These clinics make patient education a class act

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

By Robert Lowes, Midwest Editor

Every month, approximately 125 patients visit Camino Medical Group inSunnyvale, CA, to attend "school." Type II diabetics learn howto count carbohydrates and measure their blood sugar. Mothers-to-be acquirethe fine points of breast-feeding. Asthmatics practice puffing on peak-flowmeters.

In all, the 140-doctor group offers nine courses, most of them plannedwith the participants' schedules in mind. The classes, usually taught bynonphysicians, give patients the kind of in-depth information that doctorsdon't have time to dispense during office visits. "Teaching 10 peopleall at once is a lot more efficient," says Camino endocrinologist ToddKaye, 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 SiliconValley, where Kaye practices, are asking more questions, putting physiciansunder the gun to provide answers. At the same time, doctors are being pushedby managed care to give patients the information they need to stay healthyor handle chronic illnesses. Patient education, the theory goes, translatesinto better lives for patients and lower costs for health plans.

But creating a patient-ed curriculum isn't a risk-free proposition. Expenditurescan easily top $100,000, and the return on investment is hard to calculate.If an economic downturn hits your group, patient education will probablybe 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 classesfor diabetes consistently fill up, the group scratched a stress managementclass that drew nary a patient. "Participation rates are a bugabooof health education," says Dennis Tolsma, director of clinical qualityimprovement 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 physiciansto talk up health education classes like they would their favorite footballteam. Although classes spare doctors much of the job of explaining diseasepathology and self-care to patients, they still require physicians' activesupport.

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 partof physicians' disease management guidelines. Some guidelines leave thetype of patient education to the doctor's discretion, but those for persistentasthma at Camino Medical Group specify a class. Likewise, the guidelinesfor newly diagnosed type II diabetes at Kaiser Permanente in Georgia callfor class enrollment within two weeks.

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

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

"The argument for personalizing counseling is that you can tailorinstruction to the individual," says Harris. "In a class, an instructormay 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. "Patientstend to be more open and ask more questions when they know other peoplein the room have the same diagnosis," says Harris. "And patientsencourage and support each other as they try to manage an illness. It helpswhen 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 thehospital. Are these expectations being met? Too few studies have been doneto provide clear answers, says internist David Nash, director of the Officeof Health Policy and Clinical Outcomes at Thomas Jefferson University Hospitalin Philadelphia. But early findings are encouraging.

At the Beaver Medical Group in Redlands, CA, diabetics who received education--largelyin classes--had average hospital stays of 3.29 days in 1997, compared with5.87 days for patients who weren't similarly coached. Likewise, tabs fortests, 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 thehuman resources consulting firm of Towers Perrin in New York. "Knowwhat 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, newpersonnel 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 recommendationson 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 establisha core curriculum of five classes: diabetes, prenatal care, well-baby care,senior nutrition, and vaginal birth after cesarean section. Health Net requiresthat groups with 5,000 enrollees designate at least a part-time administratorto handle classes. At 20,000 enrollees, the group must have a full-timecoordinator, and larger groups usually need another employee, typicallya clerical worker to register patients, maintain a database of students,and track attendance.

The coordinator should be a registered nurse, registered dietitian, college-trainedhealth educator, or someone holding a master's degree in public health.Youcan expect to pay a full-time coordinator $40,000 to $60,000, dependingon the candidate's experience and the size of the group. "A clericalworker'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--butadditional instructors will probably be needed, says Keitel. Some groupshire them, part or full time; others use outside contractors. Given thedemand for diabetic disease management, one obvious personnel choice isa certified diabetes educator, or CDE. Most CDEs are registered nurses orregistered dietitians. RNs in ambulatory care average $28,000 a year, accordingto the American Nurses Association, while RDs average $38,000 a year. CDEstatus might boost these figures even higher.

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

In addition to hiring faculty from outside your group, you can importan entire program. The 28-doctor Obstetrical and Gynecological Associatesin Houston, for example, has arranged for a wellness institute at a localhospital to hold classes on smoking cessation and weight management at thedoctors' 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 regularlyreport to referring doctors and group administrators, says the Beaver Group'sJoan Hemmers. "It's hard for the doctors to know what's going on inclasses 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 dietitianswho each log 10 hours a week, as well as a nurse practitioner who teachesabout menopause and osteoporosis. In-house staff consists of three full-timers--Hemmers,who's an RN, an administrative assistant, and a preventive care specialistwho 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'tcome cheap. Salaries, freelance fees, and miscellaneous operating expensessuch as printed materials bring the total cost to approximately $200,000a year, says Hemmers. A corporate grant of $2,000 pays for the servicesof the nurse practitioner. The courses don't generate revenue because Beaverdoesn't charge for them. But then, the group never did expect to recoupits investment dollar-for-dollar, says medical director and FP Ronald Bangasser.

"We don't know how much of what we save on hospitalizations andsuch is due to education," he explains. "But we do know that patientswho 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? Despiteall the talk about today's patients wanting to take command of their healthcare destinies, many groups struggle to fill classes.

"We peaked about four years ago when 30,000 Health Net enrolleesa year attended our classes," says Cindy Keitel. "Today, 10,000attend, despite an increase in covered lives. One reason is that everybody'sbusier. It's harder to break away for a class. You also have more peoplegoing 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 MeridianMedical Group to scuttle a broad lineup of classes earlier this year. In1996, Meridian budgeted approximately $250,000 for patient education, employedfour educators, and offered as many as eight classes. But only breast-feedingand parenting courses drew decent crowds, according to Terri Spiegel, directorof clinical and support services. An asthma class had no takers for an entireyear.

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

Kaiser began by rewriting course descriptions to make them more informativeand enticing. "Our old flyers simply listed the course name and a phonenumber," says FP Adrienne Mims, chief of prevention and health promotion."Now, flyers describe what the class covers, how many can attend, whereand when it meets, how many sessions, how much it costs, and what take-homematerials you get for your money. Take-homes really help. If people knowthey'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 allclinics now, though more frequently at some sites than others. Class schedulesare scrambled frequently so that, say, an asthma course isn't always heldat a time when Mrs. Smith can't make it. Plus, there are Saturday classesfor people too busy on weekdays.

In keeping with the take-charge spirit of disease management, Kaiserbegan to actively round up students. "We identify people who shouldbe in a class and contact them," says Dennis Tolsma. "If a diabetichas consistently elevated blood sugar, he'll get a letter signed by hisphysician urging him to take a diabetes class."

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

The best attendance builder is the front-line physician

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

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

Some doctors simply distrust patient educators. "Physicians arenervous 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 whatoccurs in the classroom. "I found that physicians usually were in thedark," says Adrienne Mims. "So we use e-mail, newsletters, andstaff meetings to not only publicize the classes, but to review their contentand explain their importance. I tell doctors, 'You aren't losing your patientswhen you make a referral. The classes will help them understand and complywith 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 vascularsurgeon Richard Slavin. "This is a physician organization, so wheneversomebody proposes a new class, there's medical input."

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

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

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