1. Falls Program Virtual Breakthrough Series 2: (BTS 2) Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of Inquiry Wednesdays, starting January 9, 2013 2-3p

2. Julia Neily, RN., M.S., M.P.H. Julia Neily, RN, MS, MPH, has worked for the VA in various nursing roles for 26 years. She is currently the Associate Director of the NCPS Field Office. She joined the VHA National Center for Patient Safety in 2002 and has focused on fall and fall related injury prevention and evaluation of patient safety efforts such as cogni­tive aids, Ensuring Correct Surgery and Medical Team Training. Julia has a BS in Nursing from the University of New Hampshire, a Master of Science from New Hampshire College and a Masters of Public Health from Dartmouth Medical School.

3. Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Associate Director, VISN 8 Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. As Associate Chief of Nursing for Research, she is also a funded researcher with the Research Center of Excellence: Maximizing Rehabilitation Outcomes, jointly funding by HSR&D and RR&D. Her contributions to patient safety, nursing and rehabilitation are evident at a national level – with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.

4. BTS2 Program Goals: 4  Improve your organization’s infrastructure and capacity to reduce fall-related injures.  Enhance environmental safety.  Mitigate or eliminate modifiable fall risk factors.  Assure reliable handoff communication about patients’ fall and injury risk.  Integrate patient (family) as a partner in their fall prevention program.  Reduce rate of repeat falls.  Quantify impact of program changes.

5. Your Team Goals 5  Each VAMC team will select the goals that you want to work on during this 6 month period.  All teams do not need to work on all the goals, but rather are encouraged to select the goals that are congruent with you organization’s fall and injury prevention program needs.

6. Looking Ahead 6 Ten Sessions of Learning and Sharing  Jan 9 th : Improved Organizational Infrastructure and Capacity for Fall Prevention Programs  Jan 23 rd : Ensuring a Safe Environment  Feb 6 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1  Feb 20 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2  Mar 6 th : Reduce Moderate to Serious Injuries for Vulnerable Populations  Mar 20 th : Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries  Apr 3 rd : Patients/Families as Full Partners in Fall Prevention  Apr 17 th : Post Fall Management: Reducing Repeat Falls  May 1 st : Fall Program Evaluation  May 15 th : Sharing Program Successes

7. Patients/Families as Partners in Fall Prevention Session 7

8. Objectives 8 Generalize theoretical assumptions of health literacy into fall prevention patient / family education programs. Apply health literacy to teach back education strategies. Reframe patient education curricula to include "what happens after a fall". Design patient education program evaluation as a knowledge and skills checklist for cognitive and psychomotor domains of learning.

9. But first… Let’s hear from you! Report on Session 6 Assignments: 9 Who would like to share???? Examine your unit, departmental handoff communication policy and tools? Content specific for fall risk factors, injury risk factors, history of falls, and history of fall injury? Modify the handoff communication tool for your unit/program? Practice use of the handoff tool for at least 3 handoff reports?

10. Patients & Families as Full Partners

11. Patty Donaldson & Dr. Jolie Haun Patty Donaldson RN,MSN,CDE is a Veterans Health Education Coordinator Malcom Randall VAMC. Mrs. Donaldson has been providing clinical care and patient education within the VA for the past 20 years. She is the Veterans Health Education Committee Chair Person and Cultural Competency Coordinator for North Florida/South Georgia VHS. She has been involved with health literacy research within the clinical setting since 2005. Jolie Haun PhD, EdS is a Research Health Science Specialist at the HSR&D & RR&D Research Center of Excellence at Jame’s A. Haley Veterans’ Hospital. Dr. Haun’s program of research focuses on advancing the science of interpersonal health communication through meeting the communication needs of patients and providers through assessment, education, innovative response strategies, and eHealth based interventions. Email: Patricia.Donaldson@va.govPatricia.Donaldson@va.gov Phone: 352-376-1611 ext. 7005 Email: Jolie.Haun@va.govJolie.Haun@va.gov Phone: 813-558-7622

12. Health Literacy “Teach Back” and Ask Me 3 gnielsen@ihi.org

13. Theoretical Assumptions Fall prevention patient/family education programs:  Can tailor messages to increase likelihood of reader ease and comprehension  Can Be developed to be culturally relevant  Can Provide specific call to action  Can Leverage relevant images & content to promote comprehension and adoption  Should be evaluated for accuracy, acceptability, and usefulness

14. Health Literacy  Health Literacy Definition: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. (Ratzan and Parker, 2000)  According to the research, about 52% of patients understand what we tell them or give them to read?  1 in 3 patients have inadequate health literacy skills IOM Report: Health Literacy: A Prescription to End Confusion 2004 healthliteracy@ama-assn.org

15. Partnering 15  Patients  Need support and education to make good choices  Benefit from easy to use directives  Need to be accountable  Need practical examples to put principles into place  Family  Partners in Care – Advocates, Information Gatherers  Messengers  Provide ongoing assessment in the home  Teach clinicians about their safe practices

16. “Teach Back”  “Teach Back” Testing : what are the trends in patients’ difficulty to understand what is taught ? Ask the patient to describe or repeat back in his or her own words what has just been told or taught. Return demonstration is a similar technique used by diabetic educators, physical therapists, and others. When the health professional hears the patient’s description in her/his own words, further teaching can be accomplished to correct misunderstandings. Never ask whether patients understand; they always say “yes”.

17. “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?” “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” We covered a lot today about preventing falls, and I want to make sure that I explained things clearly. So let’s review what we discussed. What are three strategies that will help you prevent falls?” “I want to be sure that I did a good job of teaching you today about risk for falls. Could you please tell me in your own words what you are doing to prevent falls? How you will prevent falls in the future? Teach Back Question Card #3Teach Back Question Card #4 Teach Back Question Card #1Teach Back Question Card #2

18. When “Teach Back” Is Especially Important:  New medications  A new diagnosis  Instructions for calling for help to BR  Instructions for self care  e.g. ask, “How can you stay safe from falling in the hospital?”  Patients are cautioned on how to prevent falls in the hospital  e.g. young male patients who suddenly have high doses of pain meds but want to toilet themselves. Ask, “How will you best prevent yourself from falling when you are given this powerful drug for pain that is known to cause falls?”

19. Ask Me 3  Ask Me 3 materials are available at: http://www.npsf.org/askme3/

20. Ask Me 3 – Adapted for Falls How many patients understand what we teach them?  Teach patients with this format:  Their main problem putting them at fall risk  What they need to do to keep from falling in hospital  Why is it important for them to do this  Check the family‘s understanding:  What is the patient’s main problem?  What can the patient to do to stay safe from falling in the hospital?  Why it is important for the patient to do this?

21. Teaching: After a Fall  Reframe patient education curricula to include "what happens after a fall".  What can we learn from this event?  How can we work together to prevent this again?

22. Evaluating Patients’ Health Literacy  REALM*  Rapid Estimate of Adult Literacy in Medicine  TOFHLA*  Test of Functional Health Literacy in Adults  BRIEF  Single Screening Items  NVS*  Newest Vital Sign  Meter  Medical Term Recognition Test  SAHLSA-50  Short Assessment of Health Literacy for Spanish Adults *Long and Short Form Available

23. 23 1. How often do you have someone help you read hospital materials? 1. Always 2. Often 3. Sometimes 4. Occasionally 5. Never 2. How often do you have a problem understanding the written materials about your medical condition? 1. Always 2. Often 3. Sometimes 4. Occasionally 5. Never 3. How often do you have a problem understanding what is told to you about your medical condition? 1. Always 2. Often 3. Sometimes 4. Occasionally 5. Never 4. How confident are you filling out medical forms by yourself? 1. Not at all 2. A little bit 3. Somewhat 4. Quite a bit 5. Extremely Total Score Range = 4-20 4-12 – “Inadequate” 13-16 – “Marginal” 17-20 – “Adequate” BRIEF Health Literacy Screening items Reference: Haun, J., Noland Dodd, V. J., Graham-Pole, J., Rienzo, B., & Donaldson, P. (2009). Testing a Health Literacy Screening Tool: Implications for Utilization of a BRIEF Health Literacy Indicator. Federal Practitioner, 26(12), 24-31.

24. Evaluation of Learning  Design patient education program evaluation as a knowledge and skills checklist for cognitive and psychomotor domains of learning.  Include Health Literacy Assessment to check ability to comprehend and use health information

25. Communication With Patients/Staff About Fall Reduction/Injury Prevention 25 Label or signal patients assessed at risk of fall or injury  Use signage/other visual indicators (bracelets, colored socks, special blankets, etc.) Ensure Safe Handoffs  Verbalize and repeat-back risk of fall and risk of harm from fall at change of shift  Verbalize and repeat-back risk of fall and risk of harm from fall between departments

26. Communication With Patients/Staff about Fall Reduction/Injury Prevention 26 Verify Understanding  Use teach-back strategies to verify what patients and families understand and customize education about harm risk accordingly Learn from Failures and Transfer Learning  Use unit-based post-fall team huddles to learn what happened and how to prevent injuries from future falls  Discuss post-fall huddle findings at house-wide nurse manager meetings

27. Tools: Handouts  Patient Teach Back Education Tool – Admission  Evaluation of Patient Knowledge and Skills Tool

28. Suggested Learning Activities: Tests of Change  Observe at least one patient admission process, and ascertain key components of the fall prevention education provided.  Compare the education provided with concepts of health literacy, determining if a gap is content exists.  Trial use of the revised patient admission education program and teach back evaluation checklist with at least two patients.

29. Next Session 29 Weds, April 17 th, 2013 2-3p ET Post Fall Management: Reducing Repeat Falls