This edition of Collaborate to Educate focuses on a critically important issue in healthcare: Patient literacy. Challenges in this area can be wide-ranging, including general literacy issues (reading comprehension and language barriers); health literacy (difficulty grasping medical information); numeracy (math comprehension); and technology literacy.

With an eye on sparking a solutions-focused dialogue about this important topic within the diabetes educator (DE) community, In the Know has brought together 3 thought leaders to share their ideas and best practices.

    HEATHER LECLERC, MS, RD, CDE: Heather is a clinical supervisor of The Diabetes and Endocrine Specialists of Maine, an outpatient practice of Eastern Maine Medical Center, where she has worked for the past 28 years. Along with the office’s 5 other certified diabetes educators (CDEs), she provides education for patients with diabetes of all ages and assists the 5 providers in the office with day-to-day medical management. Approximately 8 years ago, Heather developed latent autoimmune diabetes in adults (LADA) and is treating it with the MiniMed® 530G with Enlite®.
    ELIZABETH (BETH) NARDACCI, MS, FNP-BC, CDE: Beth is a family nurse practitioner at Capital Region Diabetes and Endocrine Care in Albany, New York, who previously worked as a CDE. Her special interests include diabetes technologies, including professional and personal continuous glucose monitoring (CGM) and insulin pump therapy, chronic kidney disease, and renal transplantation. She is a principal investigator in the OpT2mise international pivotal trial for use of insulin pump therapy in type 2 diabetes (T2D).
    DANA K. WIGGINS, RN, CDE: Dana has been a certified product trainer for Medtronic Diabetes since 2007. She provides diabetes education for people of all ages with type 1 diabetes (T1D) or T2D. Her previous experience was in pediatrics and home health.
Do you have best practices to share when it comes to health literacy? Please email us with the details:
Additional Resources: In addition to the many helpful resources hyperlinked throughout this article, you also may find the whitepaper and tools below to be useful in assessing and overcoming patients’ health literacy barriers:

Q: Can you speak to the importance of assessing patients’ health literacy and meeting them where they are for successful diabetes training, education, and self-management? What are some ways in which you assess your patients’ health literacy?

“Assessing our patients’ health literacy is an extremely important factor in the education process. It helps us determine patients’ ability to perform the tasks we are going to be teaching them, which can directly affect their success on insulin pump therapy and CGM.

Doing a basic health literacy assessment prior to training can help flag warning signs that patients may have barriers that we will need to address the day of the training. The information is also extremely helpful in identifying the most appropriate teaching methods for each patient and in deciding if one-on-one training is needed, or if a group class might be an option.

The StartRightSM Pre-Assessment Forms that Medtronic’s StartRight representatives gather for patients starting on the MiniMed® 530G with Enlite® are a great starting point for pre-training assessments. The forms provide initial information about patients, and the representatives also note any concerns patients might have.

When assessing patients, I focus on questions such as: ‘How often do you check your blood sugars? Are you comfortable checking your blood glucose (BG) yourself, or do you have a caregiver who helps you at home? Do you feel comfortable with computers and other types of technology? How are your carbohydrate-counting skills?’ Using a label sample also helps to gather important information on the patients’ knowledge of carbohydrate-counting and how much they know about food and food choices.

Assessing patients’ health literacy levels may require a bit of detective work. Sometimes, what may at first glance appear to be a literacy issue may actually be a situation that requires a simple intervention. A particular patient comes to mind who told me during a pre-training assessment that his glasses prescription was outdated, and he was concerned he would not be able to read the pump screen during (or after) training. He was unable to afford glasses with an updated prescription prior to training. I asked him if he had a magnifying glass and he did, so I asked him to bring it to training. The magnifying glass allowed his to read the manual and visualize the pump. The training was successful, and he has done very well with his pump therapy.”

-Dana K. Wiggins, RN, CDE

“It is imperative that we assess our patients’ health literacy. Due to extremely busy schedules and limited appointment times, we generally do not have an opportunity to administer formal health literacy assessments. We use our professional judgement, with patient conversations and data as our guides.

Sometimes, it can be very clear that you are working with a patient with low health literacy skills. Other times, it may not be immediately evident. It’s important not to assume that highly educated professionals have an understanding of health and diabetes. In fact, they can be the very people who will end up being the biggest challenges in your day.

Almost every day, I encounter at least one patient with low health literacy skills. We sometimes get calls from patients who have a very hard time ‘putting it all together’ with insulin pump therapy. It is important not to give up on these patients and to customize training and education to fit their needs so that they are successful.”

-Heather Leclerc, MS, RD, CDE

“One clue in initially assessing patients’ health literacy can be the manner in which they complete office forms. If patients do not complete the forms at all, this can sometimes be a tip-off about their health literacy—making it especially important to follow up for further assessment.

Also, I’m a firm believer in asking patients how they prefer to learn. Would they rather see a demonstration or would they like reading material—or both? Sometimes this will give you additional insights into potential health literacy or literacy issues.

I do not automatically give patients items to read; I’ll say lightly to them: ‘I know a lot of people throw reading materials in the garbage the minute they leave here. Do you learn by reading or not?’ So many times patients are relieved to be asked this question, to not receive materials that will go over their head, and to have the information communicated to them via a demonstration, a video, or another method that works well for them.”

-Beth Nardacci, MS, FNP-BC, CDE

Q: What do you do if a patient’s literacy challenges do not become apparent until training is under way?

“Unfortunately, health literacy/general literacy issues sometimes cannot be detected until the training is under way. If I see that a patient is becoming overwhelmed due to a comprehension issue, I like to immediately slow down and reteach, while also ensuring the patient is comfortable and engaged.

It is important to adjust our training styles and methods once we identify a literacy barrier through observation or patient acknowledgment. Usually upon identification of a learning deficit, it’s possible to subtly tailor the way the material is delivered during training without the patient feeling embarrassed or uncomfortable in any way.

When a patient appears to be getting frustrated or confused, it’s a sign that the training needs to change directions. Being extremely flexible and able to switch methods quickly are key.

People learn to adapt when they know they have literacy issues. Encouraging patients to stop the training when they have questions helps decrease anxiety. Patients who are not technically oriented, including some older patients, are usually the most nervous and will often tell you without being asked that they are not good with computers.

I do not like to proceed with the training unless the patient exhibits a good comfort level following each part of the training. Once they grasp one key concept, I move on to the next one.”

-Dana K. Wiggins, RN, CDE

“One of the most effective strategies I have found to help educate patients is the Teach-Back Method, an interactive approach in which patients are asked to restate in their own words information that has been provided to them. This allows me to assess patients’ comprehension of what they are being taught and presents an opportunity to correct any misperceptions.

The Teach-Back Method helps close the gap between patient training day and going home to self-manage. Even with a high level of health literacy, the volume of information that patients receive at pump training is a lot to absorb and remember.

The Teach-Back Method can increase patient confidence in self-management of their diabetes and in managing their insulin pump/CGM. It is also an important tool for helping patients understand and remember safety precautions.

As health literacy issues come to our attention, it is extremely important that we not allow these potential barriers to disrupt the training. There’s always a workaround, and it’s up to us as educators to find it.”

-Dana K. Wiggins, RN, CDE

“It’s always important to keep your instructions clear and concise, but that need is magnified in patients with health literacy issues. Think of it this way: Before I had a GPS device, I would sometimes have to stop to ask directions in an unfamiliar town. If the person I asked kept the directions clear and did not add excess detail, I could absorb the information and get to my destination. If the directions were too wordy, I would get lost again! Therefore, I try to be especially clear and brief and speak in simple terms when teaching patients with health literacy issues.

Like most DEs, I also use the Teach-Back Method. I find that it’s important when asking patients to repeat information back to do so in an engaging, nonjudgmental way.

During any patient visit, but especially when working with patients with lower health literacy, I strive to identify 1 or 2 important messages that will have the greatest impact on the patient’s health and quality of life. For example, if a patient is not bolusing at meals or snacks, I will emphasize the importance of bolusing every time he eats. I will ask the patient if he knows why bolusing at meals and snacks is important. If he doesn’t know why, I will keep the explanation simple.

It is so important to understand that many our patients will never have the same level of understanding of certain concepts that we (or even other patients) have, and that’s okay—as long as they know what to do and are adherent in order to self-manage their diabetes.

I recently saw a woman who was instructed to take insulin with every meal, yet she was taking it only before lunch. Even though the instructions were discussed and written out at the previous visit, she truly had no idea at the follow-up appointment that she should have been taking insulin with each meal. Her blood sugars were high as a result. A person with a higher level of health literacy might have realized that if you need insulin with lunch, you also probably need it with breakfast and supper. I worked with her to ensure that she understood the importance of dosing before every meal, and she is now adherent.”

-Heather Leclerc, MS, RD, CDE

“In addition to using the Teach-Back Method, I start training appointments by telling patients what I am going to teach them about; I deliver the training and education; and finally, I repeat what I just taught them as a summary. Some people call this: ‘Tell them what you’re going to tell them, tell them, and tell them what you just told them.’ I have found this reinforcement of key messages to be extremely effective, especially for patients who have health literacy challenges.

It’s also important that patients not feel overwhelmed and know that they can always follow up if they have questions once they start pump therapy/CGM. I set expectations at the very beginning of training appointments by saying: ‘Most patients only remember half of what I say, so if you remember half, then you are doing great!’ ”

-Beth Nardacci, MS, FNP-BC, CDE

Q: What types of educational tools or aids do you find to be especially helpful in teaching patients with health literacy issues?

“Utilizing Medtronic’s “Getting Started” guides for the MiniMed® 530G insulin pump and the system’s CGM helps provide patients with exactly what they need to know. I find that if I teach directly from the guides, which include instructional graphics and step-by-step instructions, patients feel more comfortable once they are at home self-managing. During training, aids such as a calculator, food flash cards, or food pictures also are helpful.”

-Dana K. Wiggins, RN, CDE

“One tool that I use often is my whiteboard. Being able to share key points on the whiteboard in addition to having a discussion can be very helpful, especially since some patients with health literacy barriers may learn better from visual examples. I like to use the whiteboard to demonstrate how giving a bolus before a meal usually results in better blood sugar control—fewer highs and lows. Patients seem to understand the concept better by both seeing and hearing what I’m teaching them.

I still see patients who are drinking regular sugared beverages. When I use the whiteboard and show them how many carbohydrate grams they are getting from these beverages, they are shocked! We then look at their blood sugar levels after drinking these sugar-laden beverages and discuss their impact. I explain to them that there are 38 grams of fast-acting carbs in one 12-ounce regular soda—and most people drink more than 12 ounces at a time. When I tell them a 20-ounce regular soda has 63 grams of carbs—the amount of carbs in one average-sized meal—they have a point of reference, easily understood even by those patients who have literacy barriers and/or who aren’t math-oriented.

I also show instructional and informational videos during patient appointments. Medtronic has some nice, short videos on YouTube that I keep on my computer desktop. One of these videos explains the difference between sensor glucose (SG) and BG, and another explains why SG and BG won’t always match . The videos explain complex concepts in a way that patients can understand, and the graphics and analogies they use make the information more relatable and memorable.

I also show patients actual infusion sets and sensors. I keep some ‘unwrapped’ in my desk and show patients the catheter (infusion set) and sensor filament (Enlite sensor). I’ve found this to be especially helpful when a patient is making a decision about whether to start insulin pump or sensor therapy. I like to demonstrate taping tips on an artificial abdomen. Medtronic offers very good information on key taping methods that also serves as a helpful take-home tool for patients.”

-Heather Leclerc, MS, RD, CDE

“I use Medtronic patient Training Handouts all the time, especially the ‘Getting Started’ Quick-Reference Guides for the Bolus Wizard®, Dual®/Square Wave®, and Basal settings. To really drive home the most relevant points, I use a highlighter to emphasize the parts I want patients to focus on.”

-Beth Nardacci, MS, FNP-BC, CDE

“Numeracy, especially as it relates to carbohydrate counting, seems to be a huge area of low health literacy. Not only is knowing how to count carbohydrates a stressor for patients because they feel like they have to be perfect at counting all the time, but understanding how food affects BG numbers can be challenging. A lot of patients have had diabetes for years and used the exchange method, and now we are asking them to count grams of carbohydrates. This can be extremely confusing for some patients. Follow-up phone calls are a necessity to support these patients and ensure they do not go back to their old way of counting exchanges.

I hear more often than not, ‘I had no idea that is why my blood sugar stayed so high for so long after I ate pizza.’ I ask patients with smartphones to download food-tracking apps during training so I can show them how to use them. For patients with no phone or without a smartphone, I encourage them to use a calorie-counting/carb-counting book available at most book stores.”

-Dana K. Wiggins, RN, CDE

“One example of health illiteracy that I encountered recently was a child with T1D whose mother was feeding her toaster pastries for breakfast every morning. Her BG was frequently high by mid-morning even if she received the correct insulin-to-carb dose. This child also was obese and gaining weight rapidly. We developed 4 breakfast choices that were healthier and included protein to replace the high-sugar, high-carb breakfasts. Without changing her insulin-to-carb ratio, the patient’s mid-morning blood sugars improved significantly.

I encounter many patients who have problems with math and difficulty calculating the carbohydrate content of the foods that they eat. Using a food-tracking app that includes carbohydrate counts is definitely helpful. I also offer to spend time during the visit to write down patients’ most common meals with portions and calculate the carbohydrate counts for them. We work on these sample menu plans together, and they leave with specific meals, portions, and carbohydrate information.”

-Heather Leclerc, MS, RD, CDE

“Technology literacy is sometimes driven by emotion—the fear of the unknown. Showing patients exactly what different pieces of insulin pump technology are used for and how they work removes some of the mystery, which usually makes patients feel less intimidated. Often, they even start to get excited about the technology and how it can help them.

Numeracy issues can be tricky to detect unless you see the patient is making errors, or until the patient tells you. Some patients may get anxious about making a mistake and think they cannot do the math—even though they actually can with practice and confidence. Having the support of the DE can be very helpful in overcoming these obstacles. Using the MiniMed 530G with Enlite’s Bolus Wizard also helps put patients at ease, because they know they don’t have to do the math themselves.”

-Beth Nardacci, MS, FNP-BC, CDE

Q: As you know, it’s important not to pre-judge patients’ potential health literacy based on age, appearance, socioeconomic status, etc. How do you ensure that you do this when working with a wide range of patients?

“As educators, I believe we have very few trainings in which there is not some type of literacy barrier, even if it’s a minor one. Whether it’s general literacy, health literacy, technology, or just retaining the large amount of information that patients are given, nearly everyone has some type of challenge—or at least a learning curve.

I try to never assume that because a patient is a professional, especially a healthcare professional, that I can cut corners in the training. It’s also important not to pre-judge patients based on having a lower educational level, socioeconomic status, etc.—in some cases, they may end up being patients who quickly and readily succeed with training and pump therapy.

I also don’t make assumptions about patients’ health literacy based on their diabetes treatment history. When patients are switching from a different insulin pump or to an updated version, I find it is essential to go through the full training process. In doing this, I have identified situations in which patients missed information at a previous training or were unaware of how to use certain features and weren’t using them to their fullest potential.

Connecting with patients at the level of literacy they are at requires an open mind and keen observation—and it’s crucial to successfully delivering their training and education.”

-Dana K. Wiggins, RN, CDE

“I just saw a patient who was an intellectual person. It wasn’t discovered until she came back for follow-up that she had become very anxious about carb-counting and dosing with multiple daily injections (MDI). She was using some strange equation that she had in her head. We were all surprised, because she presented very differently, and appeared confident in the training she had received.

She said at follow-up: ‘I am not a math genius.’ The bigger issue was that she had become very nervous about the situation, which had left her immobilized. Emotional factors can play a significant role in health literacy.

Sometimes these types of situations aren’t identified until after patients are trained, and it becomes apparent they are experiencing challenges that need to be addressed. It would, of course, be preferable if the issues were discovered beforehand. While that’s not always possible, close communication between patients’ DEs and providers can be a great help.”

-Beth Nardacci, MS, FNP-BC, CDE

Q: How do you put patients at ease who may have increased anxiety due to health literacy concerns?

“At the beginning of a training, I let patients know how I will conduct the training, what I will be using as teaching tools, and that the training is about them leaving feeling comfortable with the training outcome. Patients need to know that we will be working together as a team, along with their physician/provider, so that they can be successful.

Unfortunately as educators, we don’t always know ahead of time whether patients have a literacy issue. When we determine that there is one, we must redirect the training so that the atmosphere is conducive to learning and patients feel comfortable.

Our ability to effectively communicate with patients who have health literacy/literacy issues depends on detecting the barriers and creating a training plan prior to (or if needed, during) training that is patient-centered and problem-centered, while ensuring patients feel comfortable.

Patients even with the best of literacy skills can find health information overwhelming and challenging. When patients become anxious because they do not understand the information being taught, it can affect their ability to learn and comprehend. I like to make sure my patients feel encouraged and know that they will have a great support system.”

-Dana K. Wiggins, RN, CDE

Q: What type of patient-follow-up do you find helpful in patients with health literacy challenges?

“I like to send home a Discharge Instructions sheet following the training. This sheet contains contact information for the Medtronic team I am working with and the 24-hour numbers for product and software assistance. It helps reassure patients to know they can get questions answered quickly and accurately once they leave the office.

The sheet also has instructions on when and how often to check their blood sugars, along with the protocols for hypoglycemia, hyperglycemia, diabetic ketoacidosis, and ketone testing and treatment. This information is pulled directly from the insulin pump “Getting Started” guide. After the initial training, it’s helpful for patients to have this sheet on-hand for quick reference. I tell them to put it on their refrigerator or in another accessible, visible spot.

Letting patients know that I will be doing follow-up phone calls to check on them also helps diminish any potential anxiety, especially when literacy issues may make them feel less confident. The follow-up calls also give me an opportunity to question patients to see if information was retained by asking pertinent questions about what they ate and the corresponding carbohydrate counts they entered into their pump.”

-Dana K. Wiggins, RN, CDE

“We use an electronic medical record (EMR) in our office. We created a helpful template called the ‘Plans and Recommendations Form,’ with help from our EMR programmers. On the form are frequently used statements such as: ‘Please wear medical identification,’ ‘Carry a fast carbohydrate with you in case you have a low blood sugar,’ ‘Avoid sugared drinks, including juice,’ ‘Take your insulin before you eat,’ etc. We simply click on the statement, and it appears on the take-home form. We can also insert clear insulin dosing instructions and other personalized comments.

This is especially helpful for patients with health literacy challenges. It is important patients have written instructions when they leave your office because we know that patients—even those who don’t have literacy barriers—do not remember everything that is discussed in a visit.”

-Heather Leclerc, MS, RD, CDE

SOURCES StartRightSM program. Medtronic Diabetes. Accessed May 14, 2015.

Introducing MiniMed® 530G with Enlite®. Medtronic Diabetes. Accessed May 14, 2015.

Getting started with the MiniMed® 530G insulin pump. Medtronic Diabetes. Accessed May 14, 2015.

Getting started with continuous glucose monitoring (CGM) for the MiniMed® 530G with Enlite. Medtronic Diabetes. Accessed May 14, 2015.

Blood glucose and sensor glucose: What’s the difference? [YouTube video]. Medtronic Diabetes. Accessed May 14, 2015.

Why SG and BG won’t always match [YouTube video]. Medtronic Diabetes. Accessed May 14, 2015.

Insertion site management: Key taping methods. Medtronic Diabetes. Accessed May 14, 2015.

Bolus Wizard® quick-reference guide for the MiniMed® 530G insulin pump. Medtronic Diabetes. Accessed May 14, 2015.

Dual®/Square Wave® quick-reference guide for the MiniMed® 530G insulin pump. Medtronic Diabetes. Accessed May 14, 2015.

Basal quick-reference guide for the MiniMed® 530G insulin pump. Medtronic Diabetes. Accessed May 14, 2015.

Settings and Features: Changing your Bolus Wizard settings. Medtronic Diabetes. Accessed May 14, 2015.

Contact us. Medtronic Diabetes. Accessed May 14, 2015.