A new priority is emerging among clinicians: timely, targeted patient education. The focus is on not only when to go to the ED, but also on self-care, medication adherence, and even how to connect with a primary-care practice that the patient will find accessible.
Despite decades-long efforts to cut avoidable ED visits, they persist in great numbers. Of more than 123 million emergency-department visits, 56 million were patients lacking an immediate, emergent or urgent condition, according to the National Hospital Ambulatory Medical Care survey for 2008, the latest year for which data is available.
The growth of specialty medicine has spurred demand for patient education, even as the flight of aspiring physicians from primary care has cut into the supply of potential educators. “There are huge gaps in patient education because of worsening fragmentation of our health-care system,” says Michael Fleming, MD, chief medical officer at Amedisys, a home-health provider based in Baton Rouge, La. “Patients see so many different specialists.”
Patients Need Just-in-Time Education.
Effective patient education means relevant health information delivered to — and reviewed with — the individual patient by a clinical problem-solver who knows how to listen. Amedisys has implemented a patient-education program, including training to improve compliance and self-management, that brought a 7.9 percent decrease in acute-care rehospitalizations.
“Patients need reinforcement of self-care instructions with a phone call a day or two after they come home from the hospital, and an appointment with their primary-care provider within five to seven days,” says Brian Jack, MD, vice chair for academic affairs at the Boston University Medical Campus. In a study led by Dr. Jack, that post-discharge call revealed that half of patients were taking their medication incorrectly or not at all, an avoidable situation that can easily lead to an ED visit or readmission. Patients who were effectively educated in post-discharge care — including how to take medications and make timely follow-up appointments — were 30 percent less likely to be readmitted or visit the emergency room, according to the study.
In addition, many truly emergent episodes could be avoided if patients were better educated to deal with their conditions. “If we can catch things early, like sudden weight gain in a heart patient, that’s huge in keeping people out of the ED,” says Wanda Filer, MD, a family physician in York, Pa., and a board member of the American Academy of Family Physicians.
An Individualized Approach to Trimming ED Use.
Effective education must be more than a few boxes checked off on a long and confusing set of post-discharge instructions intended for patients in many different situations.
Keystone Mercy Health Plan has shown that patient education can cut ED visits. The Philadelphia Medicaid insurer implemented a comprehensive program for ED “frequent flyers” — including member education — that reduced emergency-department utilization by 10 percent.
Effective patient education isn’t simple; it requires sophisticated communication. “Good education has to be individualized based on the patient’s medical situation, cultural orientation, literacy and financial situation,” says Dr. Filer. “We take a different approach with a 30-year-old patient who’s a college grad versus a less-educated elderly person with vision problems.”
Patients also need to learn how to advocate for themselves by asking the right questions of a primary-care practice to ensure that they’ll have access to practitioners when they need them, according to Dr. Filer. Patients who work jobs with inflexible hours may seek out a group practice that sees patients on evenings or weekends, so they don’t end up going to the emergency room with uncomplicated flu, for example.
As the United States becomes more diverse and complex medical conditions become more common, patient education must become more systematic and specific. “We have handouts in more than one language that identify the red flags for patients’ conditions, and we write down red flags specific to the patient,” says Dr. Fleming of Amedisys. Its staff also instructs its patients about when to call for advice or an appointment and when to go to the emergency department, as when a heart patient on Coumadin experiences bleeding.
Medication Problems a Major Cause of Avoidable ED Visits.
Medication adherence, since it concerns virtually all chronically ill or post-discharge patients, is fertile ground for improved patient education. About three quarters of American patients do not take their medications as directed, according to the National Council on Patient Information and Education, whether because a prescription was never filled, or the patient forgot to take it, took less than prescribed or stopped taking it prematurely.
Patients need to have their medications explained to them, in part because many lack the literacy to comprehend all the instructions. Tens of millions of Americans read below the fifth-grade level, but nearly all medication instructions are written at a ninth-grade level or above, according to the Institute for Safe Medication Practices.
“Cardiac patients often don’t understand that their new medications aren’t a one-shot deal, that they’ll be taking these prescriptions for life,” says Mary Clausen, RPh, of Loyola University Health System’s Gottlieb Memorial Hospital. “Pharmacists can do this education more efficiently than nurses,” says Clausen. Effective education that continues after discharge means fewer ED visits and readmissions, and improved patient-satisfaction and HCAHPS scores, which can boost reimbursement, she adds.
In addition, the millions of patients who cannot afford all their prescriptions need to be educated about other ways to get them.
Setting the Stage for Improved Patient Education.
The Affordable Care Act provides incentives, however indirectly, for improvements in patient education, says Jason Hwang, MD, executive director of health-care think tank Innosight Institute in Mountain View, Calif. “The ACA encourages medical homes and ACOs, and the patient-education component goes along with these pilot programs naturally.”
Finally, for patient education to be more effective, doctors, nurses, pharmacists and other health-care professionals need to become better educators. “Physicians need to have interviewing skills and to understand learning styles, to know how to build an active relationship with patients,” says Dr. Filer.
John Rossheim is a writer and editor who covers information technology, careers and other topics in health care.
Related Links:
> How to Conduct Patient Ed at Discharge, Cut Readmissions
> Improving Care Coordination: A Physician's Perspective
> Author of NEJM Study Sees Progress in Cutting Readmissions
