“Do you understand what I just told you?”
Hospitalists who are experts on communicating with patients say that this kind of simple, yes/no question can engender all sorts of confusion. This kind of query often results in unrealistic discharge plans, failed post-discharge treatments, and unnecessary rehospitalizations. And they happen all the time in hospitals across the country.
“Yes/no questions, unless they are very concrete—such as ‘Do you have a headache?’—have little relation to assessing a patient’s understanding of essential healthcare information,” says Jeffrey Greenwald, MD, SFHM, hospitalist and educator at Massachusetts General Hospital in Boston. Many times, he adds, patients say “yes” just to please the doctor or nurse, or to avoid looking ignorant.
A better approach to patient-provider communication, one that successfully addresses communication gaps, is teach-back, a strategy in which providers ask patients to repeat (or “teach back”), in their own words, what they have just learned about their medical condition, treatments, and self-care. For example, a physician using the teach-back method could ask, “Mr. Smith, can you tell me why you are in the hospital?”
The approach is an integral part of SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions) care-transitions quality initiative, says Dr. Greenwald, a BOOST coinvestigator. But too often, hospitalists fail to embrace the mandate of effective communication, he says, leaving responsibility to clarify the patient’s understanding to nurses and other members of the care team.
“Having taught this skill all over the country, I continue to find members of my own profession who feel that it is not their job to assess if patients understand self-care and medication instructions. To me, there’s no question that physicians have a role to play as teachers. We educate patients, whether we think we do or not,” Dr. Greenwald says, adding that some hospitalists do so with greater effectiveness than others.
In an era of accountable-care organizations, patient-centered care, and shared decision-making, hospitalists need to provide their patients the same core messages as the rest of the care team does. According to a recent report by the University of California San Francisco (UCSF) Center for Vulnerable Populations at San Francisco General Hospital, 77 million Americans have difficulty understanding even basic healthcare information.1
In addition to widespread language barriers, the Institute of Medicine in a 2004 report concluded that 90 million U.S. adults have literacy skills that test below the high-school level.2 As most hospitalists know, many inpatients go to great lengths to mask these limitations—appearing knowledgeable while failing to grasp essential health concepts. Medical jargon, acronyms, and instructions can be confusing, even for patients with a high level of education.
“First and foremost, we have to be able to communicate with our patients—to make sure that we understand their goals and that they understand our approach to treatment and the therapeutic goals we are proposing,” Dr. Greenwald says. “This process also helps to achieve true informed consent. We want to ensure that their questions are being answered, and that the options we are discussing are in line with their goals of care so that they are more likely to actually undertake them when they go home. And if they can’t, we need to know that in advance, so that we can intervene in other ways.”
Embracing the Method
One health system that has embraced teach-back as a patient-education strategy is the Lehigh Valley Health Network (LVHN), a 988-bed, three-hospital system based in Allentown, Pa. In an HM12 workshop, the Lehigh Valley team explained how its teach-back initiative grew out of quality initiatives to target patient flow and readmissions. Lehigh joined an Institute for Healthcare Improvement quality collaborative, implemented “Lean” quality-improvement (QI) methodologies, and adopted a patient-coaching program.3
“This process has shined a stark spotlight on how poorly we as physicians communicate with patients overall,” says Michael Pistoria, DO, SFHM, former hospitalist and president of medical staff at LVHN who was a member of the teach-back team.
“I’d like to think I’m a little above averagein this regard, but it has made me realize how much better I could be in checking in with patients, gauging their health literacy, and engaging them with the care plan. As hospitalists, we all have to rethink how we talk to patients and families.”
A multidisciplinary team, originally created to analyze care transitions, was divided into four work groups. One group, which focused on patient/family understanding of the disease process, quickly learned that care-team members often failed to identify the patient’s “key learner”—the patient, a family member, or someone else. If the information is given to the wrong person, breakdowns can result. Such breakdowns usually lead to readmissions. One instrumental change that came as a result of the QI team’s efforts is that LVHN care-team members now recognize it is their responsibility to ask who the key learner is and to put that person’s name on a whiteboard in the patient’s room.
In the workshop in at SHM’s annual meeting in San Diego, Kim Jordan, MHA, BSN, RN, NE-BC, LVHN’s administrator of patient-care services, described teach-back as an effective, easy-to-use communication strategy that improves patient learning outcomes. “We created a standard work process using teach-back strategies across the healthcare system,” with training offered to all professionals who provide education to patients and families, she said.
Starting with heart failure, prompts were written into the electronic health record (EHR) to provide four scripted teach-back questions, each focused on the patient’s knowledge, attitudes, and behavior, to be asked consecutively over three days. Information was “chunked” into manageable pieces, emphasizing what was most important for the patient to learn on that day.
Results from one of the pilot units showed 30-day readmission rates for heart failure patients were cut in half, from 28% to 14%.4 Teach-back scripts also are being developed for the anticoagulant clinic and for patients with stroke, myocardial infarction, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and diabetes.
“Continued analysis continues to show reduced rehospitalizations, and we even find that for those who are readmitted, their second admissions have been shorter,” Dr. Pistoria says, noting LVHN nurses have reported higher satisfaction. “They say, ‘This is wonderful. This is what I love about nursing—I get to teach the patients.’”
A Quality Mandate
The importance of effective communication with hospitalized patients is recognized in the federal Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)5 quality ratings and, more recently, by Consumers Union’s new hospital safety ratings,6 which include communication in its six categories of patient-safety measures. And a recent study from the University of Washington says patients place high value on verbal communication about their discharge care plans and how to improve their health, and personal communication between their inpatient and outpatient providers.7
Large volumes of important information often are “dumped” on hospitalized patients, and many times patients are provided insufficient time to assimilate the information or ask questions about it.8 Such situations are especially common at discharge. And although physicians and other care-team members might feel they can’t afford the time to assure themselves that the patient understands what they are saying, the alternative is a lot more time spent dealing with preventable crises, misunderstandings—and preventable readmissions.
“People say, ‘I don’t have time for this,’” says Laura Vento, MSN, RN, clinical nurse leader on an acute-care medical unit at the University of California at San Diego medical center, who spearheaded teach-back at her hospital. “I did some observations around discharge visits, and it took an average of six minutes. After we implemented teach-back, it took eight to nine minutes. Nurses and patients were both very satisfied with the results. I say to staff: ‘Give it a try, and see what a difference an extra two minutes can make.’”
Dr. Pistoria describes teach-back as “humble inquiry...the simple need and ability to ask patients, ‘I know I’ve been throwing a lot of information at you. Can you tell me what I just said?’ Then, shut up and listen.” The goal is to have patients confirm that they understand fully what the provider thinks they need to know. The technique is presented as a test not of the patient’s learning ability, but of the provider’s communication effectiveness and success in explaining the information (see Figure 1). If the message has not been transmitted successfully, the professional reteaches, corrects misconceptions, and again asks the patient to teach back.
The theory is that physicians will then avoid the closed-ended questions (“Do you understand what I just told you?”) that make patients uncomfortable or inhibit the communication that needs to happen between patient and provider.
“We didn’t invent teach-back, which long predated Project BOOST,” Dr. Greenwald says. “But we use it and endorse it strongly, and believe it is an important part of communication with patients, particularly around care transitions.”
Dr. Greenwald thinks teach-back “is not a big stretch for hospitalists.” But he says it requires meaningful training and practice, ideally in a multidisciplinary team context. Participating Project BOOST (BOOST@hospitalmedicine.org) and Electronic Quality Improvement Programs (eQUIPS) sites receive a two-year license to post the “train-the-trainer” curriculum on their intranet systems.8 An instructional webinar, and the trainer curriculum and video, are available in the SHM store (www.hospitalmedicine.org/store). SHM also provides on-site training sessions for health systems or learning collaboratives (contact email@example.com).
‘Teach-Back on Steroids’
Teach-back, while a useful approach for improving patients’ understanding about hospital discharges, post-discharge care plans, and patient self-care, is just one of many teaching models that hospitalist groups can use to improve provider-to-patient communication. HM groups should assess health literacy in their regions and physician communication skills before deciding on one or more improvement tools.
LVHN, for example, has incorporated brief motivational interviewing techniques to its teach-back system, and the results are now being studied, says Paula Robinson, MSN, RN, BC, LVHN’s manager of patient, family, and consumer education.
“A lot of research out there emphasizes how patient education and knowledge alone don’t make a difference in adherence or compliance to treatment plans, even if they are getting the knowledge right 100% of the time,” Robinson says. “You also need to give patients permission to explore their feelings.”
One of Robinson’s colleagues, patient-care specialist Debra Peters, MSN, RN, BC, CMSRN, remembers using teach-back with a heart failure patient with recurrent rehospitalizations, exploring why it was important to control his salt intake. “The patient said, ‘Honey, I salt my ham, and I have no intention of changing that.’ This issue would not have come up if we had just addressed the knowledge component and told him: ‘You need to reduce your salt intake.’”
There might not be easy solutions to that kind of patient attitude, although in this case Peters made a referral to a dietitian who worked with the patient on food substitutions and other tools for managing his salt intake. “I don’t know if we made a big difference, but I haven’t seen him back in the hospital,” she says.
Motivational interviewing is a directive, client-centered counseling style for eliciting behavioral changes by helping clients to explore and resolve their ambivalence about making changes.9 Robinson calls it “the next step in our journey, with teach-back as a jumping-off place. We’ve worked on open-ended questions, getting patients to tell their stories, and our own reflective listening skills. I look at teach-back as a great communication tool and strategy—and motivational interviewing as ‘teach-back on steroids.’”
A number of similar, comparable, or complementary techniques and systems, with names like “Teach-to-Goal” and often paired with such resources as written materials, can help advance the same ends (visit the-hospitalist.org to learn about a technique for communicating bad news to patients).
The Flinders Program, developed at Flinders University in Adelaide, Australia, is a four-part structured motivational interview that asks patients to identify what they see as the biggest problem they face.10 LVHN medical educator Krista Hirschmann, MA, PhD, says this method was taught at LVHN by Australian experts and is now being used by its home-care department. “It is truly a patient-centered approach, and could be used by anybody in the health system,” she says.
Project RED (Re-Engineered Discharge), a care-transitions strategy developed by Brian Jack, MD, and colleagues at Boston University School of Medicine, was used to create a “virtual discharge advocate,” a computer avatar that simulates the face-to-face interaction between a patient and a nurse at the bedside.11 Patients interact with the avatar, named Louise, through a touch-screen display to review their after-hospital care packet and to answer her questions, confirming their understanding without being rushed for time.
Ultimately, Dr. Greenwald says, it doesn’t matter if physicians use teach-back or some other system to improve health literacy. “What matters is whether your patients understand what they need to know in order to go home and take care of themselves,” he says.
Larry Beresford is a freelance writer based in Oakland, Calif.
- Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Institute of Medicine of the National Academies website. Available at: http://iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx. Accessed Aug. 9, 2012.
- Nielsen-Bohlman L, Panzer AM, Kindig DA, eds., Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington: Institute of Medicine; 2004.
- Care Transitions Program; University of Colorado School of Medicine, Division of Health Care Policy and Research. Available at: www.caretransitions.org. Accessed July 28, 2012.
- Healthcare Benchmarks and Quality Improvement. Teach-back program reduces readmissions. HighBeam Research website. Available at: http://www.highbeam.com/doc/1G1-269890846.html. Accessed Aug. 9, 2012.
- Hospital Consumer Assessment of Healthcare Providers and Systems. Centers for Medicare & Medicaid Services website. Available at: www.hcahpsonline.org. Accessed July 23, 2012.
- Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed Aug. 1, 2012.
- Shoeb M, Merel SE, Jackson MB, Anawalt BD. “Can’t we just stop and talk?” Patients value verbal communication about discharge care plans. J Hosp Med. 2012;7(6):504-7.
- Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.
- Borrelli B, Riekert KA, Weinstein W, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clinical Immunol. 2007;120(5):1023-30.
- eQUIPS (Electronic Quality Improvement Programs). Society of Hospital Medicine website. Available at: http:// www.hospitalmedicine.org/equips. Accessed Aug. 1, 2012.
- Kelly J, Kubina N. Navigating self-management: a practical approach for Australian health agencies. Flinders University, Adelaide, Australia. Available at: www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm. Accessed Aug. 1, 2012.
- Project RED (Re-Engineered Discharge). Boston University Medical Center website. Available at: http:// www.bu.edu/fammed/projectred/publications.html. Accessed Aug. 1, 2012.