hospital discharge to home—improving care
coordination and increasing patient engagement
Taking Quality to the Next Level
Kentucky Hospital Association Annual Quality Conference
March 6, 2013
Nancy Meadows, RN, BS
Senior Project Lead
Care Integration
Health Care Excel
Kentucky Medicare Quality Improvement Organization (QIO)
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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.
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Medications
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Appointment slips
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Informed consents
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Discharge instructions
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Health education materials
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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 rates
Language barriers
Nervousness, 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!
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Educators and health professionals share an
interest in all people having the necessary
health literacy skills to realize their goals.
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22 seconds
Average time a physician allows a patient to
talk before taking the lead.
www.npsf.askmethree.org
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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/2007/7-07-19CoachingforDoctor.htm
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Patient
Discharge
Instructions
Improving Transitions of Care,” Jann
Dorman, Senior Director CMI, KAISER
Permanante
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“The patient is noncompliant”
versus
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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 points
Need to know vs. nice to know
Emphasize what patient should do
Avoid duplicating paperwork
Be 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 match
Use visual aids
Provide a health context for numbers or values
Two-word explanations: “water pill/blood
pressure pill”
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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”.
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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 pause
Use plain language, breaking content into
short statements
Segment education to allow for mastery
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Angina
Chest pain
Atherosclerosis
Clogged blood vessels
Benign
Not cancer
Carcinoma
Cancer
Immunization
Shot, vaccine
Hypertension
High blood pressure
“Negative” test
Normal test
Take 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 it
Ophthalmic use only
Put it in your eyes
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1. What Is My
Main Problem?
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2. What Do I
Need to Do?
3. Why Is It
Important for Me
to Do This?
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The doctor says:
“You have hypertension.”
1.What Is My
Main Problem?
In plain language:
“Your blood pressure is too high.”
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The doctor says:
“You need to abstain from highsodium foods.”
2. What Do I
Need to Do?
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 Is My
Main Problem?
What Do I
Need to Do?
Provide You
With a Diagnosis
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Provide You With
a Treatment Plan
Why Is It
Important for Me
to Do This?
Let You Know What
Can Happen If You
Do Not Follow the
Treatment Plan 25
Including family caregivers in learning is essential,
but hard.
 Make it easy for the front line caregivers to:
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 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.
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 Source:
Wikipedia
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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 ...
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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?
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What is the patient’s motivation?
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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.
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Does not result in asking “Do you understand?”
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Instead, ask patients to explain in their own words
or demonstrate what they will do.
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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 care
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One direction at a time
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In terms the patient will understand
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Repetition until it’s clear
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Delivered in multiple ways—verbal, written, pictures
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Yes –No
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“I’ve given you a lot of
information. Do you
understand?”
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Teach-back collaborative
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“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.”
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Teach-back directive
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“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 flareup (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
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Communication and developmental disorder
▪ communication techniques may not be effective or appropriate for
audiences with communication or developmental disorders
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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
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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.
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“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”
06/20/2012
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Read the following as written as if you are teaching a
patient using yes or no responses.
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“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.
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“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.
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“ 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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List four things for me that you are going to do
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Read the following as written as if you are teaching a patient.
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“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.
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“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 understand?
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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
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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?
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For Information Please Contact:
Nancy Meadows, RN, BS
812-234-1499, extension 211
nmeadows@inqio.sdps.org
Visit our Website at www.hce.org
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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