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Seeing Race in Healthcare

Ignoring race in an attempt to be 'sensitive' to your patients can lead to poor outcomes.

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Taiyesha Baker’s Twitter Issue

Expert advice from a proven racist on how to feed wolves.

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Giving Thanks

We have much to be thankful for this year, believe it or not.

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Veteran’s Day


When I looked up Veteran’s Day on the internet earlier in the week, the first links that appeared were related to office closures such as banks and public offices.  There was nothing about actual men and women who served in the Military.  But, there is a lot going on with the Veteran’s Health Administration and I learned some shocking facts about Veterans when researching this post.  First, approximately 8 percent of our prisoners are veterans.  The good news is that the number is falling and while there are probably a few veterans who simply committed crimes unrelated to their service to our country, many of them have PTSD.

Prison is the extreme but there are many more veterans who are suffering from PTSD.  I never thought of it as a condition that affected the elderly but Dementia and PTSD have a relationship.  Additionally, the traditional treatment of long term use of benzodiazepines to manage anxiety with PTSD is now suspected of contributing to Alzheimer’s Disease and other Dementias.  Medication recommendations have changed and are successful, but Dementia and PTSD are still closely correlated.  These are our patients – Medicare beneficiaries who fought in wars that ended long ago continuing to suffer from PTSD and losing the cognitive ability to cope.

Although younger men and women in the military are taught how to recognize PTSD and get help when needed, the older generation lived in an age when they were supposed to ‘suck it up’.  They viewed mental illness as weakness.  They had a preconceived notion that men were supposed to be ‘strong’ and boys didn’t cry.  Some of them have lived miserable lives.  But as they are approaching the end of their lives, you can help them by learning to assess for PTSD and assist your patient in getting the help they need.

The Veterans Health Administration has a seemingly unlimited amount of information available for Veterans and Healthcare Providers.  There are continuing education courses online at no cost for nurses that grant credit.  There are teaching guides that can be downloaded that will help you teach your patients about PTSD. They are yours by clicking the blue box.National Center for PTSD homepage

When I worked in critical I took care of a patient shot six times by her retired husband.   According to her family, they were the perfect couple but a flashback to a combat zone ultimately caused the death of my patient.  A few years later, in the cath lab, a patient with Alzheimer’s Dementia became very angry when a physician of Asian decent walked into his room prompting the patient to scream something about killing those Japs.  The physician was a kind man and didn’t take offense but imagine how very frightened my patient was thinking that the ‘enemy’ had found him.

Jails are now designating areas for Veterans.  The Hospice Benefit has a program to recognize veterans.  Home Health nurses won’t wait for a program to formally assist Veterans. Let’s get started by learning about PTSD and getting our Veterans Treatment.

They were willing to die for us.  We can lighten the pain of their ongoing suffering.

Schooling Me


Last week, I wrote about a study that revealed an astonishing fact:  Poor, Black people have worse home health outcomes.   I surmised that we really didn’t have time to do a full literacy assessment; nor did we have the skills to do so.  Oops.  A reader, Kyandra commented that there is a Single Question Literacy assessment and that prompted a day long journey into Health Literacy on the internet.  Some of the information I found truly was surprising – and frankly, embarrassing to us as a nation.

The statistics are wide and varied.  One study estimates that one in three adults does not have the literacy skills to understand written health materials. Most health materials are written at an 8th grade level but the average reading level of adults is closer to the 5th grade level.  Older Americans (i.e. Medicare Beneficiaries) are more likely to be unable to read or comprehend written materials.  Accidents happen, hospitalizations increase and preventative care decreases with an increase in health literacy skills that are basic or less than basic.

Should health literacy statistics bore you, know that effective January 1, you are mandated to have a working knowledge and use it.

From the new Conditions of Participation:

The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.

This is not new.  It has always been a part of the Civil Rights Act section 504 which applies to all government contractors (yes, you are a government contractor ever since your agency entered into a provider agreement with CMS).  Now it is part of the CoPs.

Finally, patients and/or their families have sued successfully when they were unable to understand consents or other forms given to them.  Judges think that a patient who cannot understand the information cannot give informed consent.  I agree.

During my rambling search, I found one video by the AMA that explains the problem much better than I do and also offers solutions.  If I ran an agency, I would play this video at a mandatory inservice for all employees.

After watching the video, consider using a single question literacy screen that has been proven to be fairly accurate in determining health literacy in adults as suggested by Kyandra.

 “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”

  1. never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always

Although the assessment is determined to be only moderately effective in research, there’s a good chance that a patient admitting to having difficulty reading medical instructions needs more than a standard teaching guide and I’m pretty sure that creative nurses will be able to accommodate those needs.

Nicole White from Chicago commented that she used a sheet of paper handed to her patients.  It had several goals written in a font similar to that found on medication bottles.  She asked them to choose a couple of goals they would like to achieve.  If they couldn’t read the sheet, she asked if she could fetch their reading glasses from another room.  She assessed patient specific goals, vision and literacy without adding time to her assessment.

Nobody is in a better position to dance around problems with literacy than home health employees.  We are in the homes where patients are typically more comfortable.  We get to the know the patients (which may suggest the need for a second screening after a few visits).  We may have more than one person to teach and we can truly give the patient our full attention watching for indications that they are not understanding.  And we can solicit questions.

Agencies can lower hospitalizations, prevent medication and other errors, save a life or two, comply with the new CoP’s, reduce risk and save Medicare millions of dollars when they take health literacy seriously.  And it only costs the time it takes to play a YouTube video and let your nurses and therapists loose to find creative, patient specific solutions.  If nurses can devise a plan to use pool noodles in their care, I’m pretty sure they can use those same skills to meet the needs of their patients.

Please share how you work with patients with limited English proficiency or literacy skills by commenting below or emailing me.

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