A QI project aims to reduce psychiatric ED use.
- Patients with mental illness frequently encounter challenges in navigating healthcare systems, engaging in preventive health, and managing physical comorbidities.
- This quality improvement project aimed to reduce the frequent use of psychiatric emergency department services among patients with mental illness by focusing on increasing patients’ understanding of their diagnosis, treatment plan, and follow-up care at discharge.
EMERGENCY DEPARTMENT (ED) providers frequently manage non-acute health issues, which could be more effectively addressed in other healthcare settings. This trend is evident in the staggering number of annual ED visits in the United States. According to Cairns, in 2020 alone an estimated 131 million ED visits occurred (about 40 visits per 100 people). A study by Mao and colleagues found that a small percentage of patients disproportionately account for up to 25% of all ED visits. Ronaldson and colleagues refer to these patients as high utilizers.
Nonemergent visits to the ED increase healthcare costs, reduce reimbursement rates, and strain healthcare organizations and professionals. Diverting resources from patients with acute medical needs to those with less emergent concerns contributes to inefficiency and decreased overall quality of care.
By your patients you’ll be taught
To address this concern in a Midwest teaching hospital, two doctor of nursing practice (DNP) students conducted a quality improvement (QI) project aimed at improving patient education during discharge.
High volume in the local ED
The Midwest teaching hospital struggled with a substantial influx of individuals who frequently visited the ED for non-acute care. The acute psychiatric unit (APU), an ED sub-unit, provides urgent care for mental health crises, suicidality, and psychosis. However, many patients use the APU for nonurgent psychosocial needs or chronic conditions. Gabet and colleagues and Ronaldson and colleagues note that many individuals who regularly visit the ED are experiencing homelessness and also grapple with substance use disorders or mental illnesses. Longitudinal care and community resources could more effectively manage these issues.
To facilitate transition across the continuum of care for patients who visit the APU, RNs provide discharge instructions and review a printed after-visit summary. The summary includes the reason for the APU visit and information regarding follow-up care, such as medication instructions and future appointments.
Informal observation by the DNP students, who served as project leads, revealed inconsistent discharge education practices among APU RNs. These variations in the quantity and content of information raised concerns that inadvertent omissions might contribute to the high volume of individuals who frequently visit the unit. (See The impact of mental illness on health literacy.)
The impact of mental illness on health literacy
According to Degan and colleagues and Ronaldson and colleagues, many individuals with mental illness have health literacy limitations, attention deficits, and memory impairments that make comprehending health information during a crisis particularly challenging. They may struggle with insight, judgment, and executive function, which can impact the ability to manage physical and mental health needs, such as grooming, dietary requirements, medication adherence, and scheduling and attending medical appointments.
Some patients with mental illness have limited aural and verbal literacy skills, which may contribute to lower education attainment and prove a significant barrier to comprehending and following through with recommended healthcare services. These challenges underscore the need for consistent patient education practices that consider health literacy barriers and intentionally assess patients’ understanding of health information and follow-up care plans.
Interventions to improve health literacy
To identify the most effective strategies to decrease frequent use of the ED, the project leads performed a comprehensive examination of existing literature from five academic databases. The literature (including Gabet and colleagues, Mao and colleagues, Mashhadi and colleagues, and the U.S. Department of Health and Human Services) supports case management, care coordination, and quality patient education as interventions to reduce high ED use. However, due to financial constraints, case management and care coordination weren’t considered viable interventions at this hospital.
After discussion with stakeholders (nursing management and RNs), the project leads proposed an evidence-based intervention targeting patient education provided during discharge from the APU. They suggested that patients would benefit from consistent and clear explanations by unit RNs during the discharge process to increase understanding of their diagnosis, treatment plan, and follow-up care.
Mashhadi and colleagues and Ronaldson and colleagues note the importance of patient-centered education as a strategy for reducing hospitalizations and return ED visits, including the effectiveness of the teach-back method in confirming patient understanding of important medical information and education. Using teach-back, the nurse asks the patient to explain the information they’ve just learned. This gives the nurse the opportunity to clarify misunderstandings and ensure accurate comprehension. The method also reinforces expectations for follow-up after discharge and facilitates the transition between the acute care setting and primary care.
Project goals and methods
This QI project aimed to fill a critical gap in consistent quality patient education by providing low-cost, structured teach-back method training to APU nurses. The project leads then evaluated whether the intervention impacted nurse confidence with the method, how frequently they used it, and their perception of the method’s effectiveness. The downstream goal was to reduce high APU utilization rates.
The project team used the Iowa Model as its framework. This model provides a systematic approach to implementing evidence-based changes in clinical practice, beginning with clinical problem identification, evidence appraisal and synthesis, decision-making collaboration, organizational priority alignment, practice change design and pilot, and intervention evaluation to support sustainment.
Participants and practice setting
The intervention took place in the APU, a locked subunit of the hospital’s ED. The unit provides 24-hour specialized behavioral health services to patients experiencing acute mental crises. Potential participants included 37 RNs working on the unit.
Project planning
Early in project development, the project leads determined the level of financial support the administration could provide for implementing the intervention. After obtaining support from nursing management and RNs, the project leads sought and received university and hospital Internal Review Board approval.
The project leads observed the APU shifts to assess the discharge process. They noted that after-visit summaries were commonly distributed with little attention to ensuring patient comprehension. The team evaluated the unit’s readiness for change via dialogue and active engagement with the RNs and nurse managers, with a focus on their openness to support the project as an effort to improve patient outcomes with minimal disruption to care. The project leads also presented them with a synthesis of the literature, followed by a discussion about the feasibility of literature-supported interventions and the resources allocated for the project.
Learning module. The project leads created a PowerPoint learning module for teach-back education, highlighting effective use of the after-visit summary at discharge—delivering summary information using simple terminology, highlighting important details, and emphasizing follow-up care. It included a video vignette incorporating the summary with the teach-back approach during a simulated discharge from the APS unit. Learning objectives included defining health literacy and high utilizers; articulating the benefits and key concepts of using the teach-back intervention; and identifying, recognizing, and adapting to common communication barriers (such as limited English comprehension, hearing impairments, low literacy skills) to enhance patient comprehension of printed discharge instructions. (See Teach-back tips.)
Teach-back tips
The key to successful use of the teach-back approach to patient discharge education is ensuring comprehension of vital information. Consider ending each instruction with the following: “To make sure I did my job well in explaining this to you, can you tell me what you’re going to do after discharge today?”
To aid understanding, remember to do the following:
- Keep it simple.
- Break complex messages into chunks.
- Avoid medical jargon and terminology.
- Ask open-ended questions that require more than a “yes” or “no” response.
Survey. To evaluate the intervention’s effectiveness, the project leads created pre- and post-intervention survey questions using Qualtrics. The survey aimed to measure nurses’ confidence in using teach-back education, the frequency of its application, and their knowledge of health literacy. The project leads adapted the survey from existing literature (including the Centers for Disease Control and Prevention’s [CDC’s] Health Literacy for Public Health Professionals and the Agency for Healthcare Quality and Research’s Tool #5 from the Health Literacy Universal Precautions Toolkit) and modified it to include questions pertinent to this project. Additionally, project leads secured a statistician to analyze the data using a paired t-test.
Incentives. To encourage participation, the project leads offered incentives, including continuing education credit for attending an in-person training or watching the asynchronous session. Nurses attending in-person education received coffee, cookies, and brownies. In addition, all nurses entered drawings for three beverage gift baskets, each containing a $5 coffee gift card; a handmade greeting card; and K-cups of coffee, hot cocoa, and tea. The gift baskets were raffled off at the conclusion of each survey phase and on implementation day.
Project implementation
To introduce the project, the leaders sent an email to all 37 RNs who work in the APU. The email provided information about the project start date and the voluntary nature of participation. It also invited RNs to attend one of two in-person, 60-minute presentations during a shift change. Nurses had the opportunity to schedule an alternative time for a face-to-face presentation or to watch the recording asynchronously on the facility’s online education platform. To boost participation, the project leads sent weekly emails, posted flyers on the unit, and encouraged word of mouth among staff.
The project timeline for incorporating teach-back methods with the after-visit summary during discharge spanned 4 weeks. The leads distributed the pre- and post-surveys via email to all participating RNs immediately before and after the intervention, with a 2-week window for completion.
The DNP leads were present on site between 4 to 8 hours on random days, before, throughout, and after project implementation. They evaluated the readiness for change, engaged stakeholders, addressed inquiries regarding the project, and provided support and feedback during implementation.
Results
Of the unit’s 37 nurses, 18 participated in a voluntary teach-back educational session (nine completed the online session, and nine participated in the face-to-face session). Six nurses completed both pre- and post-surveys. Comparison of the mean pre- and post-survey scores demonstrated an increase in nurse confidence with the teach-back method (P=0.08), teach-back education frequency (P = 0.054), and in health literacy knowledge (P=0.36). Although these results weren’t statistically significant, the education intervention proved valuable for the nurses who provided discharge instructions for patients with health literacy barriers.
Informal participant feedback included gratitude and interest in similar future initiatives. One nurse said, “I am so glad you guys are doing this. We need more patient-focused initiatives like this.” This positive feedback underscores the value of the project and the desire for continued improvements in patient education and support on the APU. However, due to the small sample size, the generalizability of these results to other nurses, facilities, and units is limited.
The project leads mined data from the electronic health record (EHR), and the hospital information technology analyst de-identified the information. In March and April 2023 (pre-intervention year), 56 patients visited the APU three or more times compared to 83 in March and April 2024 (post-intervention). These findings highlight the necessity of exploring additional quality improvement initiatives to address the growing number of ED visits.
Return on investment
Reducing ED visits can lead to significant cost savings for healthcare organizations. Mao and colleagues found that repeated ED visits contribute to increased violence toward staff, high turnover, burnout, reduced productivity, and staff distractions. Ronaldson and colleagues discovered that patients with a mental illness were more likely to be admitted to the hospital, had a 0.59-day longer hospital length of stay, and had a greater chance of readmittance within 30 days compared to patients without a mental illness.
According to Hesselink and colleagues, the teach-back approach has the potential to improve patient comprehension and adherence to treatment plans while also reducing healthcare costs and readmissions. It also offers a cost-effective opportunity during discharge to enhance the safety and quality of transitional care from the ED to the patient’s home. Hesselink and colleagues note that patients who receive teach-back education are more likely to retain detailed information about their diagnosis, treatment, medications, and follow-up appointments. This increased retention of information can lead to improved health literacy, increased confidence in managing chronic illnesses, and potentially reduced frequency of ED visits.
This project required minimal costs in terms of time, supplies, and resources with no additional financial burden on the clinical site or increased staff demands. In-kind donations from the project leads and mentors provided valuable support to the APU at no extra cost. Data analysis by a statistician amounted to $100. The project leads contributed $500 to cover other expenses, including parking, staff snacks, drinks, and prizes.
Challenges
The project leads observed significant variability in the discharge education APU nurses provided before and after the intervention. Some nurses delivered comprehensive education, but others provided only brief explanations and didn’t use the teach-back method or cover all the information on the after-visit summary. The online teach-back training didn’t offer the same interactive opportunities to practice skills with other RNs that the face-to-face sessions provided. This may account for the variability in how RNs engaged with and applied their learning.
To address this inconsistency, the project leads recommend that all RNs attend in-person sessions to allow for assessment of competency using the teach-back method and enable them to practice rephrasing messages, simplifying medical jargon, using everyday language, and breaking down instructions. RNs also can practice using EHR resources, accessing interpreter services, and printing educational materials and after-visit summaries in the patient’s preferred language. Such structured training can help ensure uniformity in the delivery of discharge education and improve patient understanding and follow-up care.
If another organization replicates this study, the project leads recommend tracking the number of patients who received discharge education using the teach-back method longitudinally to determine the annual number of ED visits. A brief survey after discharge could provide additional information on its impact. In addition, the project leads suggest offering the CDC’s Health Literacy for Public Health Professionals course to emphasize the importance of health literacy and the role of RNs in delivering health information and promoting public health literacy. Project replication might also use a guided assessment to determine participants’ learning styles.
Stakeholder engagement
Engaging participants proved challenging due to high unit acuity and the demanding nurse workload, which limited opportunities to provide feedback on the new discharge process workflows. The absence of scheduled meetings to receive RN input also led to gaps in stakeholder engagement. Scheduling dedicated weekly feedback sessions and integrating feedback mechanisms into weekly workflows could provide valuable insights with minimal disruptions.
Lack of compensation for RN attendance at educational offerings on teach-back outside of regularly scheduled shifts likely reduced participation. Providing compensation for participation and ensuring proper staffing to allow RN attendance during scheduled shifts could improve engagement. Alternatively, integrating training activities across all regularly scheduled shifts (days, evenings, nights) would allow staff to participate without the added burden of increased time at the worksite. This approach can motivate and increase staff participation despite busy schedules.
The low participation rate highlights a larger problem of an over-taxed and understaffed unit within one healthcare system. Addressing these systemic issues will prove crucial to enhancing the effectiveness of implementing evidence-based practices.
Lack of administrative communication
Although unit leaders supported the project, RNs received no administrative email endorsement due to unclear role definitions during the planning phase. The project leads expected the inclusion of updates in the weekly unit newsletter. Direct email support from the unit leaders also might have bolstered engagement. Active endorsement from leaders via emails and meetings throughout the project may help to influence staff buy-in and participation.
Survey distribution barriers
The distribution of surveys originated from the project leads’ university email addresses rather than from within the organization, which resulted in many staff members deleting or flagging the emails as spam or malware. Utilizing the healthcare organization’s official email system and conducting a pilot email with the site information technology team could improve delivery and response rates.
Language barriers
Informal feedback revealed a significant concern about the lack of discharge materials in multiple languages. A more inclusive approach to discharge education should address the diverse linguistic needs of patients.
Nursing implications
Incorporating teach-back in the discharge workflow offers a low-cost opportunity to strengthen patient and provider relationships, and to positively impact chronic conditions by reducing readmissions and improving medication adherence.
Anecdotal comments received from the nurses after the intervention period underscore the practical challenges and perceptions regarding discharge education practices. One nurse expressed a sense of inertia, noting, “I know we should be using it, but we just don’t do it here. I don’t know why.” This comment reflects an awareness of the need for thorough discharge education and a recognition of the gap between best practices and nurses’ behavior.
Another nurse highlighted the importance of direct nurse involvement, stating, “Nurses should be reviewing the [after-visit summary] instead of the [mental health] worker just handing them to the patients on the way out. It’s best practice and better for patients. It’s nursing 101.” This comment emphasizes the critical role of nurses in confirming patients understand their discharge instructions.
The unit RNs expressed enthusiasm and endorsement for initiatives aimed at improving patient care. One nurse conveyed appreciation, commenting, “It makes sense because the patients we serve need more support.”
Next steps
Further research will help identify additional barriers to the consistent use of the teach-back approach and strategies for overcoming them. Integrating interpreter services and expanding access to patient education materials and after-visit summaries in multiple languages are crucial for serving diverse populations. Incorporating teach-back education into regular nursing practice can significantly enhance patient care and outcomes.
Pamela San Miguel is a PMHNP at Prairie Care in Woodbury, Minnesota. Abdulai S. Sefoi is a PMHNP at Hennepin Healthcare in Minneapolis, Minnesota. Sandra K. Paddock is a professor at Winona State University. Marilynn H. Spencer is an assistant professor at Winona State University.
American Nurse Journal. 2025; 20(11). Doi: 10.51256/ANJ112518
References
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Key words: teach-back method, emergency department discharge, psychiatric emergency room
