Reducing Adverse Events After Care Transitions Through Better Patient and Caregiver Education
By: Rebecca Smallwood, RN, MBA
Care transitions have been described as a bridge connecting patients from one health care provider, or group of providers, to another. It's easy to imagine a grand structure, like the Golden Gate Bridge in California, with awe-inspiring towers, powerful suspension, and a rock-solid foundation. But, when patients are discharged from the hospital, the bridge they must cross looks much different: rickety, narrow, and unstable, with wide gaps between decaying boards. Patients who have not fully regained physical or cognitive health, are physically vulnerable, and often have no social support, can easily end up falling through the bridge's cracks.
Studies show that adverse events, many of which can be serious, are a high risk for patients after a care transition from hospital to home. Many of these events are preventable through good communication and education before discharge. Patients who have a clear understanding of their after-hospital care instructions, including how to take medicines, and when to make follow-up appointments, are 30% less likely to be readmitted or visit the emergency department, than patients who lack this information [i].
Patient and caregiver education after discharge should clearly cover essential elements, such as:
- Prescribed medications, how to administer them, and possible side effects
- Performing self-care and monitoring important health conditions with proper diet
- When and how to make follow-up appointments
However, many patients leave the hospital without the critical knowledge they need. In an interview study of patient perceptions and understanding of discharge instructions among patients 65 years and older, 40% were unable to accurately describe the reason for their hospitalization and 54% did not accurately recall instructions about their follow-up appointment [ii].
How to Maximize Your Communication's Effectiveness
1. Include key learners. One of the top reasons patient education fails is because key learners are not included in the learning process. To identify key learners, ask patients questions like:
- "Who will help you with at-home care?"
- "Who will go with you to follow-up appointments?"
- "Who should be included in instructions about care after discharge?"
2. Include written materials that are language and literacy appropriate. Instructions should be brief, focused on critical information, primarily directed at what the patient needs to understand to manage his or her condition, and in the patient's preferred language. The American Medical Association recommends written information be targeted to a sixth-grade audience because nearly half of the U.S. population is only marginally literate, with an elementary or middle-school reading level [iii]. Include straightforward pictures, graphs, charts, and diagrams when possible.
3. Use plain language. According to the Institute of Medicine, even well-educated individuals may not fully understand medical information, especially when these individuals may be vulnerable by poor health. The use of plain language applies to verbal and written communication, and includes avoiding medical terminology, and using everyday examples to explain technical terms. Some common examples include:
- "Feeling tired and weak" vs. "fatigue"
- "Swelling" vs. "edema"
- "Front" and "back" vs. "posterior" and "anterior"
- "High blood pressure" vs. "hypertension"
- "Blood clot" vs. "embolism"
- "All the time" or "doesn't go away" vs. "persistent"
- "Pain reliever" vs. "analgesic"
- "Sweat" vs. "perspire"
4. Use teach-back. Using the teach-back method for confirming learner understanding of the information being explained improves compliance with treatment plans and leads to better outcomes. If understood, the learner should be able to "teach-back" the information accurately. An example of a teach-back question is: "I want to make sure I explained things clearly, can you tell me some of the side effects to watch for with your medicine?"
5. Use interpreters. According to the Agency for Healthcare Research and Quality, nearly 9% of the U.S. population is at risk for adverse events because of barriers associated with their language ability. In addition, the Department of Justice and the Department of Health and Human Services have stated that failure to provide appropriate interpreter services can be considered discrimination based on national origin. Use of qualified in-person medical interpreters (or access to telephone or video) for patients with limited English proficiency is recommended for high-risk scenarios, which include medication reconciliation, patient discharge, informed consent, emergency department care, and surgical care [iv].
6. Take a multidisciplinary approach. Nurses often play a primary role in educating patients for care transitions after hospital admission, but the expertise of other practitioners, such as pharmacists, dietitians, and physical therapists is especially beneficial when patients have complex medication, dietary, and therapy regimens. In 2012, a study published in the American Journal of Medical Quality showed that pharmacist-provided discharge counseling resulted in medication interventions, improved patient satisfaction, and increased medication adherence [v].
7. Encourage questions and note-taking. Patients are sometimes embarrassed to ask questions, and in some cultures, deference to authority stifles questions. Encouraging questions is an important way to engage patients as active partners in their care. In addition, note-taking enables recall and the synthesis of new information [vi]. For especially important instructions or critical areas of emphasis, ask the patient to underline or place a star beside them.
Overcoming Communication Barriers
It can be difficult to for patients to comprehend complex post-discharge instructions, even when conditions are ideal for teaching and learning. But add in a number of common communication barriers and it's no wonder much isn't remembered or is often misunderstood. Studies show that 40–80% of the medical information patients are told during office visits is forgotten immediately, and nearly half of the information retained is incorrect [vii].
Be prepared. Good communication starts with identifying potential barriers unique to each patient. You should know the patient's preferred language, how he or she prefers to receive information, any sensory issues, and assistive devices the patient may need. Use this information to make sure the right written materials are printed, arrangements are made for language services when needed, and the appropriate resources and other aids are available.
Eliminate distractions. Closing the door and asking the patient to turn off the TV helps reduce disturbances. It also conveys the message that the information you're about to share is important and they should pay attention.
Maximize vision and hearing capabilities. Encourage the use of corrective lenses or hearing aids if they're used at home. Adjust lighting and be aware of background noise. Ask the patient where you should sit to best be seen and heard. Make sure your face is visible when you're speaking.
Be aware of your non-verbal communication. Your body language, tone of voice, and facial expressions should convey friendliness, patience, and attentiveness. Watch for non-verbal cues in the patient that might signal concerns or disagreements, a lack of understanding, or a loss of attention.
Know when it's time to change your strategy. Repeating the same thing, in the same way, again and again, isn't likely to result in a better outcome when a patient is having a hard time grasping a concept. Change it up with the use of stories, examples, demonstrations, drawings, diagrams, models, videos and other tools that may be more effective.
Don't explain too many concepts at one time. A person's attention span is like a fuel tank. When it's full, the ability to process and retain information is maximized. In other words, information is more likely to be grasped correctly and remembered for a longer period of time. As the tank becomes less full so does the ability to comprehend and retain, so concepts aren't as clear and can't be remembered as long. Once the tank is empty, communicating more information is useless—it won't go anywhere. For this reason, you should discuss the most critical information first and then stop before the tank is empty. You can wait to introduce new concepts after the patient has had time to refuel.
Don't use family members as interpreters. This is important for two main reasons:
- Bilingual family members may lack a good vocabulary of medical terminology, and
- They aren't impartial and may add their own opinions or only relay information they want the patient to hear.
When discussing important information, always use trained medical interpreters.
Don't ask, "Do you understand?" Many people who do not understand may still answer "Yes." Rather, use teach-back questions such as "I want to make sure I did a good job explaining, so would you tell me what side effects of your medication you should watch for?"
Don't blame the patient when he/she doesn't understand. It's your job to communicate in a manner the patient can understand and teach-back is a tool for testing your performance. When a misunderstanding is revealed, don't shame the patient, take ownership. You might say, "I need to do a better job of explaining" or "Maybe I should explain it in a different way."
Don't interrupt. Listening is an essential part of good communication, and patients need to feel they're fully heard and understood. Resist the urge to interrupt. After communicating important information, ask them to take a minute or two to look over things you've discussed and think about questions they have. Sitting quietly through a few seconds of silence may feel awkward for some people. Practicing this technique will help you become more comfortable.
Building a Better Bridge
An article published in the Journal of Hospital Medicine proposed key components of an ideal transition of care with each representing a structural support of the bridge patients must cross from one care environment to another during a care transition [viii].
"The lack of a domain makes the bridge weaker and prone to gaps in care and poor outcomes. It also implies that the more components are missing, the less safe the bridge or transition is." The 10 domains described are:
- Discharge planning
- Complete communication of information
- Availability, timeliness, clarity, and organization of information transfer
- Medication safety
- Patient education and promotion of self-management
- Enlisting the help of social and community supports
- Advance care planning
- Attention to coordinating care among team members
- Monitoring and managing symptoms after Discharge
- Outpatient follow-up
Effective patient and caregiver education plays a crucial role in many of the above listed components to a stronger, safer bridge. Reducing adverse events that occur after a care transition starts with maximizing your staff's communication skills and ensuring that patients are effectively educated before discharge.
Visit the Relias website to learn more about providing quality education around important topics, such as care transitions, for your entire staff.
As a registered nurse for more than 27 years, Rebecca Smallwood, RN, MBA has experience across a wide spectrum of settings including: rural and urban hospitals in medical/surgical, and ED clinical roles; school nursing; public health epidemiology; ambulatory surgery center; infection control; quality management; organizational development; and education in hospital, academic, and commercial organizations. She has authored a myriad of live and web-based courses on over 50 regulatory topics, patient safety, patient experience, and others. Her passion for education developed over the course of her career while helping patients, professionals, and organizations leverage learning to achieve their goals. Improving patient care by helping others gain new knowledge, skills, and attitudes is her mission and the driving force behind her work.
[ii]. Horwitz, L., Moriarty, J., Chen, C., Fogerty, R., Brewster, U., Kanade, S.,… Krumholz, H. (2013). Quality of discharge practices and patient understanding at an academic medical center. JAMA Internal Med, 1715.
Kessels, R. (2003). Patients' memory of medical information. J R Soc Med, 219–22.
[iv]. Betancourt, J., Renfrew, M., Green, A., Lopez, L., & Wasserman, M. (2012). Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The Disparities Solutions Center. Rockville, MD: Agency for Healthcare Research and Quality.
[v]. Sarangarm, P., London, M., Snowden, S., Dilworth, T., Koselke, L., Sanchez, C.,… Ray, G. (2013, July/August). Impact of Pharmacist Discharge Medication Therapy Counseling and Disease State Education. American Journal of Medical Quality, 28(4), 292–300.
[viii]. Burke, R., Kripalani, S., Vasilevskis, E., & Schnipper, J. (2013, Feb). Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp. Med., 8(2), 102-109. doi:10.1002/jhm.1990