A Health Literacy Tool to Ensure Patient Understanding Teach-Back A Health Literacy Tool to Ensure Patient Understanding

Do you know? Which of the following is the strongest predictor of an individual’s health status? A) Age B) Income C) Literacy skills D) Education level E) Racial or ethnic group American Medical Association www.ama.org

Objectives Define Health Literacy as The Missing Link in Health Care Communication Describe Teach-Back as an improvement methodology Getting clinical teams on board Evaluate and measure results

Health Literacy the Missing Link The capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. U.S. Department of Health and Human Services Healthy People 2010 Complex health information is outside of the personal domain of the majority of individuals

Scope of the Problem 40 Million Americans cannot read complex text 22% of adult Americans are functionally illiterate 27.5% are marginally literate Patients remember and understand less than half of what clinicians explain to them Illiteracy: total inability to read and write Functional Illiteracy: ability to only read/write/understand below 5th grade level Marginal Literacy: ability to only read/write/understand between the 5th and 8th grade level Literacy: ability to read/write/understand at the 8th grade level and above Ley Improving communication satisfaction and compliance 1988 Rost, Predictors of recall 1987

Why is it important? Limited health literacy translates into less health knowledge, worse health status and higher health care costs. more medication errors excess hospitalizations longer hospital stays more E.D. visits generally higher level of illness Literacy and the Law The Joint Commission and the National Committee for Quality Assurance have both adopted guidelines specifying the need for patient education information and consent documents to be written in a way that patients understand. Our legal system recognizes the patient-physician relationship as a fiduciary relationship – therefore, physicians have a duty to provide informed consent, which includes a process of educating patients so they understand their diagnosis and treatment.

The Right to Understand Patients have the right to understand health care information that is necessary for them to safely care for themselves, and to choose among available alternatives. Health care providers have a duty to provide information in simple, clear and plain language and to check that patients have understood the information before ending the conversation. The 2005 White House Conference on Aging; Mini-Conference on Health Literacy and Health Disparities.

Basic information about a colonoscopy, as perceived by a patient with limited literacy skills Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.

How Patients Feel Patients may have negative feelings and emotions related to their limited reading ability or limited understanding. ~ Institute of Medicine, 2004 The health care environment can make it hard for patients to tell us they don’t read well or do not understand. They hide this with a variety of coping techniques. ~ Parikh N Pt Educ and Counseling 1996

Universal Communication Principles Everyone benefits from clear information. Many patients are at risk of misunderstanding, but it is hard to identify them. Testing general reading levels does not ensure patient understanding in the clinical setting. Teach-Back supported by research Top patient safety practice: Asking that patients recall and restate what they have been told AHRQ, 2001 Report, Making Health Care Safer

Teach-Back is… Educating the patient and validating understanding in a non-threatening way Asking patients to repeat in their own words what they need to know or do, in a non- shaming way NOT a test of the patient, but of how well you explained a concept A chance to check for understanding and, if necessary, re-teach the information

Teach-Back… DO DON’T Use Plain Language Slow down “Chunk and Check” Focus on 2-3 main points & check for understanding Then go to the next concept Ask the patient to respond and confirm understanding before adding any new information Re-phrase if a patient is not able to repeat the information accurately Ask yes/no questions “Do you have any questions?” “Do you understand?” Make assumptions Education does not equate to health literacy Forget that severity of illness, trauma, medications impact ability to understand new information

Teach-Back Tips Use Ask-Me-3 Encourages person to ask, and provider to answer, three basic questions during every encounter What is my main problem? What do I need to do (about the problem)? Why is it important for me to do this? Partnership for Clear Health Communication

Asking for a Teach-Back – Examples Asking patients to demonstrate understanding “I want to be sure I explained everything clearly. Can you tell me in your own words the warning signs you need to watch?” “What next step would you take?” “The discharge instructions are very important; we’ve gone over a lot of information together; how would you explain this to someone else when you get home?” Ask patient to demonstrate understanding. The teach back allows you to check for understanding and, if necessary, re-teach the information. This technique creates the opportunity for dialogue in which the physician provides information, then encourages the patient to respond and confirm understanding before adding any new information. We must ask the patient to explain or demonstrate understanding in a way that is not demeaning. Example: “What will you tell your spouse about your condition?” or in a way that takes pressure off the patient. Example: “I want to make sure I explained everything clearly, please tell me in your own words what you heard me say so I can be sure I did” It is important not to appear rushed, annoyed, or bored during these efforts – your affect must agree with your words.

High Risk Readmission Patients who can not perform Teach-Back on vital elements of the discharge plan are at high risk for readmission Use the resources you have to get the results you need If they still do not understand, share that information and use additional resources to support the after-hospital care plan Pictures, storyboards, video, caregivers; external support, home health care, community based resources, outpatient education and support classes; phone call follow-up using Teach-Back The fundamental problem across all domains of health care is a failure to accept the need for patient-centered communication and shared decision-making Steven R. Hahn, MD, Professor of Clinical Medicine Instructor in Psychiatry, Albert Einstein College of Medicine

Using Teach-Back to Improve Patient Activation Stage 1 – Believes Active Role Important: Taking an active role in my own health care is the most important factor in determining my health and ability to function. Stage 2 – Confidence and Knowledge to Take Action: I am confident that I can follow through on medical treatments I need to do at home. Stage 3 – Taking Action: I am able to handle symptoms of my health condition on my own at home. I have made the changes in my lifestyle like diet and exercise that are recommended for my health condition. Stage 4 – Staying the Course Under Stress: I am confident I can figure out solutions when new situations or problems arise with my health condition. I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.

Teach-Back: Closing the Loop Teach back can help us close the loop between patient education and patient understanding. Teach back helps identify people who do not understand and creates an additional teachable moment or opportunity where we can ret each or reinforce the information. Briefly go through cycle. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003

Patient Rights It is neither just, nor fair, to expect a patient to make appropriate health decisions and safely manage his/her care without first understanding the information needed to do so. Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. AMA, 2007

Why Clinical Teams Enjoy Teach-Back “In the absence of Teach-Back, the only indicator of misunderstanding may be a medication mistake or patient error, which could be harmful.” Dr. Fred Marsh, 2004 IHS Ankeny Clinic Putting the Teach-Back initiative into place has been almost as simple as working a call light button in the patient room. “I make it part of my routine.” Colleen Glozzer, RN University Pittsburgh A simple communication tool – the “Teach-Back method,” aka “Closing the Loop” - if used early, often, and at strategic moments, can help promote more effective two-way discourse between clinicians and patients without lengthening the visit. Dean Schillinger, MD, UCSF Associate Professor of Clinical Medicine Teach-Back promotes a common understanding or “shared meaning,” thereby promoting a genuine alliance

Readmissions Collaborative Interventions and Process Measures You can’t improve what you do not measure Higher is better = Teach-Back Success Enter data on tracking log and submit monthly PDSA – Rapid Cycle improvement - Achieve and Spread *Option 1 Measure: Percent of clinicians observed teaching patient or other identified learner where Teach-Back is used to assess understanding N = number of observed clinicians using Teach-Back D = number of observations of clinicians teaching Observe 2-5 per week x 4 weeks = 10-20 teaching sessions per month

Readmissions Collaborative Interventions and Process Measures You can’t improve what you do not measure Higher is better = Teach-Back Success Enter data on tracking log and submit monthly PDSA – Rapid Cycle improvement- Achieve and Spread Option 2 Measure: Percent of teaching sessions where key learner and Teach-Back are documented on education record N = number of education records complete w/learner and teachback documented D = number of patients in the sample target group Chart review 2-5 per week x 4 weeks = 10-20 charts per month

Readmissions Collaborative Interventions and Process Measures You can’t improve what you do not measure Higher is better = Teach-Back Success Enter data on tracking log and submit monthly PDSA – Rapid Cycle improvement- Achieve and Spread Measure: Percent of patients who can teach back 75% or more of what they are taught when content is broken down into easy to learn segments N = number of patients in sample who teach back 3 out of 4 elements D = number of patients in the sample target group At last teaching opportunity, document 3 of 4 key elements patient can teach back. *Patient Activation measures are also available once you accomplish these steps This material was prepared by Alliant | GMCF, the Medicare Quality Improvement Organization for Georgia, 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. Publication No. 10SOW-GA-ICPC-12-33

Mari Lou Keberly, RN | Technical Advisor 678.527.3677 marilou.keberly@gmcf.org This material was prepared by Alliant | GMCF, the Medicare Quality Improvement Organization for Georgia, 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. Publication No. 10SOW-GA-ICPC-12-33