One way I’m using Twitter is to link to recent research relating to patient and family education. For example, here are Tweets I have scheduled to appear in the coming week:

http://tinyurl.com/27cz654 Relationship between treatment adherence and clinical outcomes in patients on maintenance hemodialysis. #nursing

http://tinyurl.com/2fyxueo Addressing patients’ concerns about pain management and addiction risks. #patienteducation #nursing #healthcare

http://tinyurl.com/2fzkope No, you need a conversation to ensure understanding. #healthliteracy #evidencebasedmedicine #healthcare

http://tinyurl.com/27o5jwt Patients’ beliefs about the cause of their depression: only 3.6% stated biological reasons. #patienteducation

http://tinyurl.com/235oroy Comprehensive discussions about chronic medications are uncommon in routine practice. #evidencebasedmedicine

http://tinyurl.com/2embdxo Health literacy screening questions can be used to triage patients at risk for not reading. #healthliteracy #pted

http://tinyurl.com/29ckgvs Postoperative patient education: what type of approach and mode, and at what dose? #patienteducation #surgery

Are you using Twitter now? If so, follow me @notimetoteach. Let me know what your Twitter handle is, too, so I can follow you.

If you want to learn more about Twitter, you can download the booklet, Twitter for Beginners from http://socialmediadiyworkshop.com/2010/02/ebook-twitter-for-beginners/

Some business-oriented administrators who are not health care providers may perceive patient education as a non-revenue producing, unnecessary expense. I suspect they haven’t experienced serious illness yet. Here is my response to that question:

* * * * * *
OK, try to imagine hospital care WITHOUT patient education.

You’re admitted into the hospital and things just get done to you. No informed consent. No warning about what is about to be done to you and why. No information about your problem or what the treatment options are. You get taken to surgery. You wake up not knowing what happened and you hurt. Medicine is given to you without explanation — just take it. No advice about how to take care of yourself after leaving the hospital. No plans for follow-up, no information about who to call if you have a problem. You are just handed some prescriptions written in Latin and told to leave. You have no idea what you can do to avoid going through this again.

Could you possibly have this experience and feel you got the best care possible from medical experts? When you don’t get quality patient education, you know it. You are not involved, and you don’t feel safe or cared for. Patient education is not an extra. It is an essential, but often invisible, part of care.

So now you explain: How does patient education NOT fit into the hospital business model?

* * * * * *

Looking at the business model for a restaurant, I could see how one could focus on the purpose: get food into people. It might be easy to say providing restroom facilities is an unnecessary expense, since it is diametrically off the purpose. However, a different perspective might prove otherwise. Don’t get fooled into thinking patient education is an extra service of health care providers. It IS the service.

I propose a health care organization that focuses on providing the highest quality patient and family education would easily stand out in the crowd as providing the best care. Even if it didn’t offer the most experienced surgeons who regularly publish in peer reviewed journals.

Suddenly, I felt like I had a functional literacy problem. I understood the word “native.” I understood the word “files.” But I had no idea what a “native file” was. I didn’t even have a guess. I did not want to make a mistake, so I emailed the requestor and asked for a definition. I got a polite and helpful response.

For those of you who don’t know, when they said “no native files” they actually meant “send files in the PDF format.” (Or, I learned later from a friend, maybe a JPG would qualify.) A native file is a file that is still in the format of the program in which it was created, like a Word document or a Keynote slide show.

In this situation, I may have experienced what some of our patients sometimes feel like. The words sound familiar, but they have no idea what we are talking about. They have no idea what they are supposed to do. They don’t want to make a mistake — especially if it could physically hurt them. But it’s hard to admit you don’t understand, especially when it’s presented in a way that implies, “Of course you understand this. It’s simple.”

Another reason to ask patients to teach back what we teach them.

©2010 Fran London

You can read details of the Ask Me 3 program at http://www.npsf.org/askme3/for_patients.php

They suggest that if the patient still doesn’t understand, he or she might say, “This is new to me. Will you please explain that to me one more time?”

I agree, every patient should feel comfortable asking these questions. But isn’t it also our responsibility to provide the answers to these questions without prompting? And isn’t it our responsibility to evaluate understanding and have patients teach back to us the answers to these questions? How else would we know they understand? Then, at least, if they choose to not follow our advice, it is an informed choice and not a misunderstanding.

One randomized trial of 20 practices (Galliher, Post, et al, 2010) evaluated whether implementing the Ask Me 3 program improves patients’ question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. Their conclusion: “In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.”

This, to me, means some patient populations ask questions at a lower rate. You know them. They may have poor functional health literacy skills. They may be from a lower socioeconomic group. They may be less educated. They may speak English as a second language, or not at all. I suspect handing these people a brochure that encourages them to ask questions is not enough to overcome disparities in health and health care.

I believe there should be a discussion between the health care provider and patient before the answer to “what do I need to do” becomes clear. It should include what the options are, their costs, risks, and benefits, including what happens if the patient chooses to do nothing. Then the health care provider and patient negotiate a treatment plan. At that point, “what do I need to do” becomes “what I choose to do.” This is one way we can move from provider-centered care toward patient-centered care.

So encourage your patients to Ask Me 3, but also provide the answers to these questions without prompting. Don’t think Ask Me 3 replaces your need to evaluate understanding by using teach back and return demonstration. Health care communication goes in two directions. Hold up your end, too.

If you want to learn more:
Galliher, J. M., Post, D. M., Weiss, B. D., Dickinson, L. M., Manning, B. K., Staton, E. W., et al. (2010). Patients’ question-asking behavior during primary care visits: a report from the AAFP National Research Network. Ann Fam Med, 8(2), 151-159.

But maybe that isn’t entirely true anymore. Recent research examined the impact of the desirability of content on viewers’ ratings of subjective video quality. Kortum and Sullivan (2010) studied 100 participants and 180 movie clips encoded at nine levels from 550 kbps up to DVD quality. Participants viewed clips that were 2 minutes in length and then were asked about video quality of the clips and desirability of the movie content. They found a strong correlation between the desirability of movie content and subjective ratings of video quality.

Yes, this study considered the quality of video, not the quality of camera work and lighting. But it does show people are not as spoiled as we thought they were. Perhaps the public’s values have been modified by exposure to engaging homemade movies on YouTube and other video-sharing sites. Perhaps now, while surfing through videos online, they are looking for engaging content rather than slick production. Clearly more research needs to be done in this area. Because if, indeed, high quality content persuades viewers to rate the quality of the video higher, we could save money on production by focusing on our messages, ultimately lowering the cost of patient education. That’s good news.

From: Kortum, P., & Sullivan, M. (2010). The effect of content desirability on subjective video quality ratings. Hum Factors, 52(1), 105-118. http://www.ncbi.nlm.nih.gov/pubmed/20653229?dopt=Citation

Besides, the content of the education isn’t about discharge – “discharge” is just rolling out the door. The content is about how to care for yourself after you leave the hospital. Maybe, for accuracy, it should be called “self-care teaching.”

Anyway, we’re finally moving toward focusing on evaluation of understanding of self-care behaviors. The Society of Hospital Medicine has posted on their website some Quality Improvement Clinical Tools, including:
— Discharge Patient Education Tool (DPET)
— Discharge Knowledge Assessment Tool (DKAT)
These are clearly designed to evaluate patient’s understanding of the hospitalization and continuing care. These forms could really support a useful conversation.

But there is a part I would change on the DPET. A nod and an initial do not provide evidence of understanding. I would have the patient tell me, rather than initial these statements:
• I understand which medicines I took before I came to the hospital and will now stop.
• I understand the medicines I will continue taking and new medicines I will take.
• I understand why and when I need to take each medicine.
• I understand which side effects to watch for.

What do you think? Is this a transition your organization can make? Can we evolve toward self-care teaching and evaluation of understanding? Can we get rid of discharge teaching forever?

©2010 Fran London, MS, RN

The Society of Hospital Medicine: http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIClinicalTools/Quality_Improvement.htm

Yes, I actually heard a physician say patient and family education is not necessary, since it is not reimbursed by third party payers.

Devil’s advocate or honest opinion? Does it matter?

Interesting assumption, there.
Only the things that are reimbursed are valuable.
If it is not reimbursed, it is not necessary.

Well, that doesn’t make sense. Try running a hospital without any nurses. After all, nursing care falls under overhead. Nursing is not reimbursed separately.

Or maybe the physician meant patient education is valuable, but if we intentionally don’t provide it the third party payers will soon recognize they should be paying for it.

But is it ethical, or even possible, to not provide patient education?
Can you hand someone a prescription and not tell that person what it is for or how to take it?
Can you tell someone surgery is scheduled, and not tell that person what it is for or how to prepare?
Can you give someone an injection and not tell that person it is coming or why?
Can you send someone home with oxygen, or a cast, or a central line, and not tell that person what to do with it?

And then there’s the assumption that we’re not reimbursed for education.
Being a hospital nurse, all I know about reimbursement coding is that it exists. I never had to deal with it. But a quick search on the Internet leads me to believe there may be a little money for patient education.

It appears that the CPT codebook includes the usual codes for consultation, which could include teaching, and items like:
Codes for teaching self-management of a patient’s illness or disease, or delay disease comorbidity.
98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver or family) each 30 minutes, for one patient.
98961 same for a group of 2-4 patients
98962 same for a group of 5-8 patients

It appears that HCPCS codes include:
99411 or 99412 – Preventative Group Medicine Group Counseling
99078 – Physician Education in a Group Setting
G0375 – Smoke/Tobacco counseling 3 to 10 minutes
G0376 – Smoke/Tobacco counseling more than 10 minutes

And that’s just from a search of the Internet. It appears you have to pay for a comprehensive list of reimbursement codes.

So what do you know about this? What do you think about this? Is patient education paid for under the current system of reimbursement? If so, is it enough? If not, should we stop teaching? Do you agree with the physician I quoted? In what way? Are there other reasons to provide quality patient and family education? What about all the Joint Commission standards for a safe discharge, relating to preparing the patient for self-care? Are there other benefits besides money?

Great question. How can you get nurses to teach? It depends on what the problem is.

- Do they know how to teach? Have you measured competency? Do they know how to assess the learner, individualize teaching, and evaluate understanding?
If this is the problem, give them the skills.

- Do they lack self-efficacy related to teaching?
If so, explore the areas in which they lack confidence, and help them gain confidence through your usual staff development techniques. Perhaps they are new nurses unsure of their own skills.

- Do they recognize that neonatal nurses have advanced skills in taking care of the little ones, and the families have no training and are expected to pick up care at home where the nurses left off?
These parents, especially, need to understand how to safely care for their babies, know signs of a problem, and know how to respond when the identify a problem.

- Do they not think it is their job to teach?
Is it in their job description? If so, hold them accountable for teaching. Evaluate their performance based on evidence of teaching: documentation of evaluation of understanding. If they do not provide evidence that they evaluate the understanding of, in your case, families, through teach back and return demonstration, there is no evidence they taught.

Have you struggled with the same issues? Are there other reasons nurses don’t teach patients and families? Are they not teaching, or are they just not documenting their teaching? What have you done to address this problem?

• What was your motivation for writing No Time to Teach?
• What’s the most important thing a nurse can do to ensure they connect with the patient so that learning occurs?
• What advice do you have for new nurses and veterans that want to improve their teaching skills?

Read my responses at: Interview with Fran London, Author of No Time to Teach: Part 1

Meso refers to “middle of the scale.” These facts don’t change quickly enough to get our attention, but they could trip us up if we don’t notice them.

What does this have to do with patient education?

Many things we think of as facts are actually mesofacts. Did you ever hear about mesofacts in school? When you learned about the Periodic Table in chemistry, were you told it was a mesofact, and would change over time as we collected more information? Since 1970 it has grown by 12 elements.

Some other mesofacts include first-aid interventions, therapeutic diets, and medications. A lot of people base their self-care behaviors on things they believe are unchanging facts, but which are actually mesofacts.

My run-in with a mesofact

For example, years ago I was a certified CPR instructor. When I was actively teaching CPR, I totally knew it – the hand placements, the timing, one-man, two-man. After several years I stopped teaching, and just took my renewal CPR class as required. And every time they changed the class just a little bit. They added a barrier for the mouth. They changed the hand placement. They changed the timing. They added a machine that talks to you. I used to be a CPR expert. Now I find it really difficult to replace what I used to think was right with the new way of doing things. Oh, I understand how the research supports these changes. But in my mind, CPR was a fact, not a mesofact.

Implications for patient education

Our educational system tells us tests have right answers, not the right answers at this point in time. We are not primed to expect change. So as we age, we’re somewhat unprepared for the mesofacts that pop up.

When you’re teaching a patient or family member a new self-care skill, and you notice some resistance or hesitation, check to see if there’s a mesofact in the way. What does the learner believe? What does the learner expect? Why is hard for them to accept what you are saying?

This also applies to working with colleagues. Physicians may say the handouts they give to patients have worked for 25 years, and there’s no reason to change them. However, because they haven’t evaluated understanding lately, they are unaware that their patient population has changed. They haven’t heard about the research relating to functional health literacy, and impact of poor health literacy on health outcomes. These physicians just feel the frustration of noncompliance. But in reality, a mesofact is tripping them up.

Can you give any examples of mesofacts you’ve observed in your practice?

Source: www.mesofacts.org

©2010, Fran London, MS, RN