1. Bridging the Communication Gap to Prevent Readmissions: The “Teach Back Method” (a.k.a. “Closing the Loop”) Dean Schillinger, MD UCSF Professor of Medicine Director, Center for Vulnerable Populations San Francisco General Hospital

2. Objectives l Provide 3 actionable tips to improve communication at discharge: »Reduce jargon »Assess for medication discordance »Use teach-back technique (aka teach-to- goal, closing the loop, show-me-approach)

4. Medical Jargon GLUCOMETER HEMOGLOBIN A1c DIALYSIS ANGINA RISK FACTORS CREATININE

5. Provide Health Education 29% Deliver Test Results 24% Provide Recommendations 37% Assess Symptoms 10% n = 60 Function of Jargon Castro, Schillinger AJHB 2007

6. Jargon Terms …unclarified l Glucometer l Immunizations l Weight is stable l Microvascular complication l System of nerves l HbA1c l EKG abnormalities l Dialysis l Wide Range l Risk factors l Kidney function l Interact …clarified l Angina l Microalbuminuria l Ophthalmology l Genetic l Creatinine l Symptoms …from Patient’s own visit: benign blood drawn blood count CAT scan blood count correlate stool was negative stool baseline respiratory tract polyp washed out of your system receptors short course renal clinic blood cells increase your R screening vaccine

7. Would you please tell me in your own words what dialysis means? In your own words, what do you think the doctor was trying to tell the patient? “ Check something every day. ” 1 “ Sugar is too high. ” 1 “ What? Is that about you toes? ” 1 “ I can't say it. ” 1 “ It means that your diabetes is going worse that you have to exercise to make diabetes. ” 1 “ Means that more people are getting diabetes. ” 1 “ You got to get on machine to pump.. redo blood to come up to par. ” 4 “ That the sugar was not … hmm. ” 1 “… regarding kidney. ” 2 “ Diabetes is one cause of kidney problems. ” 3 “ That is a warning … about the kidney … my doctor told me about those side effects of the diabetes. ” 3 “ About dialysis, because they are warning us, they are telling me about the complications … that if I'm having problems in my kidney, I'm going to have dialysis. ” 4 “ It ’ s a way to clean blood get off toxins out the blood. ” 4 “ That you need to be on dialysis to cleanse blood or gonna die. ” 4 Dialysis Dialysis “Do you know what the number one cause for people in this country being on dialysis is? Diabetes”

8. Unclarified / Own Visit Unclarified Jargon Clarified Jargon Patient Comprehension of Jargon (% Some /Total Understanding)

9. WHY TEACH BACK? l Clinicians frequently overwhelm patients with information and advice, and patients only recall or comprehend 1/2 what was said (probably less in hospital settings). l Physician’s advice and instruction is often delivered out of context, is based on assumptions of shared meaning, and rarely is tailored to the individual patient’s needs. l The “teach-back” method, if used early and often, can - »Ensure information is understood/integrated into memory »Check for lapses in communication »Open dialogue re health beliefs and unanticipated barriers to “action plans,” and self-mgmt »Reinforce and tailor health messages »Promote a common understanding or “shared meaning” »Elicit patient participation/activation »Maintain your curiosity in the patient as a unique person, with unique stories to tell-

10. WHAT IS IT? l I employ the “teach-back method” in all of my encounters with patients (and families) at discharge, particularly for those in whom self-management is a central component in preventing readmission. l In this interactive technique, the clinician prioritizes amongst the information exchange and explicitly asks the patient to “teach- back” what he/she has recalled and understood re those high- priority domains. l Similarly, clinicians can use the strategy to assess patient’s perceptions of the information or advice given. l The technique can be used toward the end of a visit or during the course of the visit, so as to tailor communication earlier. l Teach-back is NQF Safe Practice #10 for informed consent discussions, and is gaining momentum as a Safe Practice for Discharge

11. What is the Evidence that It Can Work? l Informed Consent Studies l Diabetes Management in Ambulatory Care l Asthma Education in Hospitalized Patients l CHF Self Management Education/Diuretic Self-Titration Sudore 2006; Schillinger 2003; Paasche-Orlow 2005; DeWalt 2006

12. l Ensures info understood/integrated into memory;checks for lapses l Opens dialogue re health beliefs; reinforces and tailors health messages l Promotes a common understanding; elicits patient participation

14. Closing the Loop l Physicians assessed recall or comprehension for 15/124 new concepts (12%) l When new concepts included patient assessment, patient provided incorrect response half the time (7/15=47%) l Visits using interactive communication loop not longer (20.3 min. vs. 22.1 min) l Application of loop associated with better HbA1c (AOR 9.0, p=.02) Schillinger Arch Int Med 2003

15. Characteristic% 1 pass% 2 passes% >2 passes Adequate literacy364519 Marginal literacy226216 Inadequate literacy116227 US born374617 Born outside US156125 The number of passes required through consent process to obtain informed consent, by participant characteristics Sudore, Schillinger 2006 JGIM

16. Provider-Patient Concordance in Medication Regimen l Patients with atrial fibrillation at high risk of stroke l Treatment with warfarin (blood-thinner) reduces risk of stroke by 70% l Requires close monitoring and frequent dose adjustments l Miscommunication/ inappropriate dosing can lead to poor outcomes (stroke or bleeding) l Studies have shown miscommunication rates (discordance) as high as 50%

17. l Anticoagulant regimen concordance lower for patients with inadequate vs adequate literacy (42 % vs 64 %, OR = 0.41, P<0.01), l Anticoagulant discordance associated with being out of therapeutic range: »under-anticoagulation (AOR 1.67, p=.05) »over-anticoagulation (AOR 3.44, p=.01) Literacy, Discordance and Safety Schillinger J Health Comm 2006

18. Computerized Visual Medication Schedule Linked to Brief Scripted “Teach-Back” Machtinger, Schillinger 2007 in press

19. Intervention Reduces Time To Therapeutic Range (N=142)

20. Overall Results: Time To Therapeutic Range (N=142)

21. HOW? Example 1 ( medication change ): l Doctor (to patient): “ I want to make sure I did a good job explaining your heart medications, because this can sometimes be confusing. Can you tell me what changes we decided to make and how you NOW will take the medications? “ l Note especially how the physician places the onus of any possible mis-communication on him/herself. In other words, the “teach-back” task is conveyed not as a test of the patient, but of how well the physician explained the concept.

22. HOW? Example #2: Behavior Change l Nurse (to patient): “ We’ve spent the last few minutes discussing how you are going to exercise and how you are going to change what you eat. These things can be heard to change. Can you repeat back to me these new plans on exercise and eating? And can you tell me how easy or difficult these will be for you to do and what problems you might have in doing them? This will help me give you the best advice? “ l Note how the nurse normatizes any possible dis-agreement re the plan or future non-adherence to the agreed-upon plan by framing such disclosures as one means to improve on the nature of any advice. l It is important to give the patient time and space to respond; avoid interrupting the patient before he/she has a chance to respond.

23. How Not To… Example #3: Taking the Easy Way Out l Doctor (to patient): “Do you understand what we just talked about? “ or “Do you understand the plan regarding your blood pressure medications?” “Did that makes sense?” l These routine queries, which do not require explicit articulation of recall, comprehension, or perceptions on the part of the patient, will universally be met with an uninformative (and possible falsely re-assuring) “Yes, doctor”.

24. CONCLUSIONS: l A simple communication tool – the “teach-back method”, a.k.a. “Closing the Loop” - if used early, often, and at strategic moments, can help promote more effective two-way discourse between clinicians and patients without significantly lengthening the discharge communication time l When linked very clear prioritization re key information, it is a very promising practice to prevent re-hospitalization