• Using Teach-Back to Improve Patient Adherence—and Reduce Readmissions

    Jan 24, 2012

    By Jason Bramwell

    Iowa Health System is teaching clinicians and physicians to use several key teach-back strategies-such as use plain language and don't ask "yes" or "no" questions-to help patients better understand their healthcare instructions before discharge.


    Photo courtesy of St. Luke's Hospital, Cedar Rapids, Iowa.  

    A patient with heart failure is about to be discharged from the hospital. A nurse stops by to educate him about his water pill. After giving the instructions, the nurse says, "I want to be sure I was clear when I explained how to take your water pill. Please tell me how often and when you would take it, in your own words."

    "We want to be assured the patient understands this regimen before he leaves the hospital," says Suzanne Rita, RN, MSN, improvement learning network manager, Iowa Health System's Center for Clinical Transformation, Des Moines.

    Research shows that patients remember and understand less than half of what clinicians explain to them. Iowa Health System is hoping to change that through its "Always Use Teach-Back!" initiative.

    "During teach-back, the nurse asks open-ended questions in a nonshaming way so it doesn't sound like a test," says Gail Nielsen, director, learning and innovation, Iowa Health System. "The patients say back in their own words their healthcare instructions. This enables the nurse to check for understanding and, if necessary, to re-teach the information, and check again for understanding."

    Use of communication techniques like teach-back have been linked to improved patient outcomes-and reduced hospital readmissions, says Nielsen. For example, teach-back was successfully used to prevent readmissions of patients with heart failure at Santa Clara Valley Medical Center, San Jose, Calif. None of the 56 patients who received teach-back education were readmitted during a 90-day implementation period. (Garcia, C., "Teach Back Method: Improving Heart Failure Patient Education Retention and Preventing Readmission.")

    Ensuring Patient Understanding

    Iowa Health System is creating a teach-back training toolkit that is being funded by a $50,000 matching grant through the Picker Institute's Always Events® initiative. Always Events supports aspects of the patient and family experience that should always occur during interactions with healthcare professionals. The Always Events grant program provides matching funds in support of innovative approaches that achieve measurable improvements in patient- and family-centered care. (See the entire list of 2011 Always Events grant recipients.)

    The teach-back training toolkit-which will eventually be available through Iowa Health, Health Literacy Iowa, the Picker Institute, and the Institute for Healthcare Improvement-will help providers clearly communicate self-care information to patients and their families, including danger signs and symptoms to watch for after discharge and steps to take in case these symptoms occur. The toolkit will include training modules in three key areas:

    • Handoffs at hospital discharge
    • Primary care follow-up
    • Home health care

    "We hope to increase the number of patients who can teach back their warning signs and symptoms," says Nielsen. For example, a patient with heart failure is asked to monitor several symptoms at home, including:

    • Weight gain (three pounds in a day or five pounds in a week)
    • Swollen feet or ankles
    • Exhaustion or difficulty doing activities, like walking
    • Coughing

    "We would tell a heart failure patient not only when she should call the doctor if she has any of these symptoms, but how to get a hold of the doctor," says Rita.

    Using Teach-Back Effectively

    Iowa Health System plans to use the teach-back training toolkit to educate and coach physicians and nurses so they can incorporate teach-back into their daily practices. Nurses at 224-bed Iowa Lutheran Hospital and Iowa Health Home Care are currently testing the toolkit. Initial results are expected in March 2012.

    What makes a good teach-back experience? Mary Ann Abrams, MD, health literacy medical advisor for Iowa Health System, says there are several key strategies a clinician should consider:

    • Use plain language; don't use jargon.
    • Slow down when speaking.
    • Break the instructions down into short statements.
    • Do not ask "yes" or "no" questions (for example, "Do you understand?" or "Do you have any questions?").
    • Focus on the two or three most important concepts.
    • Use another strategy if a patient is unable to teach back.

    If a patient is unable to teach back, there are a few options a clinician can pursue:

    • Try again when the patient is not fatigued.
    • Explain the healthcare instructions to a family member or friend.
    • Reschedule an appointment.

    "Many patients can teach back on the first try, and most of the others can teach back the second time," says Abrams. "It's not real common to go more than two or three cycles. When patients are not able to teach back, then it's our responsibility as health professionals to ensure that a family member or other caregiver understands and can assist the patient and use teach-back with the patient, as well."

    Gaining Physician Engagement

    Iowa Health System is also asking its physicians to adopt teach-back. The biggest challenge is helping physicians overcome the perception that it will take a lot of extra time to use teach-back.

    To help alleviate that time concern-and help physicians become more comfortable using teach-back-the health system is suggesting that physicians start small, such as using teach-back once a day on their last patient (for example, their last patient of the morning or their last patient during rounds).

    "Our physicians are realizing that using teach-back doesn't take quite as long as they thought it would, and they are getting better and better at using it," says Abrams. "Physicians often have an 'a-ha' moment when they realize that, 'This person really did not understand.'"

    Extending the Use of Teach-Back

    Using teach-back is not only helpful in improving patient understanding-it can also help improve communication and handoffs among hospital staff on a day-to-day basis, says Abrams.

    One way to encourage the use of teach-back in various types of encounters: Invite hospital senior leaders to observe how nurses and other clinicians use the teach-back method with patients. "The better we get at doing this with patients, the better we will be at using this method with any other work that we touch," says Nielsen.

    Jason Bramwell is associate editor, newsletters & forums, HFMA (jbramwell@hfma.org).

    Interviewed for this article:

    Mary Ann Abrams, MD, is health literacy medical advisor, Center for Clinical Transformation, Iowa Health System, Des Moines, Iowa (abramsma@ihs.org).

    Gail Nielsen is director of learning and innovation, Center for Clinical Transformation, Iowa Health System (nielsega@ihs.org).

    Suzanne Rita, RN, MSN, is improvement learning network manager, Center for Clinical Transformation, Iowa Health System (ritasa@ihs.org).