Here’s one of the responses I might offer:

Imagine you have been given some written material from a professional in a field you are totally unfamiliar with, yet your decisions based on this professional’s advice will seriously impact your life. For example, you might be facing financial ruin or imprisonment, and a lawyer hands you a document to sign.

Now, choose the professional behavior which you consider more condescending or offensive:

A) The document is written with words you have never seen before, with long sentences you cannot follow (“if this than that, or maybe this and that”). The type is small, the page is packed with unintelligible content. You have no idea what you’re agreeing to.

B) The document is written in clear language, in words you understand, and formatted to help you follow the ifs and thens. You understand it and agree this is what you want.

Are you offended by the clearly written document? Do you even notice it is clearly written, or do you just read it?
It is more likely you will be offended by the condescending attitude of a jargon-filled, unintelligible document, because its message is, “you are too stupid to understand this.”

Dumbing down implies oversimplifying, leaving out details, and adding a pat on the head.
By attending to health literacy, we are not dumbing down health information, but making it clear so learners can understand and apply it.

If you still feel the need to hand patients written materials filled with technical terms and jargon, consider this:
How do you see your job?
Is your focus to be brilliant in your specialized field?
Or is it to improve health outcomes?
Maybe that’s the problem.

You know many of our patients understand the components of a healthy lifestyle: good nutrition, activity, sleep, balance. However, many have difficulty applying this knowledge to their lives. Medicine doesn’t work if patients don’t take it. Surgery doesn’t change outcomes if the behaviors that brought on the problem continue. Health coaching can help them decide what changes they want to make, and then help them figure out how they might actually do it.

How do we create a health care system that supports healthy behaviors?

Behavior change is difficult, but it does happen every day, so it is very possible. Perhaps this is where we need to put more of our medical research dollars: learning how to effectively help folks make healthier choices.

What do you think?

“If you can’t explain it to a six year old, you don’t understand it yourself.”
and
“Everything should be made as simple as possible, but not one bit simpler.”

It’s all about clarity, no?

Put the link to this funny 32-second video on your computer, phone, or iPad. Then, when you want to start a conversation on teach back, show it.

Here are a few points to consider:
• I would say, “Are you using your inhaler?” and “Why don’t you show me how your inhaler works.”
• I would not say, “Are you sure you’re using it right?” That’s there for the joke.
• It appears that, upon evaluating understanding, this physician was less than compassionate. It would be best if we don’t elicit the response the patient in the video had. Discuss how you might respond after this return demonstration to enhance the therapeutic relationship, rather than damage it.

This video can also be used to initiate conversations about health literacy, medication adherence, and the assumptions we make.

Enjoy!

Let me know how this works for you.

View the video at: http://www.youtube.com/watch?feature=player_embedded&v=akunCCxRVBk

http://www.youtube.com/watch?feature=player_embedded&v=akunCCxRVBk

©2012 Fran London, MS, RN

I was recently in Hawaii, and, among other things, took a week-long course in hula. After the second class I passed a classmate in the hotel hallway. She stopped me and started to complain about the class.

“What is wrong with us?” she said. “She made us do that one step for 45 minutes! But she never told us what we were doing wrong! She just kept telling us what to do differently!”

The student was very upset. “We couldn’t all have been that bad. Were we all doing it wrong? What were we doing wrong?” She ended with, “I just wanted to learn a hula!”

I didn’t get to say much in that conversation, but her reaction actually stunned me. That was not my response to that experience at all. Over the years I had taken many classes like this, such as ballet and tai chi. And it was not unusual for the teacher to repeat an essential element so you can explore the subtleties and get the basics right. In my experience, spending 45 minutes to learn one step was normal. I was comfortable with it.

So what’s my point here?

The hula teacher did a fine job, but lost a student because goals did not match. The student wanted to learn a hula, not how to do hula. She just wanted to go home knowing a little dance routine. The teacher wanted to share a deep understanding of the art; the dance routine was secondary to her. No one was right or wrong here. It was a mismatch, a lack of communication. Mutual goals were not established before the class began.

We probably lose folks in patient education for the same reason. But instead of exploring what happened, we label it non-adherence and decide it was their fault. But maybe that new diabetic perceived the teaching as sending a “you are bad” message. People don’t like to feel bad, so they remove themselves from situations that give them that message. We can avoid this with a conversation that discusses goals and human responses to change. This may take a little time, but it can improve compliance and outcomes.

In the next, third class, we learned the hula steps to an entire song. By the last class we were all able to do the dance on our own. But that fellow student never returned to get her needs met. She dropped out of the class. Too bad.

©2012 Fran London, MS, RN

An analysis of the outcomes (Morse, et al., 2011) concluded compliance with the home management plan of care component was not associated with fewer post-discharge ED visits or asthma-related readmissions. Handing a family a piece of paper did not change health outcomes.

Are you surprised?

Are we measuring the right things in patient education? What if that third measure was the family successfully taught back the contents of the Asthma Action Plan? When presented with a scenario, they were able to apply the information on how to respond appropriately? What if we asked how confident they were in their ability to obtain the prescription meds, have them always available, and follow the home management plan of care successfully?

Patient education may not be as simple as handing folks a piece of paper. But it’s not rocket science, either.

Source: Morse, R. B., Hall, M., Fieldston, E. S., McGwire, G., et al. (2011). Hospital-level compliance with asthma care quality measures at children’s hospitals and subsequent asthma-related outcomes. JAMA, 306(13), 1454-1460.

©2012 Fran London, MS, RN

“For patients, being engaged means that providers have tried to cultivate their trust, making sure on repeated occasions that they understand their diagnosis and the importance of adhering to the prescribed care regimen, and of course, doing adequate follow-up.” — Clark, 2011

How does this relate to patient education? Active listening cultivates trust. Teach back evaluates understanding. Coaching addresses adherence.

As I’ve noted before (London, 2009), the current research relating to effective and efficient patient education boils down to two things: involve and individualize. Involve the learner in the process, and individualize teaching to that learner’s needs. The same actions support patient engagement.

A new buzzword, but the message is the same: have a conversation with your patient. A real, two-way conversation.

Sources:

Clark, C. (2011). Top 12 Healthcare Buzzwords for 2012. Retrieved from http://www.healthleadersmedia.com/content/QUA-274645/Top-12-Healthcare-Buzzwords-for-2012.html##

London, F. (2009). No Time To Teach: The Essence of Patient and Family Education for Health Care Providers. Atlanta: Pritchett & Hull.

©(2012) Fran London, MS, RN

Why? Your patient population is low on resources, or lacks health literacy skills, or don’t speak English, and you want to better accommodate their needs. Your patient satisfaction scores may be showing your patient education services need improvement. Your readmission rate or your emergency department visits may reflect your patients’ inability or unwillingness to apply the information you provided. Perhaps you’re thinking about the future, health care reform, and the demands of meaningful use. There are many reasons you may be motivated to improve the patient education you provide.

Where do you start?

The key is to build the infrastructure that supports quality patient and family education from every angle, then train and hold folks accountable.

Here are some essential pieces:

Job descriptions: Is the expectation of provision of patient education in your job descriptions?

Policies and procedures: Have you clearly defined the who, when, and what to teach? Have you defined the appropriate and unacceptable sources of teaching tools? (Not everything on the Internet is valid and reliable.)

Teaching skills: Have you measured the competency of your staff to provide patient education? Do they know what needs to be taught, and what is only nice to know? Do they have the skills of identifying teachable moments, assessing learning needs, individualizing teaching, and evaluating understanding? Do they know how to assess self-efficacy and how to respond? Have they demonstrated competency using teach back?

Documentation: Is your documentation system for patient education interdisciplinary, easy to use, and does it share meaningful information?

Teaching tools: Are teaching tools, like handouts and videos, standardized throughout the organization and easily accessible? Are they appropriate for your patient population? Are they appropriate for the services you provide? How are you using technology?

Interpreters: Does your staff have easy access to language interpreters, for teaching patients who are deaf or don’t speak English?

Physical environment: Is the environment conducive to conversation, quiet and lacking distractions?

Accountability: Do you hold staff accountable for the provision of quality patient education?

Coaching: Do you provide follow-up calls? Do you reassess at subsequent visits? Are you offering resources for continuing support and adherence?

Sustainability: How are you maintaining the gains? Do you recognize and reward the provision of quality patient and family education? Do you continually monitor implementation of the pieces you have put in place? Do you communicate the status of patient education to continuing care providers?

Measure outcomes: What do you want to change by improving patient education, and how will you measure it? Measure this before and after your interventions.

A lot to think about. A lot to tweak. But worth it. The provision of quality patient and family education does not cost a lot of money, but offers great returns in quality of care, health outcomes, and relationships. It’s the “helping people” part of health care; the reason many of us choose the profession.

© 2012, Fran London, MS, RN

So why not use that contact as an opportunity to encourage your patients to come in with a list of questions? That can serve many purposes, all of which can increase patient satisfaction:
— the patient comes prepared
— you find out quickly what the patient is concerned about
— you can efficiently address the patient’s most pressing needs

Many patients don’t know what they want to know, or don’t know how to ask for it, or get anxious and forget what they meant to ask. You might want to refer them to the Question Builder on the AHRQ (Agency for Healthcare Research and Quality) website. This Question Builder asks them what sort of appointment they have, (To talk about a health problem, To get or change a medicine, To get medical tests, or To talk about surgery), then walks them through the steps of formulating their questions.

Send them to this website:

http://www.ahrq.gov/questions/qb

In the same study only 25% of more than 2,200 healthcare providers said they believe it’s their job to keep patients on track between office visits. Yet, these providers also believe that most patients would become more treatment compliant with motivation and coaching.

So, in general, our medical support is not matching real needs or evidence. We have hit the wall of non-adherence. Medications and other treatments get research funding, but can be less effective then predicted when they are not used as directed.

We have an evidence-based, effective solution, but we rarely apply it. Patient education has two parts: (1) information sharing, and (2) health coaching, which is helping patients change behaviors based on this new information. Coaching is one-on-one assistance with problem-solving, using open-ended questions, affirmation of strengths, and reflective listening. Many studies show health coaching can positively impact self-care behaviors and improve health outcomes.

For example, a randomized clinical trial of 56 patients with type 2 diabetes compared usual care to an intervention of individualized integrative health coaching that focused on patients’ values and sense of purpose. They found health coaching significantly reduced their A1C, and produced self-reported improvements in adherence, exercise frequency, stress, and perceived health status. (Wolever, Dreusicke, et al., 2010)

Sperl-Hillen and Beaton, et al. (2011) found in a randomized study that individual education for patients with established suboptimally-controlled diabetes resulted in better glucose control outcomes than the usual care group education. Those with individual education also trended toward better psychosocial and behavioral outcomes.

Sacks (2011) found that telephone coaching can be as effective as in-person counseling for weight loss, and Terry and Seaverson, et al. (2010) found telephone and mail programs can be effective in reducing participants’ health risk status, though the telephone program was slightly more effective.

One Family Health Center published their experiences implementing an approach where each physician teamed with a health coach to help manage patients with chronic conditions, calling the pair a teamlet. (Ngo, Hammer, et al., 2010). They found it to be beneficial, and suggested that primary care sites—whether community health centers, private offices or teaching clinics—consider incorporating the teamlet concept into their care model.

We readily prescribe medications that cost thousands of dollars per treatment course — or even dose — yet do not fully take advantage of effective interventions that involve human relationships and support. Health coaching not only improves health outcomes, it offers employment to health care providers, with the potential of improving our economy through jobs.

On the other hand, data from the U.S. Health and Retirement Study shows long term improvement in behavior change is hard, and intensive efforts are required to help initiate and maintain lifestyle improvements in the chronically ill (Newsom, Huguet, et al., 2011). Health coaching may not always be a short-term intervention. We have a lot of work ahead.

© (2011) Fran London, MS, RN

Resources:

Newsom, J. T., Huguet, N., et al. (2011). Health Behavior Change Following Chronic Illness in Middle and Later Life. J Gerontol B Psychol Sci Soc Sci. [Epub ahead of print]

Ngo, V., Hammer, H. et al. (2010). Health coaching in the teamlet model: a case study. J Gen Intern Med 25(12): 1375-1378. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988157/?tool=pubmed

Sacks, F. (2011). Telephone coaching as effective for weight loss as in-person counseling. Endocrine Today. 11/15/11. Available from http://www.endocrinetoday.com/view.aspx?rid=89604.

Sperl-Hillen, J., S. Beaton, et al. (2011). Comparative Effectiveness of Patient Education Methods for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med. 10/10/11. Published online doi:10.1001/archinternmed.2011.507

TeleVox (2011) A Fragile Nation in Poor Health: Realities About Why So Many Americans Fail to Follow Their Doctor’s Orders Strategies For Improving Patient Cooperation. Available from http://www.jonespr.net/images/TeleVox-PoorHealthStudyFNL.pdf

Terry, P. E., Seaverson, E. L., et al. (2010). A comparison of the effectiveness of a telephone coaching program and a mail-based program. Health Educ Behav 37(6): 895-912.

Wolever, R. Q.; Dreusicke, M. et al. (2010). “Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial.” Diabetes Educ 36(4): 629-639.