Broaden scope of patient ed for better outcomes

Monitoring, follow-up are keys to effectiveness

Effective patient education can improve compliance to physician advice — which results in better treatment outcomes, happier patients, and even better Health Plan Employer Data and Information Set (HEDIS) scores. But that also requires developing a patient education program that goes beyond a rack of brochures in the reception area.

Medical groups need to take a comprehensive view of patient education rather than relying on any one publication or video, patient education experts advise.

"Just as chronic diseases are for life, most of these educational interventions have to be planned in a continuous, ongoing way," says Paul Terry, PhD, vice president of education for the Institute for Research in Education at HealthSystem Minnesota in Minneapolis, which includes Park Nicollet Clinic, a large multispecialty group practice.

"It’s sort of like expecting a hypertensive patient to take one pill and be cured," he says. "From an educational standpoint, it requires that the learners regard themselves as being learners for life about their conditions."

In fact, patient education will be a crucial element of maintaining high quality care under the cost and time constraints of managed care, says Preston G. Ribnick, MS, president of Professional Resources, a health care consulting firm in South Wellfleet, MA.

"The medical experience of the near future is going to be so different from what we’ve seen all our lives," he says. "Instead of being evaluated based on how much time the patient spends with the provider, or how affable the provider is, [it] is going to be dependent on the flow of information and patient education."

To improve the effectiveness of educational efforts, patient education experts offer the following advice:

1. Begin with a health risk assessment.

A health risk assessment is, in itself, a primer on prevention. The patient learns which health behaviors could lead to future problems and what preventive tests and lifestyle changes are necessary. (For more information on administering health risk assessments, see Patient Satisfaction & Outcomes Management July 1997, pp. 75-76.)

The assessment also can trigger a discussion with the physician about conditions or habits of concern (such as high cholesterol or smoking) and can prompt further educational interventions.

For example, Park Nicollet Clinic provides personal health risk assessments to patients at their work sites. Terry and his colleagues are developing a system to allow patients to complete their assessments before their preventive health visit via the Internet, or answer questions on a computer kiosk while waiting for a clinic visit.

Messages from the health assessments are reinforced through posters and reminder cards in the clinic and elevators, self-care education books, newsletters, and seminars, Terry says.

A health assessment can be useful even if it’s informal, notes Barbara Hebert Snyder, MPH, president of Making Change, a health education consulting firm in Cleveland that specializes in improving communication between clinicians and patients. Physicians can ask, "How would you rate your own health?" or "How healthy do you think you are?"

"That can open a conversation about what you can do to have a healthier lifestyle," says Snyder.

2. Maintain the physician as the No. 1 educator.

From a time standpoint, the physician doesn’t need to provide all or even most of the patient education. Physicians can rely on nutritionists, nurses, patient educators, and others on their staff or use available resources at hospitals, clinics, health plans, or medical libraries.

But patient education experts stress that physicians are the most important source of information for their patients.

"People remember what their doctor said to them," says Snyder. "If they only hear a dietician talking about food or diet, they discount some of that, [thinking], ‘That’s their job, they’re supposed to talk to me about that.’

"If their physician says, ‘I want you to make an appointment with this nutritionist. They have some important things to tell you about your diet,’ it makes all the difference in the world."

Terry is conducting a study comparing the effectiveness of medical self-care information books mailed directly to the home compared with those handed out by the physician at a medical visit.

"Our hypothesis is that patients prefer and find more credibility with self-care education books handed out at the visit," Terry says. "The physician is the No. 1 preferred source of information (for patients)."

3. Follow up after initial patient education.

When a patient is diagnosed with a condition that requires considerable self-management, such as asthma or diabetes, either the physician or someone else on staff should schedule a follow-up visit to discuss care plans and other information needs, advises Snyder.

"Don’t assume you can cover it all in one visit or even assume that the patient can ask all questions in the visit in which they get a diagnosis," she says.

With the time pressures of patient visits, patients following a complex protocol may need a "clinical management appointment," or a visit devoted specifically to education, she says.

Ribnick suggests that physicians and their staff check on their patients’ understanding of instructions with a brief phone call and ask, "How are you doing with exercise? How are you maintaining your weight?"

Education that occurs over time reminds patients about their regimen and encourages them to comply with physician advice, according to a study by Krames Communications, patient education publishers based in San Bruno, CA, and Columbia San Jose (CA) Medical Center.

Congestive heart failure patients who received information packets in four mailings over a 12-week period had 51% fewer readmissions to the hospital. They also were more likely to comply with medical advice, such as taking their medications consistently, changing their diet, and weighing themselves often.1

"If you took all that material and gave it to them in one day, there’s no way it would have the same impact," says Seth Serxner, PhD, MPH, director of research for Krames Communications.

4. Monitor physician and staff performance on patient education.

The practice may have one staff person who gathers and evaluates patient education materials, or even someone who meets with patients to discuss treatment protocols in detail. But patient education should be part of job expectations of physicians and other clinical staff, she says.

Periodic monitoring helps raise the profile of patient education, as well as measuring how well the practice is doing in this important area, says Snyder.

For example, a volunteer or a staff member could ask patients to describe their home instructions at the end of their appointments. What are their medications, their dietary or physical restrictions or instructions? When are they supposed to follow up with a phone call or next visit? Are there things they are still confused about? Did the physician ask them if they had any other questions?

Patients’ misperceptions of their home instructions can be corrected immediately, and they can be tracked to determine whether patients have received and understood the information they need to know.

The "exit interviews" could occur one morning a week, or one week out of a month, Snyder suggests . Or such questions could be incorporated into a patient satisfaction survey.

"It’s a matter of taking patient education as one of the [critical] functions of the practice and putting it under a microscope to see how well we’re doing," she says.

[Editor’s note: For more information on improving patient education and communication, contact: Barbara Hebert Snyder, President, Making Change, 1030 Allston Road, Cleveland, OH 44121. Telephone: (216) 691-9393. Or contact: Preston Ribnick, President, Professional Resources, 160 Old County Road, P.O. Box 963, South Wellfleet, MA 02663. Telephone: (508) 349-6161. Or contact: Seth Serxner, Director of Research, Krames Communications, 1100 Grundy Lane, San Bruno, CA 94066-3080. Telephone: (415) 244-4428. Internet:]


1. Serxner S, Miyaji M. Case study: Surviving the disease-management challenge with patient education. Presented at the National Managed Health Care Congress. Washington, DC; April 1997.