1. What’s Teach-Back All About ?
Teach Me, Show Me-
What’s Teach-Back All About ?
April 29, 2015
Gale Billingsley 1

2. The Rationale for the teach-back method
Program Objectives
The Rationale for the teach-back method
Define teach- back
Describe the key elements for using teach-back
Impact of teach-back in the hospital setting

3. Health Literacy
“The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions .”
Health People 2010
“Health Literacy is more than a measurement of reading skills, it also includes writing, listening, speaking, cultural and conceptual knowledge.”
IOM ,2004

4. Low Health Literacy and Patient Safety
40-80% of medical information patients receive is forgotten immediately and nearly half of the retained information is incorrect (AHRQ, 2010)
Ninety-eight percent of medical errors are communication- related (AMA, 2007)
Nearly half of all adult Americans -90 million people- have difficulty understanding & using health information due to low health literacy (IOM, 2004)
Patients with limited literacy say they feel shame and hide their limited reading ability from others (Parikh,1996; Wolf,2007
This has safety implications which is why some organization’s whose mission is to improve patient outcomes and safety are calling for “ universal precautions-
Triple Aim:
Institute for Health Care Improvement

5. How Patients Feel
Patients may have negative feelings and emotions related to their limited reading ability or limited understanding.
Institute of Medicine, 2004
The health care environment can make it difficult for patients to tell us they don’t read well or do not understand
Patients hide their lack of health literacy with a variety of coping techniques 5

6. Health Literacy Skill Set
Basic reading skills
Ability to understand oral communication
Ability to use numbers and math skills
Basic understanding of how to navigate the health system
Ability to communicate with health care providers and their staff.

7. Recommendations for Addressing Health Literacy Concerns
Use evidence-based models of communication health-related information and skills to people with low health literacy
Improve health literacy awareness ,knowledge and skills among professions in the health care arenas
Identify strategies to better communicate health education messages to people with low health literacy.
Adapted from : North Carolina Institute of Medicine Health Literacy
Task Force, 2007.

8. Universal Communication Principles
Everyone benefits from clear information
Many patients are at risk of misunderstanding, but it is difficult to identify them
Testing general reading levels does not ensure patient understanding in the clinical setting
Adapted form : “Reducing the Risk by Designing a Safer,Shame-Free Health Care Environment. AMA, 2007 8

9. The Right to Understand
Patients have the right to understand healthcare information that is necessary for them to safely care for themselves ,and to choose among available alternatives
Health care providers have a duty to provide information in simple, clear and plain language and to check that patients have understood the information before ending the conversation.
The 2005 White House Conference on Health Literacy and Health
Disparities. 9

10. “Self-Management and Health Literacy Are Two Sides of A Coin.”
Joanne G. Schwartzberg, MD, Director of the Program on Aging and Community
Health at the American Medical Association (AMA) in Chicago. 10

11. Teach-Back What Is It ? Why Do I Use It ? How Do I Use It?
When Do I Use It? 11

12. Teach- Back: A Health Literacy Tool To Ensure Patient Understanding12

13. What is the Teach Back Technique
Teach Back is a communication technique used to help patients remember and understand the important information regarding their diagnosis ,treatment or medication.
Also known as the “show-me” method or “closing the loop.”
Closes the communication gap between clinician and patient.
Involves asking patients to recall and then explain or demonstrate the important information discussed during an interaction with the health care team.

14. Why is Teach-Back Important
Only 12% of adults,in general, have proficient health literacy.
Almost 9 out of 10 adults may lack the skills needed to manage their health to prevent disease
Patients frequently leave the health care setting without understanding what they need to do to follow medical recommendations.
Health Literacy Basics. US Department of Health & Human Services Office of Disease
Prevention & Health 14

15. Factors that Cause Misunderstanding
Provider Factors
Difficulty simplifying complex or confusing medical terms or concepts
Limited time for discussion
Having to communicate a lot of information at once
Overestimating the patient’s understanding of information
C o m p l e x o r c o n f u s i n g m e d i c a l t e r m s o r c o n c e p t s
L i m i t e d t i m e f o r d i s c u s s i o n
C o m m u n i c a t i n g a l o t o f i n f o r m a t i o n a t o n
Patient Factors
Lack of understanding of medical terms/jargon
Older age and possible cognitive decline
Language barriers
Feeling overwhelmed by information or emotion
Lack of focus caused by illness
Medication affecting memory or cognition 15

16. Teach Back Is …
A research –based health literacy intervention that improves patient- provider communication and patient health outcomes
(Schillinger, 2003)
Combines educational and communication theories to
-Transfer knowledge and skill from provider to patient
-Enhance patient understanding and integration of
health related information and behaviors
- Goal is patient competency in management of self
care.
Recommended as a top patient safety practice by the National Quality Forum (NQF)

17. Teach-back is Supported by Research
“Asking that patients recall and restate what they have been told “ is one of the 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 Internal Medicine/Vol 163, Jan 13,2003, “Closing the Loop.” 17

18. “Despite recent research showing that many benefits of teach-back, based on market research, few providers actually use it every day. This may be because clinicians may not be familiar with the teach-back method or may find it difficult to change their Communication Style” Joanne G. Schwartzberg, MD

19. Teach-back is…
Asking patients to repeat in their own words what they need to know or do, in a non-shaming way
Not a test of the patient, but of how well you explained the concept
A chance to check for understanding and, if necessary to reteach the information 19

20. Using Teach Back
Assures you – the health care provider-explained information clearly. It is not a test of patients .
Involves asking a patient or patient care giver (PCG) to repeat back information shared, in order to assess additional needs and close communication gaps
Offers the opportunity to re-explain ,in a different way, and assess again until patient understanding is confirmed.
Let’s look at some examples on pages 4 & 5 in your work book.
There are behaviors and methods of communicating that should be avoided- see page 6 of the work book.

21. Asking for a Teach-back
Ask patients to demonstrate understanding , using their own words:
“I want to be sure I explained everything clearly. Can you 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, a lot of things you can do to
get more exercise in your day. In your own words, please review/
tell me what we talked about.
How will you make it work at home ?” 21

22. Teach-Back
Creates an opportunity for dialogue in which the provider gives information, then ask 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 the patient still does not understand, consider other strategies. 22

23. This diagram depicts the flow of the teach back process.
Now let’s take a look at some interactive , HCP- Patient Conversations that will demonstrate both successful and unsuccessful examples of the Teach Back Method. After we read through the conversations, write down some examples showing when the Teach back technique was used . Also, suggest ways the conversation could have been conducted differently.
Ask for two volunteers to read the First Exercise.
Use the Discussion questions on the slide as a prompt.

24. 10 Elements of Competency
Use a caring tone of voice and attitude
Display comfortable body language and make eye contact
Use plain language
Ask the patient to explain back, using their own words
Use non-shaming, open-ended questions
Avoid asking questions that can be answered with a simple yes or no.
Emphasize that the responsibility to explain clearly is on you, the provider or health care professional
If the patient is not able to teach back correctly, explain again and recheck
Use reader –friendly print materials to support learning.
Document use of and patient response to teach-back
Slow down
Use plain, non-medical language
Show or draw pictures

25. Examples of Plain Language
INSTEAD OF
TRY SAYING
Hypertension
Modify
Respiratory
Oral
Ambulate
Optimal
Negative
Diet
High Blood pressure
Change
Breathing
By mouth
Walk
Best way
“Good” or “bad” result
What you eat

26. When Using Teach-back, Be Sure To:
“Chunk and check”-repeat for understanding for next important concept before moving on to the next
Re-phrase ,rather than repeat, information patient does not understand
Continue use of Teach Back until you are comfortable the patient understands.
Include information on how to integrate new skills into lifestyle
If the patient is not able to teach back after several times, consider other strategies: pcg ; pictures /icons ; take a break or ask another member of the team to explain.
Review the Teach back Technique workflow on page 6
Now let’s put into practice some of the techniques which we just discussed . Turn to page 7 in your booklets.
Review the instructions
Select two volunteers to read Interactive Exercise 1

27. Non-shaming Assessment of Understanding
“ I want to be sure I did a good job explaining everything clearly. Can you explain back to me so I can be sure I did?”
“What will you tell your wife about the changes we made to your medicine today?”
“We’ve gone over a lot of information. In your own words ,please review with me what we talked about.”

28. Teach-back- Additional Points
Avoid asking yes/no questions like :
“Do you understand?”
“Do you have any questions?”
For more than one concept:
Teach the 2-3 main points for the first concept & check for understanding using teach back…
Then go to the next concept 29

29. Use Health Education Material to Support Teach-back
Use in Conjunction with Spoken Instruction
Help facilitate discussion
Focus on a specific point of care that needs further reinforcement
Review the material with the patient
Make note of important information by circling or highlighting it
in the material. Consider personalizing the material by adding the
patient’s name ,medications or specific care instructions
Repeat & Follow up:
** Provide follow up phone contact and refer to the educational material
again in future visits.
** If needed give the material to the patient more than once & focus on
different topics at subsequent visits. 30

30. HCAHPS H- Hospital C- Consumer A- Assessment H- Healthcare
P - Providers
S- Systems
Standardized survey instrument & data collection tool to measure patient’s perspective on hospital care
Administered to a random sample of patients continuously throughout the year
CMS cleans, adjusts and analyzes the data, then publicly reports the results
Ensuring that patients receive culturally & linguistically appropriate services (CLAS) is a factor under Standard 1 –Enhance Access and Continuity.
Hospital level results are publicly reported on the Hospital Compare website 4 times a year.
HCA 31

31. HCAPS survey is 32 questions in length. Composite topics
Nurse communication (questions 1,2.3)
Doctor communication (questions 5,6,7)
Responsiveness of hospital staff (questions 4,11)
Pain management (questions 13,14)
Communication about medicine (questions 16,17)
Discharge information (questions 19,20)
Individual topics
Cleanliness of hospital environment (question 8)
Quietness of hospital environment (question 9)
Global topics
Overall rating of hospital (question 21)
Willingness to recommend hospital (question 22) 32

32. Talking with Patients & Families at Discharge
ALWAYS:
Use Plain Language
Slow Down
Break the information down into short statements
Focus on the 2 or 3 most important concepts
Check for understanding using teach-back 33

33. References
Can Teach –Back Reduce Hospital Admissions; Melanie Haney, BSN,RN,PCCN, and Jessica Shepard,BSN,RN. American Nurse Today. Volume 9, Number 3 pp
The Relationship Between Hospital Patients’ Ratings of Quality of Care and Communication. Anita Keller et al. Internal Journal for Quality Care 2014; Volume 26,Number 1:pp

34. References
Quality of Discharge Practices and Patient Understanding at an Academic Medical Center,Leora I. Horwitz, M.D et al; JAMA Internal Medicine;
Is Teach-Back Associated with Knowledge Retention
and Hospital Readmission in Hospitalized Heart
Failure Patients? Matthew White,RN,NP et al; Journal
of Cardiovascular Nursing, DOI: /JCN 35

35. Teach-Back: “What’s In It for Me ?"
Improved Patient Self Management & Patient Engagement
Patient Empowerment
Patient Safety
Reduced Hospital Admissions & Readmissions
Reduced Clinician Burnout
Improved Productivity & Efficiency in the clinical setting 37

36. Teach-Back : Getting Started38

37. Questions to Consider
What are specific topics or directions you commonly discuss with your patients that you can use the teach-back method with?
What can you & your colleagues do to commit to using the teach-back technique in your patient setting
How can you better incorporate patient education materials into teach-back
How in your practice/hospital will you track & monitor the results from using teach-back
Ideas- Insulin injections; inhalers; medication changes ; chronic disease self care ; colonoscopy prep.

38. Prior to discharge, develop a diabetes education plan for each patient
Educational Strategies Prior to Discharge
Prior to discharge, develop a diabetes education plan for each patient
They MUST know the TYPE of diabetes they have (Type I, Type II, Gest.)
They MUST know their updated HbA1c (within last 60 days) AND understand it. Provide the eAG (estimated Average Glucose) value of their HbA1c. The Conversion Table: HbA1c to eAG is in the unit Diabetes Resource Notebook.
They must understand monitoring and know home glucose level goals
They must know the definition, recognize, and understand treatment and prevention of hypoglycemia ( the Rule of 15’s) as well as hyperglycemia
Prevention choices of other acute and chronic complications are good to know
Identification of the healthcare provider who will provide diabetes care after
discharge must be made, AND an appointment set for f/u documented BEFORE discharge with date and time and name of provider. This must be documented in the “Follow up Provider” section of the After Visit Summary
7. Information: consistent eating patterns and dietary guidelines, ? refer to RD
8. When & how to take medication, with proper disposal of needles /lancets
9. Sick day management: Do they know when to call their provider?
10. Incorporating physical activity into lifestyle can reduce medication needs
11. Strategies for accomplishing psychosocial and behavioral goals- ? support groups *Based on ADA and AACE recommendations 41

39. Tools/ Resources for Getting Started 39

40. Patient Rights
It is neither just, nor fair , to expect a patient to make appropriate health decisions and safely manage his/her care without first understanding the information needed to so.
Reducing the Risk of Designing a Safer , Shame –Free Health Care Environment , AMA, 2007

43. Questions
Thank-You 38