1. Making Sure Your Message is Understood
TEACH BACK
Module 2
Welcome to the training called Teach Back: Making Sure Your Message is Understood
The purpose of this training module is to understand health literacy and it’s impact on the patient’s ability to understand and act upon information. The participant will learn strategies and techniques designed to enhance and assess the patient’s understanding of educational concepts.
This intervention is designed to identify and correct misunderstandings of health information, engage the patient in their care and improve outcomes.
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Making Sure Your Message is Understood
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2. Upon Completion of this Module the Participant Will Be Able To:
Module 2 Teach Back
Upon Completion of this Module the Participant Will Be Able To:
Define health literacy
Describe the health care experiences of low-literacy patients
Understand health literacy and its impact on the patient’s ability to understand information
Implement techniques shown to improve communication with low-literacy patients

3. Health Literacy Defined:
Module 2 Teach Back
Health Literacy Defined:
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
The key aspect when thinking about health literacy is that people have trouble understanding health information. Most of the research to date has focused on the barrier of low general literacy. Low literacy is, indeed, an important barrier and one we need to keep in mind. However, we can all recognize that a large part of the problem in health care is the complexity of the system and the complexity of information we give to our clients.
Healthy People nd ed. With Understanding and Improving Health and Objectives for Improving Health.

4. Low Health Literacy Can Affect the Patients Ability To:
Module 2 Teach Back
Low Health Literacy Can Affect the Patients Ability To:
Read prescription bottles
Figure out appointment slips
Understand informed consent documents
Understand discharge instructions
Follow diagnostic test instructions
Read health education materials
Complete health insurance applications
Health literacy is context-specific

5. Health Literacy in America
Module 2 Teach Back
Health Literacy in America
12%
14%
22%
53%
Proficient: Define medical term from complex document, Calculate share of employee’s health insurance costs
Intermediate: Determine healthy weight from BMI chart, Interpret prescription and over-the-counter drug labels
Basic: Understand simple patient education handout
Below Basic: Circle date on appointment slip, Understand simple pamphlet about pre-test instructions
Kutner et al 2006

6. High Risk Groups Include:
Module 2 Teach Back
High Risk Groups Include:
Elderly
Minorities
Immigrants
Poor
Homeless
Prisoners
Persons with limited education
Schillinger et al 2003

7. The Effect on the Health Care Experience
Module 2 Teach Back
The Effect on the Health Care Experience
Low-literacy patients commonly hide their difficulty
Many feel ashamed
Use avoidant behaviors
Don’t ask questions
Take a moment and think about how you think someone with limited reading ability might feel?
Many feel ashamed
Use avoidant behaviors
Don’t ask questions
Additionally this population may feel:
Exhausted
Numb
Withdrawn
Intimidated
Powerless
Parikh et al Weiss 2003.

8. Universal Precautions for Health Literacy
Module 2 Teach Back
Universal Precautions for Health Literacy
Because you can’t tell by looking, it is important to deliver healthcare information in a standardized way at all times.
As a clinician it is your job to be familiar with the concept and recognize common red flags that indicate low health literacy.

9. You Can’t Tell By Looking!
Module 2 Teach Back
You Can’t Tell By Looking!
Patients are very savvy in masking the signs of limited health literacy, as there is a great deal of shame associated with this. In fact, one study found that 24% of individuals who suffered from limited health literacy had never informed their spouse.

10. Recognize Red Flags Seeking help only when illness is advanced
Module 2 Teach Back
Recognize Red Flags
Seeking help only when illness is advanced
Making excuses
Becoming angry/demanding or quiet/passive
Unable to name medications or explain purpose or timing of administration
Difficulty explaining medical concerns
Have no questions
Frequently missing appointments, tests
Non-compliant with meds or treatment
It is important to become familiar with the concept and recognize common red flags that indicate low health literacy.

11. Strategies to Improve Communication
Module 2 Teach Back
Strategies to Improve Communication
Explain things clearly in plain language
Focus on key messages and repeat
Use a “teach back” technique to check understanding
Effectively solicit questions
Use patient-friendly educational materials to enhance interaction
Weiss Kripalani and Weiss 2006.

12. Explain Things Clearly in Plain Language
Module 2 Teach Back
Explain Things Clearly in Plain Language
Slow down the pace of your speech
Use plain, non-medical language
“Blood pressure pill” instead of “antihypertensive”
Pay attention to patient’s own terms and use them back
Avoid vague terms
“Take 1 hour before you eat breakfast” instead of “Take on an empty stomach”

13. What Could We Say Instead Of…
Module 2 Teach Back
What Could We Say Instead Of… 
Side effect
Low sugar
When you need it
Pill that goes in your bottom/behind
On skin
Adverse reaction
Hypoglycemia
PRN
Suppository
Topical

14. Focus on Key Messages and Repeat
Module 2 Teach Back
Focus on Key Messages and Repeat
Limit the amount of information given at one time to 1-3 key points
Develop short explanations for common medical conditions and side effects
Focus on what the patient needs to know and do, rather than general concepts
Review each point at the end
The principle behind this approach is that advice is remembered better, and patients are more likely to act on it, when the advice is given in small pieces and is relevant to the patient’s current needs or situation. Make sure that the patient understands what to do to manage their care at home.
Repeat messages several times.
These key messages should be repeated several times during the visit and summarized/reviewed at the end because people learn more effectively when they hear things more than once.
Have staff reinforce key messages.
Working with your staff to reinforce the key messages is also very effective. Ideally, the information will be reviewed and repeated by multiple members of the health care team, the physician, nurse, pharmacist, dietician, and others.
Repetition can also be achieved through handouts that reinforce key points. Consider reading the handouts to patients to emphasize the importance of the information. If the handout is too long to read, it may be too complex.

15. Use “Teach Back” To Assess Understanding
Module 2 Teach Back
Use “Teach Back” To Assess Understanding
Teach back can help us close the loop between patient education and patient understanding.
Teach back helps identify people who do not understand and creates an additional teachable moment to reinforce the information provided.
Schillinger et al 2003

16. Understand the “Teach Back” Diagram
Module 2 Teach Back
Understand the “Teach Back” Diagram
Explain a new concept
Assess the patient’s recall and understanding
Clarify your explanation as needed
Reassess comprehension
Continue to clarify until the patient expresses satisfactory understanding
Ask the patient to demonstrate understanding.
The teach back allows you to check for understanding and, if necessary, re-teach the information.
This technique creates the opportunity for dialogue in which information is given, then encourages the patient to respond and confirm understanding before adding any new information.
We must ask the patient to explain or demonstrate understanding in a way that is not demeaning.
Example: “What will you tell your spouse about your condition?”
It is important not to appear rushed, annoyed, or bored during these efforts – your affect must agree with your words.
Do not ask, “Do you understand?”
Never ask this….You are likely to get a “yes” whether or not they understand. This technique is not considered effective.
Research also indicates that “teach back” works.
“Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on strength of scientific evidence.

17. Teach Back Scripts I want to make sure I explained everything clearly.
Module 2 Teach Back
Teach Back Scripts
I want to make sure I explained everything clearly.
“If you were trying to explain to your husband how to take this medicine, what would you say?”
Let’s review the main side effects of this new medicine.
“What are the 2 things that I asked you to watch out for?”
Show me how you would use this inhaler.

18. Effectively Solicit Questions
Module 2 Teach Back
Effectively Solicit Questions
Don’t ask:
Do you have any questions?
Any questions?
Instead say:
What questions do you have?

19. Summary Module 2 Teach Back
Step 1: Using simple lay language, explain the concept or demonstrate the process to the patient/caregiver. Technical terms should generally be avoided. If the patient/caregiver has limited English proficiency, a professional translator should be utilized to reduce miscommunication.
Step 2: Ask the patient/caregiver to repeat in his or her own words how he or she understands the concept explained. If a process was demonstrated to the patient, ask the patient/caregiver to demonstrate it, independent of assistance, for the clinician.
Step 3: Identify and correct misunderstandings of or incorrect procedures by the patient/caregiver.
Step 4: Ask the patient/caregiver to demonstrate his or her understanding or procedural ability again to ensure the above-noted misunderstandings are now corrected.
Step 5: Repeat Steps 4 and 5 until the clinician is convinced the comprehension of the patient/ caregiver about the concept or ability to perform the procedure accurately and safely is ensured

20. References Module 2 Teach Back
Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Assessment of Adult Literacy (NAAL) .
Kripalani S, Weiss BD. Teaching About Health Literacy and Clear Communication. Journal of General Internal Medicine. 2006;21(8):
ParikhN, Parker R, Nurss J. Shame and health literacy: The Unspoken Connection. Patient Education and Counseling ;25:
Partnership for Clear Communication
Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K; Castro C, Bindman AB. Closing the Loop: Physician Communication Schillinger et al 2003.
U.S. Department of Health and Human Services. Healthy People nd ed. With Understanding and Improving Health and Objectives for Improving Health.
Vogel DR, Dickson GW, Lehman JA. Driving the audience action response. In: Petterson R. Visuals for Information: Research and Practice. Englewood Cliffs, NJ: Education Technology Publications, 1989.
Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association and American Medical Association Foundation; 2003
AHRQ, 2001 Report on Making Health Care Safer

21. Module 2 Teach Back
This material was prepared by AQAF, the Medicare Quality Improvement Organization for Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents do not necessarily reflect CMS policy. 9SOW-AL-CT-10-52

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