The easy, affordable demand management strategy might also be the most effective.
Fam Pract Manag. 1998 Sep;5(8):65-70.
Does the pairing of demand management and patient education surprise you? It shouldn't. After all, demand management is largely a process of educating patients about how to make appropriate use of health care services. Every time you tell a patient not to worry about a temperature of 101°F, you're managing demand — as you are every time you try to get a patient to understand that antibiotics aren't effective against cold viruses and every time you say, “and if it doesn't get better in a week, call the office.” While the purposes of patient education are usually thought of as increasing adherence to therapy and reducing health risks, demand management is and always has been an integral part of it.
The concept of patient education is central to all efforts to manage demand, from computerized or telephonic decision- support systems for self-help and triage to the poster about the risks of high cholesterol that hangs on your waiting room wall. Are these demand management tools that provide patient education or patient education tools that manage demand? Your answer probably depends on whether you're a managed care executive or a physician. But the benefits of these strategies accrue to both groups, and to patients too.
New uses for a familiar tool
“A patient who understands his or her condition and treatment and how his or her health care plan works can reduce your telephone hassle factor and improve access to your practice for other patients,” says Thomas J. Weida, MD, medical director of Penn State Geisinger Health Group in Hershey, Pa., and a member of the FPM Board of Editors.
But managing demand with patient education is not just a way of keeping patients out of the office, Weida emphasizes, it's about keeping them healthy, which also means getting patients into the office.
“Physician profiling by HMOs is focusing on how effective we are at providing screening tests and other preventive services. Mammography is a service for which we typically need to increase demand, for instance, and patient education is the key to doing that,” Weida says.
In his article on page 49, Steven E. Goldberg, MD, MBA, explains how to identify a demand problem and implement a program for improving it. A key step is identifying barriers to appropriate utilization by a target population. In Weida's example, if the physician were to determine that patients' lack of awareness about the benefits of mammography were a significant barrier, then a printed patient education brochure that focused on that would be a valuable tool.
A growing number of patients are educating themselves about screening recommendations, treatment options and self-care, and that phenomenon is another important reason for physicians to be proactive in their patient education efforts.
“The quantity of health care information and patients' access to it have grown dramatically in the last several years. Although patients may be anxious to be informed and play a more active role in their own care, they aren't always sophisticated enough to be able to judge which are the more credible sources, so there's potential for them to be misinformed,” says Donna Falvo, RN, PhD, director of behavioral science for the Department of Family and Community Medicine at Southern Illinois University in Carbondale, Ill., and author of Effective Patient Education: A Guide to Increased Compliance (Gaithersburg, Md: Aspen Publishers; 1994).
By working to ensure that your patients are well-informed, you'll also be addressing another requirement of the current health care environment — that you reduce your malpractice risk.
“By educating the patient and enabling him or her to make some decisions about treatment options, for example, you're sharing some of the responsibility,” says Falvo. “If something goes wrong, the patient will be less likely to blame you for the outcome.”
Spending time to make time
One common objection to patient education is that it takes time — a precious commodity in today's productivity-driven practices. But choosing not to provide patient education for that reason may be shortsighted, physicians warn, and it may be doubly so where demand management is an issue. Consider this scenario: You've got more patients to see than time to see them. Feeling rushed, you find yourself almost unconsciously cutting back on visit length, spending less time with and talking less with each patient. But by not taking a minute to make sure that Mrs. Jones understands how long it might be before her son's temperature returns to normal and the possible side effects of the antibiotic prescribed for his infection, you inadvertently ensure that she and her son will be back in your office for an unnecessary visit in just a few days.
Your strategies don't need to be elaborate to be effective. Weida points out that mammography screening rates, for example, can be improved by a process as simple as giving patient education handouts to women of the appropriate age when they come in for annual exams.
Once you've identified the treatment, process, procedure, disease or other subject you want to target with patient education, you'll be ready to find the right tool.
Make communication a high priority
The heightened demand for services that physicians must meet in managed care does little to encourage communication, but physicians must resist the temptation to use patient education materials as a substitute for direct communication.
“We can't afford to get in such a hurry that we allow our communication skills to atrophy,” says Frederic Platt, MD, regional consultant for the Bayer Institute for Health Care Communication and clinical professor of internal medicine at the University of Colorado in Denver. “The time we spend with patients is limited, so we must approach our interactions with even more care. Managed care forces us to be better communicators.”
Physicians must identify barriers to understanding and adherence, and they must facilitate learning and problem solving, Platt says. And careful listening is critical. “Doctors don't understand enough. We need to find out more, explain less and understand more,” he says.
The following organizations offer courses for physicians interested in honing their communication skills:
American Academy on Physician and Patient
6728 Old McLean Village Drive
McLean, VA 22101-3906
Each year the AAPP holds a five-day national course for medical faculty on teaching the medical interview. The organization also co-sponsors with medical societies, managed care organizations and medical schools to present short courses for medical faculty and full-time physicians.
Bayer Institute for Health Care Communication
400 Morgan Lane
West Haven, CT 06516
Bayer Institute offers continuing medical education programs through sponsoring organizations. More than 400 Institute faculty members have been trained to conduct workshops throughout North America. In six states, malpractice premiums may be reduced for physicians who take Bayer Institute courses.
The Foundation for Medical Excellence Northwest
Center for Physician-Patient Communication
4000 Kruse Way Place
Bldg. 2, Suite 100
Lake Oswego, OR 97035
Northwest Center offers continuing medical education programs on a variety of topics for hospitals and physician organizations. They are offered onsite and can be scheduled at the convenience of the medical staff.
Evaluating patient education materials
Printed patient education materials can be extremely useful, timesaving tools, but they can be ineffective or even counterproductive if they confuse the patient or contradict what you say. Consequently, it's unwise to give a patient any handout you haven't read first.
Here is an abbreviated list of guidelines to help you distinguish the best patient education materials from the rest. They were developed with the help of Leigh McKinney, special projects manager for the AAFP Publications Division, who oversees development of the AAFP's Health Notes brochures and other patient information products.
Reading level. Newspapers and other commonly read materials are written on the sixth-grade to eighth-grade level. Even patients who read at a much higher level generally appreciate information that is simple and to the point — as long as the tone isn't condescending.
To conduct your own quick assessment of a handout, keep these general guidelines in mind as you read: One or two syllables per word, one idea per sentence, one concept per paragraph, no more than five key points per handout. Medical terminology should be avoided whenever possible. If it can't be avoided, the terms should be carefully defined. For example, bed wetting should be used rather than enuresis. Because there is no lay term for rosacea, a handout on that topic should explain how to pronounce the word and what the condition involves. Consistency in terminology is also important. Analogies, simple punctuation, contractions and even slang are good if they enhance understanding.
Design. The type should be big enough to be easily read. Fancy typefaces and long stretches of text in italic type or all in capital letters should be avoided. White space (generous margins, blank lines between sections, etc.) and subheadings enhance readability. A ragged right margin is generally more readable than an even one.
Illustrations. Illustrations aid comprehension for those with poor reading skills and are generally easier to remember than text. But a bad illustration can wreck an otherwise excellent patient education handout. The illustration must match the words and be understandable without text accompanying it. Illustrations should be simple; a detailed anatomical diagram may not be as effective as a simple line drawing. Illustrations of patients should be representative of your target audience.
Content. Above all, the information needs to be accurate, up-to-date and consistent with what you would teach. Also ask yourself these questions: Is the benefit of the information clear to the reader? Is too much detail provided, or too little? The American Academy of Family Physicians Foundation reviews the content of patient education materials and publishes a list of those that have been favorably reviewed (see the resources list on page 70).
Demand-management value. Look for handouts that include specific advice to help patients understand when they should (and should not) seek your attention. For example, a patient education handout about the flu and colds would include a list of symptoms that should prompt the patient to call you.
Balance. Ask yourself whether the content respects diverse cultural and religious views and avoids bias. Does it present information about treatment objectively, address both sides of controversial issues and explain positive and negative aspects of procedures?
Source. Finally, consider how the content of the material might have been affected by its source. Determine who funded the piece, who endorsed it and whether these organizations have a commercial interest in its content. If the information isn't copyrighted, you can adapt the content to suit your purposes.
Increasing patient education effectiveness
Choosing a good patient education tool is important to the success of any demand management program. But just as important is the way the tool is used. It's not enough to simply disseminate information. How and when a patient education handout is presented to a patient will affect what the patient learns from it and how it affects his or her behavior.
“We've run into a number of physicians across the country who say that patient education is wonderful because they can just hand patients something instead of spending time with them,” says Falvo.
She says this misconception is particularly prevalent in managed care environments where productivity demands are high. “The most important ingredient is a trusting relationship between patient and physician,” she says. “Patient education materials won't be effective if they're misused, and can even damage the relationship.” She encourages physicians to think of patient education as a supplement to direct communication, not a substitute.
She offers these tips to physicians incorporating patient education handouts into their practices:
Consider your timing. If the patient is anxious, in a hurry or in discomfort, he or she won't be receptive to additional information. You may need to rely on nonverbal cues to assess how receptive the patient is. Also be sensitive to the fact that information you wouldn't find anxiety-provoking may indeed be troublesome to your patient. Give the information the patient will need immediately, and make sure that he or she schedules a follow-up appointment.
Address the patient's concerns immediately and directly. If the patient expresses worry or fear about the diagnosis you're explaining or a treatment procedure you're recommending, talk about it before providing any written information. If you don't, the patient might perceive you as uncaring. Even the best patient handout is no substitute for your personal reassurance.
Present the handout to the patient yourself, if possible. If you can't, explain to the patient that your nurse will be giving him or her some important piece of information.
Endorse it. Tell the patient how important it is to you that he or she read this information and understand it. Your endorsement of the handout is powerful.
Hit the highlights. You don't have to cover everything in one sitting, and you shouldn't. Studies have shown that patients tend to remember only a small part of what they're told in the exam room. Instead, determine what the patient knows, what the patient wants to know and what the patient wants to know right now. Then stress the most important points in the handout to reinforce them, and say that there are more details you want the patient to read and become familiar with.
Test the patient's understanding. Pause periodically and ask the patient to explain in his or her own words what you've just said. Encourage the patient to stop you if he or she begins feeling overloaded.
Demonstrate your interest in continuing the discussion. Be careful to avoid giving the patient the impression that the handout is being used to preempt questions or minimize contact with you. Encourage the patient to ask you any questions he or she has, schedule another appointment or call you so you can discuss the information in more detail, whichever approach is most appropriate in the situation. Emphasize that you want to be sensitive to the patient's needs.
Want to write your own patient education handout?
The most common patient education handouts explain medical conditions and procedures and offer self-care guidance and prevention-related tips. (See “Resources.”) Although less common, patient education handouts that address demand issues directly are potentially just as useful.
Consider the impact that handouts on subjects like the ones listed below could have on the efficiency of your office and the quality of care and service your patients receive. If you see potential for improvement, it might be worth your effort to develop one or two handouts of your own.
Our tips on evaluating patient education materials (in the main article) will help you get started, and of course you'll want to tailor the content of your piece to your practice's procedures, your health plans' restrictions and your own preferences. Give it a shot — and show us what you come up with! We'll review, edit and publish selected handouts in future issues of Family Practice Management.
Base your handout on one of the following topics, or on another practice-management-related subject:
Prescription refill requests,
How to help your doctor run on time,
The role of midlevel providers,
Doctors' availability after hours,
Procedures for school physical appointments.
Send your patient education handouts to:
Family Practice Management
11400 Tomahawk Creek Pkwy.
Leawood, KS 66211
Give it a try
Although some demand management strategies require a significant financial investment, a demand management program built around a written patient education handout is within reach of every practice — and the potential for improving patient care makes it a strategy you can't afford to ignore.
American Academy of Family Physicians and AAFP Foundation
8880 Ward Parkway
Kansas City, MO 64114
American Academy of Pediatrics
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
American College of Obstetricians and Gynecologists
409 12th Street SW
Washington, DC 20024-2188
American Diabetes Association
1660 Duke St.
Alexandria, VA 22314
800-ADA-DISC, ext. 363
American Public Health Association
1015 15th St. NW
Washington, DC 20005
Asthma and Allergy Foundation of America
1125 15th St. NW
Washington, DC 20005
Center for Health Promotion and Education
Centers for Disease Control
1600 Clifton Road NE
Atlanta, GA 30333
National Council of Patient
Information and Education
666 11th St. NW
Washington, DC 20001
The AAFP produces Health Notes, a series of 60 patient education brochures. The brochures are updated regularly, and topics are chosen based on surveys of family physicians. Sample packs are available. For more information, call the AAFP Order Department at 800-944-0000 or visit the AAFP web site at http://www.aafp.org/catalog/patient/brochures.html.
Through its Health Education Program, the AAFP Foundation administers reviews of patient education materials by a panel of health care professionals. Review criteria include scientific accuracy, content and appropriateness for use in a family practice setting. Items that have been reviewed favorably carry the AAFP Foundation seal. You can obtain a free list of more than 450 favorably reviewed materials on the World Wide Web at http://www.healthanswers.com/health_answers/aafpf/ or by calling 800-274-2237, ext. 4406. Customized database searches are also available.
Copyright © 1998 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
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