Teach-back program reduces readmissions

IHI collaborative helps quality staff

The Lehigh Valley Health Network in Allentown, PA, was one of 18 recipients of The Hospital & Healthsystem Association of Pennsylvania (HAP) 2011 Achievement Awards, given in recognition of innovative programs. The Lehigh Valley program involved the use of teach back to reduce readmission rates in heart failure patients who had been hospitalized.

According to the system's award entry, heart failure patients who received teach back had a readmission rate of 26.9%. "This rate is 12% lower than the readmission rate for those heart failure patients who did not receive teach back (30.6%)," said the system. In addition, they noted, the heart failure readmission rate on the pilot unit decreased by more than 50%. "Furthermore, an early cohort of patients demonstrated a shorter length-of-stay during the second hospitalization if the patient received teach back during the index stay," the entry said.

"Back in the fall of 2009 we had a work group in progress to look at reducing readmissions and enhancing care," says Debra Peter, MSN, RN, BC, CMSRN, patient care specialist at Lehigh Valley Hospital. "At that point we were also in an IHI collaborative with 26 other hospitals on the same topic."

The work group, she continues, divided into four subgroups to examine different aspects of enhancing the process and reducing readmissions, one of which was patient education. "The idea for teach back came from the collaborative itself; IHI had offered it as one of the alternatives," Peter adds.

The assistance from IHI was welcome, she explains, because "we were not that familiar with what teach back was, and I believe we had missed opportunities we now have to rephrase and state back, which provides a better understanding of outcomes."

Getting started

Peter says that IHI indicated the strategy works best when you place accountability for learning on the provider side, not on the key learner. "They gave us sample scripting," she says. In addition, she says, the group conducted an evidence review to "see what was out there." They were surprised to find that most of the information on teach back dealt with physician offices, not acute care settings.

However, they did find one article — "Closing the loop — physician communication with diabetic patients that have low health literacy" (Schillinger D, Piette J, Grumbach K, Arch. Intern. Med. 2003 Jan. 13;163(1):83-90.) — that they found to be most helpful. "The paper heightened our awareness that this is not happening consistently — that many times in acute care there is minimal education provided in teaching patients how to better manage their disease process," Peter says. "We often give out written materials, but we do not have patient teach back."

The strategy recommended by the IHI collaborative included performing small tests of change and seeing how to develop a process for the network. A group that included a physical therapist, a heart failure nurse practitioner, a pharmacist, staff nurses, and a representative from a local skilled nursing facility addressed those issues.

Even before implementation could begin, an e-learning program was made accessible to the entire staff; the program was mandatory. A video featuring Peter described the process. In addition, a two-hour interdisciplinary workshop was presented. "During that workshop we highlighted the importance of education and of bringing it to the forefront," Peter explains. "We then had an opportunity for each of them to be validated on the process; we developed a performance checklist to standardize how we validated everyone." On the unit level, she adds, each unit educator was to validate his or her RNs; leaders in other disciplines had to do the same.

Motivation was also handled from a unit perspective, although it was given a strong foundation by the inclusion of teach back among the goals set by the administration. "And we would do unit-based strategies, even things to heighten awareness like contests with raffles," Peter says. "But the education was motivating in itself; I've been an educator for 15 years and have often gotten pushback, but with this they basically said this was what we should have been doing."

As for her unit staff, Peter says the nurses did complain that they did not have time to work this program into their daily schedule, but "I said we must have this, because patients continue to come back."

So she had the 30-bed medical unit for which she was head nurse conduct small tests of change with suggestions from IHI. "They gave us four questions specific to the heart failure population," she says. "Our action plan was to teach the entire network the general concept related to teach back, but as a subgroup we got direction from our sponsors to really focus on heart failure."

The questions, she says, home in on core measures, and as noted above, this pilot achieved a 50% reduction in readmissions. "The final standard work process includes three days of sequential questions that probe the patient's knowledge, attitude and likelihood for behavioral changes related to heart failure," noted the Lehigh Valley entry. "Day one focuses on knowledge, day two on why these practices are important, and day three on behavior," adds Peter.

Hardwiring the process into the nurse's daily routine using an electronic prompt on the patient medication screen has been essential to the success of the project, says Peter. "It makes the nurse and provider more accountable," she explains.

Throughout the day, she continues, the nurse focuses primarily on the patient medication screen. "We decided to have a 12:00 noon entry for teach back; we purposely did that because that's when the bulk of the meds will have been given," she says. "We thought if we did it when the meds started to decrease the nurse could decide when it's best to teach — when the family comes in, in the evening, or move it to tomorrow." When the nurse double clicks, the details of the program are all there, she notes, including how to conduct teach back.

Peter says the process is "absolutely" replicable at any facility. "When The Advisory Board heard what we were doing, they came to the hospital to do a site visit," she says. "They called it not only a best practice, but a 'megapractice.' When their reference went out we started getting call after call for site visits. Just this morning I answered an e-mail from a nurse in Massachusetts."

[For additional information, contact: Debra Peter MSN,RN,BC,CMSRN, Patient Care Specialist, Lehigh Valley Hospital, 1200 S. Cedar Crest Blvd., Allentown, PA 18105. Phone: (610) 402-5046.]