Well, MedlinePlus.gov offers free, reliable, up-to-date health information in English and Spanish, with no advertisements. It’s called MedlinePlus Connect. This service lets health organizations and health providers to link patient portals and electronic health record (EHR) systems to MedlinePlus, an authoritative up-to-date health information resource for patients, families, and health care providers. Upon receiving a problem code request, MedlinePlus Connect returns relevant MedlinePlus health information.

Content includes:
— Information on hundreds of diseases, conditions and wellness topics
— Interactive tutorials, videos and other multimedia
— An illustrated medical encyclopedia, dictionary definitions, and health news
— Links to health information in over 40 languages

MedlinePlus Connect can also link your EHR system to drug and supplement information written especially for patients. When an EHR system sends MedlinePlus Connect a request that includes a medication code, the service will return links to the most appropriate drug information.

Doesn’t this sound too good to be true?
Access to good, clear health information for free!
What a great use of tax dollars!

For more information, send your IT expert to: http://www.nlm.nih.gov/medlineplus/connect/overview.html

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

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Plain language is important for clear communications. There are many PDF booklets and books offering you step-by-step instructions on how to edit your materials for clarity. Best of all, they are free to download from the Internet. Here are links to a few:

America’s Health Insurance Plans (AHIP). (2010). Health Literacy: A Toolkit for Communicators Retrieved from http://www.ahip.org/healthliteracy/toolkit

Centers for medicare and Medicaid Services (CMS). (2010). Toolkit for Making Written Material Clear and Effective. Retrieved from https://www.cms.gov/WrittenMaterialsToolkit/.

Children’s Hospital & Regional Medical Center. (2005). Family Education Materials Development Kit Retrieved 3/4, 2006, from www.seattlechildrens.org/pdf/PEMatDevKit.pdf

Covering Kids & Families National Program Office. (2005). The Health Literacy Style Manual, from http://www.coveringkidsandfamilies.org/resources/docs/stylemanual.pdf

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

Ridpath, J. R., Greene, S. M., & Wiese, C. J. (2007). PRISM Readability Toolkit Retrieved from http://www.grouphealthresearch.org/capabilities/readability/ghchs_readability_toolkit.pdf

Weiss, B. D. (2003). Health Literacy: A manual for clinicians Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

So stop wasting resources by giving your patients printed information they cannot understand. Apply evidence to practice, edit your patient education materials to optimize readability, and observe the differences in health outcomes.

Happy teaching!

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.

Yes, I’m picking at semantics. But words influence thoughts, and thoughts create actions. If we don’t look at our words, it could lead us down the path of ineffective action.

The dictionary has 3 definitions of empower:

1. give (someone) the authority or power to do something, as in “nobody was empowered to sign checks on her behalf.”

Well, that one doesn’t apply to health care. We don’t give them power or authority. Patients already have the right and authority to manage their own health.

2. enable (someone) to do (something)

This doesn’t apply to health care either. They are either able (capable) or not able (incapable). They may not have the skills, or the knowledge, or the motivation. But we don’t give them ability.

3. make (someone) stronger and more confident, especially in controlling their life and claiming their rights

Ah, this is the one you’re talking about. But when you use the word empower in this context, it doesn’t really describe the next step. You might be fooled into thinking it’s just a transfer of power. This could result in the health care provider giving up (“The ball is in your court, patient. There’s nothing more I can do.”) rather than taking action to improve health outcomes.

No, when you use the word empower you’re really talking about self-efficacy. Self-efficacy is the level of perceived confidence and comfort in completing a specific task. It is the belief, “I can do that.” Self-efficacy is measurable (“on a scale of one to ten, how confident are you that you can . . .”).

There are defined interventions to improve self-efficacy: Self-efficacy can be enhanced through skills mastery, modeling, reinterpreting the meaning of symptoms, and persuasion. (Lorig, 1996)

So catch yourself the next time you find yourself talking about empowering a patient. Substitute self-efficacy for empowerment. Then think about what you just said.

Changing that one word should give you a better idea about what to do. Help the patient master a skill. Introduce the patient to another, similar patient who succeeded. Help the patient see the symptoms from another point of view, one that supports success. Find out what the patient is having trouble with, and apply health coaching to address it.

Jane Vella (2002) said it best:
“Teachers do not empower adult learners; they encourage the use of the power that learners were born with.”

So go forth and take steps to encourage that increase in self-efficacy!

Resources:


Lorig, K. R. (1996). Patient Education and Counseling for Prevention. from http://odphp.osophs.dhhs.gov/pubs/GUIDECPS/text/iv_edu.txt


Vella, J. (2002). Learning to listen, learning to teach: The power of dialogue in educating adults (Revised ed.). New York: Jossey-Bass. page 10

©(2011) Fran London, MS, RN

You might want to check that.

The Toolkit for Making Written Material Clear and Effective (2010) says, “Even when the original text is written in plain English that is easy to read, it can lose this ease of reading in translation. This can happen if translators have not been thoroughly briefed about the reading skills of the audience, or if they lack the ability to write text that is easy for less-skilled readers to understand and use.” (page 5) Don’t assume the translation you receive is at the same register and reading level as your original.

Is your translator raising the register to make your work look more official, formal, and educated? Are your readers able to understand the translations? Make sure your translator knows your audience, and check your translator’s understanding of the principles of health literacy.

Here’s a fact some translators may not know: No matter what the language, the guidelines that identify features of writing and design that make written materials easy for readers to understand and use still apply. (Toolkit, page 12) Just like in English, when there is more than one good word choice, it is best to choose the simplest word. Hire a translator who understands the need to write in plain language. Note the Suitability Assessment of Materials (SAM) score (Doak, Doak, and Root, 1996) insists that the two criteria that must be met for suitability are reading level and cultural appropriateness.

If you don’t speak both languages, you’ll have to depend on those around you who do to help you evaluate the appropriateness of the translations you get.

Free PDF resources:
Centers for Medicare and Medicaid Services (CMS) (2010). SECTION 5: Detailed guidelines for translation PART 11 Understanding and using the “Toolkit Guidelines for Culturally Appropriate Translation”. Toolkit for Making Written Material Clear and Effective. From: https://www.cms.gov/WrittenMaterialsToolkit/

Doak, C. C., L. G. Doak, et al. (1996). Chapter 4: Assessing Suitability of Materials. Teaching patients with low literacy skills. Philadelphia, J. B. Lippincott Company.
From: http://www.hsph.harvard.edu/healthliteracy/resources/doak-book/

©(2011) Fran London, MS, RN