Note: Teach-back has been shown to decrease readmissions, change patient behaviors, and improve communication with patients. These are all highly desirable outcomes for a tool that is both free and quick. But, even today, it is not readily embraced as a standard of practice by many providers.
That is why The Wellness Network decided to publish a new white paper, Teach-back, Communicating More Effectively With Patients to Improve Health Outcomes. The goal of this white paper is to define what teach-back is, show why it is relevant to healthcare today, and offer guidelines for successfully implementing teach-back in your organization.
The Evolution of teach-back
One of the earliest mentions of teach-back occurred in a 1987 in a book called Knowledge Acquisition for Expert Systems. Even though health literacy gained a foothold in the literature and in practice in the mid-1990s, teach-back was slower to be adopted and validated, especially considering its proven effectiveness.
“In a study of 189 coronary artery bypass surgery patients who received teach-back patient education, readmissions were 25% in the pre-intervention group compared with 12% in the post-intervention group. Admissions were cut in half for the group who received teach-back.”
In 2003, the American Medical Association (AMA) mentioned teach-back in its "Health Literacy: A Manual for Clinicians. In 2007, the Joint Commission published “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety, and the AMA released its Health Literacy Kit. The Agency for Healthcare Research and Quality (AHRQ) followed in 2010 with its Health Literacy Universal Precautions Toolkit and a second edition was recently released. All of these cited teach-back as a useful tool for patient education and patient safety, lending great credibility to its usefulness in patient education.
AHRQ’s toolkit is a rich resource for getting started. It walks potential users through the basic steps of conducting teach-back and provides other useful materials such as a 5-minute video that gives two examples of using teach-back with medication changes, a PowerPoint presentation, and an AMA video on teach-back, as well as a Teach-Back Self Evaluation and Tracking Log. The AHRQ materials are free and online, as is the Joint Commission report and the AMA kit.
The Process of teach-back
Teach-back, at its core, is asking a patient to repeat what a provider has told them in the patient’s own words. It is important to note that the onus of teach-back is not on the patient but on the provider. It is a checks and balances approach to healthcare, a kind of active listening technique. In addition, it can be used to assess a patient’s knowledge base and activities at home, not just their understanding of a provider’s instructions.
With teach-back, the provider asks open-ended questions – ones that cannot be answered to by “yes” or “no.”
Here are some examples:
- “I want to be sure I explained how to take this medicine clearly. Can you please explain it back to me so I can be sure I did?”
- “Your husband couldn’t come with you today. What will you tell him about the changes we made to your medicines today?”
- “We’ve gone over a lot of information about adding exercise to your day. In your own words, tell me what we talked about and how you will make it work at home.”
Although teach-back doesn’t sound difficult, it becomes easier once it becomes a habit. It is a powerful tool that can make the difference between successful and failed patient outcomes. But it is essential that educators know how to use it properly.
Recall is an integral part of the teach-back process. Studies show that “between 40-80% of the medical information that patients receive is forgotten immediately after a provider-patient encounter – and that nearly half of the [recalled] information is incorrect.”
“One cannot assume that people understand health communications based on dress, education, and how they present themselves. It’s entirely possible to have a high level of overall literacy but low health literacy.”
If patients are alone, they might recall very little of the provider encounter. Teach-back gives them another chance to try to understand what is happening to them and to ask the provider for clarification.
Aimee Lamb, PA-C, MMSC of Sinai Grace Hospital in Detroit stresses that it’s an assessment tool for educators. “It is a rare skill to be able to teach another successfully. Teach-back allows us to objectively assess this ability in ourselves and further encourages us to focus on the most important take-away points for the patient.”
Teach-back and health literacy
Comprehension is just as important, if not more so, than recall. Comprehension is an integral component of health literacy, which is defined as “the ability to obtain, process, and understand health information to make informed decisions about health care.”
One of the earliest mentions of the term “health literacy” was in a 1995 Journal of General Internal Medicine article in which the authors developed the Test of Functional Health Literacy in Adults, or TOFHLA.
TOFHLA is a 50-item reading comprehension and 17-item numerical ability test that has a corresponding Spanish version. In 1995, only 52% of the English speakers completed more than 80% of the questions correctly.
Today, a similar situation exists with regard to health literacy. According to the National Assessment of Adult Literacy (NAAL), only 12% of Americans are proficient in health literacy. Someone falls below basic health literacy if they can only “identify how often a person should have a specified medical test (based on information in a clearly written pamphlet), identify what is permissible to drink before a medical test based on a set of short instructions, or circle the date of a medical appointment on a hospital appointment slip.”
Teach-back can help providers communicate with people with low health literacy, but it can also help with communicating overall – even with people with proficient health literacy. In addition, one cannot assume that people understand health communications based on dress, education, and how they present themselves. It’s entirely possible to have a high level of overall literacy but low health literacy.
“Teach-back is especially important for people who are managing complicated health problems…As the millions of baby boomers age, chronic conditions such as obesity, diabetes, and heart failure are increasing. It is imperative that people understand how to manage their conditions and that providers provide them with understandable and useful information.”
Aside from a lack of knowledge, there are other factors to consider. Magdalyn Patyk, MS, RN, BC, Patient & Family Education Manager at Northwestern Memorial Hospital in Chicago, cautions, “Many variables at a given moment can hinder anyone’s health literacy. If a person is upset, under great stress, or experiencing pain during a consultation, their ability to discern and retain information can decrease dramatically.”
Patients with high health literacy may question what providers are saying and challenge their instructions. So teach-back can aid in improving these communications as well. In the article, Teach-Back on a Daily Basis, published in Patient Education Update, there is the example of a college professor who was resistant to his physician’s recommendation to start on yet another blood pressure medication. He wanted to be listened to and he wanted to be able to have his questions answered in a way that was understandable. When the doctor turned the patient over to a clinical pharmacist who was skilled in teach-back, she helped this patient understand why he was being put on another medicine.
Teach-back is especially important for people who are managing complicated health problems. In study after study, it has been shown to reduce readmissions for chronic complicated conditions. As the millions of baby boomers age, chronic conditions such as obesity, diabetes, and heart failure are increasing. It is imperative that people understand how to manage their conditions and that providers provide them with understandable and useful information.
Lamb thinks teach-back is a particularly useful method when educating patients about complex topics in that it allows “both the provider and the patient to focus on what is most important.” It might be that multiple visits are needed when dealing with complex disease states such as diabetes or heart failure. Focusing and educating on only one or two particular points allows for greater understanding when patients are struggling with information overload.
Part 2 focuses on implementing teach-back in your organization.
Click here to receive the complete white paper, Teach-back, Communicating More Effectively With Patients to Improve Health Outcomes.