Teachback Powerpoint Presentation - HealthInsighthealthinsight.org/Internal/events/Readmissions_6-22-11/R18-Teach... · Member of Iowa Health System ... Schillinger et al. JAMA, 2002

June 22, 2011

Nevada Partnership for Value-Driven Healthcare

HealthInsight

Peg M. Bradke, RN, MA

St. Lukes Hospital, Cedar Rapids, Iowa

Teachback

St. Lukes Hospital

Member of Iowa Health System

Private hospital

Part of the Iowa Health System

Licensed for 500 Beds with more than 17,000

admissions

Top 100 Heart Hospital for three years

Magnet designation 2009

The Joint Commission Disease-Specific

Certification for Advanced Heart Failure since

2008

Transition to Home Team

Heart Failure team since 2001

St. Lukes joined the Institute for Health Care

Improvement (IHI) Innovation Project for Transitions

to Home in February 2006

Work concentrated on the Heart Failure patient to

provide the ideal transition to home

Goal: To Improve the reliability of the care patients

receive and resultant outcomes

Worked in tandem with compliance to CMS Core

Measures

Current State: Spread transition process to Pulmonary

population

Who Owns the Transition?

Are we placing the burden on the patient?

What is causing the readmissions? Do we know?

Are we being proactive?

Need for a Paradigm Shift

Past Focus Focus Going Forward

Traditional focus on

discharging patients

D/C to home

Facilitating transitions in care with a

shift to handoffs (senders and receivers

design the process)

Admission to Home (30-day LOS)

Hospital problem Continuum issue

Focus is on what clinicians are

teaching

Focus on what the patient is learning

Patient is the focus of the care

team

Patient and defined family are essential

members of the care team

Immediate focus on clinical

needs

Focus on the whole person and their

social situation over time

Focus on patient care needs in

various settings

Focus on the patients experience over

time

St. Lukes Heart Failure Continuum

Standardized care through order sets

Patients identified via BNP daily reports

Written discharge instructions sent home with patient and available immediately on-line in clinic or community facilities with portals

Teach back - Utilizing Universal Health Literacy Concepts performed in hospital, at Home Care visit, at seven-day follow-up call

Touch points

Home Care - care coordination visit 24 to 48 hours post discharge

Follow-up physician clinic visit appointment in three to five days

APN - follow-up phone call on seventh day post discharge

Outpatient Heart Failure class seeing increased participation

Collaboration with cardiology office Heart Failure Clinic

Degree of Will

This is important to our organization for two reasons: It is part of our Mission: To give the care we would like our

loved ones to receive

It is part of our strategic plan for preventing avoidable

readmission to be proactive for Health Care Reform changes.

Institute for Healthcare Improvement

How to Guide: Creating an Ideal Transition to Home

SNF

Office Practice

[email protected]

http://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCareGeneral/Tools/TCABHowToGuideTransitionHomeforHF.htm

mailto:[email protected]://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCareGeneral/Tools/TCABHowToGuideTransitionHomeforHF.htmhttp://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCareGeneral/Tools/TCABHowToGuideTransitionHomeforHF.htm

How-to Guide: Creating an Ideal Transition Home

Creating an Ideal Transition Home

I. Perform Enhanced Admission Assessment for Post-Hospital Needs

A. Include family caregivers and community providers as full partners in completing

standardized assessments, planning discharge, and predicting home-going needs.

B. Reconcile medications upon admission.

C. Initiate a standard plan of care based on the results of the assessment.

II. Provide Effective Teaching and Enhanced Learning

A. Identify all learners on admission.

B. Customize the patient education process for patients, family caregivers, and

providers in community settings.

C. Use Teach Back daily in the hospital and during follow-up phone calls to assess the

patients and family caregivers understanding of discharge instructions and ability to

perform self-care.

III. Conduct Real-Time Patient and Family-Centered Handoff Communication

A.Reconcile medications at discharge.

B.Provide customized, real-time critical information to the next care provider(s).

IV. Ensure Post-Hospital Care Follow-Up

A. High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home

care visit, care coordination visit, or physician office visit) to occur within 48 hours

after discharge.

B. Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48

hours and schedule a physician office visit within five days.

Provide Effective Teaching and

Facilitate Enhanced Learning

Changes:

A. Customize the patient education materials and

processes for patients and family caregivers

B. Identify all learners on admission

C. Use teach back regularly throughout the hospital stay to

assess the patients and family caregivers understanding

of discharge instructions and ability to perform self-care

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

patients level of health literacy or current health status

Failure to ask clarifying question about instructions and plan of

care limited time for discussion

Overestimating patients understanding of information

Communicating too much information at one time

Patient Factors

Age cognitive function decreases with age starting in

mid 50s

Lower literacy rates

Language barriers

Nervousness, emotional response to information, lack of

focus, medications, in a hurry to be discharged

Language barriers



A.Customize the patient education materials and processes for patients and family caregiversRedesign written materials using Health Literacy principles

Redesign teaching methods

IOM, 2004:

Health Literacy

is fundamental to quality care

Relates to 3 of the 6 aims in IOM Quality Chasm Report: Safety Patient-centered

care Equitable treatment

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.

16

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.

People may hide their

limited reading ability

*Parikh N Pt Education and Counseling 1996

Percent Who Never Told*

19%

52%

62%68%

85%91%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Supervisor Coworkers Health Care

Providers

Spouses Friends Children Anyone

17

Inadequate Health Literacy

Half of the US 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 patients 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.

18

19

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

Increase font size

Remove ranges

On all written material, assure words/ terminology match

Use visual aids

Provide a health context for numbers or values

Two-word explanations: water pill/blood pressure pill

Keys to Success with Health Literacy

21

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

22

Redesign Patient Teaching Materials

During acute care hospitalizations for HF, only essential

education is recommended

Reinforce within one to two weeks after discharge

Continue for three to six months

Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure

Vol. 12, No. 1, pg. 61 February 2006

http://www.heartfailureguideline.org/document/hfsa_2006_comprehensive_heart_failure_guidelines.pdf

23

Intervention: Patient Education Material

Key small tests of change

Cross-Continuum Team reviewed content of educational

materials utilizing health literacy concepts with goal to have

similar material that built on each other

Outpatient Heart Failure class utilized as focus group for

content

Family member on team, along with her siblings, reviewed

content for understanding Health Literacy

24

Evaluation of New Patient Education

Material

Results from 15 follow-up phone calls:

Information very helpful.

Able to state where information was and reported that they

were referring to it.

Understood content.

St Lukes Hospital, Cedar Rapids, Iowa

Heart Failure Magnet

Heart Failure Zones

EVERY DAY

Every day:

Weigh yourself in the morning before breakfast and write it down.

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

Which Heart Failure Zone are you today? Green, Yellow or Red

GREEN ZONE

All Clear This zone is your goal Your symptoms are under control You have:

No shortness of breath No weight gain more than 2 pounds

(it may change 1 or 2 pounds some days) No swelling of your feet, ankles, legs or stomach No chest pain

YELLOW ZONE

Caution This zone is a warning Call your doctors office if:

You have a weight gain of 3 pounds in 1 day or a weight gain of 5 pounds or more in 1 week

More shortness of breath More swelling of your feet, ankles, legs, or stomach Feeling more tired. No energy Dry hacky cough

Dizziness Feeling uneasy, you know something is not right It is harder for you to breathe when lying down. You are needing to

sleep sitting up in a chair

RED ZONE

EMERGENCY Go to the emergency room or call 911 if you have any of the following:

Struggling to breathe. Unrelieved shortness of breath while sitting still

Have chest pain Have confusion or cant think clearly

2/6/09

Heart Failure Zones

Example of Calendar

32



B. 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

Who Are Key Learners?

Caregiver and/or patient may not be the key learner.

Who helps the patient with:

Understanding whats 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

34

Sample of White Board

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 & how/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



C.Use teach back regularly throughout the hospital stay to assess the patients and family caregivers understanding of discharge

instructions and ability to perform self-care

Include all the learners

Assess patients 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

Arch Intern Med, 2003;163:83-90 Copyright 2003, American Medical Association. All Rights reserved

How Often Do We Close the Loop?

Checkpoints to evaluate how well transactions are going.

How well are we doing giving the information?

Paradigm Shift

The patient is noncompliant

vs.

Asking: What is our responsibility as the sender of the

information?

42

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?

43


Utilizing Teach Back

Explain 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

44

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

45

Enhance Teaching and Facilitate Learning

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.

46


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

Common perception is:

It will take more time

It should not substantially take more time

48

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?


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?

50

Teach-back with Discharge Instructions

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?

Generic Teachback

Pick an educational topic to teach your patient/family. Narrow it down to four or more teaching points: the must haves or vital few for the patient/family to know when discharged. Teachback techniques offer several scripts to introduce the teachback session. Suggestions for opening script to the teachback questions. You want to ask in a non-shaming way for the individual to explain in his/her own words what was understood.

I just gave you a lot of information. Maybe you could explain to me

I sometimes talk fast and maybe have gone over the information too quickly. Lets talk about what you would do if

Your family was not here today when we talked about When they come in, how would you explain to them

I want to be sure I did a good job of explaining this to you today because it can be very confusing. Could you please tell me in your own words why you should call your doctor?

I want to make sure I explained everything to you clearly. Could you explain back to me in your own words

We just discussed a lot of things for you to do every day. You may be doing some of these already. Which one are you doing and which ones will be new to you?

Generic Heart Failure COPD Stroke Chronic Kidney Disease Mental Health

Elicit from patient what and how they would explain diagnosis and health problems for which they need care General understanding of disease process and self care. Identify reason for hospitalization and current medical diagnosis.

How would you explain heart failure to your family?

Tell me how you would describe your COPD.

From the information we reviewed, tell me what you would tell your family about your stroke.

Assure they can say they had a stroke

Not enough blood got to my brain

What do you need to do every day when you get home?

Monitor B/P

Weigh daily in the morning before breakfast; compare that to yesterdays weight

Eat a balanced diet; monitor and limit your intake of protein, salt and sugar

Reduce or stop drinking alcohol

Eat low-salt food

Balance activity with rest periods

Tell me how you would describe your condition to someone.

Who would you call if What problems would you call your doctor about?

Weight gain of 3 lb. in one day

Weight gain of 5 lb. in one week

More shortness of breath

More swelling in your

What are the warning signs for you that would indicate that you should call your doctor?

Wheezing and coughing more than normal

Increased and more shortness of breath

Why is early recognition and treatment of stroke important?

To prevent damage to my brain that could lead to some physical limitations

When would you or your

What are you going to watch for when you get home?

B/P

Swelling of legs, hands, face or stomach

Maintaining stable weight - no weight gain

What symptoms should you report to your doctor or therapist?

Unable to take medications

Not sleeping or sleeping too much

No appetite

Trouble paying

52

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 patients, familys or caregivers ability and

confidence

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 patients own words, and no do

you understand questions

Small Tests of Change Using Teach Back

Test 1: One nurse on one day tests whether Teach Back with one

patient helps the patient learn the reasons to call the physician for

help after discharge (e.g., weight gain, difficulty breathing, or

exhaustion). Documents % of patients who taught back 75%.

Test 2: Nurse tests whether a video is more effective than verbal

teaching. Documents % who taught back 75% after the video.

Test 3: Nurse tests whether using Teach Back on every day of the

patients stay increases retention.

Process Measure


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

65%

70%

75%

80%

85%

90%

95%

100%

Aug

06 Dec

Apr

Aug

Dec

Apr

Aug

Dec

Apr

Aug

Dec

Apr

Aug

APN VNA In Hospital

Successful Teach Back RateAug 06 Sep 10 (4 questions)

Updated 12/20/10

VNA teachback

initiated

Follow-up phone

calls initiatedNurse competency evaluations in

health literacy started

What Are We Learning About Enhanced

Teaching and Facilitation of Learning?

Team members generally have readily embraced teach back to enhance patient teaching.

Team members on medical and surgical units can immediately test this approach to

enhance patient education.

Teach back must be practiced and perfected over time.

There is value in multiple teaching sessions with patients and family caregivers.

Many hospitals have spread teach back competencies to all hospital staff and include

these competencies in the yearly competency certification process.

There is a need for uniform and patient-friendly teaching materials in all clinical

settings for the common clinical conditions.

59

Teach Back Competency Validation


Nursing Competency Assessment

Annual competency validation day

Methodology

The learning station will use discussion, role playing and

patient teaching scenarios to help RNs communicate

effectively to patient/family.

60

Staff Competency Validation for Teach

Back

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 understand?

Staff Competency Validation for Teach

Back

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

Teach Back Practice #1

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

Teach Back Practice #1

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


Shortness of Breath

Weight gain from fluid build-up

Swelling in feet, ankles, legs or stomach

Dry, hacky cough

Feeling more tired, no energy

Its harder for you to breath when lying down

Teach back Practice #5-B



Shortness of Breath

Weight gain from fluid build-up


Dry, hacky cough

Feeling more tired, no energy

Do you understand these? Do you have questions?

Teach back Practice #5-G


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


Dry hacky cough

Feeling more tired. No energy

I know we just talked about a lot of things. Your wife wasnt able to be with us today. When she asks you what we talked about, what are you going to tell her?

Evaluation What was the patients 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?

Teach back #2-B

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

Im 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

Teach back #2-GRead the following as if you have all the time in the world to teach this patient. Your

voice sounds positive, helpful and pleasant.


Every day:

Weigh yourself in the morning before breakfast and write it down

Take your medication according to this record

Check for swelling in your feet, ankles, legs and stomach

Eat low-salt food

Balance activity and rest periods

Teach back Practice #3-BRead 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.


Every day:


Take your medication the way you should


Eat low-salt food

Balance activity and rest periods.

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




Every day:




Eat low-salt food


I teach people about this every day, and sometimes I go over it quickly or may not make myself clear. I want to make sure you know what you need to do. So, can you tell me some things you will do each day?




Every day:




Eat low-salt food


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?

Health Literacy

If they dont do what we want, we havent given them the right

information.

Vice Admiral Richard Carmona,

Former Surgeon General

Thank You

Peg Bradke RN MA

Director of Heart Care Services

St. Lukes Hospital

[email protected]