To reduce heart failure readmissions use the teach-back method

Tips for how to keep teaching consistent

Teach-back protocols in educational programs for heart failure patients have been helpful in reducing readmissions. When this technique is used to assess skills in key areas pertaining to the management of this disease, gaps in understanding can be addressed swiftly.

"Teach-back works for us because we are providing a method that allows us to very quickly assess or measure a patient's learning outcomes. If the patient misses the mark on a question, we know we need to find another way to deliver the message or approach the topic," says Paula Robinson, RN, BC, MSN, patient, family and consumer education manager for Lehigh Valley Health Network in Allentown, PA.

At Lehigh Valley Hospital, data analyzed from July 1, 2010, to the present demonstrates a 12% reduction in readmission rates for heart failure patients who received teach-back, dropping from 30.6% to 26.9%. On the pilot unit for the educational program, there has been a 50% reduction in heart failure readmission rates from the time of implementation, dropping from 28.2% to 14%. The pilot program was implemented in December 2009.

Although teach-back protocols are being designed for other disease states such as stroke, it was important to begin with heart failure because the Centers for Medicare and Medicaid Services in Baltimore, MD, will focus on hospital readmissions for this patient group in 2013, says Robinson.

When a patient with a primary or secondary diagnosis of heart failure is admitted to Lehigh Valley Hospital, an order set is entered into the electronic medical record that generates an education prompter for the nurse, says Debra Peter, MSN, RN, BC, CMSRN, a patient care specialist. Education takes place over a three-day period, and nurses teach from a series of "prompter" questions, Peter explains. On day one, the sessions focus on general knowledge. On day two, they focus on attitude, and on day three, they focus on behavior. Therefore the questions follow a pattern of "what," "why," and "how." These questions not only prompt the patient education, but they also are teach-back questions.

"We constructed the questions according to core measure concepts for heart failure, so the concepts of medication, diet, weight, and identifying and managing signs and symptoms are key concepts that are constantly being taught to the patient within those three days," says Robinson.

Finding what works

Other healthcare institutions have had similar success with teach-back. Staff at the University of California, San Francisco (UCSF) Medical Center began to revamp education when given a grant for half a million dollars by the Gordon and Betty Moore Foundation to reduce readmissions for heart failure patients.

Staff researched best practice at other healthcare institutions, worked with the cardiologists and dietitians at UCSF Medical Center, and worked with the Institute of Healthcare Improvement in Cambridge, MA. From the information gathered, an educational binder was created that guides the teaching across the continuum of care, explains Eileen Brinker, RN, MSN, Heart Failure Program coordinator.

Brinker and a colleague, Maureen Carroll, RN, perform the teaching for the heart failure program. Brinker says, "Teach-back is the best practice method of patient education to assess the patient or family member's level of understanding."

Instead of just telling people to eat a low salt diet and weigh daily, education focuses on what salt does to their heart and why they are asked to weigh daily. When patients understand that eating chips cause water retention, which makes their heart work hard, they can better understand how to change behavior, she adds.

The heart failure education program has reduced readmission rates at UCSF Medical Center for patients over age 65 by nearly one-third.

For good education results, include the "teach-back" questions nurses will focus on when teaching patients and caregivers on educational handouts, advises Peg M. Bradke, RN, MA, director of Heart Care Services at St. Luke's Hospital in Cedar Rapids, IA. At this healthcare institution, the questions are on the back of the cover sheet of a packet of educational materials that are kept in a clear plastic sleeve with a magnet so it can be hung on the refrigerator.

The questions are included for two reasons, says Bradke. The patient can see the information staff want them to understand and put into practice. Also it is a reference for nurses.

The educational packet also has a red/yellow/green warning zone for managing symptoms and knowing when to seek medical help; a brochure on salt delivered in a "don't eat this, eat that" style; quick reference on medical terms, and a calendar to chart weight gain.

The teach-back questions are not used only within the hospital; they are reviewed during a home care visit within 24-48 hours after discharge. They are used once again during a seven-day follow-up call by a nurse. The use of these questions reinforces the key points continuously, explains Bradke.