Physical Exam: Client & Family Education

I. Adult Learning Theory

• Self-directed
• Reservoir of experience
• Adults prefer mutual planning/goal setting
• Internally motivated
• Established orientation to learning
• Educator is facilitator of learning
• Experiential rather than didactic
• Must be immediately applicable to life

II. Teaching/Learning Process

• Assessment
• Identification of learning needs
• Outcome (goal) setting
• Educational offerings
• Evaluation of outcomes

III. Learning Styles

• Vary with individuals
• Learners can be visual, auditory, or tactile (kinesthetic)

IV. Teaching Strategies

• Demonstration/ return demonstration
• Programmed instruction
• Role playing
• Simulation
• Case study analysis
• May be individualized or in groups
• May be computerized
• May be media-based or print

V. Legal Implications

• American Hospital Association issued the Patient Bill of Rights in 1973 that guaranteed clients the right to information necessary to give informed consent before treatment begins
• Individualized teaching must be documented in client's chart
• Alterations for geriatric clients - (i) make sure client has glasses or hearing aid (ii) face the client and use a lower pitched voice (iii) supplement oral presentation with print materials (iv) use large print (v) provide good lighting (vi) some clients have a hard time seeing color; use black on white or yellow paper (vii) keep sessions short and work with survival-level information initially (viii) repeat often for clients prone to memory loss (ix) break down learning into small steps (x) use specific, step by step directions and have the client redemonstrate them (xi) get frequent feedback regarding client's level of understanding
• Patient Protection and Affordable Care Act (PPACA) - signed into law in 2010. This law includes important new protections for millions of working Americans and their families who have preexisting medical conditions or might suffer discrimination in health coverage based on a factor that relates to an individual's health. PPACA places requirements on employer-sponsored group health plans, insurance companies and health maintenance organizations. PPACA includes changes that:

1. Guaranteed issue and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to most pre-existing conditions (excluding tobacco use).
2. A shared responsibility requirement, commonly called an individual mandate, requires that nearly all persons not covered by Medicaid, Medicare, or other insurance programs purchase and comply with an approved insurance policy or pay a penalty, unless the applicable individual "is a member of a recognized religious sect" exempted by the Internal Revenue Service, or waived in cases of financial hardship.
3. Medicaid eligibility is expanded to include all individuals and families with incomes up to 133% of the poverty level along with a simplified CHIPenrollment process.
4. Health insurance exchanges will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).
5. Low income persons and families above the Medicaid level and up to 400% of the poverty level will receive federal subsidies on a sliding scale if they choose to purchase insurance via an exchange (persons at 150% of the poverty level would be subsidized such that their premium cost would be of 2% of income or $50 a month for a family of 4).
6. Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.
7. Very small businesses will be able to get subsidies if they purchase insurance through an exchange.
8. Insurers are prohibited from establishing annual spending caps. Insurance companies will also be required to spend a certain percent of premium dollars on medical care improvement. If an insurer fails to meet this requirement, it will be required to provide a rebate to the policy holder.
9. Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package" for Level A or Level B preventive care
10. The law will introduce minimum standards for health insurance policies and remove all annual and lifetime coverage caps.
11. Changes are enacted which allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payments."
12. Establishment of a national voluntary insurance program for purchasing community living assistance services and support.
13. Additional support is provided for medical research and the National Institutes of Health.

• The first ever federal privacy standards to protect patient's medical records and other health information provided to health plans, doctors, hospitals and other health care providers took on April 12, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed
• The new privacy regulations ensure protection for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use protected medical records and to other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include:

1. access to medical records
2. notice of privacy practices
3. limits use of personal medical information
4. prohibition on marketing
5. stronger state laws
6. confidential communications
7. complaints

POINTS TO REMEMBER:

• Teaching-learning process mirrors the nursing process
• Select teaching strategies that are compatible with the client's learning style, age, culture, level of education
• Client teaching should be multi-sensory
• Always confirm the client's understanding of the information presented
• Teaching must be geared to the level of the learner
• Repeat key information and summarize main points at intervals
• Explain medical terminology in lay terms
• Determine the client's learning style and gear teaching methods to using that style
• Sequence information the way the client will use it
• Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress