Avoid the Smile and Nod:

1. Avoid the Smile and Nod: Using Teachback and Health Literacy Principles to Make Sure Patients (and Staff) Understand Kelly Pick, MSN RN-BC NPD Clinical Educator: Patient and Community Education

2. Last Trip to That Store

3. Buzz Words Reducing Readmissions Affordable Care Act Improving Care Transitions Meaningful Use Increasing Patient Safety Value-Based Purchasing Core Measure Compliance Pay for Performance (P4P)

4. Health Literacy Weiss, B.D. (2007) AMA Health Literacy CEs and Kits

5. National Assessment of Adult Literacy (NAAL) Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006)

6. Why is Health Literacy Important? • Communication with providers • Health outcomes • Hospitalization rates • Screening • Morbidity and mortality • ED use • Cost Kutner et al. (2006)

7. Avoid Stereotypes and Assumptions

8. Why teach? After saving lives, the most important thing we provide is patient and family education. London, F. (2009) On the average, for every dollar invested in patient education, $3-4 were saved. London (2009) Attorneys estimate that a clinician’s communication style and attitude contribute to almost 75% of malpractice suits. Weiss, B. (2007)

9. Universal Precautions… …for Low Health Literacy • Can’t tell by looking • Communicate clearly with everyone • Confirm understanding with everyone DeWalt, et al. (2010) AHRQ Universal Precautions Toolkit

10. Clear Communication • Slow down • Use plain, non-medical language “living room language” • Show or draw pictures • Create a shame-free environment • Use Teachback Weiss, B. (2007)

11. Teachback: What is it?

12. How does Teachback help? • Improve patient safety • Reduce unnecessary clinic and ED visits and hospital readmissions • Quick and easy way to assess understanding

13. “I don’t have time” • Time saver brainstorming • Studies and Pilot Projects • Start small: • One patient encounter per day (last visit) • Work up to more as you get more comfortable

14. Key Learner Key Learner: Identify and involve as much as possible

15. Needs Assessment Assess needs and previous knowledge • Need-to-know versus Nice-to-know

16. Assessment Example Case Study: Sarah- 14-year-old • Spina Bifida • Infected sores on legs • “Frequent Flyer”

17. Assessment Example Case Study: Mrs. Walker- 66 year-old female • S/P AMI • In ED for chest pain • Hasn’t started cardiac rehab Questions for Assessing Understanding and Goals

18. Chunk ‘n Check …if more than 2-3 points “”

19. Check for Understanding • Avoid yes/no questions • Do you understand? • Does that makes sense? • Is that clear?

20. Take Responsibility… • Use “I” statements, not “you” statements • I want to be sure I’ve been clear... • not • I want to make sure youunderstand…

21. Avoid the parrot Teach back “in your own words” not “repeat back”

22. Three Types of Questions: Knowledge: Can you tell me how much insulin you should give yourself every day? Attitude: Do you know why it’s important for you to take your Lasix every day? Behavior: How do you plan to remember to take all your medicines correctly every day?

23. Effective Questioning Do you have any questions? Any questions? You don’t have any questions, do you? • What questions do you have?

24. Teachback Reminder Card • Keep card with you when teaching: • Patients • Students • Preceptors • Staff

25. Practice • Teach your partner how to use the call light (less than a minute) • Use Teachback card to remind you of steps: • Teach concept • Take responsibility • Ask for teachback in own words • Ask for questions • Switch roles

26. Evaluation of patient education

27. Teachback in Precepting and Education • Role model for patient education • Competency assessment and “Verbalizes Understanding” Skit: What does “Verbalizes understanding” really mean?

28. When Teachback isn’t used…

29. What questions do you have?

30. References and Further Reading 5 Million Lives Campaign. (2008). Getting started kit: Improved care for patients with congestive heart failure how-to guide. Cambridge, MA: Institute for Healthcare Improvement. (Available at www.ihi.org) The Advisory Board Company. (2011). Innovating on 'teach-back' to prevent avoidable readmissions. Retrieved from The Advisory Board Company. Brach C., Dreyer, B., Schyve, P., Hernandez L.M., Baur, C., Lemerise, A. J., Parker, R. (2012). Ten attributes of health literate health care organizations. Institute of Medicine Roundtable on Health Literacy. Available at: http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_HLit_Attributes.pdf Centers for Disease Control and Prevention (2009). Simply put: A guide for creating easy-to-understand materials. Third Edition. Atlanta, Georgia: DeWalt D. A., Callahan, L.F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R., & Brach, C. (April 2010). Health Literacy Universal Precautions Toolkit. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 10-0046-EF. http://www.ahrq.gov/qual/literacy/index.html Healthcare Benchmarks and Quality Improvement. (December, 2010). Readmission rates for HF reduced by 30%. Volume 17(12), p.137-138. Retrieved from http://www.henryfordconnect.com/documents/Sladen%20Library/HBQI-December2010.pdf

31. Institute for Healthcare Improvement. (2008). Good heart failure care follows patients home. Retrieved from http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/ImprovementStories/GoodHeartFailureCareFollowsPatientsHome.htm Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington DC: The National Academies Press. Kripalani, S., Bengtzen, R., Henderson, L.E., & Jacobson, T. A. (2008). Clinical research in low-literacy populations: Using Teach-Back to assess comprehension of informed consent and privacy information. IRB: Ethics and Human Research. March-April, pp.13-19. Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy. U.S. Department of Education. Washington, DC: National Center for Education Statistics. (NCES 2006–483) London, F. (2009) No time to teach: The essence of patient and family education for health care providers. Atlanta, GA: Pritchett & Hull. Morris, B. (2002, May 13, ) Overcoming Dyslexia. Fortune Magazine. Retrieved from http://money.cnn.com/magazines/fortune/fortune_archive/2002/05/13/322876/index.htm National Quality Forum (2010). Safe Practices for Better Healthcare – 2010 Update. Retrieved from http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%e2%80%93_2010_Update.aspx

32. Osborne H. (2011). In other words...Confirming understanding with the Teach-Back Technique. Health Literacy Consulting. Retrieved from http://www.healthliteracy.com/article.asp?PageID=6714 Press, V., Arora, V., Shah, L., Lewis, S., Charbeneau, J., Naureckas, E., & Krishnan, J. (2012). Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: A randomized trial. Journal of General Internal Medicine, 27(10), 1317-1325. Sandberg, E., Sharma, R., & Sandberg, W. (2012). Deficits in retention for verbally presented medical information. Anesthesiology, 117(4), 772-779. Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., … Bindman, A. B. (2003). Closing the loop: Physician communications with diabetic patients who have low health literacy. Archives of Internal Medicine; 163:83–90. US Department of Health and Human Services. (2010). Health literacy. Retrieved from http://www.health.gov/communication/literacy/quickguide/factsbasic.htm Weiss, B.D. (2007). Health literacy and patient safety: Help patients understand, manual for clinicians, Second edition, A continuing medical education opportunity. Date of most recent activity review April 2009. Chicago, IL: American Medical Association Foundation and American Medical Association. Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf