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

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Checklists for

Patients

Delivered online

and available 24/7

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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).

RS Laskin MD

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)

RS Laskin MD

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)

RS Laskin MD

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

RS Laskin MD

Identify & link to models

• Transpersonal Caring

• Relationship Centered Care

• Patient & Family Centered Care

• Transitional Care

• Magnet Model for Nursing Excellence

• Others?

RS Laskin MD

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

RS Laskin MD

Thank you!

Questions?

Jack Davis, MSN, RN, ONC

Manager, Patient Education Programs

Hospital for Special Surgery

davisj@hss.edu

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