Long-Term Care Survey Alert

Make sure staff, residents/families are on the same page.

As the concept of "health literacy" grabs hold in the patient safety world, you need to ensure your residents and their surrogates truly "get" what you're telling them.

The bottom line: "Nursing facilities need to be sensitive to a patient's or his decision-maker's ability to not only read but comprehend written and verbal health information," counsels Amy Wilson, MPP, CPHQ, associate project director and principal investigator for Hospitals, Language and Culture, at the Joint Commission.

Also keep in mind that the elderly are at "particular risk" for poor outcomes related to low health literacy, cautions Marianna Grachek, RN, NHA, executive director of Long-Term Care and Assisted Living Accreditation Programs for the Joint Commission on Accreditation of Healthcare Organizations. They may be grappling with chronic illnesses and sensory and cognitive deficits, she notes. In addition, elders in today's society may have been taught to revere authority to the extent that they "hesitate to challenge a physician or other authority figure"--or to "speak up" about their concerns, says Grachek.

Know the Survey, Accreditation Requirements

Heads up: The Centers for Medicare & Medicaid Services recently released an electronic publication for beneficiaries, "Medicare Rights and Protections," which says patients have the right to receive healthcare services in a language they can understand and in a "culturally sensitive way." Medicare patients also have the right to learn about all of their treatment choices in clear language they can understand, according to the publication (www.medicare.gov/Publications/Pubs/pdf/10112.pdf).

And while health literacy isn't tied to a specific survey requirement, "the more a concept or practice becomes known and used"--the more it becomes the standard to which your facility will be judged in a liability and malpractice arena, cautions John Lessner, an attorney with Ober/Kaler in Baltimore. And as health literacy assessments become commonplace, "tailoring communications to an individual's particular needs will accordingly become the standard."

Meet the challenge: And that is "to work with the resident to understand his or her expectations based on his culture, health literacy status, cognitive and sensory status and other factors, such as generational differences," says Grachek.

Information Packets May Come Back to Haunt You

In a survey context, health literacy issues actually begin at admission because the resident or his decision-makers need to understand the admission agreement/contract and the services the resident will receive, says Lessner. So look at how much your facility relies on written material as part of the admission process, suggests Wilson. If you're simply handing people packets of information or asking them sign admissions agreements and informed consent forms, that's not going to fly with surveyors, legal experts caution.

Instead, do a good assessment and document a resident's ability to learn and understand and provide assessment information based on his cognitive status, verbal ability, cultural background, socioeconomic and educational level, advises Regina Fink, RN, PhD, AOCN, a nurse researcher in Denver.

Test residents' comprehension: Wilson suggests using open-ended questions such as "What is your understanding of what's going on with you? What is your understanding about what will happen with this treatment?"

4 Points Where You'll Be Vulnerable

Beyond admission, residents and their family members can be at risk for misunderstanding health information at various times throughout the nursing home stay, says Wilson. These include:

• Initial care planning.

• Informing the resident about his rights and safety information.

• Obtaining informed consent. Informed consent occurs at various points throughout the person's stay in the facility, Wilson notes. And "informed consent is a process of educating the person [or his decision-maker] about the risks and benefits of a treatment or proposed plan of care so the person can make a true informed choice," she adds. "It's not just about having the person sign a document," she adds.

• Discharge planning and instructions, including how to take medications. "You have to assess the health literacy level of the caregiver who is helping the person in the home," says Wilson. Also assess the caregiver's understanding of the instructions for post-discharge care.

Head Off 'Dignity Tags'

Lessner has seen surveyors hand out dignity tags where staff "talk over" a resident in another language as they provide her care. "The resident may complain in such cases that she doesn't understand what the caregivers are saying--and doesn't know if they might be talking about her," says Lessner. Although caregivers don't "necessarily have to be fluent in English," he says, "they should be able to communicate on some level with residents--and be able to understand and respond to residents' questions."

A bigger problem: The larger challenge is for facilities to address the needs of non-English speaking residents so they can communicate effectively "with these folks," Lessner adds. One approach is to "identify key staff members who do speak the same language as the resident," he suggests. Identify those staff members as a "facility contact person for the resident who can help facilitate communication."

Know the Ins and Outs of Using a Medical Interpreter

In some cases, you may want to obtain the services of a trained medical interpreter to ensure a resident or his surrogate understands critical information. Wilson notes that if English isn't the person's first language, he may speak the language better than he understands it--especially when the person is ill or when the family member is in a stressful situation, such as caring for an ill loved one. In such cases, ask the person if "he or she would be more comfortable having the information presented by a trained medical interpreter in his/her native language--especially for informed consent," she suggests.

Know the options: The National Council on Interpreting in Healthcare recently released guidance to organizations looking for people who understand the practice of interpreting, notes Wilson. "Facilities can also network with hospitals in their areas that have made some progress in addressing these issues," she adds. Some language service companies provide interpretation by telephone, including Pacific Interpreters, Cyracom and AT&T Language Lines Services, Wilson advises.