A Guide to Educating Patients

Patient Education - Introduction

• Skill Building and Responsibility – Patients need to know when, how, and why they need to make a lifestyle change

• Group Effort – Each member of the patient’s health care team needs to be involved

What is Patient Education?

Patient Education - Introduction

• Increased Compliance – Effective communication and patient education increases patient motivation to comply

• Patient Outcomes – Patients more likely to respond well to their treatment plan – fewer complications

• Informed Consent – Patients feel you’ve provided the information they need

• Utilization – More effective use of medical services – fewer unnecessary phone calls and visits.

• Satisfaction and referrals – Patients more likely to stay with your practice and refer other patients

Patient Education Value – The results of clear communication

Patient Education ResearchTargeted Programs Reduce the Risks that Increase Costs

Patient Education RationaleModel of Patient Education Outcomes

Patient Education Print Verbal Multimedia Combination

Patient Education Print Verbal Multimedia Combination

Behavior Changes Health services utilization Compliance Lifestyle Self-care

Behavior Changes Health services utilization Compliance Lifestyle Self-care

Costs Length of stay Utilization Provider image Regulatory compliance

Costs Length of stay Utilization Provider image Regulatory compliance

Health Status Physical health Well-being Symptoms Complications

Health Status Physical health Well-being Symptoms Complications

Knowledge and Attitude Changes Increased understanding Increased confidence Increased satisfaction Improved emotional state

Knowledge and Attitude Changes Increased understanding Increased confidence Increased satisfaction Improved emotional state

Patient Education - Introduction

• Effective Patient Educator skills include:

+ Determining patient concerns

+ Avoiding Assumptions

+ Explaining things clearly

• Question the educator must ask:

+ How do I determine patients’ needs and concerns?

+ How do I treat patients equally and as individuals?

+ How do I know when I’ve explained things clearly?

The Effective Educator

Patient Education - Steps

• Assess – Define patient and family needs and concerns; observe readiness to learn.

• Plan – Set objectives with your patient; select materials.

• Implement – Put the plan in motion; help patients along the way to reach the objectives you’ve set together.

• Document – Create a written history and keep records.

Four Steps to Educating

Evaluate - Evaluation is critical and should be continuous through all four steps! This will help you stay on track and spot problems quickly.

Patient Education - Introduction

• Time is limited

• Patient Education must be as efficient and effective as possible

• Educators must think of every moment with patients as a teachable moment!

Maximizing Teaching Moments

Patient Education – Step 1 - Assessment

• Assessment provides you with essential information about your patient

• Patient education success depends on the assessment of needs, concerns, and preferences

• Assessment should be ongoing – make it a part of every encounter with your patient.

Assessment

Patient Education – Step 1 - Assessment

• Avoiding Assumptions –

+ Never assume! Incorrect assumptions can be counterproductive.+ Gather as much information on the patient’s situation as you can early on.

• Getting to Know Your Patient –

+ Review the patient’s chart first

+ Introduce yourself by name and clearly explain your role

+ Ask basic, introductory questions

– Support – is there family or a friend who can assist with care?

– Limitations – address known physical or mental problems early

– Cultural History – Note language barriers and cultural preferences

Grasping Patient Concerns

Patient Education – Step 1 - Assessment

• Understanding Cultural Issues

+ Treat all patients without judgment+ Show respect – remain open to the unfamiliar+ Gain patient trust+ When in doubt – ask questions!

• Challenging your own views

+ Set aside all your conflicts+ Avoid making assumptions about your patients

Recognizing Diversity

Patient Education – Step 1 - Assessment

• Establishing Rapport –

+ The patient must feel comfortable with you

+ When meeting a patient:

– Try to be empathetic

– Avoid focusing on a chart

– Make Eye Contact

– Communicate nonverbally if there are language barriers

– Ask who’s in a photo

– Ask about a book the patient may be reading

• Learning the Patient’s Perspective –

+ Fears, worries, misconceptions – get everything out in the open early!

+ Ask: “When you think of (this condition), what do you think of?

+ Patient concern should be primary focus in your education plan.

Grasping Patient Concerns

Patient Education – Step 1 - Assessment

• Answers should uncover core beliefs – Ask specific questions - ask to discover what motivates your patient:

+ “What are you afraid might happen?”

+ “What barriers get in your way?”

+ “When you tried this before, what problems did you have”

• Asking open-ended questions – Increases the information you get and decreases the number of questions you need to ask.

Asking the Right Questions

Closed Open

Are you upset?

Are you in pain?

Is this hard for you to deal with?

Are you taking your medicine every day?

What’s bothering you?

How would you describe your pain?

What are some problems this is causing?

How and when do you take your medicine?

Patient Education – Step 1 - Assessment

• Determining readiness to learn – Your patient will present challenges if resistant to education

+ Motivation – Patients are motivated when they learn how their lives could improve. Focus on the benefits of education.

+ Attitude – Denial, Fear, Anger, Anxiety – all could be barriers to education. Patient must know that he or she will make gains by learning new skills.

+ Outlook – A patient’s beliefs about their situation could effect education. Let them know that learning new skills can help them feel better or slow disease progression.

• Assessing Patient Skills – Request a demonstration of what he or she has learned in the past

Grasping Patient Concerns

Patient Education – Step 1 - Assessment

• Redefining the Family

+ Patient support is a cultural issue. “Family” could be anybody the patient designates. + When possible, let your patient designate a person to receive info from the team.

• Assessing Your Patient’s Support

+ The patient’s support should be trusted and able to carry out tasks.+ Look for the following when the patient’s support is present:

Understanding the Support Network

Does the patient . . . Does the support person . ..

Seem pleased with this person’s input?

Look forward to visits with this person?

Interact favorably with this person?

Appear with the patient frequently?

Show concern for the patient?

Encourage following medical advice?

Patient Education – Step 1 - Assessment

Evaluating Your Assessment

Look back on the info you have gathered and determine if you are readyto move on to the next phase

Needs and Concerns:What are the patient’s needs?What are his or her concerns?What does the patient already know?

Beliefs and Attitudes:What does your patient believe?How are support people coping?

Skills:What health-promoting skills does the patient possess?What skills will the patient need to develop?

Behavior:What barriers to change is the patient showing?What barriers do the patient’s support people have?

Patient Education – Step 2 - Planning

• Once you know your patients needs, planning begins.

• You both should set some mutually agreeable goals.

• Gather the materials you need to meet these goals

• When building your plan, make building patient skills and addressing concerns the top priority!

Planning

Patient Education – Step 2 - Planning

• Thinking Realistically

+ Goals should focus on what is necessary / critical to patient survival first.

+ Pay attention to patient concerns – they could stand in the way of progress

+ Respect stated limits – if a patient has refused to do something, try to work around the problem and incorporate something new as best you can.

• Helping a Patient Make Life Changes

+ If your patient needs to make lifestyle changes, make sure he or she:

– Understands the need for changing behavior

– Has the confidence to complete the required tasks

– Successfully begins to change behavior.

Setting Goals

Patient Education – Step 2 - Planning

• Effective Plan –

+ Essential Skills – what a patient needs to know

+ Benefits and Barriers – what a patient’s concerns are

+ For a plan to be effective, you must find ways to build bridges between patient needs and patient concerns.

+ The bridges you build will be framed by what you learned during assessment

Building Bridges

Patient Needs Patient ConcernsBridge

Patient Education – Step 2 – Planning

Below are some simple examples of ways in which someone might decide to bridge the gap between needs and concerns.

Building Bridges

Patient should exercise “Exercising hurts” “By exercising, you’ll improve muscle strength, which lessens pain. Let’s find an exercise that works for you.”

Chemotherapy is required “My hair will fall out” “Chemo kills quick-growing cells, like hair and cancer. In the meantime, let’s see what kind of hat, turban, or wig we can find.”

Heart patient should lower cholesterol.

“I won’t get to eat all of my favorite foods”

“Low-cholesterol foods can be tasty. Here are some great recipes. And you can also treat yourself once in a while.”

Patient Needs Patient Concerns Bridge

Patient Education – Step 2 - Planning

• Finding Resources

+ Printed Materials, Video or Audio CDs/DVDs, Electronic content

+ Look for inconsistencies between your goals and those of the materials.

+ Make sure the resources are up-to-date

+ Patient Education publishers provide information on patient education techniques and practices.

+ Premade plans may be available from pharmaceutical companies or other organizations. Be careful they are not biased!!

+ Clinical pathways that your facility already uses can work as effective plans.

+ Disease-specific or voluntary organizations may provide materials.

+ Experienced colleagues can be useful resources in helping you come up with a plan.

Setting Goals

Patient Education – Step 2 – Planning

Make sure the plan contains the information that your patient both needs and wants to know – discuss with your patient and support people

Evaluating Your Plan

Needs and Concerns:How well does your plan cover what your patient needs to know?What part of the plan address patient concerns?

Beliefs and Attitudes:Where in the plan are your patients beliefs and attitudes addressed?How does your plan address any barriers that the patient may have?

Skills:How will the plan develop the life-enhancing or essential skills your patient needs?

Behavior:How will the plan influence or even change your patient’s behavior?

Patient Education – Step 3 - Implementing

• Implementing your plan begins with reassessment

+ Surprises can arise that will cause you to adjust the plan.

• Assess continually

+ Reassess the patient during each contact

+ The success of your plan depends on the quality of your assessment and the patient’s ability to meet goals.

Implementing

Patient Education – Step 3 – Implementing

• Providing a Good Learning Environment

+ Tone of voice, eye contact, and touch vary for all cultural backgrounds

– Use the knowledge you gained during assessment

+ Environment

– Good lighting

– Comfortable temperature

– Low noise

– Room to spread out

+ Privacy

– If possible, seek out a place you can work privately with the patient and his or her support person

Getting your Message Across

Patient Education – Step 3 – Implementing

• Setting Implementation Priorities

+ Let your patients know:

– What they should do and why

– When they should expect results

– Possible danger signs to watch for

– What they should do if problems arise

– Whom they should contact for referrals

Getting your Message Across

Your priorities and your patient’s should be clearly stated, mutually understood, and mutually agreed upon.

Patient Education – Step 3 – Implementing

• Alerting Patients to What’s Ahead

+ Develop time frames for you patients

+ Provide a number to call in case conditions change – make them feel self-directed and in control.

+ Let patients know what to accept – avoiding surprises and promoting patient acceptance

+ Emphasize on quality-of-life changes over cures

• Thinking Small

+ Small steps are better than none – take small steps toward achieving a goal

+ Avoid overloading the patient with information

+ Accept whatever number of steps the patient is willing to accept, and always offer the opportunity to learn more at a later time.

Working Toward Goals

Thinking in terms of improvements, recovery schedule, and follow up care

Patient Education – Step 3 – Implementing

• Keep content simple

+ Speak with all patients using simple language

+ Focus on one goal or behavior change per visit

+ Highlight key concepts and provide printed materials

+ Stay interactive – let the patient show you what he/she learned

• Use visuals

+ Drawings, visuals, illustrations can reinforce key concepts

+ Some people learn visually

+ Illustrations boost comprehension

Getting Your Message Across

Patient Education – Step 3 – Implementing

• Mixing Education Media

+ You will never have all the time you would like so supply your patients with educational material

+ Give your patients printed material, or even video or audio material - go over what they should focus on.

+ Different patients respond to different material – the more options, the better

+ Document what you’ve coached on – so your team knows what’s been covered

+ Ask your patient to demonstrate what he or she has learned.

Getting Your Message Across

Patient Education – Step 3 – Implementing

• Choose material with special emphasis on:

+ Clear focus and goals

+ Headings that present key concepts for busy, scanning, or low-literacy readers

+ Step-by-step instructions

+ Practical tips to improve daily living

+ A clear language level that matches the bulk of your patients

+ Translations if your patient population warrants it

Reinforce the message: Choosing the right patient education materials

Patient Education – Step 3 – Implementing

• Highlight Key Concepts

+ Open and flip through the booklet or brochure with the patient

+ Write in any notes of your own

• Check a Patient’s Understanding

+ Ask your patient to repeat complex explanations back to you

• Involve a Patient’s Family

+ Suggest bringing in a support person to show the materials to also and to hear your instructions

• Build on Success

+ Build on skills the patient is confident in and motivated by

Reinforcing the message: How to use patient education materials

Patient Education – Step 3 – Implementing

• Reassessing Patient Concerns

+ Patients can become resistant

+ Physical and emotional stress of illness can present challenges

+ Ask open ended questions to understand new concerns

– What’s standing in your way? What concerns you about doing?

• Helping a patient over a barrier

+ Reassess, looking for core concerns

+ Address concerns such as pain, fear, misunderstanding

+ Consult with other members of the health care team

+ Arrange for follow-up care

+ Get help from the patient’s support person when appropriate.

• Reading Patient Signals

+ Continually assess and ease into your plan

+ Emphasize the benefits of education instead of nagging the patient

Overcoming Challenges

Patient Education – Step 3 – Implementing

Breaking Through Barriers – Here are some examples of barriers you may encounter, along with some ways to work through them

Overcoming Challenges

Barrier Behavior ImplementationDenial, anger, anxiety, or depression

Patient is distracted, disinterested, hostile, or doesn’t believe there’s a problem.

Tell your patient that these feelings are normal, that anyone would be concerned. Use the opportunity to reassess for new concerns.

Physical Pain Patient is unable to concentrate Focus on managing your patient's pain before

implementing the plan.

Acute Illness All patient’s energy is focused on coping with the illness. Patient finds it difficult to learn

Address patient’s fear, pain or anxiety first, and then focus on developing new skills.

Learning disability Patient finds it difficult to comprehend educational materials presented

Try to give a wide variety of materials. Including demonstrations.

Patient Education – Step 3 – ImplementingEvaluating Your Implementation

Needs and Concerns:How will your patient successfully integrate the essential new skills needed into daily life?How have the patient’s concerns been addressed?

Beliefs and Attitudes:Which new skills have positively affected your patient’s perceptions about his or her condition?

Skills:What new skills has your patient learned to improve the quality of his or her life? Where will he or she seek assistance when ready to learn more?

Behavior:What elements of your patient’s behavior promote healthy habits?Which behaviors could be improved later?

Patient Education – Step 4 – Documenting

• Patient records inform colleagues what you’ve done.

• Properly documented patient education can help you meet Meaningful Use Requirements for reimbursement

• Patient education documentation is a large part of TJC review standards

• A record of patient education provides future health care providers a starting point should your patient need assistance in the future

Documenting

Patient Education – Step 4 – Documenting

Keeping Detailed Records

Meaningful Use – documenting patient education within your EMR/EHR provides evidence that you have met the Meaningful Use criteria for patient education.

Patient Education – Step 4 – Documenting

Keeping Detailed Records

Joint Commission – documenting patient education and the individual learning preferences of each patient also provides evidence for the Joint Commission whose minimum compliance goals for patient communication and education are summarized below

PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services.

PC.02.03.01 The hospital provides patient education and training based on each patient’s needs and abilities.

RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she understands

RI.01.02.01 The hospital respects the patient’s right to participate in decisions about his or her care, treatment, and services.

RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and services. (EP 1 notes specifically: “The patient’s communication needs, including preferred language for discussing health care”)

Patient Education – Step 4 – Documenting

Additional Joint Commission Requirements

Core Measures Smoking Cessation Heart Failure Heart Attack Pneumonia Pregnancy Stroke Pediatric Asthma Mental Health Influenza Risk Factors

http://www.jointcommission.org/performance_measurement.aspx

National Patient Safety Goals Comprehensive drug information Anticoagulant information Infection Control

• Hand washing• Healthcare Associated infections

o MRSA, VRE, C-DIFF, PNEUMONIA• Central Line• Pre-Op / Post-Op care

Fall Prevention Focus on behavior change Suicide prevention Warning sign content for patients and

families

http://www.jointcommission.org/standards_information/npsgs.aspx

Patient Education – Step 4 – Documenting

• Knowing the Education Process

+ TJC surveyors want to see whether you understand the patient education process.

+ TJC wants to see documentation, and what kind of education materials you use

• Making Use of Forms

+ The documents you keep can be used for training, to help outpatient specialists, or for future patient assistance if needed

• Getting Patient Feedback

+ Feedback from the patient and family provides valuable perspective on the effectiveness of patient education

+ Consider surveys, documents for patients to sign, questionnaires

Keeping Detailed Records

Resources

The following national organizations provide material that may enhance your patient education goals. Many of these organizations have regional chapters that present workshops and offer community services. Also consult local health care organizations, your Area Agency on Aging, senior centers, and county health departments for more support.

American Cancer Society

800-227-2345

American Diabetes Association

800-ADA-DISC (800-232-3472)

American Heart Association

214-373-6300

American Lung Association

800-LUNG-USA (800-586-4872)

Arthritis Foundation

800-283-7800

Centers for Disease Control National AIDS Clearinghouse

800-458-5231

National Digestive Diseases Information Clearinghouse

301-654-3810

National Head Injury Foundation

800-444-6443

National Heart, Lung, and Blood Institute

301-251-1222

National Jewish Center for Immunology and Respiratory Medicine

800-222-LUNG (800-222-5864)

National Library Service for the Blind and Physically Handicapped

800-424-8567

National Organization for Rare Disorders

800-999-NORD (800-999-6673)

The following books will provide additional guidance and in-depth discussion on patient education theory and technique.

Doak, Cecilia C.; Doak, Leonard G.; Root, Jane H.: Teaching Patients with Low Literacy Skills (Lippincott, 1996)

Lorig, Kate: Patient Education: A Practical Approach (Sage Publications, 1996)

Rankin, Sally H.; Stallings, Karen Duffy: Patient Education: Issues, Principles, Practices (Lippincott, 1996)

Resources

Sources

Consultants:

Kate Lorig, RN, Dr.PH Associate Professor (Research) Patient Education Research Center Stanford University School of Medicine, Palo Alto, CA

Virginia M. González, MPH Health Educator Patient Education Research Center Stanford University School of Medicine, Palo Alto, CA

Louise M. Romer, MPH, CHES Health Education Coordinator Kaiser Permanente Medical Center, San Jose, CA

With contributions by:

Minerva R. de Pacheco, RN, MSN Southwest Hospital, Louisville, KY

Madeline L. Pimenta, RN Boston Regional Medical Center, Stoneham, MA

Rose Mary Pries, MSPH, CHES U.S. Department of Veterans Affairs, St. Louis, MO

With special thanks to: Kaiser Permanente Medical Center, San Jose, CA