Teach-Back Method and Readmission Rates in Congestive Heart Failure Patients

Teach-Back Method and Readmission Rates in Congestive Heart Failure Patients

Clinical Problem

Hospital readmissions are considered an admission within thirty-days of being discharged from the same condition or illness. Congestive heart failure (CHF) is a chronic condition in which “accounts for an estimated 25% of all-cause readmissions” and accumulates to “more than $33 billion” in health care costs (Almkuist, 2017, p. 309). However, it is estimated that half of all CHF patients that are readmitted could have been prevented. Primary reasons for rehospitalization include the lack of education a patient has in regards to their medical condition, medication regimens, noncompliance in dietary restrictions, and/or waiting too long to seek medical attention.

Patients who do not have a clear understanding of their disease, medications, or necessary follow-ups are more likely to be noncompliant with discharge instructions. Therefore, increasing the risk of readmission. Discharge instructions and patient education are always documented within a patient’s chart, but specific methods used to educate and evaluate comprehension are not always evaluated. Teach-back is a strategy that involves the patient recalling key points of information to demonstrate a firm understanding of instructions prior to discharge home. This method includes asking the patient questions about their discharge instructions to determine which information was understood and what might need to be reiterated or clarified. Patients who leave the hospital with a clear understanding of their post-discharge instructions, including medication regimens and signs of worsening symptoms, are 30% less likely to return to the hospital or be readmitted (Peter, Robinson, Jordan, Lawrence, Casey, & Salas-Lopez, 2015). The teach-back intervention is a way of improving the quality of patient care. The more a patient understands and feels comfortable with their condition and treatment plan, the more likely they are to adhere to a long term therapy schedule and improve their overall health outcome.

PICO

• Population: Patients 65 years or older diagnosed with CHF. The prevalence of CHF increases with age and it is currently the leading cause of hospitalization. These patients are associated with a “30-day readmission rate of 21%” and 50% readmission rate by six months (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013, p. 137).
• Intervention: Using teach-back techniques while discussing discharge instructions. Almkuist (2017) found that the use of the teach-back method can positively affect health outcomes and self-care as well as increase knowledge about patient conditions. This intervention is low cost and does not require an extensive increase in the nurse’s time.
• Comparison: Giving a patient a printed handout of discharge instructions. Most electronic health record systems have education packets already put together and ready to print out with the discharge papers. This makes it easy for the nurses to just briefly skim during discharge and hand over, assuming the patient will just read it if they have any questions.
• Outcome: Improve the quality of patient care. Quality of care has a huge impact on patient recovery and the need for readmission regardless of health condition. However, studies show that the more the CHF patient understands about their condition and treatment regimen, the less likely they are to return within the 30-day readmission window for the same concerns (Peter et al., 2015).

PICO Question

For patients diagnosed with CHF, does the use of teach-back techniques compared to a printed handout of discharge instructions reduce the future risk of readmission within thirty days?

Search Strategy

Research began by using the Google search engine to determine which medical condition was consistent with the highest hospital readmission rates. The search continued with exploring reasons as to why readmission rates were so high and what could be done differently to decrease these numbers in the future. After searching Google and reading through articles on PubMed and Google Scholar, it was concluded that CHF had the highest readmission rates. This is the reason why this population was selected. While searching for articles, specific terminology included various combinations of CHF, readmission rates, discharge strategies, teach-back method, and quality of patient care. The search was further narrowed down to peer-reviewed nursing journals and articles with nursing authors, that had been published within the last five years. This was to ensure the research was up to date as the medical field is always changing and making advancements to optimize patient health outcomes.

Article Review

Article One – “Using Teach-Back Method to Prevent 30-day Readmissions in Patients with Heart Failure: A Systematic Review”

This study identifies the use of teach-back as an effective way to assess the knowledge of a CHF patient’s current health status (Almkuist, 2017). In this systematic review, five articles were retrieved and extensively reviewed. One was a metanalysis that involved studies that used many interventions including teach-back, two articles specifically looked at teach-back reducing readmissions in HF patients, and the other two articles analyzed various chronic conditions. It was found that in the absence of using teach-back, patients with CHF were unable to demonstrate the importance of certain daily tasks. This includes the significance of recording daily weights and when it is necessary to report weight gain to their health care provider (Almkuist, 2017). However, with the use of teach-back education 43% of the patients were able to remember to reduce their sodium intake (Almkuist, 2017). This investigation concluded that the use of the teach-back method improves retention of knowledge in relation to the specific disease process, treatment regimens, and self-care, as well as a reduction in the rate of readmission (Almkuist, 2017).  All of the reviewed studies included in this article indicated positive outcomes in patient self-care with the implementation of this discharge method. Not only does teach-back increase the quality of patient care but it also helps nurses to identify those patients who may need more extensive information and education about managing their condition at home (Almkuist, 2017). This positively perceived intervention is evidence-based and requires no additional costs to health care organizations. Limitations of this study include the lack of ability to control the study groups as well as the inconsistency in some of the educational sessions. These limitations decrease the credibility of the study’s findings. The level of evidence that this study utilized was a systematic review, which is classified as level one evidence or the highest level according to the hierarchy of evidence (Hoffman & Sullivan, 2017). This type of research is the most ideal because it includes data from specific studies that use randomized control and experimental groups.

Article Two – “Is “Teach-Back” Associated with Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients?”

This study was performed to determine whether or not heart failure patients were more capable of retaining self-care information with the use of the teach-back method and if it had an impact on hospital readmissions. Study participants included 276 hospitalized CHF patients over the age of 65 who underwent an education session performed by two nurses (White et al., 2013). The education sessions varied in time, lasting anywhere from 15 to 120 minutes and included four teach-back questions. Information was assessed before discharge and then again during a follow-up phone call that took place seven days after discharge. The patients that endured a longer teaching session retained a greater amount of information compared to the patients who received just brief teaching (White et al., 2013). The results of the study report that while hospitalized, patients correctly answered 75% of the questions 84.4% of the time and 77.1% of the time during the follow-up session after discharge (White et al., 2013). However, there were no significant findings that linked answering teach-back questions correctly to a reduced readmission rate. Teach-back proved as a reliable method to assess the amount of learning that was achieved by the patient as well as the ability to use that content at home once discharged from the hospital (White et al., 2013). A limitation of this study is that teach-back has an open nature to it which leaves a possibility for bias when trying to achieve full learning with a patient. Future research should investigate whether it would be more beneficial to have multiple information sessions compared to just one longer teaching session. The level of evidence in this study is a prospective cohort study, which is classified as a level four based on the hierarchy of evidence (Hoffman & Sullivan, 2017).

Article Three – “Reducing Readmissions Using Teach-Back: Enhancing Patient and Family Education”

The purpose of this study was to evaluate the insufficient quality of care transitions and the burden of readmission costs. The review of literature prior to conducting the study showed that readmissions are negatively influenced by low health literacy (Peter et al., 2015). The population observed throughout the study included 469 heart failure patients on the medical-surgical unit however, only 180 patients received teach-back interventions. The study utilized an education team that was comprised of twelve health care professionals who all typically carry at least some level of responsibility in educating the patient and family about an individual’s health conditions. The teaching strategy was designed as a three-day process where three domains of learning were addressed based on the individual’s learning needs (Peter et al., 2015). This allowed for the education team to explore the patient’s misunderstandings, planned compliance, or lack thereof. Day one assessed the current knowledge of the patient as well as any possible learning gaps to help develop a personalized education plan. Teach-back was utilized on day two to identify how the patient felt about their condition. Whereas day three evaluated the likelihood of the patient modifying their behaviors or lifestyle choices after discharge (Peter et al., 2015). Findings concluded that the educated patients averaged 94% of the correct answers for the knowledge questions and 90% for the change of behavior questions. Readmission rates were also positively impacted as they revealed a 12% reduction. An unintended but important finding that this study unveiled was that during the second hospitalization there was a reduction in length of stay amongst the patient group that received teach-back learning (Peter et al., 2015). The level of evidence of this study is a randomized controlled study that is classified as a level one based on the hierarchy of evidence (Hoffman & Sullivan, 2017). The higher the level of evidence the more reliable and valid the data is.

Reflection of Evidence

All three of the articles contributed significant evidence to support the use of the teach-back method to increase the effectiveness in the discharge instruction process. Low health literacy is associated with readmissions and a decrease in patient quality of life. Articles one and three reported a reduction in readmissions with the use of this intervention and indicated that it provides positive effects on self-care, disease-related knowledge, and overall health outcomes. However, article two noted the increase in knowledge retention but failed to find a correlation with reduced hospital readmissions. Overall, each article supplied applicable and relevant information regarding the chosen research topic and confirmed the positive effects of teach-back on CHF patients. Future research studies should evaluate the effects of utilizing teach-back with a combination of care transitioning interventions such as medication reconciliation or assessing any financial or psychosocial barriers that are inhibiting patients from receiving necessary care. Implementing the teach-back intervention as a routine aspect of the nursing discharge process enhances both the quality and safety of patient care.

References

• Almkuist, K. (2017). Using teach-back method to prevent 30-day readmissions in patients with heart failure: A systematic review. MedSurg Nursing Journal, 26(5), 309-312.
• Hoffman, J. J., & Sullivan, N. J. (2017). Medical-surgical nursing: making connections to practice. Philadelphia: F. A. Davis Company.
• Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., & Salas-Lopez, D. (2015). Reducing readmissions using teach-back. JONA: The Journal of Nursing Administration, 45(1), 35–42. doi:10.1097/nna.0000000000000155
• White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “Teach-Back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? The Journal of Cardiovascular Nursing, 28(2), 137–146. doi:10.1097/jcn.0b013e31824987bd