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Almkuist, K. D. (2017). Using teach-back method to prevent 30-day readmissions in patients with heart failure: A systematic review. Medsurg nursing, 26(5), 309-351. Retrieved from http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=1&sid=5bd353d8-7695-437c-aa62-3d61b2e37dcf%40pdc-v-sessmgr01.

Burke, R. E., Guo, R., Prochazka, A. V., & Misky, G. J. (2014). Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health service research, 14(423), 1-10. http://www.biomedcentral.com/1472-6963/14/423.

Dastoom, M., Elahi, N., Baraz, S., & Latifi, S. M. (2016). The Effects of Group Education with the Teach-Back Method on Hospital Readmission Rates of Heart Failure Patients. Jundishapur journal of chronic disease Care, 5(1). doi: 10.17795/jjcdc-30377.

Dinh, T. T. H., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach‐back method on adherence and self‐management in health education for people with chronic disease: a systematic review. JBI database of systematic reviews and implementation reports, 14(1), 210-247. doi: 10.11124/jbisrir-2016-2296

Driscoll, A., Meagher, S., Kennedy, R., Hay, M., Banerji, J., Campbell, D., ... & Nadurata, V. (2016). What is the impact of systems of care for heart failure on patients diagnosed with heart failure: A systematic review. BMC cardiovascular disorders, 16(1), 195. doi: 10.1186/s12872-016-0371-7

Center for Innovation in Research and Teaching (2018). Quantitative approaches. Retrieved from https://cirt.gcu.edu/research/developmentresources/research_ready/quantresearch/approaches

Gheorghiu, V., & Barkley, T. W. (2017). Identification and prevention of secondary heart failure: A case study. Critical care nurse, 37(4), 29-35. https://doi.org/10.4037/ccn2017478

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., ... & Ting, H. H. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA internal medicine, 174(7), 1095-1107. doi:10.1001/jamainternmed.2014.1608

Long, G., Babbitt, A., & Cohn, T. (2017). Impact of home telemonitoring on 30-day hospital readmission rates for patients with heart failure: A systematic review. Medsurg nursing, 26(5), 337-348. Retrieved from http://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?vid=1&sid=3937df68-871f-4de5-aa19-862229b22e18%40sessionmgr4009

LoBiondo-Wood, G. & Haber, J (2014). Nursing research: Methods and critical appraisal for evidence-based practice. St. Louis, MO. Elsevier.

Mangla, A., Doukky, R., Richardson, D., Avery, E. F., Dawar, R., Calvin, J. E., & Powell, L. H. (2018). Design of a bilevel clinical trial targeting adherence in heart failure patients and their providers: The Congestive Heart Failure Adherence Redesign Trial (CHART). American heart journal, 195, 139-150. https://doi.org/10.1016/j.ahj.2017.09.016

Melnyk, B. M., Gallagher-Ford, L., & Overholt, E. F. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on evidence-based nursing linking evidence to Action, 11(1), 5-15. doi:10.1111/wvn.12021.

Noori, A., Shokoohi, M., Baneshi, M. R., Naderi, N., Bakhshandeh, H., & Haghdoost, A. A. (2014). Impact of socio-economic status on the hospital readmission of Congestive Heart Failure patients: A prospective cohort study. International journal of health policy and management, 3(5), 251.doi:10.15171/ijhpm.2014.94

Ong, M. K., Romano, P. S., Edgington, S., Aronow, H. U., Auerbach, A. D., Black, J. T., ... & Ganiats, T. G. (2016). Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: The better effectiveness after transition–heart failure (BEAT-HF) randomized clinical trial. JAMA internal medicine, 176(3), 310-318. doi:10.1001/jamainternmed.2015.7712

Wyer, P., Stojanovic, Z., Shaffer, J. A., Placencia, M., Klink, K., Fosina, M. J., ... & Graham, I. D. (2016). Combining training in knowledge translation with quality improvement reduced 30‐day heart failure readmissions in a community hospital: a case study. Journal of evaluation in clinical practice, 22(2), 171-179. doi:10.1111/jep.12450

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J., (2013). Is “Teach-Back” Associated with Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Journal of cardiovascular nursing Vol. 28, NO.2, PP 137-146.Wolters Kluwer Health. Lippincott Williams & Wilkins

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Research Design:

Descriptive research design

Descriptive research design identifies a current problem. A hypothesis is formed after the data is collected. The data could be obtained from either primary or secondary sources (Center for Innovation in Research and Teaching [CIRT], 2018).

| Experimental research design. Experimental Research Design investigates the casual relationship between variables in research study. It provides answers to already formulated hypothesis (CIRT, 2018).

| Quasi-experimental research design .A quasi-experiment refers to an empirical interventional study used to test casual hypothesis on a target population without random assignment (CIRT, 2018).

A Systematic Review
A systematic review involves collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

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Definition: The concept of sampling in quantitative research is selecting a target population in a study (LoBiondo-Wood & Haber, 2014).

Non-probability- non-random method of choosing study samples. Example convenience sampling

Probability- Methods of random sampling is done.  Example stratified random sampling

Power analysis-  Statistical methods used to determine the sample size.

Measurement: The Measurement of a study focuses on:

Validly (accuracy)

Reliability ( consistency)

(LoBiondo-Wood & Haber, 2014).

Date Analysis:
Independent Variables and dependent variables are identified in the study

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Initial e-poster in the developing stages of the DNP project

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The majority of the literature findings indicated that Teach-Back methods increase health literacy. However, more research is needed to assess the effect of the Teach-Back method in reducing 30-day readmission rate among CHF patients.
The DNP graduate plans to make revision to the developing project.
This class has inspired the DNP graduate to revise the current literature obtained. The DNP graduate will  subsequently add more substantial evidence-based literature to the evidence table.

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The return to hospital rates of congestive heart failure(CHF) patients are significantly high. Additionally, CHF is amongst the most common 30-day readmission diagnoses with an estimated 25% readmission rate in Medicare (Almkuist 2017), The estimated CHF direct cost is $ 33 billion, which imposes an economic burden on the healthcare system. Evidence-based literature suggest that Teach-Back is an effective patient education strategy. This Doctor of Nursing Practice (DNP) project examines the impact of using the Teach-back method for patients with congestive heart failure (CHF). The project takes place on a 30-bed cardiac unit in a community hospital. The purpose of the DNP project is to integrate Teach-back as a standard practice for CHF patients. The aim is to assist nurses in becoming comfortable and competent in using teach-back effectively. The project aims to prevent 30-day readmission for CHF patients, and educate patient about self-care while improving their quality of life.  Evidence-based material is used to improve processes and evaluate the effectiveness of Teach-back in reducing the readmission rates of CHF patients. Teach-back when used correctly by nurses assesses the patient’s readiness to learn, and skills in specific areas related to the management of their disease. The interactive method of Teach-Back using simple plain languages, focuses on key points and ask the patient and or family to recall or repeat back in their own words the information discussed (Beresford, 2012).

Keywords: Congestive Heart Failure, Teach-Back, Readmission, Education.

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Teach-Back is an interactive teaching method that uses plain languages, focuses on key points, and ask the patient to verbally recall the information just discussed. Patient education using Teach-Back method has a significant potential to increase self-care behavior among CHF patients and decrease adverse clinical outcomes, and readmission rates to emergency department (White et al., 2013).

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Review of the Literature Comparison and Contrast of Various Literature Findings on Effectiveness of Teach-Back

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Review of the Literature Comparison and Contrast of Various Literature Findings on Effectiveness of Teach-Back

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Ong et al. (2016) conducted a study to assess the efficacy of Teach-Back strategies. Remote patient monitoring is used to reduce 30 and 180-day readmission, mortality, and quality of life among elderly patients hospitalized with CHF. Ong et al. randomized 1437 patients who had been hospitalized for HF between 2011 and 2013. The researchers combined telemonitoring and health coaching telephone calls. The results indicated that the interventions neither had a significant effect in reducing 30-day mortality nor 180-day mortality.

The researchers noted a significant variance in 180-day quality of life between the intervention and control group (Ong et al. (2016). Similarly, Almkuist (2017) conducted a systematic review to analyze recorded evidence on the application of Teach-Back in-patient education to prevent 30-day readmission among patients with CHF. Almkuist findings were similar to those of Ong et al., which outlined that Teach-Back methods reduce the rate of readmission when combined with another initiative such as telemonitoring. Additionally,

Almkuist (2017) analyzed additional outcomes of Teach-Back method other than readmission. The findings indicated that the Teach-Back methods have a positive effect on health outcomes, self-care, and health literacy.

Additionally, Dinh et al. (2016) stated that Teach-Back methods were introduced as a way of promoting health literacy among patients. However, evidence supporting the efficacy of health education imparted through teach-back strategies has not been systematically reviewed. The researchers conducted a systematic review to analyze evidence on the application of Teach-Back methods in health education programs for improving adherence to recommended outpatients services and self-management among patients with chronic diseases. Randomized, non-randomized, and cohort case-control studies discussing the application of Teach-Back on adults of ages 18 and above with one or more chronic illness were systematically reviewed. The outcomes measured by the researchers were self-management, compliance with recommendations, disease-specific knowledge, quality of life, readmission rate, and knowledge retention. Dinh et al. (2016) findings were similar to that of Ong et al. (2016) that predominantly, Teach-Back methods have positive effects in various healthcare outcomes such as adherence rate and disease-specific knowledge. The intervention group had a P value of 0.06 when compared to the control group.  However, in some outcomes such as readmission rate and hospitalization, the reduction was not consistently significant (Dinh et al., 2016; Ong et al. 2016).

According to Dastoom, Elahi, Baraz, & Latifi (2016) published guidelines stipulate that education is an essential intervention in readmission prevention. However, the most effective method of educating hospitalized patients suffering from myocardial infarction about self-care is unknown. The researchers conducted RCTs in two academic healthcare systems on one hundred HF patients aged 50 and above. The participants in the intervention group were educated and evaluated using Teach-Back method. Dastoom et al. (2016) findings were similar to that of Dinh et al. and Ong et al. that the teach-back method increased the patients’ knowledge of self-care. The outcomes that 75% of the patients answered the Teach-Back questions correctly (P < .001) was significantly associated with the time spent teaching in the intervention group.

However, Dastoom et al. and Dinh et al. differed on the significance of the effect of Teach-Back on readmission rate. Dastoom et al. findings indicated that Teach-Back methods significantly reduced readmission rates by 56.2% and a P value of 0.004, while Dinh et al. concluded that the reduction in re-hospitalization was insignificant.

Wyer et al. 2016 conducted a case study, which associated multidisciplinary training in evidence-based practice (EBP) with reduction of 30-day readmission among patients with CHF hospitalized in a community teaching hospital. HCPs attended a three-day innovative capacity building conference in evidence-based healthcare in three years. The facilitators applied a knowledge-to-action model in training the interdisciplinary healthcare team.

The researchers concluded that the knowledge transition model resulted in the implementation of an efficient budget program that decreased readmission of patients with HF. Similarly, a systematic and meta-analysis conducted by Leppin et al. indicated that 30-day readmission rate could be decreased through tested interventions such as teach-back strategies. However, Long, Babbitt, & Cohn, (2017) conducted a systematic review to analyze the effect of home telemonitoring on patients with CHF on 30-day re-hospitalization which contrasted with Wyer et al. and Leppin et al.

Long et al. analyzed six articles with a sample size of 51,014 participants. Each study was appraised to determine the level of evidence using the American Association of Critical Care Nurses (AACN) grading system. The researchers could not give recommendations for practice because of the limited evidence. Long et al. (2016) recommend that future research should be performed to facilitate comprehension of home telemonitoring and how the intervention effectively reduces 30-day readmission for patients suffering from CHF.

Burke, Guo, Prochazka, & Misky, (2014) conducted a research to assess the effectiveness of various interventions in reducing readmission. Through the electronic database search 4045, studies were identified, among which 3979 were excluded. The researchers analyzed 66 studies, which had met the inclusion criteria to analyze the efficacy of patient education and care coordination in the reduction of re-hospitalization. The researchers’ analyzed re-hospitalization using Chi-Square tests and concluded that increasing the number of targeted domains within the ideal transition of care (ITC) could result in a reduction of 30-day readmission.

The findings by Burke et al. that the integration of education, monitoring, and managing symptoms after discharge effectively reduced readmission were similar to those of Ong et al. The differences in the studies were that Ong et al. analyzed telemonitoring is assessing the patients, while Burke et al. examined physical follow-ups.

Drisoll et al. (2016) conducted a systematic review with the purpose of examining the systems of care for CHF that facilitate the reduction of re-hospitalization and mortality. The researchers analyzed electronic databases for RCTs, non-randomized trials, and cohort studies based on the PRISMA statement. Three reviewers independently assessed the eligibility of the studies using Newcastle-Ottawa and GRADE rating tools for non-randomized and RCTs respectively to eliminate selection bias. Five hundred and twenty studies were identified, however after removing the duplicates and analyzing the title and abstract, 491 studies were excluded. The researchers selected 29 articles on workforce system of care, primary care, telemonitoring, and transitional care. The research findings indicated that proficient CHF team, quality improvement programs, and nurse-led clinics improved the quality of care and reduced hospital mortality and readmission. However, similar to Long et al. (2016), Drisoll et al. (2016) could not give a conclusive finding on the efficacy of telemonitoring in reducing the readmission of patients with CHF because many studies outlined conflicting evidence.

Noori et al. (2014) conducted a cohort study to analyze the effect of multiple indicators of social-economic status (SES) on CHF related readmission. The researchers involved 315 patients with no history of hospitalization because of CHF. The principal component analysis (PCA) was applied to facilitate the subdivision of patients into quarters regarding SES. The stratified Cox regression analysis was used in calculating the Hazard Ratios (HRs). Noori et al. concluded that 40% of patients with CHF are readmitted to healthcare facilities. Additionally, patients with earnings ranging from $176–$352 had a higher probability of being re-hospitalized in comparison to individuals with an income of $752 or higher and as indicated by 2.66 (95% Cl=1.51-4.66). Similarly,

Mangla et al. (2018) outlined the socioeconomically disadvantaged patients are at an increased peril of adverse CHF outcomes because of non-adherence to medication and follow-up recommendations. The study recruited 72 physicians and their 320 patients within two years. The CHF patients were randomized into two groups of 157 and 163 participants in the intervention and control group respectively. The researchers assessed the impact of weekly home visits from community health workers and monthly HF management through educational tip sheets in reducing 30-day readmission among patients with an annual income of $30,000. The researchers applied Congestive Heart Failure Adherence Redesign Trial (CHART) to analyze the outcomes of the interventions and concluded that home visits and education decreased non-compliance, which resulted in reduced readmission rates (Mangla et al., 2018).

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To share the development of the DNP project with the professor and fellow classmates.

To show case scientific evidence from quantitative research articles addressing the impact of Teach-Back in reducing the readmission rates of congestive heart failure (CHF) patients.

To outline the evaluation plan for the proposed DNP project

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The literature search for this project shows there are a wide selection of evidence-based literature related to Teach_back and the impact it has on reducing the readmission rates of CHF patients.
The current evidence table for this DNP project is being modified to ensure that substantial evidence-based materials are  being used in the development of the project. The DNP graduate will  look at the literature from the prospective of the various methods used  during this course such as; research design, sampling, measurement, and data analysis.