The existing regulations and accreditation standards honestly say little when you consider the impact that patient education and instruction have on a patient’s overall health. The disconnects between the information gathered during a patient’s hospitalization and the information used to develop meaningful patient specific education and training content rarely aligns, and while this disconnect can affect your regulatory survey and accreditation survey outcomes, it more importantly has the potential to have a negative impact on patient outcomes, experience and hospital readmission rates.
To begin to understand the problem we need to look at the Current State.
Having worked within the regulatory and accreditation arena for many, many years, the emphasis on patient education has waxed and waned over the years. Currently, requirements are not specific, not focused, and lack clear expectations. In fact, the only requirement that clearly addresses health literacy right now resides in the Primary Medical Home standards of the Hospital Accreditation Manual of TJC. All other references seem to have an unspoken inference to compliance.
Focusing our efforts on learning needs, we must begin with a core understanding of health literacy and its implications. The World Health Organization defines health literacy as “representing the personal knowledge and competencies that accumulate through daily activities, social interactions and across generations. Personal knowledge and competencies are mediated by the organizational structures and availability of resources that enable people to access, understand, appraise, and use information and services in ways that promote and maintain good health and well-being for themselves and those around them.” In simpler terms, it is the degree to which an individual has the capacity to obtain, process, and understand basic health information and services in order to make decisions about their health. According to The Agency for Healthcare Research & Quality, (AHRQ) only 12% of the American public is literate in health care.
In addition, only 54% of our population read at a level above sixth grade. When we couple these two statistics together, we have the beginnings of a recipe for failure, and this is before we factor in our neighbors that may have limited proficiency in English.
5 steps for assessing the meaningfulness of your patient education process.
Step 1: Reading Level and Literacy
An easy place to begin this body of work is to first begin assessing the literacy or reading level of your educational materials. Most document management software applications contain options to perform this function within the editing features of the application. While assessing the reading or literacy level of the document is easy, simplifying the language or finding proper word substitutes that convey the necessary message without using medical terminology can be challenging.
For instance, consider the below sentence:
“Insulin resistance is a condition that raises your risk for type 2 diabetes and heart disease. When you have insulin resistance, your body has problems using insulin. Over time, this makes your blood glucose (sugar) levels go up. The good news is that cutting calories, being active, and losing weight can reverse insulin resistance and lower your risk for type 2 diabetes and heart disease.”
This sentence was copied from several Diabetes Patient Educational materials currently in publication. Using the Flesch- Kincaid reading level system-which is commonly part of the proofing components of software, this sentence is written at a ninth-grade level. Recognizing these statistics and assessing overall our patient educational materials is essential if we do not want to leave 54% of our communities behind. Determining an individual’s degree of health literacy is essential in order to develop an educational plan that will meet their needs. This can be accomplished by conducting a Learning Needs Assessment and tailoring a patient’s education program to best meet their needs. Inquiring as to how a patient usually does when reading health care information can provide particularly useful information. Patients will often reply with things like:
- I do not read it – I let my spouse, child, neighbor read it and tell me what it says.
- I get enough information from it – but it takes me a long time to get through it…
- I throw it out.
Step 2: Individualization
Consider the individual patient. Take a look at your patient educational materials with the lens of an elderly patient, or patient with disabilities or someone that does not have a command of the English language.
When you look more closely at topics related to health literacy, many accrediting organizations set forth expectations related to the conduct of a patient-specific Learning Needs Assessment and specifically focus our attention on cultural/religious beliefs, emotional barriers, desire & motivation to learn along with physical and cognitive limitation which can identify the barriers and allow staff to adjust their education plan by making simple adjustments such as ensuring the patient has their reading glasses, hearing aids or translation service in place prior to beginning the education process.
Step 3: Eliminate redundant data gathering.
We recognize from our time with our various clients over the years that the Electronic Health Records companies have designed an educational process to meet a universal, global standard, a “One size for all” choice. And if the option is available, drilling down to specific patient education content based upon each individual patients assessed learning needs is cumbersome at best.
For instance, the patient’s primary language is identified immediately upon entry into the healthcare organization. It is again determined as a component of the initial nursing assessment and again as a component of the learning needs assessment. Could we save valuable time if the process were designed where this information was only collected once upon admission and was communicated to the care provider at various times depending on the care interventions being performed? Could software of the future be designed to recognize the patient’s preferred language and prohibit the printing of information for the patient in a language other than the language recorded in the record as the preferred language? Could the software be mapped to pull key pieces of information from the care plan and the nurses’ notes and flow sheets and populate an education plan with the key pieces of educational content that will help that patient most? Could it pull information that identifies that the patient needs glasses to read and automatically increase the font size of the printed materials?
Step 4: Create prompts for your staff.
Create straightforward ways to support your staff in supporting their patients. For instance, we routinely place signs for patients at risk for falls, how about signs with Eyeglasses on them, or Hearing aids images that attach to the whiteboards? Or a simple sign stating “ Italian” or “ Spanish” as a reminder to care providers of the patient’s needs to ensure effective, meaningful education and instruction.
There are currently no standards that speak to the determination of targeted education needs of the patient based upon the circumstances or conditions that have generated the visit to the hospital and the considerations that must be taken into account related to existing conditions or lived experiences that impact patient decisions. For instance, how do we convince a recovering substance user to allow us to manage their pain? Do we consider alcohol content in medications when prescribing for recovering alcoholics?
Step 5: Create a meaningful education process for each individual patient.
For approximately 12-18 months, organizations have been assessing their patients for their social determinants of health. These assessments focus on several core areas such as housing insecurity, community resources, food insecurity, transportation gaps or availability, and ability to secure medications. This information can give us specific, very targeted areas in which we can focus our patient education and instructions. Each organization should pause and review their patient educational materials. Does your organization have materials that can be provided to patients on how to secure medications when they cannot afford them? Are there materials around how to access care providers when transportation is not available or not affordable? Additionally, are these identified social determinants of health being incorporated into the patient’s plan of care or being used to inform the plan of care of special needs? If you are – KUDOS to you and your organization. If you are not, think about the impact you could have on one individual patient…
Where we fall short:
Let us spend a minute or two looking at just a few examples of education or instruction that are widely used. Let us use the lens that we have just spoken about:
Some very commonly used statements:
| If fever occurs, call your doctor…
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But there was no definition of fever provided.
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| Do not get dressing wet…
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But no instructions on how to avoid getting it wet and most importantly what to do if the dressing does get wet.
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| Watch for signs and symptoms of infection and call your doctor… | But there are no descriptions as to what signs/symptoms of infection are |
| Take your medications as advised by your physician… | Many hospitals have automatic substitution policies for medications, but rarely do we find clear direction or instruction as to what the patient should do. Do they continue with the substituted medication or go back to what they were using before admission, after all they have a 90 day supply they already paid for at home.
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In closing, we must remember:
- Our patients are older and sicker than in years past.
- Because of our ability to sustain life longer, more patients are dependent upon assistive devices of all types: hearing aids, eyeglasses, prosthetics, implanted devices, and mobility devices.
- English is not always the preferred language, nor is reading the preferred means to learn.
- Discharge plans are more complex, access to professional home support is more difficult to secure and the length of stay is shorter.
- The discharge information/education we are providing is not patient-centric and is designed in most cases to meet every patient’s needs and actually meets the needs of very few.
This means by focusing on the education and discharge instructions we provide to our patients is even more essential now for their success.
There is a huge opportunity to rework our patient educational materials and process. The timing is perfect for this as organizations begin to implement various virtual nursing models. Virtual nursing models almost always include the provision of patient educational materials and provision of discharge instructions as a virtual service. But we need to make certain that the CONTENT provides sufficient information for the patient to be successful at home.
The greatest opportunity lies in developing patient specific learning needs assessment as it creates the foundation or framework for the provision of education/training. It provides a consolidated/documented insight into the initiatives that will promote ongoing patient recovery post-discharge. When implemented correctly it brings together all of the documentation within the medical record that sets the foundation, identifies potential barriers, inclusive of barriers created by identified social determinants so that we can provide meaningful instruction to our patients.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
