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SECTION VII Patient Education and Long-Term Care 55 Patient Education and...

SECTION VII Patient Education and Long-Term Care 55 Patient Education and Health Promotion Donna D. Gardner CHAPTER OBJECTIVES After reading this chapter you will be able to: Compare and contrast the different stages of learning Discuss the importance of patient education based on age. Describe the components of a patient’s culture. Describe learning differences between children and adults. Explain the impact culture has on a patient’s perception of Describe the methods used to evaluate patient education. health. Discuss the impact health literacy has on patient education Identify two strategies respiratory therapists may use Explain when to use the teach back or show me method when educating and caring for patients from different Define patient centered care cultures. Define population health Reflect on your own cultural background. Describe the importance of incorporating a patient’s Discuss two communication strategies when teaching a culture into patient education. patient identified as having low health literacy. Discuss the chronic care model as it applies to patient Determine patient education goals from the patient’s centered care. perspective. Identify the settings that are appropriate for the Write learning objectives in the cognitive, affective, and implementation of health promotion activities. psychomotor domains. Describe the respiratory therapist’s role as patient educator. CHAPTER OUTLINE Patient Education, 1244 Teaching Children and Their Health Education, 1252 Cultural Awareness, 1244 Parents, 1250 Health Promotion and Disease Health Literacy, 1244 Teaching Adolescents and Adults, Prevention, 1253 Establishing Goals for the Patient 1250 Chronic Disease Management and Teaching, 1246 Teaching Older Adults, 1251 Population Health, 1256 Performance Objectives, 1246 Teach Back or Echo Method, 1251 Implications for the Respiratory Learning Domains, 1247 Evaluation of Patient Education, Therapist, 1258 Provide Educational Resources, 1249 1251 Teaching Children, Adolescents, Patient Education Teaching Tips, Adults, and Older Adults, 1249 1252 KEY TERMS affective domain disease management patient-centered care chronic care health education population health cognitive domain health literacy psychomotor domain culture health promotion recidivism 1243 1244 SECTION VII Patient Education and Long-Term Care Effective patient education is invaluable to the healthcare of behavior common to members of the group. In addition, some society. Respiratory therapists (RTs) educate patients by provid- cultures have subcultures based on ethnicity, occupation, sexual ing information about their condition, disease processes, risks orientation, or religion and the subculture may have its own and benefits of treatment, medication, or procedures. They teach language or behaviors. Therefore individuals may identify with patients how to perform diagnostic tests, such as basic spirometry, more than one cultural group. (e.g., an individual may be con- and educate patients about health promotion issues such as sidered “black” and be African American or Caribbean and not tobacco cessation and taking ownership to manage their cardio- American nor African. Native American Indians are lumped into pulmonary disease. RTs educate patients in all age groups, includ- one group when there are over 550 different tribes in the United ing geriatric, adult, adolescent, and pediatric patients. In certain States).2 RTs must be aware that culture and health perspectives situations, RTs educate the parents or the spouse of the patient go hand in hand (Table 55.1). in the hospital setting before discharge and in the home-care The health of a patient is influenced by their cultural back- setting (see Chapter 57). RTs are also frequently called on to ground, which determines the individual’s definition of health provide educational programs to patients with pulmonary dis- and how to deal with illness. A patient’s culture impacts their eases such as chronic obstructive pulmonary disease (COPD), willingness to seek healthcare when experiencing symptoms of asthma, and cystic fibrosis to help minimize hospitalizations illness and influences their actions associated with any interven- and short-term readmissions. For these reasons, this chapter tion or treatment. Therefore some strategies RTs may use when reviews important issues related to patient education, disease educating and caring for patients from different cultures are management, and health promotion. displayed in Table 55.2. The top three causes of death in the United States are heart disease, cancer, and chronic lower respiratory system disease, RULE OF THUMB A person’s health condition may be impacted by their with chronic obstructive lung disease (i.e., bronchitis and emphy- culture. sema) being the deadliest.1 Public education about risk factors is the key to preventing these diseases and probably has the greatest potential for making an impact on healthcare in this Health Literacy country. Therefore, in the future, RTs should focus on and empha- Health literacy is the degree to which individuals have the capac- size health promotion and disease prevention. ity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.6 Health literacy encompasses educational, social, and cultural factors that PATIENT EDUCATION influence an individual. Entire books have been devoted to patient If we think of patient care as customer service—which it indeed education and health literacy because people are neither familiar is—then we cannot ignore education as a crucial component of with medical terms nor how their bodies work. People with that service. If we buy a car or a television set, for example, we strong literacy skills may also face health literacy challenges. Low expect the salesperson to educate us about the essential aspects health literacy affects the patient’s ability to participate in their of our purchase. We also expect this information to be provided own care, results in patient safety concerns and poor health in writing. Likewise, education is an essential component of outcomes. patient care. For patients to assume or resume control of their RTs must be aware of the stereotypes that surround low lit- health, they must be educated. Because they rely on the healthcare eracy such as lower socioeconomic level, poor language, and low practitioner to provide this education, every respiratory care education levels. There are studies that correlate literacy and education program should include instruction regarding patient economic status with education level. In the United States most education. individuals with low literacy are Caucasian and low literacy is RTs are able to assess patient learning needs and readiness to found in all types of individuals and not limited to one specific learn by asking patients what they know about their condition group or educational or socioeconomic status, which then become and therapies. By asking these questions, the RT will be able to barriers to patient education and patient learning.7 Because there identify the patient’s gap in knowledge or skills to help identify is limited health literacy in the United States, patients may not where to start the patient education. There is limited time to be able to read; however, this does not provide information teach patients, therefore the RT must speak in a manner the regarding a patient’s intellect, but it may impact their ability to patient can understand and focus on the health problem to assist use a handout or pamphlet with paragraphs of words. Results the patient becoming engaged in his/her own care. from the most recent survey of literacy skills among adults has been used to develop a literacy scale that describes the different Cultural Awareness levels of health literacy in Table 55.3.7 Behaviors, values and patterns of beliefs shared by a group is Respiratory patients with low health literacy will not be able referred to as culture. Culture is not limited to gender, socio- to be self-directed and navigate the healthcare system nor follow economic status, racial background, or ethnicity. Culture is learned an educational program or instructions provided. Reading and and communicated from one generation to another. For example; comprehension may not always go hand in hand. Patients often families, social organizations, and religions are where individuals will not voluntarily admit that they do not understand to avoid learn to follow the norms, traditions or customs, practices or embarrassment. Therefore to determine whether a patient under- taboos, and values of the culture that impact the thinking or stands, RTs should look for clues that indicate reading or writing  CHAPTER 55 Patient Education and Health Promotion 1245 TABLE 55.1 Health Perspectives for Emerging Majority Groups in the United States Traditional Methods Traditional Traditional Definitions of Maintaining and Traditional Methods of Group Definitions of Health of Illness Protecting Health Restoring Health American Indian Living in total harmony Illness is the price to be paid for Maintain positive relationship Removal of the external causative factor by and Alaska with nature and being past or future negative events. with nature. a traditional healer after spiritual Native able to survive under Details are specific to different Treat body with respect. ceremony to determine cause and population extremely challenging nations. Purification acts using water, treatment. situations Illness may result from the herbal remedies and rituals Drumming presence of evil spirits. These types of illness are contagious with generalized symptoms Asian population Living in total physical and Human body considered as whole, Body is a gift from parents Acupuncture spiritual harmony with with harmony between organs and ancestors and must be Applying poultices the universe. and superficial structures. protected. Cupping Four major religious Integration of human body within Dietary practices Bleeding traditions pose variations context of environment. Formal daily exercise for Massage on cultural values. Imbalance of ying and yang example, tai chi; Herbal remedies Examples: respect for life, (Chinese). Amulets (Chinese) Other products moderation of basic Use of physicians, with women treating relationships, balance women. between evil and good Use of immunizations Important to keep the body intact (Chinese). African A process of energy force, Process of disharmony attributed Dietary practices Voodoo and magic population rather than a state. to demons and evil spirts. Rest and clean environment Use of immunizations Consists of body, mind and Pain as a sign of illness. Use of laxatives and cod liver Cared for by the entire community spirit. If no pain, then illness is gone oil taken internally, sulfur Prayer State of harmony with and molasses on back Use of healers nature. Protective materials of various Pictures of catholic saints or relics Elderly held in high regard substances, for example, Sugars and turpentine orally copper or silver, dried flesh Poultices, herbs, minerals, oral preparations, Prayer including hot water and lemon, garlic, flannel with camphorated oil Hispanic Gift from God Imbalance in body or punishment Maintain equilibrium in the Prayer population for wrongdoing. universe through behavior, Dietary practices of hot and cold Imbalance between hot and cold diet, and work Magical and religious rituals, artifacts or wet and dry (definitions vary). frequently in Catholic and Pentecostal Dislocation of body parts. traditions, such as offerings confession, Magic or supernatural causes candles, laying on of hands. such as evil eye. Folk, holistic healers called curanderos, Strong emotions envy using herbs, prayer, massage, social rapport, spiritual. Amulets Modified from Wilson and Dorne: Impact of culture on the education of the geriatric patient.3 is a concern and to be sensitive to prevent any feelings of shame. BOX 55.1 Clues Indicative of a Lack of Lack of understanding clues are listed in Box 55.1. Understanding Patient repeatedly is noncompliant RULE OF THUMB Health literacy influences a patient’s ability to adhere Patient uses the excuse being too busy, tired, or sick to maintain attention to self-management medication or a therapy regimen. when given instruction Claims that the patient did not feel like reading the information, gave the information to a family member, or lost or forgot their glasses Patients’ ability to understand health information is a pre- Insistence on taking the information home to read requisite to patient adherence. Patients need to be able to read Demonstrates nervousness and stress, confused about the materials and understand the instructions, prescriptions, informed consent, Talks about something else and not on topic and written documents to optimize their potential. Health literacy Returns documents that are not complete or are illegible experts emphasize important behaviors to be developed for clear communication with patients (Table 55.4). 1246 SECTION VII Patient Education and Long-Term Care TABLE 55.2 Recommended Patient MINI CLINI Teaching for Cultural Awareness A Hispanic parent of a child with asthma is a concerned mother who wants Learn about the ethnic/cultural/ Pay attention to body language to do the best for her child. She is a single parent with no other family. The religious/spiritual traditions of (nonverbal communication), lack of child is prescribed a controller medication in a metered-dose inhaler (MDI) the patients in your clinic or response or expressions of anxiety with a spacer. The respiratory therapist (RT) teaches the mother how to use healthcare facility to establish that may signal the patient or family the MDI with a spacer and provides the mother with a pamphlet to use for inclusion is in conflict about the education or reference. The RT also shares the importance of taking the medication twice a treatment and hesitant to tell you day every day to prevent asthma exacerbations. The mother nodded in agree- Arrange for language translators Be aware of cues from the patient ment. A week later the mother and child are back in the clinic for an asthma when necessary and/or family comprehend the exacerbation. The RT asks the mother about using the MDI and spacer twice teaching and assess with the daily and asked about her referring to the pamphlet. The mother nodded and cultural awareness in mind. (nodding smiled and informed the RT she had bought a hairless chihuahua to take the does not guarantee understanding, asthma away from the child. Unknowingly to the RT, in some Hispanic cultures, ask the patient to state the there is belief that a chihuahua will cure the child’s asthma.9 The RT assumed information in his/her own words) the mother would be able to read the pamphlet, understand the steps to use Ask the patient and family or Remain nonjudgmental when given the MDI with a spacer, and would know that a dog is an asthma trigger. What healthcare provider open- information that reflects the values the RT does not know is that the mother is unable to read. The RT must take ended questions to gain more that differ from your own time to have the patient demonstrate the use of the MDI and spacer correctly information about their and ask questions about understanding the pamphlet or make sure there are assumptions and expectations plenty of pictures on the pamphlet that a person who is unable to read can Follow the advice given by the Healthcare providers should assess follow, and to inquire about cultural beliefs related to the disease processes. patient about appropriate ways their own ethnic/cultural/religious or to facilitate communication spiritual beliefs that may not reflect within or between the family the patients and healthcare providers disorganized or haphazard. This type of teaching is neither effi- Expand knowledge about sexual Healthcare providers must be aware cient nor effective. The RT needs to have an organized prede- orientation, gender identity, of their own biases and prejudices termined plan with short- and long-term goals and objectives and learn the definitions for and these need to be examined and that include the patient and will be used to evaluate the patient’s Lesbian, Gay, Bi-sexual recognized progress. Setting goals that are aligned with the patient’s needs Transgender, Queer (LGBTQ) populations will contribute to successful learning activities. This can be accomplished by asking what should the patient be able to do Modified from McLaughlin L, Braun K, and Siebert PS.4,5 because of this education session? What information should the patient need to carry out the instruction? These two questions TABLE 55.3 Levels of Health Literacy have different answers for each patient. Different goals will be required for teaching respiratory patients with acute or chronic Levels of Health Literacy conditions and for those related to health promotion. For example, Proficient Able to perform complex activities such as when teaching a respiratory patient how to use the prescribed searching documents to define medical terms or other information controller medication for asthma in the MDI with a spacer, the Intermediate Able to conduct moderately challenging task short-term goals may be to fill the prescription and to take the such as finding an age range for a specific medication correctly using the MDI with a spacer. vaccination from a childhood vaccination chart After this the patient needs to know the name and type of Base Able to complete simple tasks such a giving medication, when to take the medication, why the patient should two precautions to follow if taking a specific take the medication as directed, what should the patient expect medication, based on information in a clearly to occur when taking the medication (breathing is improved, written pamphlet and to keep taking the medicine because it is working, do not Below basic Demonstrates lower level of performance such stop taking the medicine), and any special action the patient as identifying what can be eaten or drunk should take (if the patient stops taking the medicine the patient before having a medical test based on a set is more likely to have an exacerbation). Understanding the why, of short instructions Not literate in English Not literate in English what, and how increases the likelihood that the patient will take the medication. Establishing long-term goals will decrease the frequency of asthma exacerbations. This information will need to be simplified and broken down into smaller or shorter time Establishing Goals for the Patient Teaching segments for the patient. When considering the content to teach patients depends on the needs of the patient and the goals to be accomplished. Setting Performance Objectives collaborative goals with the patient will direct the patient teach- Initially it is helpful for the RT to develop learning objectives ing. Sometimes RTs are overwhelmed with the amount of infor- that are appropriate for the specific patient and the education mation to teach and try to cover everything, which may appear topic to be addressed. These learning objectives will help the  CHAPTER 55 Patient Education and Health Promotion 1247 TABLE 55.4 Recommended Strategies for Clear Communication With Patients With Low Health Literacy 1. Assess the patient understanding at baseline before moving forward with detailed information. (This usually takes 30 s or less.) For example, for a patient newly diagnosed with asthma ask the following question; “Before we go on, could you tell me what you already know about asthma?” This will provide the respiratory therapist with an understanding of the patient’s information needs and where to tailor the educational content 2. Explain using plain language or lay terms. Avoid using medical terms, jargon, or vague terms. Example say: “increased breath rate” instead of tachypnea Example say: “causes of asthma attacks” instead of “triggers asthma exacerbations” Example say: Instead of “You have asthma”, say “Your breathing test results were positive for asthma” 3. Focus on 1 to 3 key points Repeat these points throughout the education session 4. Encourage the patient to ask questions by asking open-ended questions. Example: ask “What questions do you have?” instead of “Do you have any questions?” 5. Use the teach-back method to confirm the patient understands and to make sure you have explained the information clearly to the patient; be specific when asking the patient to demonstrate back to you. Example: “I always ask my patient to repeat things back to me to make sure I have explained the information to them clearly. I would like you to tell me when you will take the new medication we talked about today.” Example: “When you get home, your wife or spouse will ask you what happened today and what will you tell them?” To confirm the patient understands how to use their medication or a different skill, ask the patent to demonstrate back to you. This usually takes 1–2 min For example: have the patient demonstrate how to use the puffer metered-dose inhaler (pMDI) with a spacer 6. Write down important instructions to inform the patient what they do after meeting with you 7. Provide useful patient education materials The education materials provide the patient (and spouse or family member) with the information to reference when at home Modified from Kripalani S, Weiss BD: Teaching about health literacy and clear communication. J Gen Intern Med 21(8):888–90, 2006.8 learner focus on more relevant topics and will help the educator MINI CLINI clarify the teaching strategies that are needed for patient educa- tion sessions. Objectives should be stated in attainable and mea- Developing Learning Objectives for the Use of an surable terms so that the RT and the patient can recognize when Albuterol Metered-Dose Inhaler the objective has been accomplished. Clear objectives describe Problem what is to be accomplished and how evaluation will occur. Your 31-year-old patient is newly diagnosed with asthma, and she is being The format for writing an objective is as follows: discharged tomorrow. She requires instruction regarding how to properly use 1. Begin with the phrase, “At the end of the lesson, the patient her controller medication, Advair diskus, and the reliever medication albuterol will…” metered-dose inhaler. Develop learning objectives for her and address each 2. Write the action verb (e.g., “list,” “describe,” “demonstrate”). learning domain. 3. Write a condition, if needed (e.g., with or without the use of Solution notes). Use a variety of learning objectives, including the following: 4. Write a standard, if needed (e.g., how fast, how accurate). Cognitive domain: Describe the action of albuterol on the bronchial smooth For example: At the end of the session, the patient will be muscle; recognize when it is necessary to seek medical attention. given an MDI and a spacer and be able to demonstrate the Affective domain: Agree that it is important not to skip a dose; verbalize correct technique for using it without error. willingness to use the Advair diskus daily; feel satisfaction by controlling the Action verb: “demonstrate” (from the psychomotor domain; disease. the relevant domains are discussed later in this chapter) Psychomotor domain: Demonstrate the ability to assemble the metered-dose Condition: “given an MDI and a spacer” inhaler and the spacer; inhale slowly and deeply with an inspiratory hold. Standard: “without error” Learning Domains Learning occurs in three domains: cognitive, psychomotor, and affective. Some learning sessions will involve only one domain, Cognitive Domain whereas others may involve all three. The cognitive domain is The cognitive domain is probably the easiest to translate into very important, because it will address the knowledge that a learning objectives because it involves the facts and concepts patient needs regarding his or her illness and how to manage it. that the RT wants the patient to know and apply by the end of The psychomotor domain addresses the skills that the patient the education session. Objectives for the cognitive domain might will need to acquire to perform specific treatment modalities include the following: (e.g., the use of MDIs). The affective domain involves teaching 1. List the indications for oxygen therapy. patients about the necessary attitudes and motivations for suc- 2. Discuss the importance of using the prescribed liter flow. cessfully living with their diseases. 3. Explain the relationship between oxygen and combustion. 1248 SECTION VII Patient Education and Long-Term Care Any factual information that you expect the patient to under- Examples of action verbs for the psychomotor domain are stand and apply falls under the cognitive domain. Action verbs included in Table 55.6.10 for the cognitive domain are included in Table 55.5.10 Psychomotor Domain RULE OF THUMB People learn by doing. Get the learner involved. Repetition and active involvement are important when teaching a psychomotor skill. RTs who teach new skills to patients need to provide plenty of opportunity for the patient to practice the Affective Domain activities. Simple demonstration of the skill to the patient is not The patient’s attitudes and motivations influence his or her enough. To confirm performance in the psychomotor domain, ability to learn. It is important to remember that, with patient have your patients provide a return demonstration. Be sure to education, timing is everything. Patients who have recently provide help and encouragement as needed. Be patient; not been given a poor prognosis or who are in pain are not in an everyone develops skills at the same rate. optimal position to learn. Maslow suggested a hierarchy of TABLE 55.5 Cognitive Domain Level Samples Ambiguous terms to avoid Knowledge Define, identify, list, label, name, state Know, memorize Example: List your medications. Comprehension Describe, defend, explain, generalize, summarize Understand, believe Example: Describe how your medication works on your condition. Application Apply, construct, demonstrate, calculate, operate Realize Example: Demonstrate how you take your medication. Analysis Analyze, break down, contrast, differentiate, distinguish, infer Conceptualize Example: Distinguish between the types of pain. Synthesis Categorize, combine, create, design, formulate, integrate, plan, revise, rearrange, write Experience Example: Integrate diet and exercise into your rehabilitation plan. Evaluation Appraise, assess, compare, conclude, critique, evaluate, judge, weigh Perceive Example: Compare your level of wellness now to this time last year. Data from Borich GD: Effective teaching methods, et 3, Englewood cliffs, NJ, 1996, Merrill; Bloom BS: Taxonomy of educational objectives, Handbook I: The cognitive domain. New York, 1956, David McKay Co Inc.; French D, Hale C, Johnson C, et al: Blended learning: An ongoing process for internet integration. Austin, TX: 2003, e-Linkages, Inc and Trafford, p 231. TABLE 55.6 Psychomotor Domain Level Samples Ambiguous terms to avoid Perception/awareness Choose, describe, detect, distinguish, identify, relate, select Perceive, comprehend, recognize Example: Identifies body language. Mindset/ready to act Begin, display, explain, move, react, show, state, volunteer Think, understand, feel Example: Shows willingness to change health behavior. Guided response/imitation Copy, duplicate, imitate, trace, follow, react, reproduce Appear Example: Follows instructions when learning crutch gait. Mechanism/efficiency Assemble, calibrate, manipulate, demonstrate, improve, perform, produce Experience Example: Demonstrates proficiency in crutch gait. Complex overt response/skilled Assemble, calibrate, manipulate, demonstrate, improve, perform, produce Become familiar with Example: Performs crutch gait confidently and without hesitation. Adaptation Adapt, alter, change, rearrange, reorganize, revise, vary Conceptualize, display interest in Example: Adapts to new terrain and obstacles confidently when using crutches. Origination Arrange, combine, create, design, initiate, make, originate Self-actualize Example: Creates new ways to meet needs while adapting to functional limits. Data from Borich GD: Effective teaching methods, ed 3, Englewood cliffs, NJ: 1996, Merrill; French D, Hale C, Johnson C, et al: Blended learning: An ongoing process for internet integration. Austin, TX: 2003, e-Linkages, Inc and Trafford, p 231; Simpson EJ: The classification of educational objectives in the psychomotor domain, Washington, DC, 1972, Gryphon House.  CHAPTER 55 Patient Education and Health Promotion 1249 TABLE 55.7 Affective Domain Level Samples Ambiguous terms to avoid Receive/awareness Accept, acknowledge, alert, choose, give, attend, notice, tolerate, select Realize, comprehend, perceive, Example: Acknowledges loss. become conscious of Respond/display interest Agree, assist with, aid, answer, comply, communicate, consent, volunteer Think, know, feel Example: Consents to treatment. Value Adopt, behave, choose, demonstrate, commit, desire, initiate, join Understand, enjoy Example: Demonstrates a desire to change. Organize Adapt, adjust, arrange, balance, compare group, rank, verify, strengthen Experience, become familiar with Example: Balance work and home life. Characterize/internalize values Advocate, avoid, defend, demonstrate, exhibit, justify, resolve, support Self-actualize Example: Demonstrates a change in lifestyle. Data from Borich GD: Effective teaching methods, ed 3, Englewood cliffs, NJ: 1996, Merrill; Bloom BS: Taxonomy of educational objectives, Handbook I: The cognitive domain. New York, 1956, David McKay Co Inc.; French D, Hale C, Johnson C, et al: Blended learning: An ongoing process for internet integration. Austin, TX: 2003, e-Linkages, Inc and Trafford, p 231. needs, and he identified physiologic needs as the most basic TABLE 55.8 Defined Ages Across of human needs, followed by safety, love, esteem, and self- the Lifespan actualization. Lower-level needs must first be satisfied before moving on to higher-level needs. For example, if a patient is Age Range Title dyspneic or in pain, he or she will probably not be receptive Children to learning the steps that are involved in cleaning a small- Birth to 28th day of life Newborn, neonate volume nebulizer. It is important for RTs to assess a patient’s 1 month to 1 year of age Infant 1-3 years Toddler readiness to learn by talking with the patient and his or her 3-5 years Preschooler family and by listening to the patient’s concerns. It is important 6-12 years or onset of puberty School-age to develop a relationship of trust and to be empathetic with 13-20 years Adolescent the patient. The RT should begin with easy-to-master facts and skills. Adults After the patient conquers these, motivation should increase, 18-25 Emerging adult, young adult and the patient will have a feeling of accomplishment. Motiva- 30-65 Middle adult tion is also enhanced by presenting material clearly with the use Over 65 years Late adulthood, older adult of a variety of teaching methods and by relating the facts and Data from Potter PA, Perry AG, Stockert PA, et al: Fundamentals of skills to practical applications. Getting patients to see how these nursing, ed 9, St Louis, 2017, Elsevier. skills will benefit them is the key to motivation. Communicating to the patient that there is something that he or she can do to maintain or improve his or her health and sense of well-being is important. condition. These educational resources may be in a format such Objectives in the affective domain—using the oxygen therapy as a brochure, handout, and app on a cell phone, YouTube videos, example mentioned earlier—might include the following: website or other technology as appropriate. The educational 1. Express genuine concern for yourself by using your oxygen materials must be at a readability level that is equal to the fourth therapy correctly. or fifth grade for most patients to understand. Because the inter- 2. Commit to learn by being an active participant in the net is a valuable resource for patient education, make sure the program. websites shared are appropriate for the patient population. Affective domain action verbs are included in Table 55.7.10 However, YouTube videos are not peer reviewed and may not be balanced information; therefore RTs should make sure the source is credible. RULE OF THUMB Measuring the patient’s commitment to caring for him/herself is essential for behavior change. Teaching Children, Adolescents, Adults, and Older Adults Teaching children and their parents, adults, and older adults Provide Educational Resources requires different formats, time spans, and educational tools. When using a short period of time for teaching, there is a need This section will provide the RT with various strategies to for the patient to repeat or practice, and therefore the patient address each age group. To be clear on age definition, refer must be given educational resources to reference about their Table 55.8. 1250 SECTION VII Patient Education and Long-Term Care TABLE 55.9 Teaching Methods Based on Patient’s Developmental Capacity Infant Keep routines (e.g., feeding, bathing) consistent. Hold infant firmly while smiling and speaking softly to convey sense of trust. Have infant touch different textures (e.g., soft fabric, hard plastic). Toddler Use play to teach procedure or activity (e.g., handling examination equipment, applying bandage to doll). Offer picture books that describe story of children in hospital or clinic. Use simple words such as cut instead of laceration to promote understanding. Preschooler Use role play, imitation, and play to make learning fun. Encourage questions and offer explanations. Use simple explanations and demonstrations. Encourage children to learn together through pictures and short stories about how to perform hygiene. School-age child Teach psychomotor skills needed to maintain health. (Complicated skills such as learning to use a syringe take considerable practice.) Offer opportunities to discuss health problems and answer questions. Adolescent Help adolescent learn about feelings and need for self-expression. Use teaching as collaborative activity. Allow adolescents to make decisions about health and health promotion (safety, sex education, substance abuse). Use problem solving to help adolescents make choices. Young or middle adult Encourage participation in teaching plan by setting mutual goals. Encourage independent learning. Offer information so adult understands effects of health problem. Older adult Teach when patient is alert and rested. Involve adult in discussion or activity. Focus on wellness and person’s strength. Use approaches that enhance patient’s reception of stimuli when they have a sensory impairment. Keep teaching sessions short. From Potter PA, Perry AG, Stockert PA, et al: Fundamentals of nursing, ed 9, St Louis, 2017, Elsevier. Teaching Children and Their Parents but have a very short attention span; therefore the educa- Teaching children often includes educating their parents because tion sessions may need to be limited to no longer than 15 to of the dependence of the age group and the parents are consid- 20 minutes. ered the primary learner. Therefore the parents must be included Older children may learn by example and RTs may use to participate with the child as much as possible, which includes simple or familiar terms the child is used to using. As the setting goals, objectives, and evaluation or feedback. Teaching child matures and enters adolescence, the parent needs to shift parents of a child with a cardiopulmonary disease allows them the responsibility to the adolescent who is able and willing to to better understand the diagnosis, common signs and symptoms, assume the responsibility. Other important issues related to and specifics associated with the treatment or care plan. The differences between children and adult learners are listed in parents need to be assessed for a readiness to learn by listening Box 55.2, and allocated time for teaching is given by age in for cues the parent is using to ask for more information (e.g., Box 55.3. Ideally, a child can concentrate for 2 to 5 minutes per “I am having a really hard time getting my child to take his/her year of age. medication). Stages of learning for infants to older adults are listed in Table 55.9. Teaching Adolescents and Adults When teaching adolescents and adults we need to remember they have internal motivating factors and will learn quicker if RULE OF THUMB Parents need to be communicated in a manner that they can easily see the intrinsic value of knowing more about is easily understood and includes their culture. their illness. Some refer to this internal motivating factor as the “WIIFM (what’s in it for me) concept. Adults are more When teaching parents of toddlers, the toddler should be independent and self-directed, and they do not like being included in the teaching and encouraged to participate in the dependent on others. Adults are task- or problem oriented education activities. Toddlers are more motivated by external and prefer practical activities such as discussion or hands on factors (e.g., prizes) and may need a more obvious reward activities to drive the important points home. They also bring system in place before learning can take place. Toddlers can experience to the situation and this can be a rich resource grasp a cause-and-effect relationship between two things and used to connect to new information. This suggests that  CHAPTER 55 Patient Education and Health Promotion 1251 BOX 55.2 Learning Differences Between an answer of “yes” and will communicate to the RT the patient Children and Adults actually lacks comprehension about the information provided. The teach-back method was introduced to reinforce education Child Adult to patients. This method has been shown to have positively Motivated by external factors like Motivated internally affected patient adherence and self-efficacy, improved self-care, grades Is self-directed and reduced hospital readmission rates. This method includes Directed by others Learning is only one part of his using questions to determine what the individual understood Learning is a big part of his or or her life from the education session such as “We have discussed quite a her life Questions the teacher bit today, would you please tell me two things you will share Trusts teacher Has rich life experiences Has limited experience Learns for the present with your family that we discussed today?” Or “Before you leave Learns for the future May learn more slowly today, please show me how to use the puffer MDI?”12 If the Learns quickly Varies regarding learning ability individual responds incorrectly or seems to be deficient in under- Tends to learn in accordance with Dislikes a slow pace of learning standing, the RT should reinforce the positive actions or behaviors his or her developmental stage Problem oriented of the patient first and then repeat the information missed for Has no problem with a slow pace clarification, or re-demonstrate the steps for the use of the equip- of learning ment or medication delivery device. This cycle repeats itself until Subject oriented the individual can answer or demonstrate correctly. The teach- back or echo method is not a test of the individual’s knowledge as much as ascertaining how well the information was taught and what needs to be reviewed. The Agency for Healthcare BOX 55.3 Attention Spans for Different Research and Quality (AHRQ) created the Teach-back Observa- Ages tion Tool to evaluate the RT and his/her ability to use the Teach Toddlers: about 4–10 min back method. School-aged children: about 10–20 min The teach-back method also allows those with low lit- Adolescents and adults: about 20–30 min eracy levels to actively engage and for information to be reiterated. This method is useful for teaching individuals to understand treatment regimens and disease warning signs. Chronic disease management incorporates self-management adults should be more involved in setting program goals strategies that are designed to assist patients and their fami- and that they will readily learn skills that make them more lies to better manage the disease. These programs focus on independent. symptom recognition, self-monitoring, medication adherence, exercise, and reduction in smoking. These programs have Teaching Older Adults contributed to reducing hospitalizations, readmission rates, Older adults may have special considerations because of func- days in the hospital, outpatient visits and healthcare utiliza- tional, cognitive, and psychosocial changes that occur over time. tion and costs. Box 55.4 provides recommendations for the Also, remember many older adults have comorbidities that impact teach-back method. coexisting conditions on the functional capacity of the individual. Quality of life or life expectancy may be considered when pri- oritizing content for older adults. Older adults may require more RULE OF THUMB The teach-back method reflects the respiratory thera- time to assimilate the information and benefit from slower paced pist’s ability to communicate the information correctly to the patient. education sessions. Also, a caregiver may need to be incorporated into the education session if the patient is not able to assume full responsibility for his/her self-care. Other important issues Evaluation of Patient Education related to differences between children and adult learners are The critical question that remains when all the patient educa- listed in Box 55.2, and allocated time for teaching is given by tion sessions are complete is, “Has the patient learned?” Evalu- age in Box 55.3. ation is the process that answers that question. The method used to evaluate learning is determined by the measurable learning objectives (i.e., cognitive, affective, or psychomo- TEACH BACK OR ECHO METHOD tor). Cognitive objectives are often evaluated with the use of Many of the patients RTs care for have chronic diseases, and a written examination. Objectives in the affective and psycho- teaching these individuals about their chronic disease and self- motor domains are evaluated with the use of performance management is best done using the teach-back method or show checklists. me method to improve the individual’s understanding of the disease, and ask the individual to repeat or demonstrate back RULE OF THUMB Evaluation results reflect the quality of instruction as the key points of the education.12 Asking a patient “Do you much as the degree of learning. understand?” will usually elicit a response of head nodding or 1252 SECTION VII Patient Education and Long-Term Care Patient Education Teaching Tips BOX 55.4 Recommendations for the Teach-Back Method Following is a list of time-honored suggestions for improving patient education: Plan the approach Address the patient’s immediate concerns first. Think how you will incorporate the teach-back method into the information Include the patient in setting the goals and objectives. provided Create an optimal learning environment. Teach in a quiet “We covered a lot today and I want to make sure I explained everything clearly. Let’s review what was discussed. Could you tell me 3 things you and relaxed setting. agreed to do to help you control your disease?” Avoid using medical jargon; use lay terms to explain the Chunk and check information Do not wait until the end of the session to have the teach back session. Have patients use as many of their senses as possible during Chunk out the information into small segments and have the patient teach their learning session. Whenever possible, include hearing, it back to you. Repeat this several times during the education session seeing, smelling, speaking, touching, and doing. Clarify and check again Keep sessions short. If the material is complex, break it down When the teach-back method uncovers misunderstanding, explain the infor- into brief segments. mation again and ask the patient to teach back again until they can correctly Repeat, repeat, repeat! describe in their own words or demonstrate how to use the medication or Provide many opportunities for the patient to ask questions equipment again. and state in their own words about the education. Also, provide Start slowly and use it consistently Use the teach back method with every patient every time you provide ample time to practice psychomotor skills and demonstrate education session back to you using the teach-back method. Practice Be specific when emphasizing key points. Practice your delivery and make teach back part of your routine Be prepared. Use this teach-back AND show me methods when using new medications Be organized. People learn more quickly when they are pre- or equipment by asking the patient to show you how to use these devices. sented with information that is well organized. “I have noticed many people have trouble remembering how to take their Demonstrate enthusiasm for what you are doing. The learner puffer metered-dose inhaler with a spacer. Can you show me how you will can always sense your level of motivation. take your medication?” Evaluate in a nonthreatening manner and provide helpful Use handouts with the teach-back method feedback. Use evaluation as a learning tool. It is important to have written instructions for follow-up when the patient is at home. Point out the important steps by reviewing the written instructions and reinforce your patient’s understanding. The patient may use the handout HEALTH EDUCATION when teaching you. Health education may have been the earliest form of organized health promotion in the United States. Health programs in schools MINI CLINI is a result of Lemuel Shattuck’s report in 1850 to the Sanitary Metered-Dose Inhaler Instruction for a Pediatric Commission of Massachusetts, which described the value of Patient schools helping contain communicable diseases. However, it was not until 1875 that health education became widespread. During Problem How would you change the approach to the metered-dose inhaler situation that year, the Women’s Christian Temperance Union lobbied for described in the previous Mini Clini if your patient was a 7-year-old boy with alcohol education in the schools. Because of these efforts, 38 asthma? states passed legislation to require this education, which later turned into tobacco, alcohol, and drug education. From that Solution time, health education has been enhanced and expanded in Although the learning objectives may remain the same, the methods may be schools. There are public health agencies at the local, state, different. You may compare the slow, deep inspiration to getting ready to blow national, and international levels that provide health education out the candles on a birthday cake. You may use swimming under water as and care for those who would otherwise have none. an image to encourage breath holding. Use simple diagrams to show how the medication will act on the patient’s lungs. If he likes sports, tell him about Health education is a process of planned learning that is athletes who compete well despite having asthma (you may also use this designed to enable individuals to make informed decisions and illustration to stress the importance of controlling asthma). An abundance of to take responsible actions regarding their health. The primary resource materials is available for children with asthma; make use of them. goal of health education is behavior change, and it is designed Many local, state, and national lung associations (www.ala.org) offer such to promote, maintain, and improve both individual and com- learning aids as age-appropriate books, coloring books, and puppets to make munity health. Health education covers the continuum between the learning process more fun for children. To utilize the teach-back and show health and disease and between prevention and treatment. me method ask the patient to tell you what was discussed during the education Health promotion helps people change their lifestyles through session to see if what you told the patient was clear. Also ask the patient coping strategies to prevent illness in a variety of settings, from what three things will he/she do when he/she gets home to manage his/her the home or school to the workplace or the healthcare agency disease. Last, ask the patient to show you how to use the puffer MDI (pMDI) or institution, which require different approaches to patient care correctly. Any misunderstandings should be addressed immediately, and the patient should re-demonstrate the use of the pMDI. planning. The RT assesses patterns and uses their assessment to facilitate an individual’s maintenance of well-being toward  CHAPTER 55 Patient Education and Health Promotion 1253 BOX 55.5 American Association for BOX 55.6 American Association for Respiratory Care Health Promotion and Respiratory Care Role Model Statement Disease Prevention Statement As healthcare professionals engaged in the performance of cardiopulmonary Health Promotion and Disease Prevention care, RTs must strive to maintain the highest personal and professional The AARC acknowledges that respiratory therapists in both the civilian and standards. uniformed/military services are integral members of the healthcare team, In addition to upholding the code of ethics, the RT shall serve as a leader in hospitals, home healthcare settings, pulmonary laboratories, rehabilitation and advocate of public health. programs, and all other environments (including ICUs and critical care trans- The RT shall participate in activities leading to awareness of the causes port) where respiratory care is practiced. and prevention of pulmonary disease and the problems associated with the The AARC recognizes that education and training of the respiratory therapist cardiopulmonary system. The RT shall support the development and promo- is the best method by which to instill the ability to improve the patient’s tion of pulmonary disease awareness programs, to include smoking cessation quality and longevity of life, and that such information should be included programs, pulmonary function screenings, air pollution monitoring, allergy in their formal education and training in CoARC accredited programs. warnings, and other public education programs. The AARC recognizes the respiratory therapist’s responsibility to participate The RT shall support research to improve health and prevent disease. in pulmonary disease teaching, smoking cessation programs, pulmonary The RT shall provide leadership in determining health promotion and disease function studies for the public, air pollution alerts, allergy warnings, and prevention activities for students, faculty, practitioners, patients, and the sulfite warnings in restaurants, as well as research in those and other areas general public. where efforts could promote improved health and disease prevention. Fur- The RT shall serve as a physical example of cardiopulmonary health by thermore, the respiratory therapist is in a unique position to provide leadership abstaining from tobacco use and shall make a special personal effort to in determining health promotion and disease prevention activities for students, eliminate smoking and the use of other tobacco products from the home faculty, practitioners, patients, and the general public in both civilian and and work environment. uniformed service environments. The RT shall strive to be a model for all members of the healthcare team The AARC recognizes the need to (1) provide and promote consumer educa- by demonstrating responsibility and cooperating with other healthcare tion related to the prevention and control of pulmonary disease; (2) establish professionals to meet the health needs of the public. a strong working relationship with other health agencies, educational institu- Effective March 1990. tions, federal and state government, businesses, military, and other com- Revised March 2000. munity organizations; and (3) monitor such activities. Furthermore, the AARC RT, Respiratory therapist. supports efforts to develop personal and professional wellness models and From the American Association for Respiratory Care: Position action plans that will inspire and encourage all respiratory therapists to statement (website): www.aarc.org/resources/position_statements/ cooperate on health promotion and cardiorespiratory disease prevention. rms.html. Effective 1985. Revised 2000. Revised 2005. Association for Respiratory Care has created a role-model state- ment to encourage RTs to set a positive example for the public AARC, American Association for Respiratory Care; CoARC, Commission (Box 55.6). on Accreditation for Respiratory Care; ICU, intensive care unit. From the American Association for Respiratory Care (AARC): Position Providing a good example is not enough to ensure successful statement (website): www.aarc.org/resources/position_statements/ health education programming. For the desired outcomes to be rms.html. achieved, certain conditions must first be met. The components are remarkably like patient education requirements. The essential components of effective health education are listed in Box 55.7. wellness. To be effective, health education must be combined For RTs to assist patients, caregivers, or the public about the with strategies for health promotion; the two are strongly linked. development of healthier lifestyles, greater emphasis must be In the United States, Healthy People 2020, the national health placed on health promotion and disease prevention strategies promotion initiative establishes national goals and provides a Box 55.8. framework for prevention.13 Healthy People 2020 publishes national health objectives that identify the most significant pre- HEALTH PROMOTION AND ventable threats to health. The objectives and associated evalu- ation tools demonstrate progress toward the goals of attaining DISEASE PREVENTION high-quality, longer lives, decreasing health disparities, and creat- In 2015, the United States spent $3.2 trillion, or $9,990 per person, ing an environment—all of which promote health and improve on healthcare, the highest spending by far of any developed quality of life.13 The American Association for Respiratory Care country.14 The top three causes of death in the United States are has created a statement for health promotion and disease pre- heart disease, cancer, and COPD. All three lead to chronic condi- vention (Box 55.5). tions and might be preventable by avoiding tobacco use, poor Although individuals must ultimately assume responsibility diet, and physical inactivity. for their own health, promoting healthy behaviors through edu- Current medical practice is designed to respond to the acute cation is an important part of being an RT. In this capacity, the problems of patients by focusing on diagnosis and treatment of RT should serve as a role model for the public. Unless healthcare the presenting symptoms. Only focusing on the acute or epi- professionals’ model healthy behaviors, successful health outcomes sodic health problems creates a discrepancy when using this cannot be expected from the public. To this end, the American model of care for chronic conditions that may be prevented or 1254 SECTION VII Patient Education and Long-Term Care BOX 55.7 Essential Components of managed. This type of care requires refocusing on the prevention Effective Health Education of disease by identifying risk factors and providing methods for behavioral changes. Preventative healthcare is very different from 1. Program participants must be actively engaged in the learning process. chronic care. 2. Activities must incorporate the values and beliefs of the learner. Familial, A quote from Rufus Howe is appropriate: “What a rare privi- cultural, societal, and economic factors must be considered. lege it is to be in a position to improve the lives of others.”14a 3. The role of the health educator is to facilitate behavioral change. Thus the learning process should be approached together by both the learner and A patient with asthma goes to the emergency department and the educator. is treated effectively and efficiently. The patient received good 4. The process of predisposing an individual toward improved health as well quality care, and, in many people’s minds, the patient was “fixed.” as enabling and reinforcing health attitudes requires effort, which will only However, asthma is manageable to the point that the patient reap results over time. should not have to be in the emergency department. There are 5. The healthcare educator must be willing to listen nonjudgmentally to the excellent international and national guidelines (www.GINA.org concerns of the learners. Empathy and understanding are necessary to and www.NAEPP.org) that outline how to manage asthma, state foster a trusting relationship. the importance of patient education, and follow up with evalu- 6. The level of the learners’ self-esteem and self-concept may either enhance or ating the patient inhaler technique. There are medications that inhibit their ability to make decisions about their own health. The healthcare control asthma and keep the patient out of this situation. Usually, educator should be willing to provide emotional support as necessary. the reason for the emergency visit is that the patient’s asthma is 7. The healthcare educator’s personal characteristics have a direct impact on the outcome of the educational program. Generally, successful outcomes not in control; this may occur because the patient is not using occur because of a confident and professional approach. inhaled steroids because he or she has a poor understanding of the disease and how to manage it, because the national guidelines are not being used, or because of a combination of all these issues. Either way, this chronic disease can be better self-managed by a BOX 55.8 Health Promotion and Disease patient with the proper multidisciplinary education and follow-up. Prevention The public health model attempts to reduce disease in the nation through mass education campaigns. Examples include The AARC submits this paper to identify and illustrate the involvement of the RT in the promotion of health and prevention of disease and supports education about the hazards of drinking and driving, tobacco these activities. The AARC realizes that RTs are integral members of the use (both smokeless and smoking) education, and food labeling healthcare team, in hospitals, home healthcare settings, pulmonary labo- to indicate fat and cholesterol content. This is known as health ratories, rehabilitation programs, and all other environments where respiratory promotion and disease prevention.15 By participating in public care is practiced. education programs, RTs have the potential to affect the health The AARC recognizes that education and training of the RT is the best of individuals and the population as a whole.16 This approach method by which to instill the ability to improve the patient’s quality and is intended to look at the health disparities from infancy through longevity of life, and that such information should be included in their formal to older age and to highlight opportunities to promote health education and training. and improve quality of life for all Americans. The AARC recognizes the RT responsibility to participate in pulmonary disease RTs can take an active role in the development of educational teaching, smoking cessation programs, pulmonary function studies for the materials to assist both the public and other health professionals public, air pollution alerts, allergy warnings, and sulfite warnings in res- taurants, as well as research in those and other areas where efforts could about health promotion activities. Many medical manufacturers promote improved health and disease prevention. Furthermore, the RT is have also developed health promotion or education kits for a in a unique position to provide leadership in determining health promotion variety of diseases such as asthma, COPD, or tobacco and and disease prevention activities for students, faculty, practitioners, patients, e-cigarettes use. These kits are generally developed with input and the general public. from the medical community and from RTs. An example of an The AARC recognizes the need to provide and promote consumer education asthma program is given in Table 55.10.12 Respiratory care edu- related to the prevention and control of pulmonary disease and to establish cational programs need to be diligent when incorporating health a strong working relationship with other health agencies, educational institu- promotion and disease prevention activities into all learning tions, federal and state government, businesses, and other community domains as part of their curricula. organizations and to monitor such. Furthermore, the AARC supports efforts Another specific area of health promotion that receives much to develop personal and professional wellness models and action plans attention in both hospital and public health settings is nicotine that will inspire and encourage all RT to cooperate on health promotion and disease prevention. intervention. Hospitalized patients are more motivated to try Effective 7/85. to quit smoking for two reasons: the illness that resulted in the Revised 3/00. patient being in the hospital may have been made worse due to tobacco use, and hospitals have smoke-free environments. RT, Respiratory therapist. Therefore RTs should use this opportunity to promote nicotine From the American Association for Respiratory Care (AARC): Position statement (website): www.aarc.org/resources/position_statements/ treatments. hpdp.html. Nicotine intervention is a progressive, comprehensive program that incorporates a series of steps from risk identification to maintenance support. Smoking is the leading cause of prevent- able disease and death in the United States. January 11, 2014  CHAPTER 55 Patient Education and Health Promotion 1255 TABLE 55.10 Components of an Asthma Disease Management Program Component 1: Assessment Assessment: and monitoring Detailed patient history Thorough physical examination Spirometry to document the reversibility of airflow obstruction Monitoring: Periodic assessment and ongoing monitoring of asthma to determine if goals are being met Minimal or no chronic and troublesome symptoms, day or night Normal or near-normal pulmonary function No limitations on activities Minimal or no recurrent exacerbations of asthma Optimal medications with minimal or no adverse side effects Satisfaction with asthma care Component 2: Control of the Identify the allergens and irritants factors that contribute to House dust mites, cockroach feces, molds, and animal dander asthma Tobacco smoke, emissions from wood-burning stoves, strong odors and sprays, such as perfume and hairspray Nitrogen dioxide and sulfur dioxide Rhinitis and sinusitis Gastroesophageal reflux disease Viral respiratory infections Aspirin Sulfites Reduce exposure to the allergens and irritants, and provide medications or immunotherapy Component 3: Pharmacologic Classify the asthma severity into one of the four levels based on the severity of recurrent symptoms and lung function therapy: managing asthma Prescribe medications for the level of asthma for the long term All patients with asthma need a quick-relief medication (i.e., short-acting β2-agonists) Those with persistent asthma need daily long-term control medications to achieve control (e.g., an inhaled corticosteroid) Start treatment in a stepwise approach (i.e., begin at a higher level to achieve rapid control; when control is achieved and sustained, cautiously step down treatment) Component 4: Patient Patient education begins at the time of diagnosis. education for a partnership Provide basic facts about asthma in asthma care Identify the roles of the medications Skills: correct use of the medication delivery devices, the peak flow meter, and the symptom diary Discuss environmental control measures Discuss when and how to take rescue actions Education techniques Basic facts about asthma Describe the contrast between asthmatic and normal airways Describe what happens to the airways during an asthma attack Describe the roles of the medications How the medications work Long-term control: medications that prevent symptoms, often by reducing inflammation Quick relief: short-acting bronchodilators relax muscles around the airways Stress the importance of long-term control medications, and emphasize that the patient should not expect quick relief Skills Inhaler use (patient demonstration) Spacer and holding chamber use Symptom monitoring, peak flow monitoring, and recognizing early signs of deterioration Environmental control measures Identifying and avoiding indoor and outdoor environmental precipitants or exposures When and how to take rescue actions Responding to changes in asthma severity (i.e., daily self-management plan and action plan) marked the 50th anniversary of the first Surgeon General Report General’s Report: E-Cigarette Use Among Youth and Young Adults on smoking and health that linked smoking with lung cancer is the first issued by the federal agency that comprehensively and heart disease, and the 32nd Surgeon General Report, “The reviews the public health issue of e-cigarettes and their impact on Health Consequences of Smoking—50 years of progress: A report young people.18 This is the 33rd Report of the Surgeon General of the Surgeon General,” which presents the most recent data on tobacco. The Affordable Care Act’s (ACA) Public Health and on the consequences of smoking.17,13 Also, in 2016, the Surgeon Prevention Fund expanded access to smoking cessation services 1256 SECTION VII Patient Education and Long-Term Care through most health insurance companies to include Medic- factors of disease. Our patients spend most of their lives outside aid. The ACA supports community-based programs and public our hospital or clinic doors and they make decisions about their education campaigns promoting prevention and helping people health based on their culture, community, and family practices. quit; 1.6 million smokers have tried to quit.17,13 Safe and effective Efforts to improve population health must include assessing the tobacco treatment enhances the success for quitting. Nicotine community needs, providing interventions or services for patients replacement therapies (NRT) such as nicotine gum, lozenges, at risk for these chronic diseases, which may include monitoring or patches are available over the counter. NRT combined with health risk and status. behavioral therapy is more effective for tobacco cessation. Vareni- Disease management applies the best healthcare practices to cline tartrate (Chantix) and bupropion (Zyban) do not contain a population diagnosed with a chronic illness one person at a nicotine. They are both available by prescription only.17 Chantix time. The measures of health of a person with a chronic disease interacts at the sites in the brain that are influenced by nicotine. participating in a disease management program improves while National, state, and local agencies, such as the American Cancer patient satisfaction increases, mortality decreases, quality of life Society, the American Lung Association, and the American Heart increases, and unnecessary medical treatment decreases, which, Association offer educational materials and behavioral counsel- in turn, the cost of healthcare decreases. These disease manage- ing. The educational materials that these agencies offer is available ment programs have similar components, which include a coor- via mail, telephone, and the internet. The National Cancer Institute dinated comprehensive interdisciplinary care team that has as part of the U.S. Department of Health and Human Services identified a process for measuring improvement. Most programs cessation initiative established a nationwide toll-free number have the following attributes: (800-QUIT-NOW [800-784-8669]) to serve as an access point The provision of interdisciplinary comprehensive care (i.e., for smokers who are seeking assistance with quitting. Compo- health promotion, prevention, and acute care involving inter- nents of the Office of Surgeon General’s tobacco cessation program disciplinary or multidisciplinary teams—physician, RT, nurse, is included in Tables 55.11 and 55.12.15 physical therapist (PT), occupational therapist (OT), phar- macist, and other health team members) CHRONIC DISEASE MANAGEMENT A population-identification process (for a specific disease or condition) AND POPULATION HEALTH The use of evidence-based guidelines, protocols, and pathways More than 190 million people have at least one chronic disease Collaborative and coordinated components of care and 75 million live with two or more chronic conditions or Active patient self-management and education (e.g., empow- comorbidity.19 The key risk factors for developing a chronic erment, behavior modification) disease include tobacco use, physical inactivity, poor nutrition Quality improvement methods to include outcomes measure- choices, and excessive alcohol use. Also, the aging population as ment and evaluation well as the cost of care are markedly increasing. These chronic The use of information technology to create a routine report- diseases are extremely expensive and lead to unnecessary read- ing and feedback loop missions also known as recidivism. Short-term readmissions If you were interested in creating a disease management have always been undesirable for patients and their families. program, you would want to make sure to include these com- However, the Hospital Readmission Reduction Program penal- ponents. There are many disease management programs offered izes hospitals for excessive unpreventable readmissions for diseases to patients with chronic diseases such as COPD, asthma, amyo- such as COPD and pneumonia. Hence there are financial impli- trophic lateral sclerosis, and cystic fibrosis. RTs are ideal to create, cations for effective chronic disease management programs. coordinate, and participate as members of a disease management Managing chronic diseases takes more than a magic bullet, program. The patients whom RTs care for have chronic diseases, surgery, or medical rescues. They require holistic, patient-centered and these individuals need to be taught about the health risks care with collaboration of an interdisciplinary team of providers associated with the disease, the prophylactic measures used to (RTs, physicians, nurses, pharmacists, and other allied health maintain quality health, and disease-specific respiratory therapy. providers). The team must coordinate the patient care across a For example, in a disease management program for patients continuum. with COPD, RTs would provide one-on-one counseling for The term “population health” is more common and has tobacco cessation education (if the patient continued to use several interpretations. The standard definition is “the health these products); discuss pulmonary rehabilitation that included outcomes of a group of individuals, including the distribution exercise as well as strength and endurance training; and recognize of such outcomes within a group.”20 The people included in the and manage an acute situation and appropriate medication population being discussed may vary depending on the situation, management. The RT would work with the patient to establish the organization, or the community of interest. In our hospital personal goals, including changing the person’s behaviors and settings, the patient population are those individuals who use reducing the risks associated with the chronic disease. Outcom