21
National
Center
(NQC)
Adolescent
Literacy in Medicine (REALM-Teen): A Tool to Screen Adolescents for Below-Grade Reading in Health
CareQuality
Settings.
Pediatrics.
2006, 6:1707-1714.
Non-standardized
Screening Tools
• BEKHA-HIV
• Single Item Literacy
Screen
• “How confident are you
filling out medical forms
by yourself?”
• SOS Mnemonic
• Strengths:
 Attempt to help clinicians : 1)
assess how well their individual
patients understand health
information and 2) individualize
their patient education.
 Better elucidates interventions
that can be used.
• Limitations:
 Some perform no better than
predicting literacy based on
demographics.
 Some do not perform as well as
tests evaluating reading ability.
Paasche-Orlow MK and Wolf MS. Evidence Does Not Support Clinical Screening of Literacy. Journal of General
Internal Medicine. 2007, 23(1):100-102.
22
Quality Center (NQC)
Jeppesen KM, Coyle JD, and Miser WF. Screening Questions to Predict Limited Health Literacy:National
A Cross-Sectional
Study of Patients With Diabetes Mellitus. Annals of Family Medicine. 2009, 7(1):24-31.
STANDARDIZED
HEALTH LITERACY SCREENING TOOLS
23
National Quality Center (NQC)
Rapid Estimate of Adult Literacy in Medicine
(REALM)
Description
•A 66-item health-related word recognition test arranged in order of
increasing difficulty.
•Provides a reading level grade estimate for patients that read below a
9th- grade level.
•Average administration time: 3-6 min.
Measurement
•Low health literacy
(At or below 3rd-grade reading level): 0 to 18
(4th to 6th-grade reading level): 19 to 44
•Marginal health literacy (7th to 8th-grade reading level): 45 to 60
•Adequate health literacy (9th-grade reading level): 61-66
Strengths
•Word-recognition tests are useful for predicting general reading ability
in English.
•Extensively used in research settings.
Limitations
•Not designed to measure comprehension skills.
•Most useful in a research context.
Location
Available for purchase from Terry C. Davis, PhD: tdavis@lsuhsc.edu
24 Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, and Crouch MA. Rapid
National
Quality
Estimate
of Center
Adult (NQC)
Literacy in Medicine: A Shortened Screening Instrument. Clinical Research and Methods. 1993, 25(6):391-395.
Rapid Estimate of Adult Literacy in Medicine – Revised
(REALM-R)
The word-recognition REALM test was shortened from 66 items to
Description
the following 8 items: osteoporosis, allergic, jaundice, anemia,
fatigue, directed, colitis, and constipation.
Average administration time: 2 min
Measurement
Those with a score of 6 (sixth grade) or less should be considered to
be at risk for poor health literacy
Strengths
•Additional words can be added to this assessment and still maintain
2-minute administration time. This would allow for development of
more disease-specific test, by choosing words related to a particular
disease.
•Short administration time
Limitations
•Poor literacy skills are thought to disproportionately affect the elderly
and minorities, 2 groups who were underrepresented in the study
validating the REALM-R.
•Utility in research and clinical settings less known.
Location
Available for purchase from Terry C. Davis, PhD: tdavis@lsuhsc.edu
Bass PF, Wilson JF, and Griffith CH. A Shortened Instrument for Literacy Screening. Journal of General Internal Medicine.
2003, 18:1036-1038.
25
National Quality Center (NQC)
Rapid Estimate of Adolescent Literacy in Medicine
(REALM-Teen)
Description
The word-recognition REALM test was adapted for adolescents in
health care settings. Like the REALM, there are 66 items in order of
increasing difficulty. The test allows health professionals to screen
youth in grades 6 though 12 for below-grade reading.
Average administration time: 2-5 min
Measurement
0-37 : <= 3rd grade level
38-47: 4th-5th grade level
48-58: 6th-7th grade level
59-62: 8th-9th grade level
63-66: >= 10th grade level
Strengths
•Words in test are more specific to adolescents age group than
words in REALM.
Limitations
•Like REALM, cannot diagnose specific reading or learning problems
or determine patient deficiencies in computing, comprehending, or
acting on health education.
Location
Available for purchase from Terry C. Davis, PhD: tdavis@lsuhsc.edu
Davis TC, Wolf MS, Arnold CL, Byrd RS, Long SW, Springer T, Kennen E, and Bocchini JA. Development and Validation of the Rapid Estimate of
26
National
Quality
Center
(NQC)
Adolescent Literacy in Medicine (REALM-Teen): A Tool to Screen Adolescents for Below-Grade Reading in Health
Care
Settings.
Pediatrics.
2006, 6:1707-1714.
Test of Functional Health Literacy in Adults (TOFHLA)
Two-part assessment:
Description
1) Provides participants with medical information or instructions about
various scenarios, such as instructions on a prescription label or
instructions about preparation for a diagnostic procedure. Participants
review the scenarios and then answer questions that test their
understanding of the information in the scenarios.
2) Based on the Cloze method, in which participants are given passages
of text about medical topics with selected words deleted and replaced with
blank spaces. The participants must fill in the blank spaces using words
selected from a multiple choice list of options, identifying the words most
appropriate to the context of the passage.
Administration time: 22-25 min
Measurement
Inadequate Literacy: 0-59
Adequate Literacy: 75-100
Marginal Literacy: 60-74
Strengths
Indicator of a patient’s ability to read and understand health-related prose
passages and numerical information; Used extensively in research
contexts; Spanish version available
Limitations
Primarily screens for reading ability; Long administration time
Location
Available for purchase from http://www.peppercornbooks.com/ at $70.
Parker RM, Baker DW, Williams MV, and Nurss JR. The test of functional health literacy in adults: a new instrument for
measuring patient’s literacy skills. Journal of General Internal Medicine. 1999, 10(10):537-541. National Quality Center (NQC)
27
Short Test of Functional Health Literacy in Adults
(S-TOFHLA)
Description
•The original S-TOFHLA was reduced to a 4-item numeracy section and 2
reading comprehension passages with missing words, which are at the 4th
grade reading level (preparation for an upper gastrointestinal series) and
10th grade reading level (the patients rights and responsibilities section of a
Medicaid application).
•Average administration time: 12 min
•The current S-TOFHLA does not include the numeracy section. Similar to
the TOFHLA, patients are asked to select the words that best fit into the
passages.
Average administration time: 8 min
Measurement
Inadequate health literacy: 0-53
Adequate health literacy: 67-100
Strengths
•Assesses reading comprehension
•Tested on a variety of populations (young, elderly)
•Shorter administration time
Limitations
•Numeracy not tested.
Location
Available in English and Spanish for purchase for $10
Marginal health literacy: 54-66
http://www.peppercornbooks.com/catalog/product_info.php?products_id=2765&osCsid
http://www.peppercornbooks.com/catalog/product_info.php?products_id=2766&osCsid
28 DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure
National
Qualityhealth
Centerliteracy.
(NQC)
Baker
functional
Patient Education and Counseling. 1999, 38:33-42.
Newest Vital Sign
(NVS)
Description
This 6-item assessment measures reading and comprehension of a
nutrition label and was developed through funding from Pfizer
Pharmaceuticals.
Average administration time: 3 min
Maximum administration time: 6 min
Measurement
Patients with low literacy: 0-4 questions answered correctly
Patients unlikely to have low literacy: 5-6 questions answered correctly
Strengths
•Tests for numeracy , reading ability and interpretation skills as applied to
a healthcare setting
•Available in English and Spanish
•Correlates with TOFHLA
•May be more sensitive to patients with marginal health literacy than other
functional health literacy assessments
Limitations
•May overestimate the percent of patients with low literacy, due to its
specificity
•Does not differentiate between adequate and marginal literacy well
Location
Can be ordered online free of charge from:
http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html
Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, and Hale FA. Quick Assessment of Literacy in
29Primary Care: The Newest Vital Sign. Annals of Family Medicine. 2005, 3:514-522.
National Quality Center (NQC)
NON-STANDARDIZED
HEALTH LITERACY SCREENING TOOLS
30
National Quality Center (NQC)
Brief Estimate of Health Knowledge and Action – HIV Version
(BEKHA-HIV)
Description
•An 8-item assessment of HIV treatment knowledge and action.
•The knowledge subscale measures a patient’s capacity to
understand health information, while the action subscale measures a
patient’s ability to make actionable decisions accordingly to acquired
health information.
•Three items are associated with knowledge, while 5 items are
associated with action.
Measurement
Low Literacy: 0-3 Marginal Literacy: 4-5 Adequate Literacy: 6-8
Strengths
•May better represent health literacy for HIV patients than more
general measures of reading ability or health vocabulary.
•Scores on BEKHA-HIV were significantly associated with selfreported medication adherence.
Limitations
•Not a direct test of functional health literacy in terms of reading
ability.
•Further validation needed
Location
Contact Chandra Osborn at chandra.osborn@vanderbilt.edu
Osborn CY, Davis TC, Bailey SC, and Wolf MS. Health Literacy in the Context of HIV Treatment: Introducing the Brief Estimate of
31Health Knowledge and Action (BEKHA)-HIV Version. AIDS Behavior. 2008
National Quality Center (NQC)
Single Item Literacy Screener
(SILS)
Description
A single item question intended to identify adults in need of help with
printed health material.
“How often do you need to have someone help you when you
read instructions, pamphlets, or other written material from
your doctor or pharmacy?”
Measurement
1-Never 3-Sometimes 5-Always
2-Rarely 4-Often
Scores greater than 2 are considered positive, indicating some
difficulty with reading printed health related material.
Strengths
•Very brief and practical for use during a routine clinical encounter
•More a direct assessment of need than an assessment of skill
•Simpler than an estimate based on demographic or cultural norms
Limitations
•False negatives may arise from subjects not recognizing that they
need help with reading, feeling ashamed, or not understanding the
question.
Morris NS, MacLean CD, Chew LD, and Littenberg B. The Single Item Literacy Screener: Evaluation of a brief
32instrument to identify limited reading ability. BMC Family Practice. 2006, 7(21).
National Quality Center (NQC)
How confident are you filling out medical forms by yourself?
Two studies investigated the utility of three questions to detect
Description
limited health literacy. The three questions are:
1) How often do you have problems learning about your medical
condition because of difficulty understanding written information?
2) How often do you have someone help you read
hospital materials?’’
3) How confident are you filling out medical forms by
yourself?
The researchers found that a single question was useful for
detecting patients with inadequate health literacy (according to STOFHLA and REALM).
Measurement
The 5 possible response are: always, often, sometimes,
occasionally, or never. Answers of sometimes, occasionally and
never indicate limited health literacy.
Strengths
Very brief, can be given unobtrusively in clinical settings, better at
predicting limited health literacy than some demographic
characteristics.
Limitations
Study was conducted in a large population of VA primary care
patients and may not be generalizable to other settings.
Chew LD, Griffin JM, Partin MR, Noorbaloochi S, Grill JP, Snyder A, Bradley KA, Nugent SM, Baines AD, and VanRyn M. Validation of Screening
Questions for Limited Health Literacy in a large VA Outpatient Population. Journal of General Internal Medicine. 2007, 23(5):561-566.
Wallace LR, Rogers ES, Roskos SE, Holiday DB, and Weiss BD. Brief Report: Screening Items to Identify Patients with Limited Health Literacy
Skills. Journal of General Internal Medicine. 2006, 21:874-877.
33
National Quality Center (NQC)
SOS Mnemonic
Description
•This study found that self rated reading ability, Single Item Literacy Screen
result, and highest education level independently predicted whether a
patient has limited health literacy as defined by their S-TOHFLA score.
•The study suggests that the use of all these questions is superior to the
use of any one of them individually.
Measurement
Not included in this presentation
Strengths
Asking specific questions about how an individual understands health
information may better elucidate interventions that can be used.
Limitations
•Study participants were all being treated for diabetes at a single academic
family practice center.
•Study participants knew they were receiving reading tests and may have
been less likely to attempt to conceal a reading problem.
•Model not yet validated to determine how well these results apply to other
populations, though results correlate with S-TOFHLA.
Jeppesen KM, Coyle JD, and Miser WF. Screening Questions to Predict Limited Health Literacy: A Cross-Sectional
Study of Patients With Diabetes Mellitus. Annals of Family Medicine. 2009, 7(1):24-31.
34
National Quality Center (NQC)
Summary
• Standardized health literacy screening tools:
 Focus is on measuring reading ability
 Most also test numeracy and reading comprehension of
health-related information
 Context of screening is very important because of the
assessment-like nature of the screening tools
 Cannot identify etiologies, which would help identify
interventions
• Non-standardized health literacy screening tools:
 While not all are validated or well-used, these tools offer
potential as effective screening tools as they help
clinicians better identify etiologies and interventions.
35
National Quality Center (NQC)
Example
Greater Hudson Valley Family Health Center
Iris Arzu
36
National Quality Center (NQC)
Treatment Adherence Learning Network
Current Activity
New Activity
Intervention
Change ARV
packaging
Regimen recall
Literacy
Assessment
Review of labs
Score
Reminder tools
Ed. targeted
to literacy level
Adjustments to
Patient/Provider
communication
37
National Quality Center (NQC)
Implementation (continued)
• During regimen/lab reviews, teach-back
makes explicit what patients understand
• Results are used to select materials, tools,
education and other supports
• Results are used to adjust language, visuals
and/ or the structure of the provider/patient
interaction
38
National Quality Center (NQC)
Draft Tool
For each of the items below, please use the scale underneath the question, to show your assessment of the patient’s
current grasp of or ability to use the medication-related information and tools/treatments provided. You can mark
anywhere on the line.
Sections 1 and 2 are only to be completed for patients currently on an antiretroviral regimen.
1. Recall of Medications:
During the multi-day recall of doses taken or missed,
How well was the patient able to identify his/her antiretroviral medications, by name or description? Note: Treat
recognition with prompting or visual aids the same as recognition/naming without assistance.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2. Dosage and Frequency:
During the multi-day recall of doses taken or missed,
How well did the patient recall the dosage amount (number of pills or ml per dose) for each medicine?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
How well did the patient recall the number of doses per day?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
How well did the patient seem to understand and be able to follow specific instructions with his/her antiretroviral
medications? (e.g., specific timing of doses, the point at which it’s better to wait for the next dose rather than taking a
very late dose, the need to avoid “doubling up” on doses to make up for a missed dose, and/or the requirement to
take certain medications “on an empty stomach” or “with plenty of fluids”)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
39
National Quality Center (NQC)
Limitations
• Method is indirect (items answered by
provider, not patient)
• Providers may have different views on how to
score
• Testing for reliability and validity (for use
beyond QI) has not been done
40
National Quality Center (NQC)
Lessons Learned
• Functional literacy screens miss the impact of
interventions and have practical limitations
• Standard TA activities (adherence self-report and
CD4 and VL review) provide a natural opportunity
for medication literacy
• Adoption in clinical practice depends on
acceptability to patient and provider
41
National Quality Center (NQC)
REALM
Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, and Crouch MA. Rapid Estimate of Adult
Literacy in Medicine: A Shortened Screening Instrument. Clinical Research and Methods. 1993, 25(6):391-395.
42
National Quality Center (NQC)
REALMTeen
Davis TC, Wolf MS, Arnold CL, Byrd RS,
Long SW, Springer T, Kennen E, and
Bocchini JA. Development and
Validation of the Rapid Estimate of
Adolescent Literacy in Medicine
(REALM-Teen): A Tool to Screen
Adolescents for Below-Grade Reading in
Health Care Settings. Pediatrics. 2006,
43
6:1707-1714.
National Quality Center (NQC)
S-TOFHLA
44
National Quality Center (NQC)
S-TOFHLA
45
National Quality Center (NQC)
Newest Vital Sign
46
National
Qualityin Center (NQC)
Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, and Hale FA. Quick Assessment
of Literacy
Primary Care: The Newest Vital Sign. Annals of Family Medicine. 2005, 3:514-522.
BEKHA-HIV
47
Osborn CY, Davis TC, Bailey SC, and Wolf MS. Health Literacy in the Context of HIV Treatment: Introducing the Brief Estimate of
National Quality Center (NQC)
Health Knowledge and Action (BEKHA)-HIV Version. AIDS Behavior. 2008
SOS Mnemonic
Jeppesen KM, Coyle JD, and Miser WF. Screening Questions to Predict Limited Health Literacy: A Cross-Sectional
Study of Patients With Diabetes Mellitus. Annals of Family Medicine. 2009, 7(1):24-31.
48
National Quality Center (NQC)
Next Steps:
• Testing your screening tool(s)
49
National Quality Center (NQC)
PDSA Cycle
Plan, Do, Study, Act
50
National Quality Center (NQC)
Repeated Use of Cycle
PDSA Measures
A P
Changes That
Result in
Improvement
S D
Implementation of
change
Wide-scale tests of
change
A P
S D
51
Hunches
Theories
Ideas
Follow-up tests
Very small scale
test
National Quality Center (NQC)
Example for PDSA Cycle
Patients receiving
a Health Literacy
Screen
A P
S D
A P
S D
Cycle 1E: Implement and
monitor result quarterly
Cycle 1D: Incorporate suggestions,
expand to third physician.
Cycle 1C: Continue with Dr. Z’s patients and
expand to NP J’s patients for third week.
Cycle 1B: Try out the second week with Dr. Z’s
patients incorporating suggestions from 1st week
Cycle 1A: Try out screening tool with Dr. Z’s patients during
week 1.
52
National Quality Center (NQC)
Resources
To calculate literacy rates in your area:
www.casas.org/lit/litcode/Search.cfm
Online training:
• www.hrsa.gov/healthliteracy/training.htm
• The Quality Academy, Tutorial #23 “Understanding and
Addressing Health Literacy”
www.nationalqualitycenter.org
The Literacy Assistance Center, NY http://www.lacnyc.org
53
HIV Health Literacy performance measurement
www.hivqual.org
National Quality Center (NQC)
Resources
• Overview of the National Assessment of Adult Literacy:
http://nces.ed.gov/NAAL/
• Partnership for Clear Health Communication:
www.askme3.org
• Harvard School of Public Health; Health Literacy
Studies: www.hsph.harvard.edu/healthliteracy/
• The Joint Commission (2007); “What Did the Doctor
Say?:” Improving Health Literacy to Protect Patient
Safety; http://www.mmia.org/uploads/pages/215.pdf
54
Other Resources
National Quality Center (NQC)
Thanks to AI Staff:
•
•
•
•
•
•
55
Sreela Namboordiri
Bruce Agins
Clemens Steinbock
Lyn C Stevens
Beth Woolston
Dan Belanger
National Quality Center (NQC)
Evaluation and Wrap up
Thank you 
56
National Quality Center (NQC)