When it’s time to leave, though, it’s another story. All of a sudden, patients and their families are responsible for everything involved in living with a chronic disease—managing medications, changing eating patterns, adding physical activity—and the inevitable questions about when to go back to work, when to start driving again or even when to resume sexual activity. Fortunately, the Heart Institute places a premium on patient education and on giving patients the tools they need to manage their own health.
The process starts long before patients even arrive at the Heart Institute (see “Setting the Bar High for Patient Satisfaction”). Clinical staff make sure patients know what to expect, what they can do to increase the likelihood of a successful surgery or procedure and how to prepare themselves. Then, after the surgery or procedure, the staff is at it again, as soon as patients are alert enough to pay attention. Nurses and physicians help patients understand their conditions and what they need to do to live healthy.
In addition, patients take formal classes on topics like nutrition, stress management, exercise and other elements of cardiac rehabilitation. Or they meet one-on-one with a dietitian, physiotherapist or other health professional to go over diet and ways to conserve energy and incorporate physical activity into daily life, along with other lifestyle changes. A nutrition class, for instance, helps patients learn how to read nutrition labels in the grocery store and how to interpret (or ignore) the health claims often found on packaging. It also helps patients identify reliable resources for healthy recipes.
“In the cardiac rehab program, we give people the tools to make healthy lifestyle choices, which they can carry over into their lives after graduation,” said dietitian Kathleen Turner.
“Patients are often looking for practical ideas. We get so caught up in nutrients, but in the end, people want to know what to make for dinner.”
Before going home, patients, along with family members or caregivers, take a discharge class to go over the “high points” of what they need to know. Also, a nurse reviews with each patient a personal discharge action plan, which sets out what needs to be done to continue recovery at home. Patients get several resources to take with them based on their discharge action plan, including one or more volumes of the Heart Institute’s patient guide series addressing their particular condition and, perhaps most important, the phone number for a nurse coordinator to call at any time of the day or night to answer questions.
A nurse reviews a personal discharge action plan with each patient that sets out what needs to be done to continue their recovery at home.
Patient education has several goals, explained Lorraine Montoya, an advanced practice nurse at the Heart Institute: ensuring patients understand their health conditions and the potential problems that might arise, including how to deal with them; ensuring they understand their medications, how and when to take them, what the side effects might be and when a side effect is serious enough to seek immediate help; and building skills that patients will need to manage their own health once they are at home.
Building a trusting relationship with patients is a key part of the process. They need to feel supported when they return home and that they can ask for help when they need it. Montoya called it “putting patients in the driver’s seat,” in control of their health.
What patient education is not, said Montoya, is a way to ensure compliance. “It’s about how you, as a patient, integrate this into your life in a way that works for you.”
Patient education is about what the patient needs to know. And educators won’t know unless they ask. So, for instance, rather than telling patients they need to weigh themselves every day, Montoya asks them how they usually weigh themselves. That tells her whether they need tips on weighing themselves at the same time every day in similar clothing, tools to help them track their weight and know what to do if it changes—or it tells her whether they own a scale in the first place. The questions help make patient education personal and responsive to the individual’s needs. When education is personal, Montoya said, patients hear and absorb more of what the educator is saying.
“When you start to apply a cookie-cutter approach, your chances of effective learning rapidly diminish,” she explained. Because every patient is different—has a different level of knowledge, a different learning style—it’s important to tailor education efforts and tools.
The Heart Institute offers group classes but also has one-on-one counselling available. It has written material, but also DVDs and online videos for those who learn better by watching. And it has tools to make it easier for patients to change their behaviour, like a chart patients can put on the fridge to record their weight each day. Beside the chart is information on what to do if their weight changes, making it easy for patients to act when necessary.
Montoya feels strongly about the importance of patient education—so much so that she completed a masters degree in adult education. One thing that she took away from the experience is that being action-oriented and focusing on the positives makes learning easier. For example, help a patient develop a tailored walking program rather than telling him or her to get more exercise, or ask about a patient’s readiness to quit smoking rather than emphasizing the dangers of continuing to smoke.
Another key is to deliver information in a variety of ways. The group classes are particularly helpful, Montoya indicated, because patients no longer feel so alone. They understand that they’re not the only ones with congestive heart failure or who have experienced a heart attack.
Another way group classes are effective, added advanced practice nurse Bonnie Quinlan, who led the development of the coronary artery disease patient guide, is in how the patients learn from one another. “You can see it happening,” she said. “One person will say something and someone else will sit up and listen because they’ve experienced it too.”
Patient education is about more than just individual behaviour. It also helps patients acquire basic health literacy so that they are able to process, understand, and act on basic health information and seek services when necessary. Patients need to know how to talk to health care professionals, Montoya said, as well as how to navigate the health care system. And they need to know who to call when they need help doing so. Older patients, especially, may be dealing with a cardiologist for their heart, an endocrinologist for their diabetes, a rheumatologist for their arthritis and a family doctor. That’s a lot of providers and sources of information to manage.
One of the biggest challenges that both Montoya and Quinlan face is cramming a lot of information into a short time period. What used to be a two-week hospital stay is now a day procedure, or maybe one night in the hospital. Educators can’t overwhelm people with information but, at the same time, they need to ensure patients have the information they need. That’s where the take-home material, such as the guides, which bring all the information together in one place, is so valuable.
“There’s a lot of generic material out there”, said Quinlan. The advantage of the Heart Institute guides is that they are specific to the patient and to the region. In addition to relevant recovery and health information, they list services and tools specifically available in the region. They carry the Heart Institute brand, which gives them credibility, and Heart Institute patients have vetted the guides and given feedback on what works and what doesn’t.
It’s difficult to quantify the impact of patient education. There is evidence, though, that it leads to better outcomes both for patients and the health care system. Benefits include decreased rates of complications, fewer adverse events, lower readmission rate, and better use of health care resources.
“There are many diseases we can get as human beings that are out of our control,” said Quinlan. “With coronary artery disease, there is so much we can control.” The key is ensuring that patients know what to do and how to do it.