The reduce readmission while also decreasing healthcare

The
traditional discharge instructions are not adequately understood, likely to be
ineffective, and cannot measure comprehension. The health literacy principles
guide the efforts of healthcare providers and emphasize encouraging questions,
using plain language, and limiting teaching to 3-5 concepts (CDC, n.d.). Several
research studies suggest that teach-back method is effective in assessing gaps
in patient’s knowledge, teaching new concept/skill and clarifying misunderstood
information. Evidence from this systematic review revealed improve
comprehension, knowledge, self-care, treatment adherence, and quality of life
in adult patients from healthcare providers usage of the teach-back method.

Introduction

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            Health literacy is the ability to understand and
process health information to act and make appropriate health decisions (U.S.
Department of Health and Human Services, n.d.). Sanders, Federico, Klass,
Abrams, and Dreyer (2009) detail that literacy skills are a stronger predictor
of an individual’s health status. People with low health literacy are more
likely to have poorer overall health, higher death rates, higher healthcare
costs, more hospital visits and missed appointments. Unfortunately, 47% of
Americans have difficulty understanding the medical information given by
healthcare providers (Kornburger, Gibson, Sadowski, Maletta, & Klingbeil,
2013) while some do not receive any education. Thus, patients and families are
often not adequately equipped for discharge.

Self-management education is
necessary to assist patients and families to better manage their own conditions
and reduce readmission while also decreasing healthcare costs. Health care
professionals particularly nurses are in a unique position to assess and
enhance patients’ understanding of discharge instructions. More attention
should be brought on discharge education to improve treatment adherence,
patients’ quality of care, satisfaction and outcomes.

Several health agencies including
the National Quality Forum (NQF), American Medical Association (AMA), American
Nurses Association (ANA), and The Joint Commission recommend the use of
teach-back method as a way of checking patients’ understanding of what they
need to know or do about their health, and improve health literacy and patient
safety. This systematic review examines the use of the teach-back method in
improving health literacy, patient satisfaction and outcomes (such as treatment
adherence and self-management) on adult patients admitted to the hospital.

 

Evidence

A few of the studies were
experiments comparing the use of the teach-back method with the traditional
method of instruction (i.e. handouts and verbal instructions). In a randomized
controlled study performed in an urban academic emergency department and level
1 trauma center, patients who received teach-back had higher comprehension of
post-ED care, medication, self-care, and follow-up instructions (Griffey, Shin,
Jones, Aginam, Gross, Kinsella, Williams, Carpenter, Goodman, & Kaphingst,
2015).

An experimental study on 80 first
pregnancy postpartum women in healthcare centers across Darreh Shahr County,
Ilam Province in Iran was also conducted to assess the use of the teach-back
method. The control group received routine postpartum care according to the national
guidelines while the trial group received routine care with two sessions of
postpartum self-care education based on teach-back method. The quality of life
was assessed before and after the intervention. The results showed that the
self-care program based on the teach-back method improved the postpartum
quality of life and doubled the mean overall quality of life (Ghiasvand, Riazi,
Hajian, Kazemi, & Finoozi, 2017).

Furthermore, an evidence-based
practice (EBP) project using a three-day teach back method of instruction was
piloted to COPD patients in an intermediate care step-down unit. Two groups of
20 patients were utilized for this study with one group receiving the
standardized handouts and verbal instructions. The results suggested that the
teach-back method benefitted the patient in learning and understanding the
medication instructions (Betts, 2014).

            In
addition to the experimental studies, two systematic review studies were
reviewed regarding teach-back method. Almkuist (2017) performed a systematic
review of relevant articles regarding heart failure patients published on 2011
to 2016 from PubMed, CINAHL, and Scopus databases. The review concluded that
the use of teach-back method improved self-care, better medication adherence,
and increased disease-specific knowledge. Although not statistically
significant, the search also found five studies reporting a reduction in
readmission rates. The review recommended the combination of teach-back method
and other initiatives in reducing readmissions.

            Ha
Dinh, Bonner, Clark, Ramsbotham, and Hines (2016) performed a systematic review
of articles regarding type 2 diabetic patients from CINAHL, MEDLINE, EMBASE,
Cochrane CENTRAL, Web of Science, ProQuest Nursing and Allied Health Source,
and Google Scholar databases. Although not statistically significant, the
review found that the teach-back method showed improve disease-specific
knowledge, adherence, and self-efficacy. There was also an inconsistent but
positive trend on the reduction of hospital readmission rates.

            Participants
in an in-depth interview study of asthma patients regarding the usage of
teach-back techniques in the ED discharge process were supportive of the
technique and felt that teach-back would help them confirm learning, avoid forgetting
key information and improve doctor-patient communication (Samuels-Kalow, Hardy,
Rhodes, & Mollen, 2016). This article also showed that participants with
limited health literacy were more likely to perceived judgment from providers
and perceived teach-back as condescending. These participants, however,
suggested techniques to avoid the perception.

             The Agency for Healthcare Research and Quality
(AHRQ) as well as The Institute for Healthcare Improvement endorsed their very
own teach-back method kit to further help the patients and families’ transition
from the hospital. In addition, The AMA shared a video on YouTube describing
teach-back and its contribution to improving health literacy and patient
safety.   

Strengths

Improvement in patients’ comprehension,
knowledge, self-care, and treatment adherence while using the teach-back method
was well-documented within the research articles reviewed. The articles
reviewed were also of variety which include patients diagnosed with chronic
diseases, emergency department patients and pregnant women. Moreover, this systematic
review of articles provide a wide range of evidence, from a Level II to Level
VII evidences. In the experimental study involving postpartum women, the
self-care program based on the teach-back method has proven to improve the
overall quality of life.

The teach-back method allows
feedback and corrections of misunderstanding immediately and improves the
transition from hospital to home which is the reason behind the healthcare
agencies promotion of teach-back method toolkit. Regardless of the patient’s
health literacy level, using this technique confirms the patient’s
understanding of care instructions by repeating the instructions using their
own words.

Limitations

            The randomized, controlled study and
EBP project study were both conducted using convenience sampling which may be
less generalizable than studies using probability sampling strategy
(LoBiondo-Wood & Haber, 2014). The in-depth interview study was conducted
in two tertiary care academic centers which may potentially also limit its
generalizability compared with other discharge settings. Most of the studies
were limited to English-speaking adult patients which may affect the
generalizability of findings.

            In
the systematic review of heart failure patients, there were only five studies
which reported a reduction in readmission rates while using teach-back method.
The research showed that teach-back method alone does not statistically reduce
readmission rates.          

Pros and Cons

            The Institute of Medicine (IOM)
identified high-risk situations (i.e. discharge from the ED) as contexts to
improve provider-patient communication and ensure patients’ understanding of
information (Griffey, et. al., 2015). The randomized, controlled study provided
support on the efficacy of teach-back approach and its use in busy clinical
settings. In the in-depth interview study of asthma patients, most of the
participants felt that teach-back would help improve provider-patient
communication and were receptive to the technique. In addition, even though concerns
were raised surrounding the perceived judgment from providers, participants
provided strategies for introducing teach-back to avoid such perceptions.

Stakeholders/Change
Agents

“Patient education is a requirement
for accreditation of healthcare facilities” (Marcus, 2014, p. 482). The use of
the teach-back method alone or as a supplement to discharge instructions is
likely to benefit the healthcare facilities and healthcare providers as well as
insurance companies to reduce readmission rates and help with accreditation.
Patients also benefit from this initiative to improve comprehension,
disease-specific knowledge, medication adherence, quality of life, and
transition to home. Furthermore, different healthcare agencies and
organizations such as The Joint Commission, ANA, and NQF are always concerned
with providing safe and quality care to patients and families.        

Feasibility

Evidence supports that teach-back
method is preferred for confirming patients’ understanding of health
information. Improvement in patients’ comprehension, knowledge, self-care, treatment
adherence, and quality of life is also well-noted. The stakeholders are likely
to support this initiative because it is a safe and effective method of
introducing and confirming information. Some agencies have also introduced
their own teach-back method toolkit. Despite the perceived judgment from
healthcare providers, patients were still very receptive of the teach-back
method.       

Apply the Evidence 
    

            Marcus
(2014) stated “Well-educated patients are better able to understand and manage
their own health and medical care throughout their lives” (p. 482). Effective
communication is the key in providing patients with accurate, timely, and complete
instructions to help them in their transition from the hospital to their homes.
Evidence supports that communication is improved with the use of the teach-back
method. Furthermore, teach-back method also improves patient satisfaction and
outcomes, and reduces adverse events. Therefore, implementing teach-back method
into hospitals and other healthcare facilities is recommended. To further
reduce readmission rates and costs, supplementing teach-back method with
pamphlet information is recommended.