Stick to basic four to manage CHF
Use simple handouts for low reading skills
To understand the challenge of heading the heart failure management program at MetroHealth Medical Center in Cleveland, you have to go on rounds with Glynis J. Laing, PhD, RN, CNAA, disease manager for heart failure at the large, county medical facility.
"Only 40% of my patients fit the typical profile CHF patients: adults over 65 with hypertension and CHF (??why say CHF in the profile?). The other 60% are as young as 20. Many have substance abuse issues. I didn’t realize that crack cocaine will push you into CHF until I worked here," she says. In addition to their youth and substance abuse history, many of Laing’s patients are indigent and have low literacy skills.
"These people are frequent flyers. They come through the emergency department (ED) and get admitted to the intensive care unit (ICU)," says Laing. And that’s where she first meets with patients and starts working on patient education.
Is the patient a frequent flyer’?
Laing makes rounds daily in the ICU with the social worker, case manager, and the charge nurse. "Occasionally, patients are admitted to a general medical floor instead of the ICU and the case manager or resident on the floor calls me and that’s how I find my people," she notes.
The first step in her CHF management approach is to review the patient’s chart. "I check to make sure they are on appropriate meds. If they aren’t on an ACE inhibitor, I check with the resident to see why not."
After a review of the patient’s chart, Laing talks with the patient. "For many of these patients, it’s the first time anyone has told them they have a heart problem. They don’t know what CHF is; it’s a new diagnosis for them."
If the patient is one of Laing’s "frequent flyers," she asks that person what caused the current admission. "A lot of times with this population, it’s a financial problem. The patient ran out of the prescription, and it’s a week before the next Welfare check."
At that point, Laing starts looking for solutions. "I hook up the patient with our case manager to get Medicaid or disability. I beg drug samples."
She’s learned through trial and error that everything from performing a psychosocial assessment to patient education must be kept simple with this population. To assess the patient’s environment, Laing asks the following questions:
• Who does your grocery shopping?
• Who cooks your meals?
• How do you come to the doctor?
"Many times patients tell me they come to the doctor by dialing 911," notes Laing. "I try to explain that perhaps a better option would be to schedule an appointment."
Many of Laing’s patients eat most of their meals at homeless shelters. "The personnel at the shelters have been very cooperative about working with me on low salt diets. The shelters have been very receptive about not adding salt to the food and simply putting salt on the tables instead," she says.
"I used to also ask patients who did the chores around the house until I realized that if you live in a rooming house, dusting and vacuuming are not high on your list of priorities," she adds.
Tell me about school
Once Laing establishes a fairly good rapport with patient, she assesses their literacy skills before beginning any patient education. "I ask them how many years of school they’ve completed," she says. "If they are older and graduated from high school, I assume they can read at a fairly good level. If they’re younger and they graduated from a Cleveland public high school, I assume nothing."
"I had no idea how many people cannot read well enough to follow commercial patient education materials," notes Laing. She uses a standard literacy assessment tool called the Rapid Estimate of Adult Literacy in Medicine (REALM).1 "You must tailor your materials to the literacy level of your patient. It seems so basic. We say it so often. But until you know their literacy level, you don’t know where to aim."
The lowest reading level on the REALM scale is a third-grade reading level and the highest is 12th grade. "My patients average about a fifth-grade reading level. Most commercial education materials are written at an eighth-grade level. There are too many words on a page. The type font is too small. It’s way over their heads."
In addition to their low literacy skills, most of Laing’s patients have an external locus of control. "They don’t believe they can be proactive," she says. "They are very short-term focused. Their attitude is Tell me what I need to know so that I can get out of here.’"
Laing soon realized that the best way to deliver important CHF management information to her patients was to talk in bullets. "I skip the elaborate explanations about the circulatory system," she notes. "I tell them that their hearts simply aren’t pumping right, and then I give them the four main components of CHF management."
Those components are:
1. Medication compliance.
"I simply tell patients they must take their medication every day just the way the doctor told them to take it." (See p. 73, for an example of Laing’s instruction sheet for ACE inhibitor use.)
To help her patients take their medications even when they can’t read the labels, Laing shows them their pills and counts them out into an egg carton. "To show them when they should take which pills, I draw a full sun to indicate morning doses and a sun setting for evening," says Laing. "One patient used a paper plate with three sections for morning, noon, and night. He knew the pills by how they looked."
" Unfortunately, pharmacies sometimes switch brands of generic pills without telling patients," says Laing . "One month their morning pill may be blue, and the next month it might be red. That can really confuse them."
2. Low salt diet.
"We don’t get really nervous about salt since the patients are on diuretics. I don’t expect them to count milligrams. I just tell them to put the salt shaker away and use frozen or fresh foods more often than canned or boxed foods."
3. Exercise as tolerated.
"I look at the patient to judge how conditioned I think they are," says Laing. "If they’re in a wheelchair I just urge them to lift cans . If they can walk, I tell them to start by walking around their house. Once they feel comfortable walking around the house, I tell them to start walking around the yard, then eventually around the block."
4. Daily weights.
"I used to give patients a weight range. I’d say if your weight is below 160 or above 165, call your doctor. That didn’t work," notes Laing. "Now, I skip the ranges. I tell them if your weight is 167, call your doctor. They simply could not grasp the concept of a weight range."
A small number of Laing’s patients cannot read numbers. "For those patients, I teach them how to do an ankle assessment instead of relying on daily weights. I tell them, this is how your ankles look when they’re OK. If they look different than this, call your doctor." In addition, Laing helps patients figure out how their body feels when they are putting on fluid. "I tell them to think about whether they’re having trouble lying flat."
"These people are survivors. If you talk to them in bullets. If you say, this is what you need to know, you can make a difference," she says.
1. Davis TC, Long SW, Jackson RH. Rapid Estimate of Adult Literacy in medicine: A shortened screening instrument. Family Medicine 1993; 25:391-395.