hospital discharge to home—improving care coordination and increasing patient engagement

Nancy Meadows, RN, BS Senior Project Lead

Care IntegrationHealth Care Excel

Kentucky Medicare Quality Improvement Organization (QIO)

Taking Quality to the Next LevelKentucky Hospital Association Annual Quality

ConferenceMarch 6, 2013

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 outcomesWilliams 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.

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Medications Appointment slips Informed consents Discharge instructions Health education materials Insurance applications

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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.

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Age –cognitive function decreases with age starting in mid 50’s

Lower literacy ratesLanguage barriersNervousness, emotional response to

information, lack of focus, medications, in a hurry to be discharged

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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

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We all are! Educators and health professionals share an

interest in all people having the necessary health literacy skills to realize their goals.

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Average time a physician allows a patient to talk before taking the lead.

www.npsf.askmethree.org

22 seconds

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"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

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Improving Transitions of Care,” Jann Dorman, Senior Director CMI, KAISER Permanante

Patient Discharge Instructions

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“The patient is noncompliant”

versus

Asking: “What is our responsibility as the sender of the information?”

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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.

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Focus on key pointsNeed to know vs. nice to knowEmphasize what patient should doAvoid duplicating paperworkBe careful with color

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Customize the patient education materials and processes for patients and family caregivers

Redesign written materials using Health Literacy principles

Redesign teaching methods

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Increase font size Remove ranges On all written material, assure words

and/or terminology matchUse visual aidsProvide a health context for numbers or

valuesTwo-word explanations: “water

pill/blood pressure pill”04/22/23 15

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”

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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

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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)

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Slow down when speaking to the patient and family and break messages into short statements

Take a pauseUse plain language, breaking content

into short statementsSegment education to allow for

mastery

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Angina Chest painAtherosclerosis Clogged blood vesselsBenign Not cancerCarcinoma CancerImmunization Shot, vaccineHypertension High blood pressure“Negative” test Normal testTake one tablet twice daily for seven days

Take one pill at 8:00 a.m. and another pill at 8:00 p.m. for seven days

PRN When you need itOphthalmic use only Put it in your eyes

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2. What Do I Need to Do?

1. What Is My Main Problem?

3. Why Is It Important for Me

to Do This?

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1.What Is My Main Problem?

In plain language: “Your blood pressure is too high.”

The doctor says: “You have hypertension.”

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2. What Do I Need to Do?

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.”

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3. Why Is It Important for Me

to Do This?

In plain language:“If you eat healthy food and exercise, you can stay healthy and feel better.”

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What Do I Need to Do?

What Is My Main Problem?

Why Is It Important for Me

to Do This?

Provide You With a Diagnosis Provide You With

a Treatment Plan

Let You Know What Can Happen If You Do Not Follow the

Treatment Plan04/22/23

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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)

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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?”

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Teach-Back / “Show-Me Method”

Confirming Your Message is Understood

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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

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

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.

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What are the patient’s goals? What is the patient’s motivation? What is the patient’s cognitive level?

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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.

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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

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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.

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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

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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 care04/22/23 37

One direction at a time

In terms the patient will understand

Repetition until it’s clear

Delivered in multiple ways—verbal, written, pictures

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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

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Checkpoints to evaluate how well transactions are going.

“How well are we doing giving the information?”

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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

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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?

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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?

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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

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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

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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

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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.

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Practice Lessons

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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

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Try it out on a colleague or the last patient before lunch.

Start with patients you think will be receptive.

Find the “script” that works for you.How do you envision implementing

this on Monday?

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Read the following exactly as written as if you are teaching a patient.

“I am going to talk to you about the signs of heart failure. The signs of heart failure are:

Dyspnea on exertion Weight gain from fluid retention Edema in your lower extremities and abdomen Fatigue Dry, hacky cough Difficulty breathing when supine”

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Read the following as written as if you are teaching a patient using yes or no responses.

“I am going to talk to you about the signs of heart failure. The signs of heart failure are:

Shortness of Breath Weight gain from fluid build-up Swelling in feet, ankles, legs or stomach Dry, hacky cough Feeling more tired, no energy

“Do you understand these?” “Do you have questions?”

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Read the following as if you are really busy and hurried. Have your voice show being rushed or irritated.

“I’m going to talk to you about what you need to do every day at home to control your heart failure.Every day:

Weigh yourself in the morning before breakfast and write it down

Take your medication the way you should Check for swelling in your feet, ankles, legs and stomach Eat low-salt food Balance activity and rest periods”

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Read the following as if you are quizzing the patient. You are making the patient feel like they are on the spot by asking them to repeat the information you just told them. It sounds like a test for the patient.

“ I’m going to talk to you about what you need to do every day at home to control your heart failure.Every day:

Weigh yourself in the morning before breakfast and write it down Take your medication the way you should Check for swelling in your feet, ankles, legs and stomach Eat low-salt food Balance activity and rest periods.

List four things for me that you are going to do everyday?”

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Read the following as written as if you are teaching a patient.

“I’m going to talk to you about what you need to do every day at home to control your heart failure.

Every day: Weigh yourself in the morning before breakfast and write it down Take your medication the way you should Check for swelling in your feet, ankles, legs and stomach Eat low-salt food Balance activity and rest periods

We just discussed a lot of things for you to do every day. You might be doing some of these already. Have you already been doing any of these things? What do you think will be the hardest one for you to do at home?”

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Read the following as written as if you are teaching a patient.

“I am going to talk to you about the signs of heart failure. The signs of heart failure are:

Shortness of Breath Weight gain from fluid build up Swelling in feet, ankles, legs or stomach Dry hacky cough Feeling more tired. No energy“I know we just talked about a lot of things. Your wife

wasn’t able to be with us today. When she asks you what we talked about, what are you going to tell her?”

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Find a partner. Decide on roles (Dr. Jones and Mr.

Dobbs) Look at the case study and next steps. What happens at the end of the visit? What does Dr. Jones say? What does

Mr. Dobbs say? How does it end?

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Mr. Dobbs is a 66 year old retired plumber with Type 2 diabetes and hypertension. Hypertension was diagnosed five years ago (was 160/90). BP control was gradually achieved but has risen since then. Mr. Dobbs’ blood sugar is also variable and appears to be worsening. He does not consistently monitor blood sugar at home and his most recent HbA1C’s have been rising. He came in today for a routine BP recheck.

Next steps, as of the end of the visit, are for Mr. Dobbs to take his blood pressure medicine twice a day (not once), check his blood sugar daily, and consult with a nutritionist.

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What was the patient’s reaction?What was it like for you as the nurse

doing Teach- Back?Did it feel like extra work?How would you build Teach-Back into

the daily work?How could you use Teach-Back to

communicate to the team?

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Each participant will participate in a role-play providing education to a patient. The following will be assessed: Ability to do teach back in a shame-free

way, e.g., tone is positive Utilizes plain language for explanations Does not ask patient, “Do you

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Uses statements such as: “I want to make sure I explained everything

clearly to you. Can you please explain it back to me in your own words?”

OR “I want to make sure I did a good job explaining

this to you because it can be very confusing. Can you tell me what changes we decided to make and how you will take your medicine now?”

If needed, participant will clarify and reinforce the explanation to improve patient understanding

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Can you walk me through what we’ve just discussed?

Let’s summarize what we’ve talked about today.

Is there anything that you can think of that might keep you from doing what we’ve discussed?

Describe what you’re going to do tomorrow.

Other?04/22/23 63

For Information Please Contact: Nancy Meadows, RN, BS

812-234-1499, extension 211nmeadows@inqio.sdps.org

Visit our Website at www.hce.org

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This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Kentucky, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-KY-INTCARE-13-006 03/06/2013

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