Using Teach-Back to Strengthen Your Team

1. hospital discharge to home—improving care coordination and increasing patient engagement Taking Quality to the Next LevelKentucky Hospital Association Annual Quality Conference March 6, 2013 Using Teach-Back to Strengthen Your Team Nancy Meadows, RN, BS Senior Project Lead Care Integration Health Care Excel Kentucky Medicare Quality Improvement Organization (QIO)

2. Inadequate Health Literacy • Half of the United State’s population may be at risk • Lower receipt of preventive services • Poorer knowledge of chronic conditions • Higher utilization of services (including hospitalizations) • Worse health outcomes Williams MV, Baker DW, Parker RM, et al. Relationship of functional health literacy to patient’s knowledge of their chronic disease. Arch Intern Med. 1998; 158:166-172. Scott TL, Gazmararian JA, Williams MV, et al. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care. 2002; 40(5):395-404.

3. Low health literacy equals problems with… • Medications • Appointment slips • Informed consents • Discharge instructions • Health education materials • Insurance applications

4. Inadequate Health Literacy • Literacy is a predictor of health status • Literacy is a stronger predictor than age, income, employment status, educational level or racial or ethnic group Baker DW, et al. Am J of Public Health, 2002. Schillinger et al. JAMA, 2002.

5. Patient Factors • Age –cognitive function decreases with age starting in mid 50’s • Lower literacy rates • Language barriers • Nervousness, emotional response to information, lack of focus, medications, in a hurry to be discharged

6. Provide Effective Teaching and Facilitate Enhanced Learning • Typical Failures: • Assuming the patient is the key learner • Providing written discharge instructions that are confusing, contradictory to other instructions, or not tailored to a patient’s level of health literacy or current health status • Failure to ask clarifying question about instructions and plan of care –limited time for discussion • Overestimating patient’s understanding of information • Communicating too much information at one time

7. Who is responsible for improving health literacy? • We all are! • Educators and health professionals share an interest in all people having the necessary health literacy skills to realize their goals.

8. 22 seconds Average time a physician allows a patient to talk before taking the lead. www.npsf.askmethree.org

9. "Studies show that doctors base up to 80% of their diagnoses on what patients tell them about their symptoms, history, and lifestyle.“ http://www.seniorjournal.com/NEWS/Health/2007/7-07-19-CoachingforDoctor.htm

10. Patient Discharge Instructions Improving Transitions of Care,” Jann Dorman, Senior Director CMI, KAISER Permanante 10 8/9/2014

11. Paradigm Shift • “The patient is noncompliant” versus • Asking: “What is our responsibility as the sender of the information?”

12. Universal Communication Principles • Everyone benefits from clear information. • Many patients are at risk of misunderstanding but it is difficult to identify them. • Assessing reading levels in the clinical setting does not ensure patient understanding.

13. Universal Communication Principles • Focus on key points • Need to know vs. nice to know • Emphasize what patient should do • Avoid duplicating paperwork • Be careful with color

14. Universal Communication Principles • Customize the patient education materials and processes for patients and family caregivers • Redesign written materials using Health Literacy principles • Redesign teaching methods

15. Keys to Success with Health Literacy • Increase font size • Remove ranges • On all written material, assure words and/or terminology match • Use visual aids • Provide a health context for numbers or values • Two-word explanations: “water pill/blood pressure pill”

16. Keys to Success with Health Literacy • Use universal health literacy communications principles to redesign written teaching materials • User-friendly written materials use: • Simple words (1-2 syllables) • Short sentences (4-6 words) • Short paragraphs (2-3 sentences) • No medical jargon • Headings and bullets • Highlighted or circled key information • Lots of white space • Two-word explanations: “water pill/blood pressure pill”

17. Provide Effective Teaching and Facilitate Enhanced Learning • Identify all learners on admission • Identify the appropriate family caregivers who will assist the patient with self-care after discharge • Be sure that the right learners are involved in all critical self-care education • List the names of the key learners on the whiteboard and care plan

18. Who Are Key Learners? • Caregiver and/or patient may not be the “key learner”. • Primary person who helps the patient with: • Understanding what’s being said • Self-care activities at home • Setting up or taking medications • Getting to appointments • Navigating care and treatments • Ask key learners how they prefer their education (e.g., written, verbal, video)

19. Enhanced Teaching and Learning • Slow down when speaking to the patient and family and break messages into short statements • Take a pause • Use plain language, breaking content into short statements • Segment education to allow for mastery

20. Using Plain Language:What we could say instead of…

21. 1. What Is My Main Problem? • 3. Why Is It Important for Me to Do This? 2. What Do I Need to Do? What questions do you ask?

22. 1.What Is My Main Problem? Getting information in “plain language” The doctor says: “You have hypertension.” In plain language: “Your blood pressure is too high.”

23. 2. What Do I Need to Do? Getting information in “plain language” The doctor says: “You need to abstain from high-sodium foods.” In plain language: “You need to eat less salt, and you need to exercise more.”

24. 3. Why Is It Important for Me to Do This? Getting Information in “Plain Language” In plain language: “If you eat healthy food and exercise, you can stay healthy and feel better.”

25. What Is My Main Problem? • Why Is It Important for Me to Do This? What Do I Need to Do? Provide You With a Diagnosis Provide You With a Treatment Plan Let You Know What Can Happen If You Do Not Follow the Treatment Plan What Will Your Doctor, Nurse or Pharmacist Have to Say? 25

26. Helping Staff Make It Happen • Including family caregivers in learning is essential, but hard. • Make it easy for the front line caregivers to: • Know who needs to participate in learning and how and/or when to reach them • Give learners access to getting their questions answered in the hospital and after discharge • Know and pass along critical information about learners to next care settings (e.g., patient and family caregivers cannot teach back or have low confidence in doing self care)

27. Enhanced Teaching and Learning • Ask in a non-shaming way for the individual to explain in his or her own words what was understood • Example: “I want to be sure that I did a good job of teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor?”

28. Teach-Back • Teach-Back / “Show-Me Method” • Confirming Your Message is Understood

29. Teach-Back is Part of Health Coaching • Health coaching is a method of guiding others to address their health and, if need be, make behavioral changes to improve health. Like traditional coaching, health coaches utilize goal setting, identification of obstacles, and use of personal support systems. The relationship between the coach and coachee is an accountability partnership focused on the overall health outcome goals as defined by healthcare practitioners and the patient/coach. • Source: Wikipedia

30. Health Coaching Defined Training is teaching people to do what they don’t know how ... Healthcoaching is becoming recognized as a new way to help individuals "manage" their illnesses ...

31. Teach-Back Technique • Use Teach-Back daily: • In the hospital • During home visits and follow-up visits/calls • To assess the patients’ and family caregivers’ understanding of discharge instructions and ability to do self-care. • The Teach-Back method not only can uncover misunderstanding, but also can reveal the nature of the misunderstanding, so communication can be corrected or tailored to the patient needs.

32. What are the patient’s goals? What is the patient’s motivation? What is the patient’s cognitive level? Teach-Back: setting goals 8/9/2014 32

33. Teach-Back Technique • Clinicians take responsibility for teaching – do not appear to be rushed, bored, or condescending. • Does not result in asking “Do you understand?” • Instead, ask patients to explain in their own words or demonstrate what they will do. • If patients cannot explain or demonstrate, then use an alternate approach.

34. Teach-Back Technique • Utilizing “Teach-Back” • Explains needed information to the patient or family caregiver. • You do not want your patient to view Teach-Back as a test, but rather of how well you explained the concept. You can place the responsibility on yourself. • Can be both a diagnostic and teaching tool

35. The Teach-Back Technique • Do not ask a patient, “Do you understand?” • Instead, ask patients to explain or demonstrate how they will undertake a recommended treatment or intervention. • If the patient does not explain correctly, assume that you have not provided adequate teaching. Re-teach the information using alternate approaches.

36. Teach-Back Technique • Redesign patient teaching: • Stop and check for understanding using teach back after teaching each segment of the information • If there is a gap, review again • If your patient is not able to repeat the information accurately, try to re-phrase the information rather than just repeating it. Then, ask the patient to repeat again until you feel comfortable that the patient understood. • Try to use Teach-Back as many times as you can when you interact with the patient

37. Teach-Back Technique • Use Teach-Back regularly throughout the hospital stay to assess the patient’s and family caregiver’s understanding of discharge instructions and ability to perform self-care • Include all the learners and assess ability to: • Understand and do critical self-care activities • Take medications • Access care: next appointments, medications, etc. • Close the gap in understanding or develop a new plan of care

38. The Absolutes of Teach-Back • One direction at a time • In terms the patient will understand • Repetition until it’s clear • Delivered in multiple ways—verbal, written, pictures

39. Yes –No Teach-back collaborative Teach-back directive “I’ve given you a lot of information. Do you understand?” “I imagine you’re really worried about this clot. I’ve given you a lot of information. It would be helpful to me to hear your understanding about your clot and its treatment.” “It’s really important that you do this exactly the way I explained. What do you understand?”* - Kemp, et al, JABFM, Jan – Feb 2008 Types of clinical questions

40. How Often Do We Close the Loop? • Checkpoints to evaluate how well transactions are going. • “How well are we doing giving the information?”

41. HF Teach-Back Questions • What is the name of your water pill? • What weight gain should you report to your doctor? • What foods should you avoid? • Do you know what symptoms to report to your doctor? St Luke's Hospital, Cedar Rapids, Iowa

42. COPD Teach-Back Questions • What should you do first if you are having more trouble with your breathing? • What is the name of your fast-acting/rescue inhaler? • How often do you use it? • If your shortness of breath continues without getting better, what should you do? • What are the warning signs for you that would indicate that you should call your doctor? • What should you do to prevent from having a flare-up (getting worse) with your breathing and lungs?

43. Discharge Instructions Teach-Back Questions • Can you show me on these instructions: • How you find your doctors’ office appointment? • What other tests you have scheduled? and when? • Is there anything on these instructions that could be difficult for you to do? • Have we missed anything?

44. Process Measure Enhanced Teaching and Learning • Percent of nurses with Teach-Back competency • Percent of patients with: • Preferred learning method documented on admission • 75% recall and restate on Teach Back for: • Reasons to call the physician after returning home • Medications, uses, doses

45. Sample Teach-Back

46. Teach-Back Success • Percent of time patients can teach back 75% or more of content taught related to the transition to home utilizing the four questions related to self management of heart failure • Stop and check for understanding using teach back after teaching each segment of information • Assess patient’s, family’s or caregiver’s ability and confidence

47. When Teach-Back and Plain Language may not be enough Be aware of additional barriers to understanding • Communication and developmental disorder • communication techniques may not be effective or appropriate for audiences with communication or developmental disorders • Limited English proficiency • proficiency needs to be communicated plainly in their primary language • Lack of knowledge and experience • Without appropriate knowledge, patient often fail to understand the importance of lifestyle factors—and may read commonly used directions and not understand what the terms mean • Cultural competency and differences • affects how people understand and respond to health information

48. What Are We Learning About Enhanced Teaching and Facilitation of Learning? • Team members generally have readily embraced teach-back to enhance patient teaching. • Teach-Back must be practiced and perfected over time. • There is value in multiple teaching sessions with patients and family caregivers. • Teach-back is becoming part of annual core competencies. • There is a need for uniform and patient-friendly teaching materials in all clinical settings for the common clinical conditions.

49. Teach-Back • Practice Lessons

50. Implementing Teach-Back Go Observe: “Be a Patient” • What can you learn about the current state of patient teaching and learning? • For patients being taught self-care, e.g., reasons to call the physician after discharge • Look for teaching and teach-back: staff tone of voice, attitude, non-shaming language, body language, plain terminology, request for teach back in the patient’s own words, and no “do you understand” questions