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Our presentation today is about teach-back and health literacy.

Don’t worry about taking notes. We’ll have copies of our presentation notes available at the end of our talk today. The notes are also posted on our department website. We’ll share that information at the end of the slideshow.

We’re going to get started with a short video from the American Medical Association. This video reveals the prevalence of low health literacy. It underscores how important it is that we use a method like teach-back to make sure patients understand the health information we give them. http://www.youtube.com/watch?v=BgTuD7l7LG8&feature=related

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http://www.youtube.com/watch?v=BgTuD7l7LG8&feature=related

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What are health literacy and teach-back?

Health literacy is the ability to receive, understand, and act on health information. A high level of education and general literacy does not ensure a person’s health literacy. And, a person’s health literacy decreases when they are ill, under stress, or on some medications.

Teach-back is a simple 3-step process that will help you assess whether your patients understand health information you explain to them.

Teach-back does not require you to do more in the short time you may have with a patient.

But, using teach-back may mean making some changes in your communication style.

Clinicians in many settings are realizing how important it is to use a method such as teach-back to make sure their patients understand the information they are given.

An article about kidney disease appeared in The New York Times’ “Personal Health” section recently. Its opening story tells a lot about how important it is to have the learner teach back the information you have taught. The article begins:

“A patient with early-stage kidney disease provided a recent wake-up call for Dr. Joseph Vassalotti, a leading kidney specialist. After explaining the diagnosis in great detail, the doctor asked his patient to repeat what he had heard in his own words.”

“With a rather bored look on his face, the man replied, ‘Kidney disease, yada yada yada yada.’”

* * * * * *

Are your patients thinking, “yada yada yada yada?”

How do you know?

Source: Doctors Hone Message on Kidney Disease, By JANE E. BRODY Published: August 22, 2011


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The U.S. Department of Health and Human Services recently published research that showed nearly 9 out of 10 adults have difficulty using the everyday health information that we regularly have access to. Think about how many messages about health we get every day – on TV, the radio, the Internet, magazines in the checkout line, the newspaper, the health club, and more. The messages are not all reliable, but they’re everywhere.

As an example, the bottom half of this slide is part of a fact sheet about prednisone that appears on PubMed Health, a website for consumers provided by the U.S. National Library of Medicine.

According to the research from Health and Human Services, 90% of the population have a hard time using this information.

Health literacy is not usually something you can identify easily. People who are not literate generally don’t share this information because of feeling ashamed for not understanding or not being able to read written information.

When English is a patient’s second language, special care must be taken when teaching health care information. Here are two stories recently reported by Interpreter Services at UWMC: The surgery nurse manager was concerned about a recent post-discharge call to a Vietnamese patient. Their conversation revealed that Mr. D. had almost a complete lack of understanding of his discharge instructions.

• Mr. D. had no idea which doctor his surgeon was and which doctor his primary care provider was, so he did not know who to call if he had questions.

• He had not taken any of his pain medications because he said he did not want to get constipated, although he had also received a separate medication for constipation.

• He did not know what signs or symptoms he should watch for as danger signs.

Mr. D. is an 85-year-old Vietnamese man. He had received post-surgical instruction through an interpreter, but without any family member present. He was not given any written or visual materials to reinforce the teaching.


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The second story is about a middle-aged Spanish-speaking man who was discharged from a surgical unit: A nurse called Mr. M. at home to follow up on his discharge teaching. His instructions had included:

• Ambulate as tolerated starting the first day at home – but do not exert.

• Do not lift more than 10 pounds.

• Stay off work until a follow-up clinic appointment in 4 weeks, at which point doctor will decide whether it is OK for him to go back to work.

In the phone call, the nurse asked Mr. M. how he was. He said he was fine. When the nurse asked if he had any questions, he asked:

• “Do I need to stay in bed all the time for 4 weeks? I really need to go back to work next Monday.”

• “And do I really have to lift 10 pounds like the nurse told me I had to? That sounds too heavy for me.”

Teach-back is a way to check whether your patients understand the health information and instructions you explain to them.

It’s a simple three-step process:

1. Explain

2. Check

3. Re-explain if needed

Teach-back is really just a combination of common sense and being sensitive to a patient’s needs and feelings.

Teach-back is a way to check whether YOU explained something in a way your patient understands.

It is NOT a test of patients to see if they understand.


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Clinical care is undermined if patients and their caregivers don’t know what to do when they go home. Without teach-back, you won’t know if your patient will be able to follow your instructions.

When you ask your patients to teach back what you explained, you will quickly learn if they understand. If they don’t, you can re-explain information in a way they do understand.

Teach-back is a way to “close the loop” between your teaching, the patient’s understanding, and best health outcomes.

Teach-back helps engage patients and families in their health care and what you are teaching them. Every patient interaction with every provider is a teaching opportunity. Patients learn from their doctors, nurses, social worker, pharmacist, and others.

Using teach-back creates an opportunity to talk with your patients about their ability to take care of themselves and understand their health condition.


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Teach-back helps ensure that the care patients receive results in the desired health outcomes. It also helps reduce preventable readmissions.

Here’s a quote from Fran London, Health Education Specialist at Phoenix Children’s Hospital. She has written a book about health literacy and teach-back called No Time to Teach.

“We health care providers actually provide very little direct health care. We intervene and help folks over the hump of acute situations, but more often than not, we provide instructions and prescriptions. Most health care is self-care.”

This recent article from In Focus, a publication of the National Center for Ethics in Health Care, emphasizes the importance of teach-back in good communication:

“Effective communication promotes great satisfaction and helps ensure better adherence to treatment plans, with better health outcomes for patients.

“Good communication also reduces the likelihood of lawsuits even when the patients don’t have good outcomes.”


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And this article from a busy pre-anesthesia clinic explains that teach-back is time-efficient:

It says:

“We’re the busiest clinic in the hospital. We were afraid teach-back would slow us down to the point of being nonfunctional. But my clinic is proof that teach-back doesn’t slow you down.”

In fact, this clinic has found that teach-back saves time in many ways, since it also results in fewer cancellations and fewer preventable readmissions.

Health literacy is the ability to receive, understand, and act on health information.

If both of these individuals were health literate, they would understand their health conditions and be able to participate more effectively in their own care.

The man would know that hypertension is the medical term for high blood pressure, and the pills he and his doctor are talking about are to treat it. They are not to treat a nervous condition he doesn’t have.

The woman may have chosen NOT to have a hysterectomy.

Although we can’t tell whether or not someone is health literate by how they look or speak, patients often give clues that they are not health literate. Some of these cues are:

• Filling out forms incompletely or inaccurately

• Not taking medicines correctly, even though they say they are doing so

• Not following through with lab tests or referrals to other providers

• Missing appointments

• Nodding as though they understand what you are explaining

• Not having any questions or comments after you’ve given several details about their illness or treatment


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A patient with low health literacy (or low literacy in general) might respond in these ways when asked to fill out forms or read health information:

• “I forgot my glasses. I’ll read this when I get home.”

• “I forgot my glasses. Can you read this to me?”

• “Let me take this home so I can show it to my children (or husband, sister, wife, etc.).”

A patient with low health literacy may not be able to:

• Tell you what medicines they take.

• Explain why they are taking these medicines.

• Tell you when and how to take their medicines.

A Vietnamese interpreter at UWMC recently reported that doctors often tell their patients to take Tylenol or ibuprofen. The interpreter stated that most Vietnamese patients do not know what these drugs are or what they are for. Even if the doctor writes down the name of the drug, most Vietnamese patients who need an interpreter do not know where to buy it or how to take it.

The interpreter stated that she often needed to add information to the doctor’s instructions to Vietnamese patients, to tell them what the medicine is and what it is for. The interpreter also has learned to ask the doctor to explain how to take the medicine and where to get it.

Health literacy involves being able to:

• Navigate the health care system

• Understand how to do self-care procedures

• Understand insurance policies and billing

Health literacy may be related to education and general literacy – but being highly educated does NOT guarantee being health literate.

A patient who is not health literate may not understand the medicine you prescribe, the procedure you recommend, or the explanation of their illness.

Using teach-back quickly tells you if your patient has grasped what you said. Teach-back gives you the opportunity to re-explain, if needed, before the appointment is over. Doing so may help avoid potentially costly or serious complications, such as a medication error or a preventable readmission.


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Here’s a recent example of how health literacy and teach-back affected a patient’s experience at UWMC: Mr. S was a post-transplant patient who developed type 2 diabetes that required insulin as a result of immunosuppressant meds. At his first visit in the Diabetes Care Center, Mr. S’s average blood sugar was 287, and his blood glucose range was 87 to 537. His hemoglobin A1C was 13%.

Mr. S met with dietitian in Diabetes Care Center for diabetes management and help with meal planning. He said he’d met with a dietitian while he was an inpatient. He remembered talking about cutting back on fat and salt, but he didn’t remember talking about a diabetes diet. He remembered the number “30,” so that’s how much fast-acting insulin he was taking before meals.

But, that was actually twice the amount he had been told to take. And, because it caused his blood sugar to crash, he didn’t take it regularly. Thirty was actually the number of units of long-acting insulin he had been told to take once a day.

As he continued talking with the diabetes dietitian, Mr. S stated he didn’t understand the instructions he had received from Transplant.

As they talked, the dietitian realized that Mr. S had low numeracy skills. He had been given charts to help him adjust his meal-time insulin dose, but the numbers on the chart made no sense to him. He also did not understand the instruction to “take 1 extra unit to drop ‘BG’ 50 points if over 150.” Not only were the numbers were confusing -- he also did not remember what “BG” meant.

Mr. S and the dietitian worked together to come up with a system that worked for him. This slide shows the form that they created. They used grey and blue color-coding for what type of insulin to take when, based on the color of the insulin pen of each type of insulin Mr. S used. And the dietitian created a chart that showed Mr. S how to adjust his meal-time insulin dose depending on his pre-meal blood glucose. Mr. S was able to teach back the information on this chart, showing that he truly understood his self-care plan.

After three visits over the course of several months, Mr. S’s average blood glucose went from 287 to 149.

Teach-back can help you determine if your patient will be able to take their meds correctly.

You can also use teach-back to find out whether your patients understand the information on:

• Appointment slips

• Consent forms and health history forms

• Test results


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And teach-back can help you determine if your patient will be able to read the handouts you have given them.

It is only when you know if patients understand that you can help them take care of themselves.

A patient who doesn’t understand instructions can’t follow them.

We’re going to talk about how to use teach-back in your day-to-day interactions with your patients – and specifically, how to use a method called “chunk and check.”


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Step 1 is the “chunk” step of “chunk and check.” • Give your patient information one “chunk”

at a time. Use plain language, with as few complex terms as possible.

• Explain only the essential information your patient needs at this time. It’s important not to overload your patients with too much information.

• If you are explaining more than one concept, start with the most important two or three things.

Step 2 is the “check” step. Ask your patient to explain back to you, in their own words, what you have told them.

Here are some things you might say to check whether your patient understood your teaching:

• “I want to be sure I explained how to take this medicine clearly. Can you please explain it back to me so I can be sure I did?”

• “Your husband couldn’t come with you today, like he usually does. What will you tell him about the changes we made to your medicines today?”

• “We’ve gone over a lot of information about adding exercise to your day. In your own words, tell me what we talked about and how you will make it work at home.”

If your patient is able to teach back what you have explained so far and you have more information to give, use the chunk and check method with the new information. Explain the next concept in plain language, then check for understanding again before moving on.

If your patient does not understand something, think back on the first few slides of this presentation. Remember “yada yada yada”?

Ask yourself:

• Did I use medical terms that are foreign to my patient?

• Was my explanation too detailed? Did I give more information than the patient needs?

• Did I assume my patient understood information I had provided in previous visits, that this new information builds on?


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The pictures on this slide give just a few examples of times when you can use teach-back. No doubt you are already thinking of the opportunities you have every day to use this method.

The next few slides give some tips for using teach-back.

Teach-back Tip #1 is to set the stage. Before you even meet with a patient, it may be helpful to come up with a basic “teach-back” script that you can refer to when asking your patients to teach back health information you’ve explained. Since you may have similar patient interactions throughout your day, you can use the same basic script with different patients.

At the beginning of each patient visit, let your patient know that you’ll be asking them to participate in the visit by teaching back to you information you’ve given them. Also tell them to let you know if they’re feeling overwhelmed and they need you to slow down.

Setting up your visits this way gives your patients permission to participate. This may be especially important for patients from cultures where participating is not the norm and may even be a sign of disrespect toward the clinician.

Teach-back Tip #2 is to avoid using questions that can be answered with “yes” or “no.” People often say “yes” to yes/no questions, for a variety of reasons:

• They may be embarrassed that they don’t understand and don’t want to appear stupid.

• There may be cultural reasons they are saying yes. Your patient may be reluctant to say “no” to a doctor or health care provider because they don’t want to be disrespectful.

• Your patient may nod, smile, and/or say “yes” to acknowledge they heard you, rather than to indicate that they understand or approve.

Instead of saying: “Do you understand why I’m prescribing this medicine?” You could say: “Please tell me why I’d like you to take this medicine.”

Instead of saying: “Does my explanation of your illness make sense to you?” You could say: “Please tell me in your own words why I think you got sick.”


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Teach-back Tip #3 is to think of teach-back as a way to check how you are doing.

When your patient does not understand health information you have explained, it lets you know that it needs to be said in a different way.

Remember, teach-back is a way to check to see how well you explained or taught the information. It is not a test of your patients’ ability to understand.

Teach-back Tip #4 is to put yourself in your patient’s shoes.

We can all think of a time when our ability to understand or act was compromised. Maybe it was because of a physical condition, like a broken leg or having the flu, or maybe a stressful situation at home or at work was preoccupying us. Or maybe we just got a diagnosis that requires rigorous treatment and will change our life forever.

Your patients are no different. When you are meeting with them, keep in mind that their ability to focus and take in information may be compromised because of worry over their diagnosis and the treatment they are facing, or because they don’t feel well, or because they are wondering how they are going to pay for their care, or for many other personal reasons.

Teach-back is way to have a conversation with your patients. It will give you valuable information about what you need to do next to provide what they need at that moment.

We’d now like to introduce our guest speaker, Maria Ross. Maria is a Patient Advisor at UWMC. Patient Advisors work with UWMC staff to improve the patient care experience at the medical center.

Maria will tell you her first-hand story of receiving care at Harborview and UWMC, and how health literacy and teach-back played important roles.


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As we consider what it means to “put ourselves in our patient’s shoes,” we also need to be aware of cultural differences.

Remember the elderly Vietnamese patient we talked about earlier in this presentation?

This 85-year-old Vietnamese man had received post-surgical instruction through an interpreter, but without any family member present. In Vietnamese culture, it would be unheard of for an elderly man to be expected to take care of himself.

If the nurse doing discharge teaching had known this about Vietnamese culture, she would have asked that the person who would be his caregiver be present during discharge teaching.

Patient and Family Education Services has created “Culture Clues” to assist clinicians when interacting with their patients of various cultures, in particular with those patients for whom English is a second language.

“Culture Clues” include sections on how the culture traditionally deals with illness, how medical decisions are often made, and some of the culture’s norms about touch, hygiene, and health.

There is also a generic “Culture Clue” for communicating with all patients in ways that will improve the provider-patient relationship.

All “Culture Clues” are available on the Patient and Family Education Services website. Cultures include Albanian, American Indian, Chinese, Deaf, Hard of Hearing, Korean, Latino, Russian, Somali, and Vietnamese. There are also “End-of-Life Culture Clues” for Latino, Russian, and Vietnamese cultures.

We’re going to end our presentation with a few quotes we’ve found as we’ve researched teach-back.

The first is from a resident physician in a pediatric office who had this experience when trying teach-back:

“With one mother and her child, I ended the visit by saying, ‘So tell me what you are going to do when you get home.’

“The mother just looked at me without a reply. She could not tell me what instructions I had just given her. I explained again and then she was able to teach them back to me.

“The most amazing thing about this ‘ah ha’ moment was that I had no idea she did not understand until I asked her to teach it back to me. I was so wrapped up in delivering the message that I didn’t realize it was not being received.”


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The use of teach-back is becoming more widespread, but we still have a long way to go. The senior medical director of a large health insurance company in Pennsylvania said recently:

“I got more instructions on how to take care of a goldfish I took home from the pet store as a kid than we give some people we send home from the hospital.”

And Dr. Fred Marsh of the Iowa Health Study stated that:

“In the absence of teach-back, the only indicator of misunderstanding may be a medication mistake or patient error…”

______________________________________

A couple of thoughts we’d like to leave you with:

If teach-back is new to you, remember: We’re not suggesting you do more in the time you have, just that you do it a little differently.

And, if you are already incorporating teach-back in your interactions with patients, we hope this presentation has helped reinforce your practice.

Here are some of the resources used in preparing for this presentation on teach-back.

Slide 45

Please feel free to contact us if you have questions about teach-back, health literacy, “Culture Clues,” or related issues.


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