Collaborative on Reducing Readmissions in Florida



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|Participant Guide |

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|Module 3: |

|Enhancing Patient Interaction and Communication |

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|5 Steps to Enhance Patient Interaction |

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|Conduct patient-centered visits |

|Explain things clearly in plain language |

|Focus on key messages and repeat |

|Use a “teach back” or “show me” technique to check for understanding |

|Use patient-friendly educational materials to enhance interaction |

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|Activities: |

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|Practice: Speaking in plain language |

|Practice: Key messages – DMII |

|Practice: Key messages – Strep Throat |

|Discussion: Asking for a “Teach Back” |

|Putting It All Together |

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|Medical Terms that Patients May Not Understand |

|Medical Term |Translation into Plain Language |

|Analgesic |Pain killer |

|Anti-inflammatory | |

|Benign | |

|Contraception | |

|Hypertension | |

|Oral | |

|Echocardiogram | |

|Carcinoma | |

|Cardiac problem | |

|Cellulitis | |

|Enlarge | |

|Heart failure | |

|Infertility | |

|Lateral | |

|Lipids | |

|Menopause | |

|Menses | |

|Monitor | |

|Osteoporosis | |

|Referral | |

|Terminal | |

|Toxic | |

|Practice: Using plain, non-medical language |

Note: Sample answers can be found in Weiss, BD. Help patients understand: A Manual for clinicians. 2nd ed.

|Practice Key Messages: Strep Throat |

Directions:

▪ Read the patient education handout below.

▪ Work with your partner to determine the top 3 key messages for the patient.

▪ Write the three key messages in the space below.

▪ Be prepared to share your ideas in a group discussion.

Streptococcal Pharyngitis (Strep Throat):

Your doctor has diagnosed you as having streptococcal pharyngitis, or "strep throat." Strep throat is caused by Group A beta hemolytic streptococcus, a common bacteria in the nose and throat that can cause sore throats (pharyngitis) and skin infections. Symptoms of strep throat include pain and redness in the throat, difficulty swallowing, fever, and swollen glands in the neck. Sometimes there is a rash going along with the sore throat, in which case patients are said to have "scarlet fever." Strep throat occurs most commonly in children.

The symptoms of strep throat go away by themselves, even without treatment. Without treatment, however, a small percentage of patients with strep throat will develop into rheumatic fever, a serious disease of the heart and heart valves. When patients get rheumatic fever, heart valves may be damaged and in the future, the patient may need open heart surgery to replace a heart valve. Although rheumatic fever is uncommon, in recent years there have been more cases reported.

The treatment for strep throat involves taking penicillin, an antibiotic that kills the streptococcus bacteria. The reason for treating strep throat is not to make the sore throat get better quicker. Rather, the reason for treating the strep throat is to prevent the development of rheumatic fever. Treatment with penicillin for 10 days almost always prevents rheumatic fever. It is important that you take the penicillin for the full 10 days, even if you are feeling better before the medicine is used up. That's because taking the penicillin for less than 10 days may not protect you against rheumatic fever. Patients allergic to penicillin can take one of several other medications.

Create a new handout here. If you need more space, use the back of the page……

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|How to ask for a teach back………. |

“What will you tell your spouse about your condition?”

“You have a lot of friends with arthritis. What would you tell them about your condition?”

“Tell me what you will do and how you will do it when you get home?”

“I’ve given you a lot of information. We should probably recap what we have discussed. Why don’t you start.”

Other ideas:

|Data on use of teach backs: |

▪ In a study of physician communication with diabetic patients who had low health literacy, those patients whose physicians interacted with them to assess recall or comprehension were more likely to have better glycemic control (hemoglobin A1c levels below the mean). Conclusion of this study: Overlooking the interactive communication (teach-back) reflects a missed opportunity that may have important clinical implications. (Arch Intern Med/Vol 163, Jan. 13, 2003: “Closing the Loop”.)

▪ “Asking patients to recall and restate what they have been told” is one of the 11 top patient safety practices based on strength of scientific evidence. (AHRQ, 2001 Report on Making Health Care Safer)

▪ A study on patient preferences and assessment of understanding showed patients do not mind being “quizzed” about their understanding and, in fact, prefer it to an authoritarian and/or closed-ended approach. (Kemp et al. Patients Prefer the Method of “Tell Back- Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med, January-February 2008; 21: 24 - 30.)

|Activity: Putting It All Together |

Preparation Worksheet: Follow these steps…….

Step 1: Choose a partner to work with. Turn to the person on your left or someone nearby.

Step 2: Choose a diagnosis/procedure that is common in your practice. You may choose from the list below or use something that you frequently need to explain to patients and/or family members. You and your partner may wish to choose a different diagnosis/ procedure to make the activity more interesting. Write your topic below:

▪ A 56-year old man who needs a cardiac catheterization and possible angioplasty and stent insertion

▪ A 75-year old woman who needs a cataract extraction

▪ A 60-year old man who needs a cochlear implant

▪ The parent of a 2-year old child who needs a cochlear implant

▪ A 40-year old man who needs a bronchoscopy

▪ A 50-year old woman who needs a colonoscopy

▪ A 35-year old man who needs a medial meniscus repair

▪ A 40-year old woman who needs a bladder suspension

▪ A 30-year old woman who needs an electrodessication and curatage of a basal cell carcinoma

▪ A 25-year old leukemia patient who needs a bone marrow biopsy

▪ A 53-year old woman who needs resection of a benign meningioma

▪ A 79-year old man who needs a transurethral resection of the prostate

▪ A 65-year old woman newly diagnosed with diabetes

▪ A 40-year old woman newly diagnosed with multiple sclerosis

▪ The parent of a 3-year old who needs to learn how to appropriately use child passenger safety seats

▪ The parent of 3-year old girl and a 14-year old boy (neither of whom have had either infection or immunization) who need to have a varicella vaccine.

▪ A 28-year old male (who has not had either infection or immunization) who needs a varicella vaccine.

▪ The parent of a 4-year old girl with her second UTI who needs a renal ultrasound and a VCUG (voiding cystourethrogram)

You will have 5 minutes to prepare individually using Steps 2-5:

Step 3: Write down information that you normally communicate to patients in regard to the above diagnosis or procedure. Use the space below or back of this sheet:

Step 4: Select three key messages for this discussion with the patient. Write these three key messages below:

Message #1:

Message #2:

Message #3:

Step 5: Review each of the three key messages above to check for non-medical “plain” language. Reword if necessary.

Message #1:

Message #2:

Message #3:

Step 6: Plan how you will ask for a teach back and write it in the space below:

Step 7: If you have extra time, plan to draw a picture or write stepwise instructions to use in the discussion.

Conduct Simulation #1:

• When the facilitator directs you to start, you will have 3 minutes to conduct the conversation with the “patient”, covering your three key messages, asking for a teach back and listening to what the “patient” has to say.

• After the simulation is complete you will have 2 minutes to debrief with your partner.

▪ What is the “patient’s” perception of how well the key messages were delivered? Did you stick to plain, non-medical language? Did the “teach back” feel comfortable?

▪ What is your perspective on how the conversation went? Were there times when you felt uncomfortable?

• Now switch roles and conduct the second simulation.

Conduct Simulation #2:

• When the facilitator directs you to start, you will have 3 minutes to conduct the conversation with the “patient”, covering your three key messages, asking for a teach back and listening to what the “patient” has to say.

• After the simulation is complete you will have 2 minutes to debrief with your partner.

▪ What is the “patient’s” perception of how well the key messages were delivered? Did you stick to plain, non-medical language? Did the “teach back” feel comfortable?

▪ What is your perspective on how the conversation went? Were there times when you felt uncomfortable?

• Be prepared to share some of your feedback points in the large group discussion that will follow.

|Practical Application of Key Learning Points: |

What is one practical action that I can take immediately to improve my interactions with patients?

What resources or assistance, if any, will I need to take this action?

In addition to this action, I would also like to……………

|Checklist for Patient Understanding |

This document could be useful for both patients and clinicians:

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|At the end of each office visit, a patient should be able to answer the following questions: |

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|What health problems do I have and what should I do about them? |

|Where do I go for tests, medicine, and appointments? |

|How should I take my medicine? |

|When do I take it? |

|What will it do? |

|How do I know if it is working? |

|Who do I call for if I have questions? |

|Other instructions |

|What to do. |

|How to do it. |

|When to do it. |

|Next steps |

|When do I need to be seen again? |

|Do I have another appointment? If so, what is the date and time of the appointment? |

|Are there phone numbers to call? |

|Formatting Checklist for Easy-to-Read Written Materials |

General Content

❑ Limit content to one or two key objectives. Don't provide too much information or try to cover everything at once.

❑ Limit content to what patients really need to know. Avoid information overload.

❑ Use only words that are well known to individuals without medical training.

❑ Make certain content is appropriate for age and culture of the target audience.

Text Construction

❑ Write at or below the 6th-grade level.

❑ Use one- or two-syllable words.

❑ Use short paragraphs.

❑ Use active voice.

❑ Avoid all but the most simple tables and graphs. Clear explanations (legends) should be placed adjacent to each table or graph, and also in the text.

Fonts and Typestyle

❑ Use large font (minimum 12 point) with serifs. (Serif text has the little horizontal lines that you see in this text at the bottoms of letters like f, x, n, and others. This text, on the other hand, is non-serif.)

❑ Don't use more than two or three font styles on a page. Consistency in appearance is important.

❑ Use upper- and lower-case text. ALL UPPER-CASE TEXT IS HARD TO READ.

Layout

❑ Assure a good amount of empty space on the page. Don't clutter the page with text or pictures.

❑ Use headings and subheading to separate blocks of text.

❑ Bulleted lists are preferable to blocks of text in paragraphs.

❑ Illustrations are useful if they depict common, easy to recognize objects. Images of people, places, and things should be age-appropriate and culturally appropriate to the target audience. Avoid complex anatomical diagrams.

|Examples of Patient Education Materials |

Example 1:

|An Extra Step: Mammography |

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|Women in the three high risk categories – age 50 or more, 40 or more with a family history of breast cancer, age 35 or more with a personal history of |

|breast cancer – may consider an additional routine screening method. This is x-ray mammography. Mammography uses radiation (x-rays) to create an image of |

|the breast on film or paper called a mammogram. It can reveal tumors too small to be felt by palpation. It shows other changes in the structure of the |

|breast which doctors believe point to very early cancer. A mammographic examination usually consists of two x-rays of each breast, one taken from the top |

|and one from the side. Exposure to x-rays should be carried out to assure that the lowest possible dose will be absorbed by the body. Radiologists are |

|not yet certain if there is any risk from one mammogram, although most studies indicate that the risk, if it does exist, is small relative to the benefit. |

|Recent equipment modifications and improved techniques are reducing radiation absorption and this the possible risk. |

U. S. Department of Health and Human Services, National Cancer Institute/National Institutes of Health.

Breast Exams: What You Should Know. 1984

Readability: 12th grade

Example 2:

|What is a mammogram and why should I have one? |

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|A mammogram is an x-ray picture of the breast. It can find breast cancer that is too small for you, your doctor, or nurse to feel. Studies show that if |

|you are in your forties or older, having a mammogram every 1 to 2 years could save your life. |

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|How do I know if I need a mammogram? |

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|Talk with your doctor about your chances of getting breast cancer. Your doctor can help you decide when you should start having mammograms and how often |

|you should have them. |

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|Why do I need one every 1 to 2 years? |

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|As you get older, your chances of getting breast cancer get higher. Cancer can show up at any time – so one mammogram is not enough. Decide on a plan with|

|your doctor and follow it for the rest of your life. |

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|Where can I get a mammogram? |

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|Ask your doctor of nurse |

|Ask your local health department or clinic |

|Call the National Cancer Institute’s Cancer Information Service at 1-800-4-CANCER |

U.S. Department of Health and Human Services, National Cancer Institute/National Institutes of Health.

Breast Exams: What You Should Know. 1997

Readability: 5th grade

Why is the second example more patient-friendly?

Example 3:

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|Understanding Diabetes: |

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|Your body needs sugar for energy. It gets sugar from the food you eat and drink. The insulin your body makes helps turn blood sugar into energy. When |

|your body does not make enough insulin, it cannot get energy from the sugar. Without insulin, the sugar stays in your blood. Then your blood sugar goes |

|too high and you feel tired. |

How could you make this paragraph easier to grasp? Write your ideas below…….

(see next page for sample answer)

Example 3 (revised version):

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|Understanding High Blood Sugar: |

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|Where blood sugar comes from……Blood sugar comes from the food you eat and drink. |

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|Why insulin is important……Insulin turns blood sugar into energy – so you have more pep and don’t feel tired all the time. |

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|Why your blood sugar goes high……When you don’t have enough insulin, the sugar stays in your blood. Then your blood sugar goes higher than it should. |

Note that the information has been “chunked up” into separate concepts.

The examples on the next two pages come from:

Easy Does It!

Plain Language and Clear Verbal Communication

Canadian Public Health Association

400-1565 Carling Avenue

Ottawa, Ontario K1Z 8R1

1. Ultrasound

2. Plain Facts on Health: Cholesterol

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|Useful Resources |

Seminal Health Literacy References:

❑ Health Literacy: A prescription to end confusion. Report of the Institute of Medicine. Washington DC: The National Academies Press 2004.

❑ Literacy and health outcomes: final evidence report. Rockville, MD: Agency for Healthcare Research and Quality 2004.

❑ Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding health literacy: implications for medicine and public health. Chicago: AMA Press 2005.

To find literacy data by region, state, county and town:

❑ National Institute for Literacy: reders/reder/htm

Guides to Teaching and Writing for Patients Who Have Limited Literacy Skills

❑ Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. 2nd ed. Philadelphia: JB Lippincott Company. 1996.

❑ National Literacy and Health Program. Easy Does It. Plain Language and Clear Verbal Communication. Ottawa: Canadian Public Health Association. 1998

❑ Osborne H. Overcoming Communication Barriers in Patient Education. New York: Aspen Publishers. 2001.

❑ Centers for Medicare and Medicaid Services. Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies. Order by fax # 410-786-1905

Sources for Easy-To-Read Patient Education Materials

❑ Health and Literacy Compendium. Boston, MA: World Education, 1999.

❑ What To Do For Health book series. Institute for Healthcare Advancement.

Educational Programs, Workshops, and Institutes

❑ Cancer, Culture, and Literacy Institute. H Lee Moffitt Cancer Center, Tampa, FL.

❑ Health Literacy Center. University of New England, Biddeford, ME.

❑ Clear Language Group

❑ Health Literacy Consulting. Natick, MA.

Organization Web Sites

❑ American Medical Association Foundation

❑ National Institute for Literacy

❑ US Health Resources and Services Administration

❑ American College of Physicians Foundation

❑ Partnership for Clear Health Communication

❑ Reach Out and Read

❑ Center for Health Care Strategies: Fact Sheets on Health Literacy

|References |

54 Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA 1999; 281:283-7.

55 Langewitz W, Benz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325:682-3.

56 Vogel DR, Dickson GW, Lehman JA. Driving the audience action response. In: Petterson R. Visuals for Information: Research and Practice. Englewood Cliffs, NJ: Education Technology Publications. 1989.

57 Doak CC, Doak LG, Friedell GH, Meade CD. Improving comprehension for cancer patients with low literacy skills. Strategies for clinicians. Ca Cancer J Clin. 1998; 48:151-162.

For a complete list of references, please refer to Weiss, BD. Help patients understand: A Manual for clinicians. 2nd ed.

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Health literacy: Help patients understand

A Workshop for Clinicians

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