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Patient Education

Nurcan Ilksoy, MD

Hospitalists and other members of the care team need to work with patients to help them to manage their health. Effective communication skills between patient and providers are critical to successfully maintain a cohesive approach to care in order to achieve the best possible outcomes.

Beyond the initial diagnosis and management, prescription of evidence-based medications, smoking cessation counseling, and clear, complete discharge instructions are all extremely important elements in providing optimal care to patients with HF.

Education and Counseling

Recommendations from HFSA 2006 Comprehensive HF Practice Guideline

The majority of HF care is done at home by the patient and family or caregiver. If these individuals do not know what is required or fail to see its importance, they will not participate effectively in care. For this reason, comprehensive education and counseling are the foundation for all HF management. The goals of education and counseling are to help patients, their families and caregivers acquire the knowledge, skills, strategies, and motivation necessary for adherence to the treatment plan and effective participation in self-care. The inclusion of family members and other caregivers is especially important, because HF patients often suffer from cognitive impairment, functional disabilities, multiple comorbidities and other conditions that limit their ability to fully comprehend, appreciate, or enact what they learn.

HF patients and their family members or caregivers need to receive individualized education and counseling that emphasizes self-care. This education and counseling should be delivered by providers using a team approach in which nurses with expertise in HF management provide the majority of education and counseling, supplemented by physician input and, when available and needed, input from dietitians, pharmacists, and other health care providers.

Teaching is not sufficient without skill building and specification of critical target behaviors. Essential elements of patient education to promote self-care with associated skills are shown in Table 8.1.

Table 8.1: Essential Elements of Patient Education With Associated Skills and Target Behaviors

Elements of Education	Skill Building and Critical Target Behaviors
Definition of HF (linking disease, symptoms, and treatment) and cause of patient's HF	Discuss basic HF information, cause of patient's HF, and how symptoms are related
Recognition of escalating symptoms and selection of appropriate treatments in response to particular symptoms	Monitor for specific signs and symptoms (eg, increasing fatigue doing usual activities, increasing shortness of breath with activity, shortness of breath at rest, need to sleep with increasing number of pillows, waking at night with shortness of breath, edema)
	Perform and document daily weights
	Develop action plan for how and when to notify the provider
	Institute flexible diuretic regimen, if appropriate
Indications and use of each medication	Reiterate medication dosing schedule, basic reason for specific medications, and what to do if a dose is missed
Importance of risk factor modification	Smoking cessation
	State blood pressure goal and know own blood pressure from recent measurement
	Maintain normal HgA1c, if diabetic
	Maintain specific body weight
Specific diet recommendations: individualized low-sodium diet; recommendation for alcohol intake	Reiterate recommended sodium intake
	Demonstrate how to read a food label to check sodium amount per serving and sort foods into high- and low-sodium groups
	Reiterate limits for alcohol consumption or need for abstinence if history of alcohol abuse
Specific activity/exercise recommendations	Reiterate goals for exercise and plan for achieving
	Reiterate ways to increase activity level
Importance of treatment adherence and behavioral strategies to promote	Plan and use a medication system that promotes routine adherence
	Plan for refills

Patients' literacy, cognitive status, psychologic state, culture, and access to social and financial resources should be taken into account for optimal education and counseling. Because cognitive impairment and depression are common in HF and can seriously interfere with learning, patients should be screened for these. Appropriate interventions, such as supportive counseling and pharmacotherapy, are recommended for those patients found to be depressed.

It is recommended that educational sessions begin with an assessment of current HF knowledge, issues about which the patient wants to learn, and the patient's perceived barriers to change. Address specific issues (eg, medication nonadherence) and their causes (eg, lack of knowledge vs cost vs forgetting) and employ strategies that promote behavior change, including motivational approaches.

The frequency and intensity of patient education and counseling vary according to the stage of illness. Patients with advanced HF or with persistent difficulty adhering to the recommended regimen require the most education and counseling. Patients should be offered a variety of options for learning about HF according to their individual preferences:

videotape
one-on-one or group discussion
reading materials, translators, telephone calls, mailed information
internet
visits

A study by Koelling et al described the positive impact of a single educational session prior to discharge from the hospital – link to Koelling article.

Repeated exposure to material is essential because a single session is never sufficient. During the care/education process patients be asked to:

demonstrate knowledge of the name, dose, and purpose of each medication
demonstrate their preferred method for tracking medication dosing
sort foods into high- and low-sodium categories
show provider daily weight log
reiterate symptoms of worsening HF
reiterate when to call the provider because of specific symptoms or weight changes

During acute care hospitalization, only essential education is recommended, with the goal of assisting patients to understand HF, the goals of its treatment, and posthospitalization medications and follow-up regimen. Education begun during hospitalization should be supplemented and reinforced within 1-2 weeks after discharge, continued for 3-6 months, and reassessed periodically.

Examples of patient education materials:

Dealing with HF Booklet

Please visit the Medicare Quality Improvement Community website to see an example of a patient education booklet for heart failure. The booklet contains information on the elements of the performance measure. Distribution of the booklet would not be sufficient for abstraction without the booklet being included in the medical record. The accompanying sticker can be placed in the record to document the elements contained in the materials. This tool provides content and a consistent process for teaching at a level that will facilitate retention of the material and improve patient management of heart failure.

The booklet provides teaching on the categories of commonly used medications with heart failure but does not provide patient specific teaching based on the medications ordered for that patient.

The patient education booklet and documentation sticker were developed after a need was identified at acute care hospitals. Most of the acute care facilities in Arkansas use this tool and their feedback indicates this as a key to improvement in the discharge teaching performance measure in heart failure.

Managing your Heart Failure using the “Zones”

This material from Christus Schumpert was adapted by GMCF under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 8SOW-GA-HH-06-41