The root of any patient engagement strategy must include health literacy. Clinical progress is unlikely when patients don't understand care instructions. Significant research shows health literacy interventions consistently improve quality and clinical outcomes and reduce acute utilization.
What information should the care team prioritize?
The average adult immediately forgets 40% to 80% of medical information from a doctor's appointment. As such, the care team should communicate only the most essential clinical or self-management information (e.g., hospital mortality rates for a certain procedure vs. hospital quality scores). Patient narratives can be helpful to demonstrate the impact of clinical or self-management decisions, especially for sensitive situations such as end-of-life decision-making.
In addition, the care team should use pictorial or graphical representations as much as possible when communicating information, rather than just text or data. However, when data can't be avoided (e.g., procedure recovery rates), the care team should:
- Order information so that the most important data comes first or is separate from other data;
- Ensure higher values indicate higher quality (e.g., describe staffing ratios as nurses per patient instead of patients per nurse);
- Use the same denominators for data points as much as possible; and
- Describe likelihood of occurrences with natural frequencies instead of percentages.
How can 'teach-back' help?
Teach-back is one tool to improve health literacy. After receiving important information from the care team, patients repeat key information back in their own words to improve their recall. There's strong evidence indicating the practice increases health-related knowledge, which can lead to better self-management. A few studies also indicate that teach-back can reduce utilization.
There are four major components to execute this tactic successfully:
- Identify the key learner(s) beyond just the patient. When possible, education should include caregivers and close family members who assist the patient with taking medications, scheduling appointments, and updating the care team on progress.
- Approach these conversations with humility, rather than authority. Care teams should view the interaction as mutually beneficial. While patients' receive key care plan information, staff learn about the patient's social context, clinical barriers, learning preferences, and activation levels. A patient-provider relationship with a less fraught power dynamic puts patients, particularly the historically marginalized, at greater ease and in a position to communicate more clearly.
- Frame teach-back as a check on staff's teaching skills, rather than a test on the patient. Use phrases like, "To make sure I did a good job…" to initiate what at times may seem an awkward request and respect patients' dignity.
- Encourage patients to use their own language and incorporate details based on their daily lives to ensure the information sticks. When possible, have patients demonstrate the skill they learned to cement it in their memory. The tactic is most effective when used a few times, so consider incorporating teach-back on each day during an acute stay or with different staff during a clinic appointment.
How does this fit into a care team's workflow?
Frontline staff's biggest concern is how to find time to dedicate to new patient education requirements. During short appointment windows, staff should de-prioritize explaining complex clinical information and instead emphasize core concepts, such as how patients may need to alter dietary and exercise habits.
Ideally teach-back should be used with all patients by all staff, but many organizations prioritize teach-back with the highest-risk patients, those who have new diagnoses, and/or those making major medical decisions. Train all staff in the basics, but identify the primary owner of the task (often a care manager or discharge planner) to ensure no patients fall through the cracks. Use the EHR to set up automatic alerts for any new diagnosis to trigger teach-back.
In-person education sessions held over a number of weeks, for a total of around 10 to 13 hours, are the most effective. Use group education sessions to scale efforts. Expect education to have the greatest impact on medication adherence rather than behavior change, which is typically more complex and deals with habits engrained over lifetimes.
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