A Guide to Educating Patients

Patient Education - Introduction

What is Patient Education?

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 patients health care team needs to be involved

Patient Education - Introduction

Patient Education Value The results of clear communication

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 youve 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 Research

Targeted Programs Reduce the Risks that Increase Costs

Patient Education Rationale

Model of Patient Education Outcomes

Knowledge and Attitude Changes

Health Status

Increased understanding Increased confidence Increased satisfaction Improved emotional state

Physical health Well-being Symptoms Complications

Patient Education

Print Verbal Multimedia Combination

Behavior Changes

Health services utilization Compliance Lifestyle Self-care

Costs Length of stay

Utilization Provider image Regulatory compliance

Patient Education - Introduction

The Effective Educator

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 Ive explained things clearly?

Patient Education - Steps

Four Steps to Educating

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 youve set together. Document Create a written history and keep records.

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

Maximizing Teaching Moments

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!

Patient Education Step 1 - Assessment

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.

Patient Education Step 1 - Assessment

Grasping Patient Concerns

Avoiding Assumptions

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

Getting to Know Your Patient

+ Review the patients 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

Patient Education Step 1 - Assessment

Recognizing Diversity

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

Patient Education Step 1 - Assessment

Grasping Patient Concerns

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 whos in a photo Ask about a book the patient may be reading

Learning the Patients 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.

Patient Education Step 1 - Assessment

Asking the Right Questions

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.

Closed
Are you upset? Are you in pain? Is this hard for you to deal with? Are you taking your medicine every day?

Open
Whats 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

Grasping Patient Concerns

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 patients 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

Patient Education Step 1 - Assessment

Understanding the Support Network

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 Patients Support

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

Does the patient . . .

Seem pleased with this persons input? Look forward to visits with this person?

Does the support person . ..

Appear with the patient frequently? Show concern for the patient?

Interact favorably with this person?

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 ready to move on to the next phase

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

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

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

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

Patient Education Step 2 - Planning

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!

Patient Education Step 2 - Planning

Setting Goals

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.

Patient Education Step 2 - Planning

Building Bridges

Effective Plan

+ Essential Skills what a

patient needs to know

+ Benefits and Barriers what a

patients concerns are

+ For a plan to be effective, you

must find ways to build bridges between patient needs and patient concerns.
Patient Needs

Bridge
Patient Concerns

+ The bridges you build will be

framed by what you learned during assessment

Patient Education Step 2 Planning

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

Patient Needs
Patient should exercise

Patient Concerns
Exercising hurts

Bridge
By exercising, youll improve muscle strength, which lessens pain. Lets find an exercise that works for you.
Chemo kills quick-growing cells, like hair and cancer. In the meantime, lets see what kind of hat, turban, or wig we can find. Low-cholesterol foods can be tasty. Here are some great recipes. And you can also treat yourself once in a while.

Chemotherapy is required

My hair will fall out

Heart patient should lower cholesterol.

I wont get to eat all of my favorite foods

Patient Education Step 2 - Planning

Setting Goals

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. organizations. Be careful they are not biased!!

+ Premade plans may be available from pharmaceutical companies or other + 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.

Patient Education Step 2 Planning

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

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

Skills: How will the plan develop the lifeenhancing or essential skills your patient needs?

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?

Behavior: How will the plan influence or even change your patients behavior?

Patient Education Step 3 - Implementing

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 patients ability to meet goals.

Patient Education Step 3 Implementing

Getting your Message Across

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

Patient Education Step 3 Implementing

Getting your Message Across Your priorities and your patients should be clearly stated, mutually understood, and mutually agreed upon.

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

Patient Education Step 3 Implementing

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

Alerting Patients to Whats 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.

Patient Education Step 3 Implementing

Getting Your Message Across

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

Patient Education Step 3 Implementing

Getting Your Message Across

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 youve coached on so

your team knows whats been covered

+ Ask your patient to demonstrate what he

or she has learned.

Patient Education Step 3 Implementing

Reinforce the message: Choosing the right patient education materials

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

Patient Education Step 3 Implementing

Reinforcing the message: How to use patient education materials

Highlight Key Concepts

+ Open and flip through the booklet or brochure with the patient + Write in any notes of your own
Check a Patients Understanding

+ Ask your patient to repeat complex explanations back to you

Involve a Patients 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

Patient Education Step 3 Implementing

Overcoming Challenges

Reassessing Patient Concerns

+ Patients can become resistant + Physical and emotional stress of illness can present challenges + Ask open ended questions to understand new concerns Whats 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 patients support person when appropriate. Reading Patient Signals

+ Continually assess and ease into your plan + Emphasize the benefits of education instead of nagging the patient

Patient Education Step 3 Implementing

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

Barrier
Denial, anger, anxiety, or depression

Behavior
Patient is distracted, disinterested, hostile, or doesnt believe theres a problem.

Implementation
Tell your patient that these feelings are normal, that anyone would be concerned. Use the opportunity to reassess for new concerns. Focus on managing your patient's pain before implementing the plan. Address patients fear, pain or anxiety first, and then focus on developing new skills. Try to give a wide variety of materials. Including demonstrations.

Physical Pain

Patient is unable to concentrate

Acute Illness

All patients energy is focused on coping with the illness. Patient finds it difficult to learn Patient finds it difficult to comprehend educational materials presented

Learning disability

Patient Education Step 3 Implementing

Evaluating Your Implementation

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

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?

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

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

Patient Education Step 4 Documenting

Documenting

Patient records inform colleagues what youve 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

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 patients needs and abilities.
RI.01.01.03 The hospital respects the patients right to receive information in a manner he or she understands RI.01.02.01 The hospital respects the patients 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 patients 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/nps gs.aspx

Patient Education Step 4 Documenting

Keeping Detailed Records

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

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 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

American Cancer Society

800-227-2345 American Diabetes Association 800-ADA-DISC (800-232-3472)

American Heart Association

214-373-6300

Resources
National Heart, Lung, and Blood Institute 301-251-1222 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)

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)

Sources
Consultants: Kate Lorig, RN, Dr.PH Associate Professor (Research) Patient Education Research Center Stanford University School of Medicine, Palo Alto, CA Virginia M. Gonzlez, 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