Transcript STUDY QUESTION - Florida Hospital Association

Bridging the Communication Gap
to Prevent Readmissions:
The “Teach Back Method” (a.k.a. “Closing the Loop”)
Dean Schillinger, MD
UCSF Professor of Medicine
Director, Center for Vulnerable Populations
San Francisco General Hospital
Objectives
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Provide 3 actionable tips to improve
communication at discharge:
» Reduce jargon
» Assess for medication discordance
» Use teach-back technique (aka teach-togoal, closing the loop, show-me-approach)
Medical Jargon
GLUCOMETER
HEMOGLOBIN A1c
DIALYSIS
ANGINA
RISK FACTORS
CREATININE
Function of Jargon
Assess Symptoms
10%
Deliver Test Results
24%
n = 60
Provide
Recommendations
37%
Provide Health
Education
29%
Castro, Schillinger AJHB 2007
Jargon Terms
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…unclarified
Glucometer
Immunizations
Weight is stable
Microvascular complication
System of nerves
HbA1c
EKG abnormalities
Dialysis
Wide Range
Risk factors
Kidney function
Interact
…from Patient’s own visit:
• benign
• blood drawn
• blood count
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•
•
•
•
•
•
•
•
…clarified
Angina
Microalbuminuria
Ophthalmology
Genetic
Creatinine
Symptoms
CAT scan
blood count
correlate
stool was negative
stool
baseline
respiratory tract
polyp
•washed out of your system
•receptors
•short course
•renal clinic
•blood cells
•increase your R
•screening
•vaccine
Dialysis “Do you know what the number one cause for people in
this country being on dialysis is? Diabetes”
Would you please tell me in your own words In your own words, what do you think the
what dialysis means?
doctor was trying to tell the patient?
“Check something every day.”
1 “Sugar is too high.”
1
“What? Is that about you toes?”
1 “I can't say it.”
1
“It means that your diabetes is going worse
that you have to exercise to make
diabetes.”
1
“You got to get on machine to pump.. redo
blood to come up to par.”
4 “That the sugar was not…hmm.”
“…regarding kidney.”
2 “Diabetes is one cause of kidney problems.” 3
“That is a warning…about the kidney…my
doctor told me about those side effects of
the diabetes.”
“About dialysis, because they are warning
us, they are telling me about the
3
4
complications…that if I'm having problems in
my kidney, I'm going to have dialysis.”
“It’s a way to clean blood get off toxins out
the blood.”
4
“Means that more people are getting
diabetes.”
“That you need to be on dialysis to cleanse
blood or gonna die.”
1
1
4
Patient Comprehension of Jargon (% Some /Total Understanding)
40
35
Unclarified Jargon
Unclarified /
Own Visit
Clarified
Jargon
30
25
20
15
10
5
0
Self-Report / No Con
Investigator-assessed / No Con
Self-Report / Con
Investigator-assessed / Con
WHY TEACH BACK?
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Clinicians frequently overwhelm patients with information
and advice, and patients only recall or comprehend 1/2
what was said (probably less in hospital settings).
Physician’s advice and instruction is often delivered out of
context, is based on assumptions of shared meaning, and
rarely is tailored to the individual patient’s needs.
The “teach-back” method, if used early and often, can » Ensure information is understood/integrated into memory
» Check for lapses in communication
» Open dialogue re health beliefs and unanticipated barriers to
“action plans,” and self-mgmt
» Reinforce and tailor health messages
» Promote a common understanding or “shared meaning”
» Elicit patient participation/activation
» Maintain your curiosity in the patient as a unique person, with
unique stories to tell-
WHAT IS IT?
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I employ the “teach-back method” in all of my encounters with
patients (and families) at discharge, particularly for those in
whom self-management is a central component in preventing
readmission.
In this interactive technique, the clinician prioritizes amongst the
information exchange and explicitly asks the patient to “teachback” what he/she has recalled and understood re those highpriority domains.
Similarly, clinicians can use the strategy to assess patient’s
perceptions of the information or advice given.
The technique can be used toward the end of a visit or during
the course of the visit, so as to tailor communication earlier.
Teach-back is NQF Safe Practice #10 for informed consent
discussions, and is gaining momentum as a Safe Practice for
Discharge
What is the Evidence that It Can Work?
Informed Consent Studies
 Diabetes Management in Ambulatory Care
 Asthma Education in Hospitalized Patients
 CHF Self Management Education/Diuretic
Self-Titration
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Sudore 2006; Schillinger 2003;
Paasche-Orlow 2005; DeWalt 2006
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Ensures info understood/integrated into memory;checks for
lapses
Opens dialogue re health beliefs; reinforces and tailors health
messages
Promotes a common understanding; elicits patient participation
Failure to “Close the Loop”
Health
Information,
Advice, or Change
in Management
15/124
Assessed
Patient Recall or
Comprehension
8 Recalled or
Comprehended
124 New Concepts
Explained
7 Clarified &
Tailored Explanation
Patient Recall and
Comprehension
0
Adherence
Re-Assessed
Patient Recall or
Comprehension
For only 8/124 new concepts (6%) could physician be assured the
patient recalled or comprehended the information or advice conveyed
during the outpatient encounter
Closing the Loop
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Physicians assessed recall or comprehension
for 15/124 new concepts (12%)
When new concepts included patient
assessment, patient provided incorrect
response half the time (7/15=47%)
Visits using interactive communication loop
not longer (20.3 min. vs. 22.1 min)
Application of loop associated with better
HbA1c (AOR 9.0, p=.02)
Schillinger Arch Int Med 2003
The number of passes required through consent process to obtain
informed consent, by participant characteristics
Characteristic
% 1 pass
% 2 passes
% >2 passes
Adequate literacy
36
45
19
Marginal literacy
22
62
16
Inadequate literacy
11
62
27
US born
37
46
17
Born outside US
15
61
25
Sudore, Schillinger 2006 JGIM
Provider-Patient Concordance in
Medication Regimen
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Patients with atrial fibrillation at high risk of stroke
Treatment with warfarin (blood-thinner) reduces
risk of stroke by 70%
Requires close monitoring and frequent dose
adjustments
Miscommunication/ inappropriate dosing can lead
to poor outcomes (stroke or bleeding)
Studies have shown miscommunication rates
(discordance) as high as 50%
Literacy, Discordance and Safety
Anticoagulant regimen concordance lower for
patients with inadequate vs adequate literacy
(42 % vs 64 %, OR = 0.41, P<0.01),
 Anticoagulant discordance associated with
being out of therapeutic range:
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» under-anticoagulation (AOR 1.67, p=.05)
» over-anticoagulation (AOR 3.44, p=.01)
Schillinger J Health Comm 2006
Computerized Visual Medication Schedule
Linked to Brief Scripted “Teach-Back”
Machtinger, Schillinger 2007 in press
Intervention Reduces
Time To Therapeutic Range (N=142)
Overall Results:
Time To Therapeutic Range (N=142)
HOW?
Example 1 (medication change):
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Doctor (to patient): “ I want to make sure I did a
good job explaining your heart medications,
because this can sometimes be confusing. Can
you tell me what changes we decided to make
and how you NOW will take the medications? “
Note especially how the physician places the
onus of any possible mis-communication on
him/herself. In other words, the “teach-back” task
is conveyed not as a test of the patient, but of
how well the physician explained the concept.
HOW?
Example #2: Behavior Change
Nurse (to patient):
“ We’ve spent the last few minutes discussing how you are going to
exercise and how you are going to change what you eat. These
things can be heard to change. Can you repeat back to me these new
plans on exercise and eating? And can you tell me how easy or
difficult these will be for you to do and what problems you might have
in doing them? This will help me give you the best advice? “
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Note how the nurse normatizes any possible dis-agreement re the
plan or future non-adherence to the agreed-upon plan by framing
such disclosures as one means to improve on the nature of any
advice.
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It is important to give the patient time and space to respond; avoid
interrupting the patient before he/she has a chance to respond.
How Not To…
Example #3: Taking the Easy Way Out
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Doctor (to patient): “Do you understand what we just
talked about? “ or “Do you understand the plan
regarding your blood pressure medications?” “Did
that makes sense?”
These routine queries, which do not require explicit
articulation of recall, comprehension, or perceptions
on the part of the patient, will universally be met with
an uninformative (and possible falsely re-assuring)
“Yes, doctor”.
CONCLUSIONS:
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A simple communication tool – the “teach-back
method”, a.k.a. “Closing the Loop” - if used early,
often, and at strategic moments, can help
promote more effective two-way discourse
between clinicians and patients without
significantly lengthening the discharge
communication time
When linked very clear prioritization re key
information, it is a very promising practice to
prevent re-hospitalization