Skills-based learning is an established, if not an underused approach in patient education for individuals with chronic conditions. The current issue’s article by Wehbe-Janek, Hochaleter, Castilla, and Chanhee describes such a program, using simulation with at-risk patients recruited to participate in training taught by “standardized clinicians.” Although clinicians and educators often focus on transmitting knowledge to patients, which is pertinent and central to a given disease (heart failure, diabetes, asthma, etc), approximately 80% of the skills required to succeed as a patient are common to all conditions: problem solving, decision making, setting goals and action planning, as well as seeking and receiving necessary support (clinical and otherwise).1 The need for an established “skill set” intensifies postdischarge from an acute hospitalization, as a patient (and/or their caregivers) often faces a heightened risk for readmission because of confusion about what has just occurred, what medicines to take (and why), and who to call if something goes wrong. The high readmission risk for such patients is of intense interest to hospitals facing new financial penalties in the United States, as it is for at-risk health plans and providers responsible for the higher costs incurred. Readmissions are also very stressful to the patients and caregivers involved.
I have a personal family history with the impact that an admission can have on a patient’s ability to comprehend skills-based training—in 1998, my 79-year-old father was admitted for an 11-day stay for an MI that required a left ventricular assist device and a 3-vessel coronary bypass. He also became delirious “post-pump” (the period after coming off a heart-lung bypass machine), pulling out his external pacemaker wire minutes before he experienced a cardiac arrest, which he survived. He spent a portion of his admission in restraints because medication failed to control his aggressive behavior. At other times, he appeared calm and smiled at the staff coming into his room to gain favor with his “jailors” (his words). This was the case when a nurse arrived to give discharge instructions. Although I happened to be in the room (and hence also received the information from the nurse), I found myself wondering if the same instructions would have been delivered directly to my father had I not been present. In the car on his way home from the hospital, Foley catheter still in place, he said to me, “It really was a hospital!” During the following months, he returned to his baseline status, even able to complete the Saturday New York Times crossword puzzle. I am sure that he retained very little if any of what was taught during the discharge conversation. He thought they were prison guards! Yet, the nurse’s duty required that he or she deliver the talk before discharge.
Although his experience was extreme, most patients admitted emergently are sleep deprived, drugged, and worried about the implications of their “new reality.” Likewise, family caregivers are stressed and wondering how they are going to manage their lives while providing higher levels of support for loved ones.
Using a standardized predischarge “simulation strategy” as a part of routine self-management support for patients and caregivers at high risk for acute hospitalization, if successful, would be a reasonable adjunct to other “care transition” efforts currently underway in many hospitals and health systems. A current best practice includes a health coach (from nurse practitioner or physician assistant to a community health outreach worker) meeting the patient and caregivers in the hospital, following up by a home visit within 24 to 72 hours, and culminating with a follow-up visit within 7 to 14 days with either the patient’s or a relevant specialist.2,3
Both Eric Coleman’s and Mary Naylor’s Care Transitions interventions, cited earlier, have demonstrated that postdischarge home visits provide value in reducing readmissions. Arthur Garson’s Grand-Aides Program, using trained lay staff supervised by registered nurses, takes this concept further—offering as many home visits as needed provided by trained peers. These can be combined with brief registered nurse telemedicine visits, using portable technology carried by the peer, to instruct a patient/caregiver team on how to survive their “new reality” in the context of heart failure.4 All of these programs are distinct from traditional Home Health, in that they are designed to promote self-management, rather than “care for the patient.” All 3 approaches also share a common characteristic: they are reactive. However, preventing readmissions is a subset of a larger concern—preventing avoidable hospital admissions. Programs such as Care Transitions are by nature a reactive process. Better would be to prevent the original admission.
Wehbe-Janek’s study, as designed, was intended to demonstrate that standardized skills-based training could teach at-risk patients how to engage with health care in the midst of complex health care situations. The intent was to generalize the findings to apply to currently admitted patients, but the subjects were in fact removed from the acute crisis of an admission. In addition, the patients were assigned hypothetical illnesses and hence had a reduced emotional “connection” with the content. On the provider side, the “standardized clinicians” received training in “facilitative communication techniques” that exceeds the training of many hospitalists and nurses currently working in the inpatient setting, creating a potential confounding variable should future studies eventually compare a similar intervention to “standard care.” These are obvious design weaknesses in the study acknowledged by the authors, which was limited in scope by funding and which the authors describe as a “pilot study,” thus begging further iterations. It is encouraging that the briefer “predischarge” intervention was not inferior to the more extensive “home visit” follow-up with regard to most outcomes (including patient confidence), which gives hope for the rise of cost-effective strategies in the future. The interrelation between heightened “facilitative communication techniques” and patient engagement was also of interest and speaks of the importance of empathy within the clinician-patient relationship.
The study certainly offers opportunities for further investigation into the use of simulation-based teaching to decrease the risk of hospitalization:
- Can simulated “actor” patients working with hospital teams improve the teams’ efficacy in working with elderly or cognitively impaired patients at discharge by improving providers’ “facilitative communication skills” (compared with hospital teams who meet with the same simulated patients but are not trained in facilitative communication techniques)? Does such training lead to reduced readmission rates for real patients?
- Can simulated “standard clinicians” delivering inpatient training regarding actual diagnoses to previously discharged real patients decrease their risk of readmission (compared with a matched control group receiving “usual care”)?
- Can less expensive nonprofessional personnel (aka “standardized clinicians”) using standardized “experiential”/simulation-based methods of education before discharge lower readmission rates (compared with a matched control group receiving instructions from busy nurses with similar enhanced facilitative communication skills training)? To do so will surely require that they are provided with the time and enhanced facilitative communication skills training to allow patients and their caregivers to be able to ask questions and demonstrate knowledge and skills (and thus improve patients’ confidence). A positive result here could help expand the use of less expensive personnel working at the limits of their credentials on care teams in the inpatient setting and thus lighten the load for expensive and often overwhelmed physicians and nurses. Similar use of “trained peers” has been proven effective in the ambulatory setting during the past decade, although the majority of such innovations rarely appear in the peer-reviewed literature.5
Stepping back from the current study, I find that the important finding of their carefully designed research is that skills can be taught to patients using standardized tools delivered by nonclinicians, which do not need to be based on the actual condition of a given patient, and further can be used at a time the patient is relatively stable and hence better equipped to incorporate the information. This is a new concept in the care transitions world and fits nicely with the idea that at-risk patients (those with chronic conditions) can benefit from an outpatient skills-based self-management programs to potentially reduce readmissions. Such programs exist and are variously deployed, the best example being the Chronic Disease Self-Management Program designed by Kate Lorig, RN, DrPH, and Halstead Holman, MD, at Stanford. This is a peer-led, group-based self-management program that is taught in workshops over a 6-week period, uses a standardized curriculum, is available in more than 70 countries, and has been studied extensively.6–8 Further studies are needed to better test methodologies to deliver skills-based content, but the current study gives us some confidence that we do not need to wait for the crisis to act to empower our patients in their self-care and thus help ourselves.
1. Bodenheimer T, Sobel D, Lorig K, Grumbach K. Patient self-management of chronic disease in primary care. JAMA
2002; 288: 2469.
2. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc
2004; 52: 1817–1825.
3. Naylor M. Transitional care for older adults: a cost-effective model. LDI Issue Brief
2004; 9: 1–4.
4. AHRQ. Policy Innovation Profile: clinics and hospitals use trained, certified community members to screen and support primary care and post-discharge patients, reducing physician visits and costs. AHRQ Web site. Available at: https://innovations.ahrq.gov/profiles/clinics-and-hospitals-use-trained-certified-community-members-screen-and-support-primary
. Accessed November 1, 2014.
5. Ghorob A, Vivas MM, De Vore D, et al. The effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial. BMC Public Health
2011; 11: 208.
6. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum
1993; 36: 439–446.
7. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care
1999; 37: 5–14.
8. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care
2001; 39: 1217–1223.