The Patient JourneyThe Guided CarePath, as part of a multi-modal strategy, helps create a single streamlined patient experience through the entire journey of a total joint replacement.
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Patient & Family Education: A Multi-Modal Approach to
Improve the Experience
Jack Davis, MSN, RN, ONCManager, Patient Education Programs
Hospital for Special Surgery
RS Laskin MD
HSS background
• Musculoskeletal Specialty hospital est 1863
• No. 1 ranking orthopaedics
• Magnet Recognition
• Academic center
• Research division
RS Laskin MD
Conflict of Interest
• No financial affiliation with products discussed
• My current role as Manager Pt Education Programs for HSS influences my views on the subject on which I am presenting
RS Laskin MD
Objectives
• Describe methods used to educate orthopaedic patients and families across the continuum
• Recognize factors that may improve the “experience”
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Poll Question #1
• Do you routinely use a preopeducation class to teach patients?1. Yes
2. No
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Educational Methods & Strategies
– Preop class group learning– Written materials
– Web-based
– Individual learning
– Use of technology
– Dedicated educator(s)
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Poll Question #2
• Do you routinely use internet or web -based technology to teach patients?1. Yes
2. No
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Organization’s Culture
• Identify models or theoretical frameworks
– Transpersonal Caring
– Relationship Centered Care
– Patient and Family Centered Care
– Transitional Care
– Magnet Model for Nursing Excellence
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Poll Question #3
• Do you routinely include family in the education of patients?1. Yes
2. No
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What metrics are used to evaluate the education
experience?
– Volume stats
– Cost to educate
– Outcomes associated?
– Knowledge
– Satisfaction
– HCAHPS?
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Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS)
• Publicly reported survey of patients’ perceptions of hospital care
• Satisfaction with the Experience
• Failure to report=reduced reimbursement
• HCAHPS performance linked to Value-Based Purchasing incentive payments
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Poll Question #4
• Are you modifying teaching strategies to improve HCAHPS scores?1. Yes
2. No
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Is the education of Patient/Family relevant?
Patient education is critical to helping patients successfully cope with and recover from orthopaedic
conditions and surgery
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Is education relevant to the organization?
• Sets expectations for experience– Nursing & MD Care
• Courtesy, listen, teach, respond
• Manage pain, new meds, toileting
– Environment• Clean, quiet
• Discharge disposition and transitions
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So is preop class best practice?
• Pre-op program shows mixed results– Anxiety, LOS, Pain, Expectations
• Joint Commission Disease Specific Care Certification– Formalized program that provides theory &
skills to manage disease
• AHRQ National Guideline Clearinghouse– Pre op education program = moderate LOE
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Patient Education Framework
• Provide health information
• Facilitate knowledge & understanding
• Engage patients to take an active role in care management
• Effect physical and mental health outcomes
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Patient Education
“ …is more than just having the nurse review discharge instructions prior to leaving the hospital, it is a means for the nurse to assist the patient in the
enhancement and expansion of his ability to provide effective self-care”
(Bastable, 2006).
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Increased responsibility to educate the patient’s family members and caregivers d/t shorter hospital stays and earlier transitions to home
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Is there a best or most effective method to teach
orthopaedic patients?
• Combined teaching strategies
• Repeated/reinforced three times
• Patient/Family engagement
• Grounded in multiple theory
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Transpersonal Caring
• Watson’s 10 Carative Factors
• Deep caring spiritual connection
• Provides comfort & Pain control
• Well being, Wholenss & Healing
(Gallagher-Lepak and Kubsch, 2007)
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Watson’s 7th Carative Factor…
• Promotion of transpersonal teaching-learning– Interpersonal approach nurse to patient
and not information
– Assess readiness to learn
– Respect pre-existing knowledge
– Understand feelings about content, goals/desired outcome
(Gallagher-Lepak and Kubsch, 2007)
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Relationship Centered Care
Respectful of and responsive to individual patient preferences, needs and values and ensuring that patient & family values guide all clinical decisions
(Epstein, Fiscella, Lesser & Stange, 2010)
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Healing Relationships
• A two-way sharing of info patient & provider
• Explore values & preferences
• Help patient & family make decisions
• Facilitate appropriate care
• Follow through with behavioral change
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Similar to self-management
• Model used in chronic disease
• Problem solving and decision making
• Patients engage in daily process to manage own care
• Use family, health team & community to manage consequences of health conditions
(Richard & Shea, 2011)
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Poll Question #5
• Do you routinely use Clinical guidelines or pathways?1. Yes
2. No
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Patient & Family Centered Care
• More popular approach
• Patient & Family Partnership
• Supports family presence and participation
• Enhance access to information
• Encourage shared decision-making
• Promote safety & well being
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Outcomes?
• Better adherence to medications
• Improved disease management, problem solving and decision making
• Improve self-efficacy and ability to navigate health system
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Transitional Care
• Ensure health care continuity
• Avoid preventable poor outcomes
• Promote safe and timely transfer– One level of care to another
– One type of setting to another
(Naylor et al. 2011)
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Helps identify the best time to teach
• Before surgery
• Access to information after consults?
• During the hospital when taking medications?
• Reminders sent after discharge?
• Across all transitions of care?
• Who is the target audience?
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Orthopaedic Transitions
•Patient Education
•Admission
•Nutrition
•Holding
•PACU
•In-patient
•Home
•Rehab
•Primary care
•Internist
•Anesthesia
•Other Consultant
•Out Patient office consult
•Operating Room
•Post op follow up
Surgical Service
Medical Service
Pre Surgery
Post Surgery
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Transitional Care Interventions
• Discharge planning
• Patient and family teaching
• Home visits
• Calls or surveys after discharge
• Improve continuity of care & prevent readmission?
(Coleman et al,2006)
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Magnet Model of Nursing Excellence
• Nurse as teacher concept
• Patient education program
• Interdisciplinary team input
• Other members of team?
• Address diverse patient/family needs
• Communicates across the organization
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Written
MultimediaOutcomes
Classroom
Patient
Education
Office practice
Service lines
Revise content
Condition & process
Web-based
& other
Interactive
formats
Knowledge
retention
Press Ganey
Interdisciplinary Patient/Family Centered Education Committee
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A Challenge
Research shows that patients remember and understand less than
half of what clinicians explain to them.
(Ley, 1988)
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Barriers to learning
• Patient health status
• Medications
• Anxiety
• Teaching environment
• Learning styles
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Individualistic learning & retention
• 10% of what is read
• 26% of what is heard
• 30% of what is seen
• 50% of what is seen & heard
• 70% of what they say
• 90% of what say as do something(Felder & Silverman, 2002)
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Engagement and Evaluation of Learning
• Is content provided?
• Is it effective?
• Knowledge gained?
• Ability to manage self care?
• How long is information retained?
• Target patient & family
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Teach-Back: Closing the Loop
Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop
Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003
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Teach-back – Using it Well:
Elements of Competence
● Responsibility is on the provider.
● Use a caring tone of voice & attitude.
● Use Plain Language.
● Ask patient to explain using their own words
(not yes/no).
● Use for all important patient education, specific
to the condition.
● Document use of & response to teach-back.
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Even if teaching is good, will it influence behavior?
Education occurs if learning takes place with a resultant change in behavior,
skill or attitude.
(Falvo, 1994)
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Providers should understand learning principles
• Active involvement
• Readiness to learn
• Conducive environment
• Perceived relevance
• Repetition
• Generalize info
• Pleasant experience
• Begin with known topics to unknown
• Present at appropriate rate
(DeYoung, 2009)
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Ortho Patient Education Best Practice Summary
• Multi-modal approach
• Reinforced across practice settings
• Pre-op to discharge instructions & post-op calls
• Nurses to use teaching principles and evidence-based strategies
• Engage patients & family in the process
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Identify & link to models
• Transpersonal Caring
• Relationship Centered Care
• Patient & Family Centered Care
• Transitional Care
• Magnet Model for Nursing Excellence
• Others?
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More than the preop class
• It is about the nurse-patient relationship
• It is about how we include the family and convey messages
• It is about assessing individual learning needs and styles
• It is about reinforcing across transitions
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Improving the experience
• Monitor HCAHPS & other metrics?
• Feed form focus groups?
• Engage the participants in process
• Make it convenient
• Expand access to info?
• Use technology?
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Educational Methods & Strategies case study
– Written materials
– Web-based
– Classroom group learning
– Individual learning
– Use of technology
– www.hss.edu
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Thank you!
Questions?
Jack Davis, MSN, RN, ONC
Manager, Patient Education Programs
Hospital for Special Surgery
RS Laskin MD
References
• ANCC Commission on Magnet Recognition. (2008). Application manual magnet recognition program (2008th ed.)
• Bandura, A. (1977). Self-efficacy toward unifying theory of behavioral change. Psychological Review, 191-215.
• Kearney, M., Jennrich, M. K., Lyons, S., Robinson, R., & Berger, B. (2011). Effects of preoperative education on patient outcomes after joint replacement surgery. Orthopaedic Nursing / National Association of Orthopaedic Nurses, 30(6), 391-396
• Epstein, R. M., Franks, P., Fiscella, K., Shields, C. G., Meldrum, S. C., Kravitz, R. L., et al. (2005). Measuring patient-centered communication in patient-physician consultations: Theoretical and practical issues. Social Science & Medicine (1982), 61(7), 1516-1528.
• Naylor, M. D. (2009). Transitional care model. Retrieved December 12, 2009, from www.transitionalcare.info
The Patient JourneyThe Guided CarePath, as part of a multi-modal strategy, helps create a single streamlined patient experience through the entire journey of a total joint replacement.
Guided CarePath
Smart
Checklists for
Patients
Delivered online
and available 24/7
from home