Teach-Back

1. Title

Teach-Back
Improving Patient Safety by Engaging Patients and Families in Effective ClinicianPatient Communication

2. AHRQ

Sponsored by the Agency for Healthcare Research and Quality (AHRQ), this teach-back learning module is designed to inform clinicians about the teach-back method and provide effective strategies to implement teach-back. Teach-back engages patients (and families) and ensures their clear understanding of what they need to know for improved patient safety and outcomes.

3. Introduction

At its core, teach-back is about communicating with patients. We’re going to start by reviewing two conversations between patients and clinicians.

• Examine the scenarios over the next series of screens and consider the difference between Scenario 1 and Scenario 2.
• What did the clinician in the scenarios do to produce those differences?

4. Scenario 1, Part 1

Clinician Speaking:

“I am prescribing an antibiotic called amoxicillin for Anna’s strep throat. It needs to be given 3 times a day – at breakfast, lunch and dinner. Most children like the taste of this antibiotic, which is good because Anna will need to take this medicine for 10 days. Also, it’s very important that she finish taking all of the medicine, as prescribed, even if she starts feeling better. Do you have any questions?”

Patient’s Mother Speaking:

“No.”

5. Scenario 1, Part 2

Clinician Speaking:

“If Anna develops a rash or doesn’t feel better, please give our office a call. We want to make sure that she gets better soon. Okay?”

Patient’s Mother Speaking:

“Okay.”

6. Scenario 2, Part 1

Clinician Speaking:

“I am prescribing an antibiotic called amoxicillin for Anna’s strep throat. It needs to be given 3 times a day – at breakfast, lunch and dinner. Most children like the taste of this medicine, which is good because Anna will need to take it for 10 days. Also, it’s very important that she finish taking all the medicine, even when she starts feeling better. I want to make sure I am being clear and to answer any questions you may have. In your own words, can you tell me what you need to do at home for Anna’s strep throat?”

Patient’s Mother Speaking:

“You want me to give Anna the medicine at every meal for 10 days. But Anna is at school during the day, and they don’t like to give medicine. Does she have to take it at lunch time?”

7. Scenario 2, Part 2

Clinician Speaking:

“I’m glad you told me that. I can change the dose so that Anna only takes the antibiotic at breakfast and dinner. Now if Anna develops any red spots on her body, continues to have a fever, or is not acting like herself, please call me. Even if you aren’t sure if you should call, call me any time!

Patient’s Mother Speaking:

“Got it. If Anna isn’t feeling better, she gets a rash, or I am concerned, I should call you.”

8. Scenario 1 Reflection

Now that you’ve had the opportunity to explore both scenarios again, consider the differences between Scenario 1 and Scenario 2 and ask yourself:

• What did the clinician in the scenarios do to produce those differences?

9. Learning Objectives

By the end of this lesson you should be able to:

• Start practicing using the teach-back method.
• Describe the role and value of teach-back in improving patient safety.
• Identify strategies for implementing the teach-back process.

10. Pathway Menu

Teach-Back
Select each step in the path to find out more about teach-back. Visit all steps to move on to the next section.

Oval 1: What is teach-back?

Oval 2: Why should I use teach-back?

Oval 3: What is the teach-back method?

Oval 4: When should I use teach-back?

Oval 5: How is teach-back different?

Oval 6: How do I start the teach-back process?

Oval 7: How can I communicate clearly?

Oval 8: Which patients benefit from teach-back?

Oval 9: Are there other considerations?

Oval 10: What if a patient can’t teach back?

11. What is teach-back?

A method of ensuring that patients understand what you’ve told them.

During teach-back, you ask patients to explain in their own words what they need to know or do to take care of their health. You ask them to teach back to you what you have told them.

12. Why should I use teach-back?

Info Point 1: Research shows that clinicians underestimate patients’ needs for information, and overestimate their own ability to convey information effectively.^2,3,4,5,7

Info Point 2: Studies have shown that up to 80% of the medical information patients are told during office visits is forgotten immediately, and nearly half of the information retained is incorrect.^1,8

Info Point 3: Low health literacy can affect patient adherence and ultimately patient health outcomes.¹⁰

Info Point 4: There is a 19% higher risk of nonadherence among patients whose physician communicates poorly than among patients whose physician communicates well.¹¹

Effective communication in medical care positively correlates with better patient adherence.

13. What is the teach-back method?

The Teach-Back Method

Chunk and teach information.

Ask patients to teach back in their own words. Allow patients to consult material.

If patient teaches back correctly and there’s more to explain, return to Chunk and teach information.

If patient doesn’t teach back correctly, reteach using different words.

Return to Ask patients to teach back in their own words. Allow patients to consult material.

14. When should I use teach-back?

Use teach-back whenever explaining important concepts to patients about their healthcare such as:

• New diagnosis.
• Medication.
• Home care instructions.
• Treatment plan.
• Recommended behavior changes.
• Use of a new device.
• Treatment options.
• Next steps.

15. How is teach-back different?

If you ask patients whether they have any questions, they will often say they don’t, even if they don’t really understand what you’ve told them. They may be embarrassed or intimidated, or they may think they understand.

The only way to be sure that your patients understand is to hear them teach the information back to you in their own words.

16. How do I start the teach-back process?

Info Point 1: “I want to make sure we are on the same page. Can you tell me...”

Info Point 2: “I want to make sure that I explained things clearly. Can you explain to me…”

Info Point 3: “Your inhaler is important for your health. Can you show me how you would use it at home?”

Info Point 4: “We have discussed some important information about your medicine. As a safety check, can you tell me warning signs to look for with this medicine?”

There are many ways to approach teach-back with your patients and their families.

17. How can I communicate clearly?

Info Point 1: Focus on 2 to 4 key points for that visit.

Info Point 2: Start with the most important message.

Info Point 3: Use plain language. Most patients do not understand medical jargon. Using plain language may take some practice.

Info Point 4: Use patient education materials and underline or circle the most important points during teach-back.

Info Point 5: Use pictures or draw diagrams to support your teaching.

Info Point 6: Encourage questions. You might say “We discussed a lot of information. What would you like to review again?”

Info Point 7: Engage with the patient by smiling, maintaining eye contact, nodding encouragingly, and removing any physical barriers, such as a computer, desk, or crossed arms.

18. Which patients benefit from teach-back?

All patients can benefit from teach-back. Any patient can have trouble understanding, particularly if they are feeling unwell, are tired, or are frightened, such as when facing a new diagnosis.

19. Are there other considerations when using teach-back?

With certain patient populations, there are additional considerations when using teach-back.

Older Adults

When using teach-back with older adults, consider the following:

Mild or moderate hearing impairments often occur with age:

• Use a lower voice pitch.
• Speak naturally and distinctly.
• Minimize background noise.

Information processing speed declines with age:

• Limit the amount of new information delivered during each visit.
• Speak slowly.

Children

When using teach-back with children, consider the following:

• The conversation with the child should be age and developmentally appropriate.
• Both the patient and the caregiver should understand the information being shared.
• Visual aids can support communication of new diagnoses and new therapies (such as the use of an inhaler).

Language Diversity

When using teach-back with patients who speak a different first language, consider the following:

• Medical translation services are beneficial if available.
• Both verbal and nonverbal cues can help with communication.
• Visual aids can support communication.

20. What if a patient can’t teach back?

If your patient doesn’t understand, rephrase (don’t repeat) your message and ask again for teach-back.

If the patient is unable to teach back after several attempts, consider:

• Enlisting the help of a family member or friend.
• Asking another member of the healthcare team to explain.
• Taking a break or scheduling another time to go over the information.

21. Scenario 2 Review, Part 1

Clinician Speaking:

“I am prescribing an antibiotic called Amoxicillin for Anna’s strep throat. It needs to be given 3 times a day – at breakfast, lunch and dinner. Most children like the taste of this medicine, which is important because Anna will need to take it for 10 days. Also, it’s very important that she finish taking all the medicine, even when she starts feeling better. I want to make sure I am being clear and to answer any questions you may have. In your own words, can you tell me what you need to do at home for Anna’s strep throat?”

Key Teach-Back Strategy 1: Starts with most important message.

Key Teach-Back Strategy 2: Gives an additional key point.

Key Teach-Back Strategy 3: Gives a third key point.

Key Teach-Back Strategy 4: Explains that she is trying to make sure her message is clear so the patient doesn’t feel quizzed.

Key Teach-Back Strategy 5: Engages the family/patient.

Key Teach-Back Strategy 6: Uses an effective teach-back phrase to ensure the message was clearly understood.

Patient’s Mother Speaking:

“You want me to give Anna the medicine at every meal for 10 days. But Anna is at school during the day, and they don’t like to give medicine. Does she have to take it at lunch time?”

Key Teach-Back Strategy 7: Shows understanding – teach-back was effective.

Key Teach-Back Strategy 8: Patient is able to identify a potential barrier to adherence.

22. Scenario 2 Review, Part 2

Clinician Speaking:

“I’m glad you told me that. I can change the dose so that Anna only takes the antibiotic at breakfast and dinner. Now if Anna develops any red spots on her body, continues to have a fever, or is not acting like herself, please call me. Even if you aren’t sure if you should call, call me any time!

Key Teach-Back Strategy 1: The clinician is able to adapt her recommendation to better suit the patient’s needs and constraints.

Key Teach-Back Strategy 2: Gives a key point.

Patient’s Mother Speaking:

“If Anna is not feeling better, she gets a rash, or I am concerned, I should call you.”

Key Teach-Back Strategy 3: Demonstrates understanding.

23. Congratulations

Congratulations! You have completed the teach-back training.

“Tell me and I forget, teach me and I may remember, involve me and I learn.” Benjamin Franklin

24. References

1. Anderson JL, Dodman S, Kopelman M, et al. Patient information recall in a rheumatology clinic. Rheumatology 1979 18(1):18-22.
2. Britten N, Stevenson FA, Barry CA, et al. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ 2000 Feb 19;320(7233):484-8.
3. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med 1997 May 12;157(9):1026-30.
4. Coran JJ, Koropeckyj-Cox T, Arnold CL. Are physicians and patients in agreement? Exploring dyadic concordance. Health Educ Behav 2013 40(5):603-611.
5. Hancock K, Clayton JM, Parker SM, et al. Discrepant perceptions about end-of-life communication: a systematic review. J Pain Symptom Manag 2007 Aug 31;34(2):190-200.
6. Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care 2009 Aug;47(8):826.
7. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff 2013 Feb 1;32(2):207-14.
8. Keulers BJ, Scheltinga MR, Houterman S, et al. Surgeons underestimate their patients’ desire for preoperative information. World J Surg 2008 Jun 1;32(6):964-70.
9. Kessels RP. Patients' memory for medical information. J Roy Soc Med 2003 May 1;96(5):219- 22.
10. Kripalani S, Weiss BD. Teaching about health literacy and clear communication. J of Gen Intern Med 2006 Aug 1;21(8):888-90.
11. Lagay F. Reducing the effects of low health literacy. Virtual Mentor 2003 Jun 1;5(6).
12. Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009 Aug;47(8):826.