These clinics make patient education a class act

A "Health Care U" can improve outcomes, reduce utilization, and save time. But filling the classroom takes hard work and physician buy-in.

By Robert Lowes, Midwest Editor

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Every month, approximately 125 patients visit Camino Medical Group in Sunnyvale, CA, to attend "school." Type II diabetics learn how to count carbohydrates and measure their blood sugar. Mothers-to-be acquire the fine points of breast-feeding. Asthmatics practice puffing on peak-flow meters.

In all, the 140-doctor group offers nine courses, most of them planned with the participants' schedules in mind. The classes, usually taught by nonphysicians, give patients the kind of in-depth information that doctors don't have time to dispense during office visits. "Teaching 10 people all at once is a lot more efficient," says Camino endocrinologist Todd Kaye, who refers 15 patients a month to Camino's virtual Health Care U.

Today's patients, such as the Web-surfing citizens of California's Silicon Valley, where Kaye practices, are asking more questions, putting physicians under the gun to provide answers. At the same time, doctors are being pushed by managed care to give patients the information they need to stay healthy or handle chronic illnesses. Patient education, the theory goes, translates into better lives for patients and lower costs for health plans.

But creating a patient-ed curriculum isn't a risk-free proposition. Expenditures can easily top $100,000, and the return on investment is hard to calculate. If an economic downturn hits your group, patient education will probably be among the first items axed from your budget.

Even if your coffers are full and your patient education program first-rate, recruiting students is an iffy proposition, at best. While Camino's classes for diabetes consistently fill up, the group scratched a stress management class that drew nary a patient. "Participation rates are a bugaboo of health education," says Dennis Tolsma, director of clinical quality improvement for Kaiser Permanente's Georgia division, headquartered in Atlanta.

Tolsma's organization has had its share of attendance problems, too, but it has found ways to boost the numbers. One key is getting physicians to talk up health education classes like they would their favorite football team. Although classes spare doctors much of the job of explaining disease pathology and self-care to patients, they still require physicians' active support.

Some disease management programs prescribe patient education courses

Patient education classes generally fall into three categories:

• Lifestyle classes help participants lose weight, stop smoking, or reduce stress.
• Maternity classes coach pregnant women about diet, exercise, childbirth, and breast-feeding, and give new mothers the lowdown on child care.
• Disease management courses can help patients suffering from diabetes, asthma, and hypertension.

DM courses are hot because patient education has become an integral part of physicians' disease management guidelines. Some guidelines leave the type of patient education to the doctor's discretion, but those for persistent asthma at Camino Medical Group specify a class. Likewise, the guidelines for newly diagnosed type II diabetes at Kaiser Permanente in Georgia call for class enrollment within two weeks.

At the 60-doctor Meridian Medical Group in suburban Atlanta, patient education in a DM program for diabetes takes the form of one-on-one counseling over 12 weeks. If a patient can't commit to this regimen, he can take a two-hour class, though it's not considered a part of the DM program, says diabetic educator Darlene Tinsley-Levy. Roughly 60 percent of diabetics referred for patient education land in the DM program, 30 percent opt for the class, and 10 percent decline both.

Meridian uses one-on-one counseling for disease management because it's more effective than classroom learning, says Tinsley-Levy. However, there's a place for both methods, says Dianne Harris, Kaiser Georgia's member health education coordinator.

"The argument for personalizing counseling is that you can tailor instruction to the individual," says Harris. "In a class, an instructor may not realize, say, that a student is illiterate and can't read a pamphlet. You're more likely to discover that one-on-one."

That's not to say that group education is impractical. "Patients tend to be more open and ask more questions when they know other people in the room have the same diagnosis," says Harris. "And patients encourage and support each other as they try to manage an illness. It helps when someone asks, 'Did you take your pill today?' "

The premise behind DM education is that patients in fact will take medications, eat properly, monitor their sugar, and as a result spend less time in the hospital. Are these expectations being met? Too few studies have been done to provide clear answers, says internist David Nash, director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University Hospital in Philadelphia. But early findings are encouraging.

At the Beaver Medical Group in Redlands, CA, diabetics who received education--largely in classes--had average hospital stays of 3.29 days in 1997, compared with 5.87 days for patients who weren't similarly coached. Likewise, tabs for tests, office visits, and ER visits were 47 percent lower for "educated" diabetics than for their "uneducated" counterparts.

Creating classes with measurable results in mind is the key to success, suggests former gastroenterologist Alan Spiro, now a consultant with the human resources consulting firm of Towers Perrin in New York. "Know what you're trying to achieve, then assess whether you've achieved it."

There's more than one way to assemble your education team

If your group is serious about offering patient education classes, new personnel will have to be recruited.

Cindy Keitel, director of health improvement and wellness at Health Net, a California HMO with 2.2 million enrollees, bases her staffing recommendations on Health Net's experience with group practices that contract with the HMO. If a group cares for 5,000 or more Health Net enrollees, it must establish a core curriculum of five classes: diabetes, prenatal care, well-baby care, senior nutrition, and vaginal birth after cesarean section. Health Net requires that groups with 5,000 enrollees designate at least a part-time administrator to handle classes. At 20,000 enrollees, the group must have a full-time coordinator, and larger groups usually need another employee, typically a clerical worker to register patients, maintain a database of students, and track attendance.

The coordinator should be a registered nurse, registered dietitian, college-trained health educator, or someone holding a master's degree in public health.You can expect to pay a full-time coordinator $40,000 to $60,000, depending on the candidate's experience and the size of the group. "A clerical worker's salary could run $20,000 to $25,000 a year," says Joan Hemmers, director of patient education at Beaver Medical Group.

Coordinators may teach a class or two--more likely in smaller practices--but additional instructors will probably be needed, says Keitel. Some groups hire them, part or full time; others use outside contractors. Given the demand for diabetic disease management, one obvious personnel choice is a certified diabetes educator, or CDE. Most CDEs are registered nurses or registered dietitians. RNs in ambulatory care average $28,000 a year, according to the American Nurses Association, while RDs average $38,000 a year. CDE status might boost these figures even higher.

Kaiser's Dennis Tolsma recommends the freelance approach. "It's better to contract with people certified in a particular subject than to hire generalists," he says. Keitel agrees, noting that "few medical groups have the resources to keep people in every area of expertise on staff."

In addition to hiring faculty from outside your group, you can import an entire program. The 28-doctor Obstetrical and Gynecological Associates in Houston, for example, has arranged for a wellness institute at a local hospital to hold classes on smoking cessation and weight management at the doctors' premises. The group pays the institute a flat fee for each class, then tries to recoup the cost by charging patients $185.

The drawback to using outside instructors is that they don't regularly report to referring doctors and group administrators, says the Beaver Group's Joan Hemmers. "It's hard for the doctors to know what's going on in classes when instructors are seldom around," she says. "Plus, they often rotate, so we're always seeing new faces."

Beaver Medical takes a middle road. It contracts with two freelance dietitians who each log 10 hours a week, as well as a nurse practitioner who teaches about menopause and osteoporosis. In-house staff consists of three full-timers--Hemmers, who's an RN, an administrative assistant, and a preventive care specialist who holds classes on exercise, smoking cessation, and stress management; and two part-timers--a clerk and an RN who focuses on asthma, diabetes, and congestive heart failure.

Given this kind of staffing, patient education at Beaver Medical doesn't come cheap. Salaries, freelance fees, and miscellaneous operating expenses such as printed materials bring the total cost to approximately $200,000 a year, says Hemmers. A corporate grant of $2,000 pays for the services of the nurse practitioner. The courses don't generate revenue because Beaver doesn't charge for them. But then, the group never did expect to recoup its investment dollar-for-dollar, says medical director and FP Ronald Bangasser.

"We don't know how much of what we save on hospitalizations and such is due to education," he explains. "But we do know that patients who go to classes take better care of themselves."

It's not a class if you don't have students

What if you build a patient education program and nobody comes? Despite all the talk about today's patients wanting to take command of their health care destinies, many groups struggle to fill classes.

"We peaked about four years ago when 30,000 Health Net enrollees a year attended our classes," says Cindy Keitel. "Today, 10,000 attend, despite an increase in covered lives. One reason is that everybody's busier. It's harder to break away for a class. You also have more people going to the Internet for health care information." Not surprisingly, Health Net is transforming its own Web site (www.healthnet.com) into a destination for cyber citizens seeking medical guidance.

Low attendance along with the need for fiscal belt tightening, led Meridian Medical Group to scuttle a broad lineup of classes earlier this year. In 1996, Meridian budgeted approximately $250,000 for patient education, employed four educators, and offered as many as eight classes. But only breast-feeding and parenting courses drew decent crowds, according to Terri Spiegel, director of clinical and support services. An asthma class had no takers for an entire year.

Filling classes is hardly a lost battle, though. When Kaiser Georgia confronted the issue of poor attendance in 1997, it was lucky to attract five people to a diabetes class. Today, it draws as many as 20. Other classes also enjoy bigger turnouts, thanks to a new marketing approach.

Kaiser began by rewriting course descriptions to make them more informative and enticing. "Our old flyers simply listed the course name and a phone number," says FP Adrienne Mims, chief of prevention and health promotion. "Now, flyers describe what the class covers, how many can attend, where and when it meets, how many sessions, how much it costs, and what take-home materials you get for your money. Take-homes really help. If people know they'll receive a book or a tape, they find it easier to justify the cost."

Kaiser also made its classes more accessible. They're conducted at all clinics now, though more frequently at some sites than others. Class schedules are scrambled frequently so that, say, an asthma course isn't always held at a time when Mrs. Smith can't make it. Plus, there are Saturday classes for people too busy on weekdays.

In keeping with the take-charge spirit of disease management, Kaiser began to actively round up students. "We identify people who should be in a class and contact them," says Dennis Tolsma. "If a diabetic has consistently elevated blood sugar, he'll get a letter signed by his physician urging him to take a diabetes class."

Kaiser has simplified the logistics, too. Patients can register through Kaiser's call center, open 24 hours a day. Or, if during an office visit a physician suggests a class, the patient can register for it at the front desk, while the idea is still hot. "If you insist that they register by phone, many patients will just never get around to it," says Kaiser's Dianne Harris.

The best attendance builder is the front-line physician

Patient educators say you can't stop at marketing health education classes to patients: You must market them to physicians, too. "Patients listen to their doctors," says Meridian's Terri Spiegel.

Meridian's own attendance drought may have stemmed in part from less than enthusiastic support from doctors. "They could have done a more consistent job promoting the classes," says Spiegel. "They'd do it for a while, and then it lost its priority."

Some doctors simply distrust patient educators. "Physicians are nervous about where patients get their information, and for good reason," says consultant Alan Spiro. "They want to make sure it's accurate."

The key to getting physician support, then, is letting doctors know what occurs in the classroom. "I found that physicians usually were in the dark," says Adrienne Mims. "So we use e-mail, newsletters, and staff meetings to not only publicize the classes, but to review their content and explain their importance. I tell doctors, 'You aren't losing your patients when you make a referral. The classes will help them understand and comply with the treatment plan you've ordered.' "

It's also a good idea to give physicians a say in shaping what's taught. "We determine the curriculum here," says Camino CEO and vascular surgeon Richard Slavin. "This is a physician organization, so whenever somebody proposes a new class, there's medical input."

To make referrals easier, some groups provide doctors with faux prescription pads so they can "prescribe" a class. Stocking every exam room with course descriptions also helps.

Admittedly, talking patients into attending classes is one more duty to cram into a 15-minute office visit. However, that's more appealing than trying to teach Asthma 101 yourself in that time slot--or meeting your patients in the ER because they didn't know how to head off an asthma attack. "Medicine has failed to give patient education its due," says Alan Spiro. "Classes represent a good solution."

Robert Lowes. These clinics make patient education a class act. Medical Economics 1999;19:158.