Techniques in Teach-Back & Ask Me 3 Audrey Paulman, MD, MMM Jennifer Geisert, RN, BSN This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement Organization for Nebraska, under contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NE-CT-108/0113 Objectives 2 Participants will be able to: Describe the Teach-Back principle State correctly how to solicit questions from patients Verbalize one Teach-Back script Verbalize the three questions that comprise ASK Me 3 Verbalize why it is important to encourage patients to utilize ASK Me 3 3 Standard Communication to Check for Understanding Tools exist to make sure physician and patient, or patient s family, understand the instructions Examples: Teach-Back Ask Me 3 1
Teach-Back Method 4 Creates an opportunity for dialogue in which the provider gives information, then asks the patient to respond and confirm understanding before adding any new information Re-phrase if a patient is not able to repeat the information accurately Ask the patient to teach back the information again (using their own words) until you are comfortable they really understand it If they still do not understand, consider other strategies Teach-Back Method 5 40-80 percent of medical information patients receive is forgotten immediately Nearly half of the information retained is incorrect 1. Kessels RP. Patients' memory for medical information. J R Soc Med. May 2003;96(5):219-22. 2. Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1):18-22. The Research Behind the Method 6 Asking that patients recall and restate what they have been told is one of 11 top patient safety practices based on the strength of scientific evidence. - AHRQ 2001 Report - Making Health Care Safer Physicians application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients. - Schillinger, Arch Intern Med/Vol 163, January 13, 2003, Closing the Loop 2
Teach-Back: Closing the Loop 7 Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003 Asking for a Teach-Back: Examples 8 Ask patients to demonstrate understanding, using their own words: I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did? What will you tell your husband about the changes we made to your blood pressure medicines today? We ve gone over a lot of information and several things you can do to get more exercise in your day. In your own words, please review what we talked about. How will you make it work at home? Teach-Back 9 Do not ask yes/no questions, such as: Do you understand? Do you have any questions? 3
How To Use it Well. 10 Responsibility is on the provider Use a caring tone of voice and attitude Use plain language Ask patient to explain using their own words (not yes/no) Can be used in all patient education, specific to the condition Teach Back Methods 11 This is not a test of the patient's knowledge. This is a test of how well you explained the concept Use with everyone: Use teach-back when you think the person understands and when you think someone is struggling with your directions Teach to all staff: All members of the practice staff can use it to make sure their communication is clear What is Health Literacy 12 The ability to read, understand and act on health Information Health literacy is an emerging g public health issue that affects all persons regardless of age, race and income levels Research shows that most consumers need help understanding healthcare information; patients prefer medical information that is easy to read and understand 4
The Scope of Low Health Literacy 13 The health of 90 million people in the U.S., may be at risk because of the difficulty some patients experience in understanding and acting upon health information 1 One out of five American adults reads at the 5 th grade level or below and the average American reads at the 8 th to 9 th grade level, yet most healthcare materials are written above the 10 th grade level. 3 More than 66% of U.S. adults age 60 and over have either inadequate or marginal literacy skills. 3 The Impact of Low Health Literacy 14 Annual healthcare cost for individuals with low literacy skills are 4 times higher than those with higher literacy skills. 4 Patients with low literacy skills were observed to have a 50% increased risk of hospitalization, compared with patients who had adequate literacy skills. 7 15 Research Suggests that Persons With Low Literacy: Make more medication or treatment errors 6,8 Are less able to comply with treatments 2 Lack the skills needed to successfully negotiate the healthcare system 4,7 Are at a higher risk for hospitalization than those with adequate literacy skills 7 5
Ask Me 3 16 Is dependent on the patient asking the three questions May not be enough to increase patient engagement in the process It does raise awareness among healthcare workers and helps them to structure communication Ask Me 3 17 Tool for physician, nurse or pharmacist and patient communication Questions will be asked by patient or family Reviews knowledge of basic disease, warning signs and patient s role in care 18 6
19 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 20 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 21 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 7
22Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 23 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 24 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 8
25 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 26 Source: Alliant/GFMC, the Medicare Quality Improvement Organization (QIO) for Georgia 27 9
Resources 30 NPSF, National Patient Safety Foundation Health Care Professional resources Health Literacy Patient Brochures (in English and Spanish) at www.npsf.org If you would like information about patient t brochures and posters in Arabic, Chinese, French or Russian, please send an email to info@npsf.org 10
References 31 1. Kirsch et al. A First Look at the Results of the National Adult Literacy Survey. Nat l Center for Education Statistics, 1993. 2. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association/American Medical Association Foundation, 2003. p. 7. 3. Doak CC, Doak LG, Root JH. The literacy problem. In: Teaching Patients With Low Literacy Skills. 2nd ed. Philadelphia: J.B. Lippincott Co. 1996: 1-9. 4. Weiss, BD, ed. 20 Common Problems in Primary Care. New York: McGraw Hill. 1999: 468-481. 5. Center for Health Care Strategies, Inc. Health Literacy and Understanding Medical Information Fact Sheet. 1997. 6. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015. 7. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998; 13: 791-798. 8. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996; 5(6): 329-334. Contact Information 32 CIMRO of Nebraska 1230 O Street, Suite 120 Lincoln, Nebraska 68508 P: 402.476.1399 F: 402.476.1335 www.cimronebraska.org 11