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.

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.

One way some organizations are trying to communicate with people with low functional health literacy skills is to use pictographs or pictograms in their printed materials. These are pictorial symbols for words or phrases, or statistics in a chart or graph.

Weiss (2007) states that “using pictures, including cartoons or pictographs with verbal explanations and use of models, can greatly increase patient understanding and retention of information” (page 40).

A study by Yin, Dreyer, van Schaick, Foltin, Dinglas, & Mendelsohn (2008) concluded a plain language, pictogram-based intervention used as part of medication counseling decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department.

Zeng-Treitler, Kim, & Hunter, (2008) supplemented discharge instructions with free texts with pictographs, and tested them on 13 healthy volunteers. They found the pictograph enhancement resulted in statistically significant better recall rates (p<0.001).

But before you add pictographs and pictograms into your printed materials, test them with your patient populations. Doak, Doak, & Root (1996) warned that when staff tested some computer graphic pictograms with focus groups, patients found them to be cold and unclear. They recommended you use visuals that give a sense of realism and the patient see the action recommended.

Chuang, Lin, Wang, & Cham (2010) discovered pictographs designed by medical professionals may not be optimal for elderly and low-literacy patients. They offered choices of 12 sets of pictographs and found the preference of patients and medical staff was significantly different. Comprehension was significantly different between patients and medical staff for several pictographs.

So yes, pictograms and pictographs can help your patients with low functional health literacy skills understand your printed instructions. But be sure to test them on your patient population. What may seem clear to you may make no sense to your patient. And what may work for your population may not work for each individual patient. Always evaluate understanding with teach back. After explaining to your patient what needs to be done, have your patient teach the content back to you to be sure he or she understands. This gives you the opportunity to correct misunderstandings before they become medical errors.

If you want to learn more:

Chuang, M. H., Lin, C. L., Wang, Y. F., & Cham, T. M. (2010). Development of pictographs depicting medication use instructions for low-literacy medical clinic ambulatory patients. J Manag Care Pharm, 16(5), 337-345.
http://www.amcp.org/data/jmcp/337-345.pdf

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: J. B. Lippincott Company. http://www.hsph.harvard.edu/healthliteracy/doak.html

Hill, L. H., & Roslan, M. M. (2004). Using visual concept mapping to communicate medication information to chronic disease patients with low health literacy. Paper presented at the Concept Maps: Theory, Methodology, Technology. Proceedings of the First International Conference on Concept Mapping, Pamplona. Spain.

The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL:: The Joint Commission. http://www.jointcommission.org/PatientSafety/HLC/

Weiss, B. D. (2007). Manual for clinicians: Health literacy and patient safety: Help patients understand. 2nd. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med, 162(9), 814-822. http://archpedi.ama-assn.org/cgi/content/full/162/9/814

Zeng-Treitler, Q., Kim, H., & Hunter, M. (2008). Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. AMIA Annu Symp Proc, 849-853.

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals

Rather than print it, you might want to enjoy it from your computer screen. It’s 102 pages packed with example practices, information on laws and regulations, and links to supplemental information, model policies and educational tools.

For more information go to:
http://www.jointcommission.org/PatientSafety/HLC/

For practical advice on how to meet these standards in real life, in real time, read No Time to Teach.

Another group of patients are technologically literate and fully connected. Are we doing as good a job at reaching them, or are we assuming they’ll find good information on the Internet and take care of themselves?

Students in the New Media Institute have developed ways to use powerful personal media tools (Facebook, Twitter, Mobile, and Gaming) to help people make better health behavior decisions. A report detailing their work, Personal Media Public Good, is available from:

http://nmiuga.weebly.com/personal-media–public-good.html

Who are your patients? Are you individualizing your patient education efforts to address their needs? How could you use these tools to improve your practice?

Thanks to Kathy Ordelt for sending me the CDC link that helped me find this report. http://www.cdc.gov/healthmarketing/ehm/mobile.html

Ruppar and Conn (2010) just published a meta-analysis of interventions used to promote physical activity in adults with various chronic illnesses. Their findings: Interventions are most effective in promoting physical activity among chronically ill adults when they
• targeted physical activity exclusively

• used behavioral (as opposed to cognitive) strategies

• encouraged self-monitoring.

Here are some ways to apply this evidence to practice:
• Have that conversation. Don’t just say, “improve diet and exercise.” Have the patient identify what might work for him or her. Discuss the patient’s physical activity plan in detail. What, when, how long, how often.
• Help the patient identify strategies for success. Outcomes will be better if behavior changes are targeted sequentially. It’s hard to start if the plan is overwhelming.
• Individualize the self-monitoring method to the patient’s lifestyle. Pedometers are popular. Activity records can be kept in a range of ways: on a calendar, a notebook, a log, on paper or electronically. Many computer and smart phone programs, as well as monitors, are available for keeping track of daily activity.
• Follow up over time. How is the patient doing? What adjustments need to be made to optimize success?

So health coaching can work to help chronically-ill patients increase physical activity. The article concluded that further evaluation is needed to determine the effectiveness of other physical activity interventions and how to best implement effective interventions in the clinical practice setting. Now that you have a place to start in your practice, why don’t you add your findings to the professional literature? What works for you?

Source: Ruppar, T. M., & Conn, V. S. (2010). Interventions to promote physical activity in chronically ill adults. Am J Nurs, 110(7), 30-37; quiz 38-39.

You have heard this here before: assess the learner’s needs, and individualize teaching to the learner. The two levels of teaching are (1) communicating content and (2) helping the learner apply that new information to his or her life. “Addressing knowledge deficits” and “correcting misunderstandings” refer to teaching content. “Motivating patients to comply” and “focusing on individual barriers to compliance” refer to health coaching skills. Studies from all over the world continually come up with these results, but still, we hesitate. Involve and individualize. It sounds too simple. Too easy.

Or it sounds like it takes too much time. But how much time and money are we spending — and wasting — on ineffective teaching methods and tools? How much time can we save by just finding out what THIS patient needs, and providing it? Papers don’t teach. Computers don’t teach. People teach. (Papers and computers support and reinforce teaching.) Get back in touch with the reason you went into health care — to connect with people, and help them. Have that conversation with a patient today.

Reference: van der Wal, M. H., Jaarsma, T., Moser, D. K., van Gilst, W. H., & van Veldhuisen, D. J. (2010). Qualitative examination of compliance in heart failure patients in The Netherlands. Heart Lung, 39(2), 121-130.

Don’t know how to do this? Don’t know where to start? Read No Time to Teach: The Essence of Patient and Family Education for Health Care Providers. In about 200 pages this book presents the latest evidence and proven, practical advice on how to most effectively and efficiently teach your patients.

Another study of this sort has been published by Lewis, Stabler, and Welch (2010). They explored the informational needs, problems, or concerns of patients with stage 4 chronic kidney disease (CKD) and identified what they wanted in an educational program.

They found their patients’ top concerns to be:
— the possibility of starting dialysis
— maintaining normal social relationships
— treatment options.

They found their patients wanted to know more about
— kidney disease
— treatment options
— care of a vascular access
— taking medication the physician prescribed
— financial concerns.

Are these topics included in your pre-dialysis education program? Have you asked your patients what they want to learn more about?

Source: Lewis, A. L., Stabler, K. A., & Welch, J. L. (2010). Perceived informational needs, problems, or concerns among patients with stage 4 chronic kidney disease. Nephrol Nurs J, 37(2), 143-148; quiz 149.

Fortunately, there’s a free evidence-based guide on how to most effectively share health information on the Internet. Health Literacy Online tells you how to learn about your users and their goals, write actionable content, display and organize content, simplify navigation, and engage users with interactivity. It also tells you how to evaluate and revise your site.

So why waste time and money on a site that looks good but won’t get your message across to those who need it? Download this free guide today and apply it to your site.

For more information go to: http://www.health.gov/healthliteracyonline/