Bridging the Communication Gap to Prevent Readmissions:

The “Teach Back Method” (a.k.a. “Closing the Loop”)

Dean Schillinger, MDUCSF Professor of Medicine

Director, Center for Vulnerable PopulationsSan Francisco General Hospital

Objectives

Provide 3 actionable tips to improve communication at discharge:» Reduce jargon» Assess for medication discordance » Use teach-back technique (aka teach-to-

goal, closing the loop, show-me-approach)

Medical Jargon

GLUCOMETER

HEMOGLOBIN A1c

DIALYSIS

ANGINA

RISK FACTORS

CREATININE

Provide Health Education

29%

Deliver Test Results24%

Provide Recommendations

37%

Assess Symptoms10%

n = 60

Function of Jargon

Castro, Schillinger AJHB 2007

Jargon Terms …unclarified Glucometer Glucometer ImmunizationsImmunizations Weight is stableWeight is stable Microvascular complication System of nervesSystem of nerves HbA1cHbA1c EKG abnormalitiesEKG abnormalities DialysisDialysis Wide Range Risk factorsRisk factors Kidney function Interact

…clarified Angina Microalbuminuria Ophthalmology Genetic Creatinine Symptoms

…from Patient’s own visit:• benign• blood drawn• blood count

• 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

Would you please tell me in your own words what dialysis means?

In your own words, what do you think the 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“Means that more people are getting diabetes.”

1

“You got to get on machine to pump.. redo blood to come up to par.”

4 “That the sugar was not…hmm.” 1

“…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.”

3

“About dialysis, because they are warning us, they are telling me about the complications…that if I'm having problems in my kidney, I'm going to have dialysis.”

4

“It’s a way to clean blood get off toxins out the blood.”

4“That you need to be on dialysis to cleanse blood or gonna die.”

4

Dialysis Dialysis “Do you know what the number one cause for people in this country being on dialysis is? Diabetes”

0

5

10

15

20

25

30

35

40

Self- Report / No Con Investigator- assessed / No Con Self- Report / Con Investigator- assessed / Con

Unclarified / Own Visit

Unclarified JargonClarified Jargon

Patient Comprehension of Jargon (% Some /Total Understanding)

WHY TEACH BACK?

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?

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 “teach-back” what he/she has recalled and understood re those high-priority 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

Sudore 2006; Schillinger 2003; Paasche-Orlow 2005; DeWalt 2006

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

Closing the Loop: Interactive Communication

to Enhance Recall & Comprehension

Re-AssessPatient Recall &Comprehension

Adherence

New Concept:Health Information,

Advice, or Change in Management

Provider Explains New Concept

Patient Recalls and Comprehends

AssessPatient Recall & Comprehension

Clarify & Tailor Explanation

For only 8/124 new concepts (6%) could physician be assured thepatient recalled or comprehended the information or advice conveyedduring the outpatient encounter

Failure to “Close the Loop”

Adherence

8 Recalled orComprehended

HealthInformation,

Advice, or Changein Management

0Re-Assessed

Patient Recall orComprehension

15/124Assessed

Patient Recall orComprehension

7 Clarified &Tailored Explanation

124 New ConceptsExplained

Patient Recall andComprehension

Closing the Loop 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

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

The number of passes required through consent process to obtain informed consent, by participant characteristics

Sudore, Schillinger 2006 JGIM

Provider-Patient Concordance in Medication Regimen

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%

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:» under-anticoagulation (AOR 1.67, p=.05) » over-anticoagulation (AOR 3.44, p=.01)

Literacy, Discordance and Safety

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):

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? “

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.

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

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: 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