Nurses have a responsibility to perform discharge teaching each day. Are you performing it to the best of your ability? Please read the attached article and discuss the following points:
1. What are some barriers to discharge teaching?
2. Explain how you could incorporate AskMe3 when teaching patient with a new diagnosis of a chronic disorder?
3. How could nurses be influential in prevention of hospital readmission?
30 October 2015 • Nursing Management www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Arm your patients with tools for success.
By Debra Polster, MS, APN, CCRN, CCNS
Reducing hospital readmissions
is a national focus for healthcare reform. Consequently, patient dis- charge education is increasingly important for improving clinical outcomes and reducing hospital costs.
How does a nursing intervention such as patient education impact patient outcomes and healthcare costs? According to the Centers for Medicare and Medicaid Services (CMS), nearly 20% of all Medicare patients are readmitted to the hos- pital within 30 days of discharge; 34% are readmitted within 90 days of discharge.1
In 2012, the CMS began penal- izing excess readmissions; these penalties add up to about 1%
of Medicare payments. Almost two-thirds of U.S. hospitals paid the price in 2012. These fees have increased up to a limit of 3% of total Medicare compensa- tion. Typically amounting to over
$130,000 per penalized facility, these fees have focused more attention on the discharge pro- cess and ways to prevent hos- pital readmissions.1 This article presents key educational tools essential for preparing patients to care for themselves at home, improving patient outcomes, and minimizing readmissions.
Reducing readmission risk
The CMS expects nurses and other healthcare team members to
address modifiable factors that can increase the chance of rehospital- ization. These include:
· unplanned and early discharge or insufficient postdischarge support
· inadequate follow-up
· therapeutic mistakes
· adverse drug events and other medication-associated concerns
· failed handoffs
· complications after procedures
· patient falls, healthcare-associated infections, and pressure ulcers.2
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Preventing readmissions with discharge education
Identifying patients at risk
for readmission up front and col- laborating with care managers and healthcare providers to minimize the risk are essential. As many
as 79% of readmissions are con- sidered preventable and a direct result of uncoordinated care.2 The Joint Commission recommends a multifaceted approach to prevent readmissions that includes expla- nations of discharge instructions, self-care, and ongoing or emer- gency care; inventory of outpatient resources/referrals; medication reconciliation; and understandable instructions for the patient and family. A patient-individualized approach noting preferred lan- guage, culture, and the patient’s health literacy level is also recom- mended.3 When planning any care
transition, clinicians should draw from a toolkit of effective patient education strategies and resources tailored to their patient population. (See Meeting the standard of care for transitions.)
The multifaceted discharge pro- cess begins on admission and continues throughout the hospital stay. The initial step is a baseline patient assessment, including an assessment of the patient’s risk of readmission. Risk factors for read- mission include clinical issues, such as advanced chronic obstruc- tive pulmonary disease (COPD), heart failure, stroke, diabetes, significant unintended weight loss, depression, cancer, and palliative care. Use of high-risk
medications, such as antibiotics, glucocorticoids, anticoagulants, opioids, antiepileptic drugs, anti- psychotics, antidepressants, and hypoglycemic agents, may also increase the likelihood of readmis- sion. Other factors raising the risk include polypharmacy, previous hospitalization (unscheduled hos- pitalizations within the last 6 to 12 months), low health literacy level, black race, and lack of social sup- port with inadequate or no family or friend contact by phone or in person.4
Identifying a patient’s abil-
ity to perform self-care will help the nurse prepare the patient for discharge. According to Orem’s Self-Care Deficit Theory, those who can’t independently care for themselves and need help for everyday activities have a self- care deficit.5 Other education challenges include the nurses’ inability to identify patient self-
Meeting the standard of care for transitions21
Transition of Care Consensus Conference (TOCCC) guidelines published in 2009 are based on a multistakeholder consensus conference that included physicians, nurses, pharmacists, and representatives of governmental agen- cies. This team recommended that, at a minimum, the following data should be included in the transition record:
· principle diagnosis and problem list
· medication list (reconciliation), including over-the-counter medications/ herbals, allergies, and drug interactions
· patient’s medical home or the transferring coordinating healthcare provider/ facility and contact information
· patient’s cognitive status
· test results/pending results.
Ideally, the transition record should also contain additional details, such as:
· emergency plan, contact person, and contact number
· treatment and diagnostic plan
· prognosis and goals of care
· advance directives, power of attorney, and informed consent
· planned interventions, such as wound care
· caregiver status.
The TOCCC report recommends that patients and their families/caregivers receive and understand the transfer record and be encouraged to participate in its development. All communication between patients, family, and caregivers
must be secure and private, in compliance with the Health Insurance Portabil- ity and Accountability Act.
care deficits; for example, because of limits to the time the nurse
can spend with the patient dur- ing the admission. These deficits may persist at discharge.6 Patients who can’t care for themselves will require additional resources, such as home healthcare services or physical therapy.
Nurses must dedicate time for assessments and discharge teach- ing. Effective patient teaching requires uninterrupted blocks of time. To support this, post signs outside the patient’s room to indicate a “do not disturb zone.” Patient assignments may be handed off so that the nurse can give the patient his or her undi- vided attention. Distractions, such as the television, should be elimi- nated and the patient needs to be wearing any sensory aids he or
she normally uses, such as glasses
32 October 2015 • Nursing Management www.nursingmanagement.com
or a hearing aid. (For more tips, see Eye contact and other strategies.)
Assessing health literacy
A critical patient history element is documentation of the patient’s baseline knowledge and skills.
Patient educational assessments should include health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and ser- vices needed to make appropriate health decisions.”7 A good way to evaluate health literacy is to ask patients to read their prescription containers and explain how they should take their medication.
An important component of health literacy is reading ability (literacy). This can be defined as the ability to read, write, and speak proficiently enough to function in society and at work.7 A patient’s ability to read instructions and educational materials directly affects his or her ability to adhere to the medication regimen and treatment plan. This is a challeng- ing health issue for prescribers car- ing for patients with low literacy skills.3
A common misperception of
a patient with low literacy is that he
Eye contact and other strategies4
The AHRQ offers these suggestions for establishing and maintaining rapport with the patient during education sessions:
· offer a warm greeting
· establish eye contact
· slow down
· use plain, nonmedical words
· limit content
· use the teach-back technique
· repeat key points
· involve the patient, family, and significant others (with the patient’s permission)
· use visual displays to reinforce information.
or she is deliberately nonadherent with the health plan. Never forget that a patient’s inadequate commu- nication skills may not mean resis- tance to the treatment plan or poor intellect, but rather a low skill level. People with low literacy skills may have the capability to build up these skills but haven’t had the chance to do so for any number of reasons.8
Determining reading level and readability
All education materials should include a determination of literacy level. Various formulas are avail- able to ascertain the patient’s reading grade level based on such factors as sentence length and word difficulty.
Keep in mind that the grade level a patient completed in school isn’t necessarily a good indicator of reading ability. Rather than asking about years of formal education, the nurse should use a validated assessment tool to assess literacy. For example, The Newest Vital Sign is a fast and precise bilingual (English and Spanish) screening test for general literacy, numeracy, and comprehension skills applied to health information.9 Numerancy (math) skills are needed for many health-related activities, such as
measuring medications; reading food labels; and choosing among health plans with differing pre- miums, copays, and deductibles.10 This tool is intended for use in primary care settings.
The Single Item Literacy Screener has also been found to have good sensitivity for evaluat- ing a patient’s literacy and read- ing skills when weighed against other validated tools.11 To use it, the nurse asks one question: “How often do you need to have someone help you when you read instruc- tions, pamphlets, or other writ-
ten material from your doctor or pharmacy?” The patient chooses an answer from never (1) to always (5). A score of 2 or more suggests a need for literacy assistance.9
Patient education websites, printouts, animations, and more can be used at the bedside to help edu- cate patients with low literacy skills. Printed materials should be prepared at the appropriate literacy level and visual aids tailored to the patient’s medical condition and needs.
As a general rule, patient educa- tion materials should be written
at the eighth grade level or lower.8 Keep in mind, however, that an appropriate reading level is only one component of an effective patient education tool.
Visual enhancements Understanding how adults learn can help nurses tailor education to a patient’s advantage. (See Con-
sider the patient’s learning style.) For example, one patient may learn best from reading printed instruc- tions; another may prefer to watch a demonstration. Blending ele- ments from multiple adult learning styles increases the likelihood that patients will remember essential information.
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Preventing readmissions with discharge education
Most people are visual learners, so educational visual aids enhance understanding and encourage adherence to a treatment plan. Use of visuals with animations or hand- outs can be helpful. Large fonts, colorful pictures, adequate white space on the page, and key points that are bulleted for emphasis are all essential components. The use of nonprinted educational materi- als, such as video and audiotapes, demonstrations, models, picto- grams, and other visuals, is another option.
Role-playing instructions and
simulation with the patient and family can also be a valuable strat- egy for patient learning. Work with props and real equipment when indicated. For example, nurses should use crutches when explain- ing how to use them correctly, or a real wound dressing when teach- ing about wound care. Including the appropriate learning style will increase the likelihood that patients will remember the essential infor- mation presented.9
Cultural competence also influ- ences the nurse’s ability to com- municate meaningfully with the
patient. Cultural competence allows the nurse to deliver care in a way that’s considerate of and responsive to the patient’s health beliefs, practices, and culture.
According to the National Insti- tutes of Health, “culture is often described as the combination of a body of knowledge, a body of belief, and a body of behavior. It involves
a number of elements, including personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institu- tions that are often specific to eth- nic, racial, religious, geographic, or social groups.”12 The nurse should note these elements that influence a patient’s beliefs about health, heal- ing, wellness, illness, disease, and delivery of health services.
With mounting concern for racial, ethnic, and language disparities in healthcare and the call for health- care systems to support ever more diverse patient populations, lan- guage access services have become increasingly a matter of national importance. All nurses who are responsible for patient education should take part in formal educa- tion in cross-cultural healthcare to develop a full appreciation of how culture and language influence
healthcare.12 Even bicultural and bilingual nurses will be prompted to serve patients with cultural and language preferences that are differ- ent from their own. Nurses should work toward cultivating cultural self-awareness, avoid making assumptions about patients’ needs, and be receptive to learning from the patients themselves.
Plain talk about communication According to The Joint Commission, clear and effective communication is a cornerstone of patient safety.13 When explaining a condition or treatment, nurses must use plain language to communicate as clearly as possible. The message can get lost in translation when nurses use medical terminology that patients don’t understand. Examples of communicating in plain language include using simple or everyday language instead of medical or nursing jargon, breaking down complex information into smaller chunks, and speaking directly to the patient using active (not passive) voice.7
When talking with the patient,
nurses need to speak slowly and focus on the most significant “must know” information, using the least amount of information possible.
The most essential information should be provided either first or last, making important points clear. Nurses should review, clarify, and reteach as necessary.3
Consider the patient’s learning style19,20
Adult learners respond best to an educational approach that suits their learn- ing style, which can be defined as an approach to learning based on individual strengths, weaknesses, and preferences. Although many people have one pre- ferred learning style, they benefit most from teaching that incorporates several other styles as well. Learning styles can be categorized as follows:
· verbal—written or spoken words
· visual—pictures, images
· aural—sounds, music
· physical (kinesthetic)—sense of touch
· logical—reasoning, systems
· social—a preference for learning in groups
· solitary—a preference for self-study, working alone.
Encouraging patients to ask ques- tions helps the nurse assess how well the patient understands the information being taught. Accord- ing to the Agency for Healthcare Research and Quality (AHRQ), patients can feel embarrassed to
ask questions or may not even know what questions they need to ask.4 The following are tips from
34 October 2015 • Nursing Management www.nursingmanagement.com
the AHRQ to help nurses promote questions throughout the patient encounter:
· Don’t appear rushed. Patients are reluctant to ask questions if they think nurses are too busy to talk with them.
· Tell patients that you expect ques- tions. For example, you could say, “That was a lot of information. I’m sure you must have questions.”
· Avoid asking a yes-or-no question, such as, “Do you have any ques- tions?” Patients often say no even if they do have questions.
· Listen without interrupting. Questions may emerge as the patient talks.
· Encourage family members to ask questions, too.4
The Ask Me 3 patient educa- tion program was created by the National Patient Safety Foundation
to help encourage effective commu- nication between patients and care providers with the goal of increas- ing patient comprehension.14 This program prompts patients to ask about three things before ending an encounter with a healthcare profes- sional: What is my main problem?
What do I need to do? Why is it impor- tant for me to do this? The National Patient Safety Foundation recom- mends encouraging patients to ask as many questions as necessary for complete comprehension.
Another tool, the AHRQ’s “Ques- tions Are the Answer” campaign, builds on 10 basic questions to promote better communication between patients and their health- care team.15 Using the AHRQ’s “question builder” tool, patients can focus and individualize these basic questions to learn more about their medications, diagnostic studies, and recommended treatments. Creating an inventory of individualized ques- tions can empower patients by help-
ing them get the information they need to make educated choices about their healthcare.
The teach-back technique
Also known as the “show-me” method, the teach-back technique is one of the simplest ways to bridge the communication gap between nurse and patient.9 It’s intended to help the nurse verify the patient’s understanding of new knowledge and skills. An important point to remember is that teach-back isn’t a test of the patient’s knowledge; it’s a way to confirm that the nurse has explained what the patient needs
to know in a way that the patient
Patients are reluctant to ask questions if they think nurses are too busy to talk with them.
understands. This process can also help staff members learn which descriptions and communication techniques work best with their patients.
From the North Carolina Pro- gram on Health Literacy, here are a few suggestions for nurses
using the teach-back technique in a patient teaching session.
· “I want to be sure that I explained your medication correctly. Can you tell me how you’re going to take this medicine?”
· “We covered a lot today about your diabetes, 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 control your diabetes?”9
Accurate and timely documenta- tion in the electronic health record should reflect evaluation of knowl- edge and skills taught and learned, and demonstrated by the patient in return. Documentation should
include the patient’s preferred learn- ing style; barriers identified, such as low literacy skills or limited finan- cial support; preparedness to learn; and relevant clinical information, such as a new diagnosis or poorly managed pain. Resources and sup- port available at home should be
recorded with perceived barriers, interventions to overcome barriers, and outcome achieved.
Application to chronic diseases One of the most common dis- eases that require rehospitaliza- tion within 30 days of discharge is COPD. Patient teaching during stable periods is recommended to educate patients about self-care. Many patients with COPD rely on self-taught self-management strategies during exacerbations
that they may not report. This sug- gests that clinicians should give more comprehensive education; for example, teaching patients
www.nursingmanagement.com Nursing Management • October 2015 35
Preventing readmissions with discharge education
about triggers to avoid, signs and symptoms of exacerbations, strat- egies to manage exacerbations, and information about medica- tions. When nurses simplify treat- ment regimens and verify patient knowledge and skill with new inhalers, patients are better able to self-manage their treatment and prevent exacerbations.
Another common chronic disease requiring in-depth education is dia- betes. The American Diabetes Asso- ciation (ADA) Standards of Medical Care in Diabetes provides clear guide- lines for discharge planning and self-
management education.16 The ADA’s revised recommendations published in 2015 reinforce the importance
of diabetes education: “People with diabetes should receive diabetes
self-management education (DSME) and diabetes self-management support (DSMS) according to the national standards for DSME and DSMS when their diabetes is diag- nosed and as needed thereafter.”17
In an effort to improve self- management of diabetes care, discharge plans should include at minimum:
· medication reconciliation. To ensure continuity of the medica- tion regimen, the patient’s medica- tions must be verified to be sure no essential medications were discon- tinued and to ensure the safety of
new prescriptions. Ideally, prescrip- tions for new or updated medica- tions should be filled and discussed with the patient and family at or before discharge from the hospital.
· structured discharge communica- tion. Information on medication updates, lab tests and procedures, and follow-up requirements must be precisely and promptly com- municated to outpatient providers, including the primary care provider. When the inpatient healthcare pro- viders schedule follow-up visits before discharge, the appointments are more likely to be kept.
Metrics, including readmission rates for patients at high risk for COPD exacerbations, acute myo- cardial infarction, pneumonia, and heart failure, should be monitored to determine education program success. Patient satisfaction scores for printed discharge instructions may also reflect a practice change. Ultimately, assessment and evalu- ation of the patient’s new knowl- edge and skills is the primary
goal of education.
Outcome evaluation can also be determined in postdischarge phone calls. Many hospitals have devel- oped call centers to ensure follow- up phone calls are consistently made. A phone call may reveal that the patient needs additional sup-
port at home. Follow-up visits with healthcare providers may provide additional support when indicated.
The literature notes a correla- tion between improved nurse knowledge and improved patient knowledge.18 Nurses should seek additional resources to build their teaching skills. (For examples, see the Nursing Management iPad app.)
Set patients up for success Literacy, cognition, education level, socioeconomic status, and level of social support all contribute to a patient’s adherence to discharge instructions. Careful attention to providing an individualized care plan will set the patient up for suc- cess. A well-orchestrated team of nurses, healthcare providers, thera- pists, pharmacists, respiratory care providers, dietitians, and care manag- ers can reduce readmissions, improve the patient experience, and enhance the patient’s quality of life. NM
1. Centers for Medicare and Medicaid Services. Readmissions reduction program. www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/Readmissions- Reduction-Program.html.
2. Feigenbaum P, Neuwirth E, Trowbridge
L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.
3. Schyve PM. The importance of discharge planning. www.commonwealthfund.org/~/ media/Files/Resources/2009/Reducing%20 Readmissions/Schyve_commonwealth.pdf.
4. Agency for Healthcare Research and Quality. Guide to patient and family engagement in hospital quality and safety. www.ahrq.gov/professionals/systems/ hospital/engagingfamilies/index.html.
5. Nursing theory. Self-care deficit theory. http://nursing-theory.org/theories-and- models/orem-self-care-deficit-theory.php.
6. Holland DE, Rhudy LM, Vanderboom CE, Bowles KH. Feasibility of discharge plan- ning in intensive care units: a pilot study. Am J Crit Care. 2012;21(4):e94-e101.
To build rapport with the patient, nurses should begin teaching sessions by offering a warm greeting and establishing eye contact.
36 October 2015 • Nursing Management www.nursingmanagement.com
7. Health.gov. Quick guide to health literacy. www.health.gov/communication/literacy/ quickguide/factsbasic.htm.
8. Cornett S. Assessing and addressing health literacy. Online J Issues Nurs. 2009;14(3).
9. North Carolina Program on Health Literacy. www.nchealthliteracy.org.
10. National Numeracy. What is numeracy? www.nationalnumeracy.org.uk/what-is- numeracy/index.html.
11. Morris NS, MacLean CD, Chew LD, Litten- berg B. The single item literacy screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7:21.
12. National Institutes of Health. Clear communication: cultural competency. www.nih.gov/clearcommunication/ culturalcompetency.htm.
13. The Joint Commission. “What did the
14. National Patient Safety Foundation.Ask me 3. www.npsf.org/?page=askme3.
15. Agency for Healthcare Research and Quality. Questions are the answer. www. ahrq.gov/apps/qb.
16. Standards of medical care in diabetes.
IX. Diabetes care in specific settings. Dia- betes Care. 2013;36(suppl 1):S45-S49.
17. Standards of medical care in diabetes— 2015. Diabetes Care. 2015;38(suppl 1): S20-S30.
18. American Association of Colleges of Nursing. Creating a more highly qualified nursing workforce. www.aacn.nche.edu/ media-relations/fact-sheets/nursing- workforce.
19. Dictionary.com. Learning style. dictionary. reference.com/browse/learning+style.
20. Learning styles online.com. Overview of
21. Snow V, Beck D, Budnitz T, et al. Transi- tions of Care Consensus Policy Statement American College of Physicians-Society
of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emer- gency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
Debra Polster is a critical care clinical nurse specialist and the discharge project facilitator at Advocate Illinois Masonic Medical Center in Chicago, Ill.
The author and planners have disclosed no potential conflicts of interest, financial or otherwise.
Adapted from Polster D. Patient discharge information: Tools for success. Nursing. 2015;45(5):42-49.
doctor say?” Improving health literacy learning styles. www.learning-styles-online.
to protect patient safety. www.jointcom
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Preventing readmissions with discharge education
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