A Guide to Educating Patients

1. A Guide to Educating Patients

2. Patient Education - Introduction Skill Building and Responsibility – Patients need to know when, how, and why they need to make a lifestyle change Group Effort – Each member of the patient’s health care team needs to be involved What is Patient Education?

3. Patient Education - Introduction Increased Compliance – Effective communication and patient education increases patient motivation to comply Patient Outcomes – Patients more likely to respond well to their treatment plan – fewer complications Informed Consent – Patients feel you’ve provided the information they need Utilization – More effective use of medical services – fewer unnecessary phone calls and visits. Satisfaction and referrals – Patients more likely to stay with your practice and refer other patients Patient Education Value – The results of clear communication

4. Patient Education Research Targeted Programs Reduce the Risks that Increase Costs

5. Patient Education Rationale Model of Patient Education Outcomes • Health Status • Physical health • Well-being • Symptoms • Complications Knowledge and Attitude Changes • Increased understanding • Increased confidence • Increased satisfaction • Improved emotional state • Patient • Education • Print • Verbal • Multimedia • Combination • Behavior Changes • Health services utilization • Compliance • Lifestyle • Self-care • Costs • Length of stay • Utilization • Provider image • Regulatory compliance

6. Patient Education - Introduction Effective Patient Educator skills include: • Determining patient concerns • Avoiding Assumptions • Explaining things clearly Question the educator must ask: • How do I determine patients’ needs and concerns? • How do I treat patients equally and as individuals? • How do I know when I’ve explained things clearly? The Effective Educator

7. Patient Education - Steps Assess – Define patient and family needs and concerns; observe readiness to learn. Plan – Set objectives with your patient; select materials. Implement – Put the plan in motion; help patients along the way to reach the objectives you’ve set together. Document – Create a written history and keep records. Four Steps to Educating Evaluate - Evaluation is critical and should be continuous through all four steps! This will help you stay on track and spot problems quickly.

8. Patient Education - Introduction Time is limited Patient Education must be as efficient and effective as possible Educators must think of every moment with patients as a teachable moment! Maximizing Teaching Moments

9. Patient Education – Step 1 - Assessment Assessment provides you with essential information about your patient Patient education success depends on the assessment of needs, concerns, and preferences Assessment should be ongoing – make it a part of every encounter with your patient. Assessment

10. Patient Education – Step 1 - Assessment Avoiding Assumptions – • Never assume! Incorrect assumptions can be counterproductive. • Gather as much information on the patient’s situation as you can early on. Getting to Know Your Patient – • Review the patient’s chart first • Introduce yourself by name and clearly explain your role • Ask basic, introductory questions • Support – is there family or a friend who can assist with care? • Limitations – address known physical or mental problems early • Cultural History – Note language barriers and cultural preferences Grasping Patient Concerns

11. Patient Education – Step 1 - Assessment Understanding Cultural Issues • Treat all patients without judgment • Show respect – remain open to the unfamiliar • Gain patient trust • When in doubt – ask questions! Challenging your own views • Set aside all your conflicts • Avoid making assumptions about your patients Recognizing Diversity

12. Patient Education – Step 1 - Assessment Establishing Rapport – • The patient must feel comfortable with you • When meeting a patient: • Try to be empathetic • Avoid focusing on a chart • Make Eye Contact • Communicate nonverbally if there are language barriers • Ask who’s in a photo • Ask about a book the patient may be reading Learning the Patient’s Perspective – • Fears, worries, misconceptions – get everything out in the open early! • Ask: “When you think of (this condition), what do you think of? • Patient concern should be primary focus in your education plan. Grasping Patient Concerns

13. Patient Education – Step 1 - Assessment Answers should uncover core beliefs – Ask specific questions - ask to discover what motivates your patient: • “What are you afraid might happen?” • “What barriers get in your way?” • “When you tried this before, what problems did you have” Asking open-ended questions – Increases the information you get and decreases the number of questions you need to ask. Asking the Right Questions

14. Patient Education – Step 1 - Assessment Determining readiness to learn – Your patient will present challenges if resistant to education • Motivation – Patients are motivated when they learn how their lives could improve. Focus on the benefits of education. • Attitude – Denial, Fear, Anger, Anxiety – all could be barriers to education. Patient must know that he or she will make gains by learning new skills. • Outlook – A patient’s beliefs about their situation could effect education. Let them know that learning new skills can help them feel better or slow disease progression. Assessing Patient Skills – Request a demonstration of what he or she has learned in the past Grasping Patient Concerns

15. Patient Education – Step 1 - Assessment Redefining the Family • Patient support is a cultural issue. “Family” could be anybody the patient designates. • When possible, let your patient designate a person to receive info from the team. Assessing Your Patient’s Support • The patient’s support should be trusted and able to carry out tasks. • Look for the following when the patient’s support is present: Understanding the Support Network

16. Patient Education – Step 1 - Assessment Evaluating Your Assessment Look back on the info you have gathered and determine if you are ready to move on to the next phase Skills: What health-promoting skills does the patient possess? What skills will the patient need to develop? Needs and Concerns: What are the patient’s needs? What are his or her concerns? What does the patient already know? Beliefs and Attitudes: What does your patient believe? How are support people coping? Behavior: What barriers to change is the patient showing? What barriers do the patient’s support people have?

17. Patient Education – Step 2 - Planning Once you know your patients needs, planning begins. You both should set some mutually agreeable goals. Gather the materials you need to meet these goals When building your plan, make building patient skills and addressing concerns the top priority! Planning

18. Patient Education – Step 2 - Planning Thinking Realistically • Goals should focus on what is necessary / critical to patient survival first. • Pay attention to patient concerns – they could stand in the way of progress • Respect stated limits – if a patient has refused to do something, try to work around the problem and incorporate something new as best you can. Helping a Patient Make Life Changes • If your patient needs to make lifestyle changes, make sure he or she: • Understands the need for changing behavior • Has the confidence to complete the required tasks • Successfully begins to change behavior. Setting Goals

19. Patient Education – Step 2 - Planning Effective Plan – • Essential Skills – what a patient needs to know • Benefits and Barriers – what a patient’s concerns are • For a plan to be effective, you must find ways to build bridges between patient needs and patient concerns. • The bridges you build will be framed by what you learned during assessment Building Bridges Bridge Patient Needs Patient Concerns

20. Patient Education – Step 2 – Planning Below are some simple examples of ways in which someone might decide to bridge the gap between needs and concerns. Building Bridges

21. Patient Education – Step 2 - Planning Finding Resources • Printed Materials, Video or Audio CDs/DVDs, Electronic content • Look for inconsistencies between your goals and those of the materials. • Make sure the resources are up-to-date • Patient Education publishers provide information on patient education techniques and practices. • Premade plans may be available from pharmaceutical companies or other organizations. Be careful they are not biased!! • Clinical pathways that your facility already uses can work as effective plans. • Disease-specific or voluntary organizations may provide materials. • Experienced colleagues can be useful resources in helping you come up with a plan. Setting Goals

22. Patient Education – Step 2 – Planning Make sure the plan contains the information that your patient both needs and wants to know – discuss with your patient and support people Evaluating Your Plan Needs and Concerns: How well does your plan cover what your patient needs to know? What part of the plan address patient concerns? Skills: How will the plan develop the life-enhancing or essential skills your patient needs? Beliefs and Attitudes: Where in the plan are your patients beliefs and attitudes addressed? How does your plan address any barriers that the patient may have? Behavior: How will the plan influence or even change your patient’s behavior?

23. Patient Education – Step 3 - Implementing Implementing your plan begins with reassessment • Surprises can arise that will cause you to adjust the plan. Assess continually • Reassess the patient during each contact • The success of your plan depends on the quality of your assessment and the patient’s ability to meet goals. Implementing

24. Patient Education – Step 3 – Implementing Providing a Good Learning Environment • Tone of voice, eye contact, and touch vary for all cultural backgrounds • Use the knowledge you gained during assessment • Environment • Good lighting • Comfortable temperature • Low noise • Room to spread out • Privacy • If possible, seek out a place you can work privately with the patient and his or her support person Getting your Message Across

25. Patient Education – Step 3 – Implementing Setting Implementation Priorities • Let your patients know: • What they should do and why • When they should expect results • Possible danger signs to watch for • What they should do if problems arise • Whom they should contact for referrals Getting your Message Across Your priorities and your patient’s should be clearly stated, mutually understood, and mutually agreed upon.

26. Patient Education – Step 3 – Implementing Alerting Patients to What’s Ahead • Develop time frames for you patients • Provide a number to call in case conditions change – make them feel self-directed and in control. • Let patients know what to accept – avoiding surprises and promoting patient acceptance • Emphasize on quality-of-life changes over cures Thinking Small • Small steps are better than none – take small steps toward achieving a goal • Avoid overloading the patient with information • Accept whatever number of steps the patient is willing to accept, and always offer the opportunity to learn more at a later time. Working Toward Goals Thinking in terms of improvements, recovery schedule, and follow up care

27. Patient Education – Step 3 – Implementing Keep content simple • Speak with all patients using simple language • Focus on one goal or behavior change per visit • Highlight key concepts and provide printed materials • Stay interactive – let the patient show you what he/she learned Use visuals • Drawings, visuals, illustrations can reinforce key concepts • Some people learn visually • Illustrations boost comprehension Getting Your Message Across

28. Patient Education – Step 3 – Implementing Mixing Education Media • You will never have all the time you would like so supply your patients with educational material • Give your patients printed material, or even video or audio material - go over what they should focus on. • Different patients respond to different material – the more options, the better • Document what you’ve coached on – so your team knows what’s been covered • Ask your patient to demonstrate what he or she has learned. Getting Your Message Across

29. Patient Education – Step 3 – Implementing Choose material with special emphasis on: • Clear focus and goals • Headings that present key concepts for busy, scanning, or low-literacy readers • Step-by-step instructions • Practical tips to improve daily living • A clear language level that matches the bulk of your patients • Translations if your patient population warrants it Reinforce the message: Choosing the right patient education materials

30. Patient Education – Step 3 – Implementing Highlight Key Concepts • Open and flip through the booklet or brochure with the patient • Write in any notes of your own Check a Patient’s Understanding • Ask your patient to repeat complex explanations back to you Involve a Patient’s Family • Suggest bringing in a support person to show the materials to also and to hear your instructions Build on Success • Build on skills the patient is confident in and motivated by Reinforcing the message: How to use patient education materials

31. Patient Education – Step 3 – Implementing Reassessing Patient Concerns • Patients can become resistant • Physical and emotional stress of illness can present challenges • Ask open ended questions to understand new concerns • What’s standing in your way? What concerns you about doing? Helping a patient over a barrier • Reassess, looking for core concerns • Address concerns such as pain, fear, misunderstanding • Consult with other members of the health care team • Arrange for follow-up care • Get help from the patient’s support person when appropriate. Reading Patient Signals • Continually assess and ease into your plan • Emphasize the benefits of education instead of nagging the patient Overcoming Challenges

32. Patient Education – Step 3 – Implementing Breaking Through Barriers – Here are some examples of barriers you may encounter, along with some ways to work through them Overcoming Challenges

33. Patient Education – Step 3 – Implementing Evaluating Your Implementation Needs and Concerns: How will your patient successfully integrate the essential new skills needed into daily life? How have the patient’s concerns been addressed? Skills: What new skills has your patient learned to improve the quality of his or her life? Where will he or she seek assistance when ready to learn more? Beliefs and Attitudes: Which new skills have positively affected your patient’s perceptions about his or her condition? Behavior: What elements of your patient’s behavior promote healthy habits? Which behaviors could be improved later?

34. Patient Education – Step 4 – Documenting Patient records inform colleagues what you’ve done. Properly documented patient education can help you meet Meaningful Use Requirements for reimbursement Patient education documentation is a large part of TJC review standards A record of patient education provides future health care providers a starting point should your patient need assistance in the future Documenting

35. Patient Education – Step 4 – Documenting Keeping Detailed Records Meaningful Use – documenting patient education within your EMR/EHR provides evidence that you have met the Meaningful Use criteria for patient education.

36. Patient Education – Step 4 – Documenting Keeping Detailed Records Joint Commission – documenting patient education and the individual learning preferences of each patient also provides evidence for the Joint Commission whose minimum compliance goals for patient communication and education are summarized below PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services. PC.02.03.01 The hospital provides patient education and training based on each patient’s needs and abilities. RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she understands RI.01.02.01 The hospital respects the patient’s right to participate in decisions about his or her care, treatment, and services. RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and services. (EP 1 notes specifically: “The patient’s communication needs, including preferred language for discussing health care”)

37. Patient Education – Step 4 – Documenting Additional Joint Commission Requirements • Core Measures • Smoking Cessation • Heart Failure • Heart Attack • Pneumonia • Pregnancy • Stroke • Pediatric Asthma • Mental Health • Influenza • Risk Factors • http://www.jointcommission.org/performance_measurement.aspx • National Patient Safety Goals • Comprehensive drug information • Anticoagulant information • Infection Control • Hand washing • Healthcare Associated infections • MRSA, VRE, C-DIFF, PNEUMONIA • Central Line • Pre-Op / Post-Op care • Fall Prevention • Focus on behavior change • Suicide prevention • Warning sign content for patients and families • http://www.jointcommission.org/standards_information/npsgs.aspx

38. Patient Education – Step 4 – Documenting Knowing the Education Process • TJC surveyors want to see whether you understand the patient education process. • TJC wants to see documentation, and what kind of education materials you use Making Use of Forms • The documents you keep can be used for training, to help outpatient specialists, or for future patient assistance if needed Getting Patient Feedback • Feedback from the patient and family provides valuable perspective on the effectiveness of patient education • Consider surveys, documents for patients to sign, questionnaires Keeping Detailed Records

39. Resources American Lung Association 800-LUNG-USA (800-586-4872) Arthritis Foundation 800-283-7800 Centers for Disease Control National AIDS Clearinghouse 800-458-5231 National Digestive Diseases Information Clearinghouse 301-654-3810 National Head Injury Foundation 800-444-6443 The following national organizations provide material that may enhance your patient education goals. Many of these organizations have regional chapters that present workshops and offer community services. Also consult local health care organizations, your Area Agency on Aging, senior centers, and county health departments for more support. American Cancer Society 800-227-2345 American Diabetes Association 800-ADA-DISC (800-232-3472) American Heart Association 214-373-6300

40. Resources The following books will provide additional guidance and in-depth discussion on patient education theory and technique. Doak, Cecilia C.; Doak, Leonard G.; Root, Jane H.: Teaching Patients with Low Literacy Skills (Lippincott, 1996) Lorig, Kate: Patient Education: A Practical Approach (Sage Publications, 1996) Rankin, Sally H.; Stallings, Karen Duffy: Patient Education: Issues, Principles, Practices (Lippincott, 1996) National Heart, Lung, and Blood Institute 301-251-1222 National Jewish Center for Immunology and Respiratory Medicine 800-222-LUNG (800-222-5864) National Library Service for the Blind and Physically Handicapped 800-424-8567 National Organization for Rare Disorders 800-999-NORD (800-999-6673)

41. Sources Consultants: Kate Lorig, RN, Dr.PH Associate Professor (Research) Patient Education Research Center Stanford University School of Medicine, Palo Alto, CA Virginia M. González, MPH Health Educator Patient Education Research Center Stanford University School of Medicine, Palo Alto, CA Louise M. Romer, MPH, CHES Health Education Coordinator Kaiser Permanente Medical Center, San Jose, CA With contributions by: Minerva R. de Pacheco, RN, MSN Southwest Hospital, Louisville, KY Madeline L. Pimenta, RN Boston Regional Medical Center, Stoneham, MA Rose Mary Pries, MSPH, CHES U.S. Department of Veterans Affairs, St. Louis, MO With special thanks to: Kaiser Permanente Medical Center, San Jose, CA