Patient Education and Coaching

Stages of Grief

  • Five stages of grief, helpful for understanding patient responses to health threats, defined by Elizabeth Cooper Ross (page 170).
    • Denial and isolation
    • Anger
    • Bargaining
    • Depression
    • Acceptance

Health Belief Model

  • Explains factors influencing a person's health beliefs and practices.
    • Person's perception of developing a disease:
      • Common in young people: "It can never happen to me."
      • Example: "I'm not old enough to get that."
    • Person's perception of the severity of the disease:
      • Example: "Oh, my God. I've got cancer. I'm dying."
      • Feeling of a "death sentence" and hopelessness.
    • Whether the person will take preventative actions:
      • Patient deciding to take steps to improve their health.
      • Example: "I can do this, this, and this, and I can make myself okay."

Domains of Learning

  • Different ways people gain knowledge and skills (chapter 171).
    • Cognitive Domain:
      • Mental processes of recall, application, and evaluation.
    • Psychomotor Domain:
      • The "doing" domain or movement.
    • Affective Domain:
      • Feelings, emotions, values, and attitudes.

Learning and Information Processing

  • Learning is gaining new knowledge or skills through instruction, experience, or study.
  • Information is processed in three domains: cognitive, psychomotor, and affective.
    • These domains apply to everyone, not just patients.

Goal of Patient Education

  • To effectively impart information so that patients remember and apply it.
  • Example: Patient recalling advice to "Eat low sodium. Stay away from sugar."

Cognitive Domain Strategies (Table 72, page 172)

  • Involves new learning concepts and information.
  • Stages:
    • Sensory stage
    • Short-term memory
    • Long-term memory
  • Strategies:
    • Present information at an appropriate level for the patient (adult vs. child).
    • Be sensitive to those for whom English is a second language.
    • Build on the patient's prior knowledge about the topic.
    • Present information in small chunks in a clear, well-organized manner.
    • Provide written and demonstrative instructions.
    • Use pamphlets with drawings or pictures.
    • Have the patient teach back the information.
      • Example: Patient explaining how they will cut back on sugar.

Psychomotor Domain

  • Involves learning a new skill or procedure (the "doing" domain).
  • Provide step-by-step directions to the patient.
    • Example: Instructions for taking medication: "Unscrew the top, pull back the safety tablet, dump one pill into your hand, take one pill, put it in your mouth, swallow it with a glass of water."
  • Give timely feedback on the patient's performance.
    • Example: Praising a patient for correctly performing a blood sugar draw.
  • Patient teaches back what they have been taught while performing the skill.
  • Repeated practice is important for recall.
  • Use the equipment and supplies that the patient will be using at home.

Affective Domain

  • Involves a change in attitude or emotions that will influence a person's behavior (the "feelings" domain).
  • Includes feelings, emotions, values, and attitudes.
  • Positive attitude is crucial for recovery (reportedly 90%).
  • Emotional upset can hinder the body's ability to heal.
  • Address affective domain issues before educating the patient.
  • Involve family members for support and reinforcement.
  • Provide written instructions for reference at home.

Coaching

  • Provides patients with skills, knowledge, support, and confidence to manage their disease between provider visits.
  • Includes:
    • Disease prevention
    • Health maintenance
    • Diagnostic tests
    • Treatment plans
    • Specific needs
    • Community resources

Developmental Stages

  • Thought processes and behaviors change as we grow and develop.
  • Erickson's psychosocial developmental stages (pages 173-174):
    • Trust versus mistrust
    • Autonomy versus shame and doubt
    • Initiative versus guilt
    • Industry versus inferiority
    • Identity versus role confusion
    • Intimacy versus isolation
    • Generativity versus stagnation
    • Ego integrity versus despair
  • Table on page 174 gives ages and goals for each stage.

Adaptive Barriers to Patient Coaching

  • Impaired vision
  • Impaired hearing
  • Language barrier
  • Estimated percentages in the U.S.:
    • Visual impairment: 2%2\%
    • Hearing impairment: 3%3\%
    • Limited English proficiency: 9%9\%

Strategies for Patients with Impaired Vision

  • Ensure patient can hear you.
  • Speak clearly and enunciate.
  • Avoid speaking too fast or too slow.
  • Announce yourself when entering the room.
  • Use a clear voice.
  • Provide written material in large font or print size.
  • Consider color contrast.
  • Maintain eye contact if possible.

Strategies for Patients with Hearing Impairments

  • Use sign language if possible; otherwise, use interpreters or language boxes (clinics).
  • Ask the patient if their hearing aid is on and working.
  • Use a low-pitched voice and speak clearly, slowly, and distinctly.
  • Rephrase if the patient has difficulty understanding.
  • Ensure the patient is using their hearing aid.
  • Say the patient's name before beginning a conversation.
  • Keep hands away from your face when speaking to allow for lip reading.

Strategies for Patients with Language Barriers

  • Use a translator, considering different dialects.
  • Address the patient by name.
  • Be respectful and courteous.
  • Use simple phrases if an interpreter is present.
  • Focus on the patient while the interpreter communicates.
  • Use translated materials.
  • Use pictures and models.

Cultural Diversity

  • Set of behaviors, ideas, and customs shared by a specific group of people.
  • Characteristics: language, religion, geographic origin, ethnicity, sexual orientation, socioeconomic class.
  • Cultural differences on page 175.
  • Consider the role of family and community, religion, views on health and wellness, death and dying, complementary therapies, gender roles, beliefs related to food, diet, illness, health, sexuality, fertility, and childbirth.
  • Be mindful of cultural differences and beliefs when providing care.

Teaching/Learning Process

  • Identify the patient's educational needs.
  • Identify barriers hindering learning.
  • Coach the patient on the topic.
  • Evaluate the patient's learning.
  • Document the coaching provided.
  • Ensure information is truthful and accurate.
  • Treat each patient as an individual.

Coaching on Disease Prevention by Age Group

  • School age: Basic hand washing.
  • Teens and adults: Prevention of STDs, cigarette/tobacco use, and drug use.
  • All age groups: Respiratory hygiene, coughing etiquette, vaccinations, and general hygiene.

Coaching on Health Maintenance and Wellness

  • Routine lab work, colonoscopies, mammograms, bone density tests.
  • Based on patient's answers to screening questions.
  • Educate patients for self at-home self-exams.
    • Breast exam: after period, yearly mammograms starting between 45 and 50.
    • Testicular self-exam: part of physical and monthly self-checks.
    • Skin self-exam: ABCDE (asymmetry, border, color, diameter, evolving) - changes in color, size, shape.

Regular Screenings

  • Blood pressure
  • Bone density
  • Cholesterol
  • Colorectal cancer screening (colonoscopy)
  • Dental exam (referral)
  • Fall risk screening
  • Lung cancer screening (chest x-ray, start with asking if they are a smoker)
  • Mammogram
  • Pap test
  • Prostate cancer exam
  • Glucose test

One-Time Screenings

  • Abdominal aortic aneurysm:
    • Recommended for men between 65 and 75 who have smoked.
  • HIV screening:
    • Between 15 and 65 or when sexually active.
    • Annually for pregnant women and people with high risks (healthcare workers).
  • Hepatitis:
    • Born between 1945 and 1965; history of blood transfusion before 1992, injected illegal drugs, or chronic liver disease.

Additional Screenings

  • PHQ-9: Depression screening.
  • Alcohol misuse screening
  • Nicotine/tobacco screening
  • Drug abuse screening (urinalysis)
  • Intimate partner violence screening
  • Elderly safety screening
  • Neurological exam status
  • Functional status screening
  • Peripheral neuropathy screening: use monofilament.

Coaching on Diagnostic Testing

  • Provide necessary information for diagnostic and laboratory tests.
  • Fasting requirements for some tests (cholesterol, sugar).
  • Answer questions:
    • What is the test?
    • What does the patient need to do for the test?
    • When is the test scheduled?
    • Does the test require fasting? If so, for how long?
    • Should patients continue or stop taking medication?

Coaching on Treatment Plans

  • Review treatment plans with patients.
  • Includes:
    • Taking medications
    • Monitoring blood pressure
    • Caring for casts or splints
    • Applying hot/cold therapy
    • Using assistive devices (cane, walker, crutches)
    • Testing blood glucose levels and coagulation.
  • Suggest medication boxes for organization (page 186).
  • Common patient instructions (page 186).

Care Coordination

  • Provides personalized, patient- and family-centered care in a team-based environment.
  • Advantages:
    • Greater efficiency, reduced cost, better patient care
    • Individualized guidance and services
    • Encouraging self-management
    • Reducing hospital/ER visits
    • Ensuring patient needs and preferences are met
    • Providing instructions and directions
    • Ensuring test results are available
    • Communicating patient needs and concerns
  • Medical assistants as patient navigators (pages 187-188).

Patient Navigator Responsibilities

  • Assist patients and families with insurance problems.
  • Explain treatments and care.
  • Communicate with the healthcare team.
  • Assist caregivers.
  • Manage paperwork.
  • Provide assistance to the patient.
  • Medical assistants are cross-trained in administration skills.

Patient Coaching Materials

  • Paper materials, apps, YouTube links, websites.
  • Use only provider-approved sites.

Legal and Ethical Issues

  • Patient confidentiality.
  • Patients have the right to information before receiving care (VIS for vaccinations).
  • Conduct adequate patient education and follow-up.
  • Document each patient education intervention completely and accurately.
  • Meet the needs of all patients without prejudice.

Patient-Centered Care

  • Care coordinators provide individual assistance.
  • Patients who feel well-cared for stay with their provider.
  • Care coordination will increase in popularity.