50 PART I: PATIENT EDUCATION
thepatientisconfused,andaskifinformationcanbebetter
explained.Itisimportanttobenonthreateningandtoput
oneselfonthesamelevelasthepatient.Ifthepatientfeels
inferior,thepatientwillshutdownandinhibitfurtherdis-
cussionabouthisorherhealth.Nextconsidertiming.Ifthe
patientfeelsrushed,uncomfortable,orangry,heorshewill
notbereceptivetoinformationoffered.
10
If this is the case,
givethepatientthevitalinformationandencouragehimor
her to schedule a follow-up appointment while showing
concernaboutcontinuingtheconversation.Ifthepatientis
inagoodpositiontodiscusstheissueathand,addresshis
orherconcernsdirectlywithempathy.Rememberthatthe
patientmaybescared,uncertain,ornervous.Thereisno
substitute for reassurance from a trusted care provider.
Lastly,beforeapatientleaves,reiteratethemostimportant
detailsabouthisorhercondition.Encouragethepatientto
becomefamiliarwithwhathasbeenoutlined,andreassure
himorherthatthereisawillingnesstodiscusshisorher
conditionagain.Thisleavesanopenlineofcommunication
between the provider and the patient.
10
Patient Education Materials
Practitionersoftenresorttohandingoutpatienteducation
materials(PEMs)asasubstituteforgoodone-on-onepatient
education.However, one study shows thatPEMs, suchas
pamphlets,mayhaveabenecialeffectonprocessoutcomes
but not on patient outcomes.
11
This begs the question, If
PEMsarenotchangingpatientoutcomes,aretheyreallyan
effectiveeducationaltool?Perhapstheycouldbeiftheprac-
titionerreviewsthemwiththepatient.Aspreviouslystated,
taking time to go through the material with patients will
prevent confusion and allow them to ask questions about
terms they do not understand. The following information
mayhelphealthcareprovidersnd anddistributethebest
PEMsinprint(alsoseeChapter2).
First,readandbecomefamiliarwithmaterials.Donot
simplyhand out somethinggivenby a drugsales repre-
sentativethatcouldpossiblybebiasedor,evenworse,at
oddswithone’sphilosophyofcare.Makesurethematerial
isthorough,accurate,andeasytoread.TheInstitutefor
Healthcare Advancement (IHA) notes that “experts rec-
ommendthatprintedpatienteducationmaterialsbewrit-
tenatnohigherthana6thgradereadinglevel,orlower
if possible. Research has shown that 36% of American
adultshaveBelowBasicorBasichealthliteracyskills,and
abouthalfcannotreadabovea5thgradelevel.Unfortu-
nately, most patient education materials arewritten at a
9thto12thgradereadinglevel,orhigher.”
12
Trytoavoid
medicalterminologyifpossible. “For example, bedwet-
ting,shouldbeusedratherthanenuresis.”
10
Ifamedical
term is used, deneit. Make sure theprint is largeand
legible to accommodate patients with impaired vision.
Avoidfancytypefacesthatmaybedifculttoread.Type-
facesshouldbeclearandbold.“Araggedrightmarginis
generallymorereadablethananevenone.”
10
Illustrations
oftenaidincomprehension,especiallyforthosewithpoor
readinglevels.Illustrationsshouldmatchthewordsinthe
text without text accompanyingit. Try to ndmaterials
thatrespectdiverseculturalandreligiousviewsandavoid
bias.Makesuretheinformationrepresentsobjectivetreat-
mentstylesandaddresses thepositiveandnegativeout-
comes or side effects of the treatment, surgery, or
medicationbeingpresented.
10
Finally,explainthePEMto
thepatientinlayman’sterms,andaskthepatienttoreiter-
atewhatwastaughttoensureunderstanding.
What to Do When Your Child Gets Sick by Mayer and
KuklieruswaspublishedbytheIHAinanefforttoincrease
health literacy in the United States.
13
It features a fourth
grade reading level, easy-to-read large print, explanatory
illustrations, and focuses on what parents need to know
when making a decision regarding their childs healthcare
needs.Thisbookismarketedtoclinicsthatcareforminor-
ity populations who may not have access to the Internet
or television and those who have trouble comprehending
literature. The IHA recommends that when this book is
handed out, the healthcare provider should counsel the
patient on how to use the book, ensure that the patient
understands howtouseit,and, ifneeded,followupwith
thepatientinthefollowingmonthstoseeifthebookhas
beenausefulresource(BeverlyWhite,CenterforHealthand
Wellness,interview,October1,2009).
Arecentstudyfound
that givingparentsacopyofthisbook andtrainingthem
howtouseitathometocarefortheirchild’sminorailments
andinjuriesreducedhospitalemergencydepartmentvisits
bymorethan50percentandsavedmorethan$550perfam-
ilyannually.
14
Aseparate2-yearstudyfoundthattheuseof
aself-helphandbookresultedina12.2percentreductionin
primarycarevisits,a17.1percentreductioninurgentcare
visits,anda15.4percentreductioninemergencydepartment
visits.
15
Thebenetsfoundinthesestudiescanbereplicated
whenhealthcareprovidersincreasehealthliteracybyprovid-
ingpatients with reading materials written at a levelthey
comprehend.
Ifadequatematerialcannotbefound,considerdevelop-
ingpatienteducationhandouts.Family Practice Manage-
ment can tailor content into a pamphlet specic to a
patient’s needs.
10
Inconclusion,ifahandoutorPEMisavailable,offerit
tothepatientandhighlightmainpointsinitbeforeheor
she leaves the ofce (Table 6–2). This will help assure a
Table 6–2
Tips for Effective Patient Education Materials
• Read it before you give it to patients!
• Make sure it’s written at an appropriate reading
level.
• Use pictures or drawings to enhance understanding.
• Use typefaces that are clear and bold.
• Makesuretheinformationrepresentsobjective
treatment styles.
• Make sure it discusses positive and negative
outcomes.
• Go through it with the patient.
• Ask them if they have any questions.
Chapter 6: Incorporating Patient Education into Clinical Practice 51
patient’sunderstandingofwhatisimportant.Ifthepatient
requestsmoreinformationthanprovidedinthePEM,pro-
videWebsitesthatareavailable(seeChapter2).Thiswill
helpavoidthefrustrationthatmayresultwhenapatient
goes home and nds poor research on the Internet with
inaccuratestatementsabouthisorherprognosis.
Group Visits
What Is a Group Visit?
Agroupvisitisnot a classora grouptherapy session.
16
Groupvisitsincludeagroupeducationalsessionplusmost
componentsofindividualvisits,includingthecollection
ofvitalsigns,historytaking,andaphysicalexam.
16,17
They
offeracost-effectivesolutiontoprovidetimeforpatients
tospendwiththeirprovider.Researchshowsthatgroup
visits provide improved quality of care, easier access to
providers, and increased patient and provider satisfac-
tion.
16
Such visits are best for chronic disease manage-
ment,suchasdiabetes,obesity,smoking,coronaryartery
disease,asthma,gastroesophagealreuxdisease,andirri-
table bowel syndrome.
16,18
These visits provide patients
with the opportunity to get answers to questions they
might otherwise never have asked, and it gives them a
senseofempowerment.Groupvisitsalsoallowproviders
to teach what they believe is important, increase their
patients’ knowledge and compliance, and bill multiple
patientsinareasonabletimeframe.
18
Anatomy of a Group Visit
Atypicalgroupvisitlasts2hoursandconsistsofapproxi-
mately 20 patients. A welcome and introduction should
take no more than 15 minutes. A presentation, group
interaction, or workshop should last 30 to 45 minutes
withabout20minutesforquestionsandclosure.One-on-
onepatienttimeshouldtake30to50minutes,depending
onhowmanyprovidersareseeingpatients.Twoorthree
careprovidersshouldbepresent.
16,18
Beawarethatfrustra-
tionmayresultwithinagroupvisitifpatientshavetowait
for their individual medical sessions before or after the
groupeducationsession.Thebestwaytopreventthisis
toschedulehalfoftheindividualvisitsbeforethegroup
visit and half after.
17
Planning a Group Visit
Consider the following when planning a group
visit
16,18
:
• Eightto12weeksinadvance:
• Planthegoalsandcurriculum.
• Meet with the team and discuss details and
strategies.
• Schedulethevenueandguestspeakers.
• Write letters to inform patients about the event,
andencouragethemtoscheduleanappointment.
Letpatientsknowthatthevisitwilltakeapproxi-
mately 2 hours and that the usual ofce fee or
co-payisrequired.
• Encouragespousestocomeatnocharge.
• Oneweekinadvance:
• Prepare and organize teaching materials for the
presentation.
• Reviewpatientcharts.
• Createprogressnotesandtemplatesforthevisits.
• Plan for refreshments, name tags, and sign-in
sheets.
• Prepareexamroomswithadequatesupplies.
Challenges of Group Visits
Thereareafewchallengestoconsiderwhenconducting
a group visit, including coding, condentiality, drop-
outs,andno-shows.Becausegroupvisitsarenotdeni-
tively covered by Medicare and many private insurance
plans,itmaybeconfusingtocodeforthem.TheAmerican
AcademyofFamilyPhysicians(AAFP)foundthat“when
eachindividualpatientisprovidedamedicallynecessary,
one-on-one encounter, in addition to the time in the
groupdiscussions,thereshouldbenoprobleminbilling
for the visit based solely on the documented services
provided in a direct one-on-one encounter.”
19
It is also
recommended that “group visits be billed as individual
ofce visits, using existing CPT codes (e.g., 99212 to
99214,dependingonthelevelofcareprovided).ACPT
codeshouldbeselectedbasedonthelevelofcomplexity
of the individual visit and not on length of time spent
withthepatientinthegroupeducationsession;timecan
be used as a controlling factor when counseling domi-
natesindividualvisitsbutnotwhenitissharedingroup
context.”
17
Ifthegroupvisitincludesservicesfromnutri-
tionistsorbehavioralhealthspecialists,theycanbecoded
asmedicalnutritiontherapy(97804)orhealthandbehav-
iorintervention(96153).Asalways,theprovidershould
contactpayersaheadoftimetodeterminewhatportion
ofeachgroupvisitcanbedirectlybilledbynonphysician
providers. For compliancepurposes, theAAFPsuggests
that providers ask each payer for these instructions in
writingandkeepthemonlewithanyotheradvicefrom
apayer.
19
It is also wise to consider creating a release form for
patients to sign that states they cannot reveal personal
healthinformationaboutotherpatientsoutsideoftheclini-
cal setting.
17
Althoughmostpatientsunderstandtheimpor-
tanceofcondentiality,itiswisetoreafrmthisconcept
to all patients and cover your legal bases if a complaint
arises.Aninformedconsentcontractcouldeasilybesigned
whenreviewingHealthInsurancePortabilityandAccount-
abilityActcompliances.
Topreventno-showsordrop-outs,considersendinga
reminderletter 2 weeks in advance. It is also helpful to
haveastaffmembercall each patient thedaybeforethe
appointmenttoconrm.Itmaybeimportanttoreiterate
thatitisanofcevisitandnotaclass.Patientswhounder-
standthattheproviderisexpectingtoseethemattheir
appointment are less likely to no-show as opposed to
patients who think they can skip a class.
18
Studies also
showthatattritionratesarehighestforgroupsthatmeet
onlyevery3to6monthsovera2-yearperiod.
17
Itmaybe
most benecial to establish group visits as a norm for
chronic illnesses that must be followed up weekly or

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