SDB education programs create smarter and more treatment-compliant patients, and starting one may be easier than you think.

At nearly every lecture I present across the country, I find that colleague interest in patient education is on the rise. Common sense as well as scientific research results remind us of the benefits of patient education. However, finding simple strategies for providing this education without physically and financially overburdening already inundated sleep-disorders practices may seem daunting. In demanding practices, staffs often lack the time and training to develop an effective patient education program that uses tools such as verbal directives, written materials, and personal counseling, as well as audio, video, and Internet resources.

Patient education for sleep disordered breathing (SDB) patients has been shown to improve treatment adherence, outcomes, and satisfaction. If you have decided that it is time to institute such a program in your practice, this article will serve as a primer and give you an overview of simple strategies for effective patient teaching. Planning and implementing patient- and public-education programs need not be overwhelming. As with most things, with practice comes ease, thus setting the stage for success while employing efficiency and time management. Eventually, through practice, your staff will naturally get quicker at effective patient teaching and will perform this work within the targeted time frames determined by your teaching team.

The time is Ripe
Increased media coverage of sleep has made the public more aware of sleep disorders. However, according to some estimates, 50 to 70 million Americans may still suffer chronically from a disorder of sleep and wakefulness. In addition, as many as 40 million Americans may have SDB, but only an estimated 10% of them have been diagnosed. As the average body mass index continues to ascend and the population ages, the need to treat SDB will only increase.

Although public awareness of sleep disorders may not be at an optimal level just yet, remarkable efforts by the sleep community in the last decade have done much to create noise. On April 4 of this year, the Institute of Medicine (IOM) of the National Academies’ Committee on Sleep Medicine and Research issued a landmark report titled “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.” It recognizes that a coordinated strategy is required to ensure continued scientific and clinical advances in sleep medicine and makes increasing awareness of the burden of sleep loss and sleep disorders among the general public a top goal.

The IOM also recognizes the need for disease-management strategies that would include patient-education components. If I asked you who should be involved in SDB, I am sure you will agree that the answer is all of us. Anyone that “touches” the SDB patient should be involved. Including your entire sleep center clinical and support staff, representatives from your referral chain, and your durable medical equipment (DME) providers in patient education only reinforces and strengthens the use of a consistent message from which patients will benefit.

Research has shown that medical information is too difficult for many people to understand. A study from the Journal of Hypertension found that patients quickly forget about 40% of what caregivers tell them once.1 However, information is easier to remember if it is heard more than once.

If the key to making a message stick is repetition, patient education should be delivered before, during, and after a sleep study. A good patient-education program will help patients participate in their own health care, but the effort does require spending time with patients. It is a good idea for caregivers to learn to not waste a minute when they are with patients and to teach whenever the opportunity arises.

The Patient-Education Team
All it takes to begin patient education is one person from a team with some desire to start the ball rolling. You do not have to be the one to ultimately lead the effort, or do it all alone, but someone has to get the idea on the table. Personally, I am thrilled to see technicians—the foot soldiers at the front line of sleep patient care—be empowered to serve in this role.

One of the best ways to get organized and see the “big picture” is by utilizing a technique called “SWOT” (strengths, weaknesses, opportunities, and threats) Analysis. SWOT, which is used primarily by strategic planning specialists, is a process for identifying the limitations of your facility and examining the opportunities you face. Some research into the subject and the simple components of a SWOT Analysis may save you and your team some additional or unnecessary steps as you move forward with a patient- and public-education sleep program.

Utilization of SWOT Analysis can be as simple as creating a diagram similar to the template example in Figure 1 and listing the items appropriate to your facility’s situation. In addition, a detailed, step-by-step lesson on SWOT Analysis may be accessed at no charge at: www.marketingteacher.com/Lessons/lesson_swot.htm.

For an initial brainstorming meeting, poll the core group—your entire sleep staff (physicians, clinicians, nurses, technicians, practice managers, administrative assistants, scheduling secretaries, and public relations department representatives)—for a convenient off-hours time to get together. Present your overall idea about a patient-education program with one of your goals being to achieve core-group consensus that the team include outside members, such as DME providers and referring-practice representatives.

Once these strategic partnerships have been created, invite all internal and external stakeholders to another meeting to outline the steps of your program. It is critical that, at the beginning of this meeting, an education budget that includes marketing components be created.

Outline a series of steps that can be used to improve patient education:

Step 1) Develop a comprehensive plan. Everyone in the office should be involved. Front-office staff should be taught to be alert to patient requests for information and, when a request is made, to inform other staff members who can provide counseling and educational materials.

Step 2) Appoint a coordinator. This person—whether a sleep technologist physician, physician assistant, other PhD, or nurse—will obtain educational materials, train staff, and hold meetings.

Step 3) Establish planning and implementation committees.

Step 4) Create a meeting schedule. Monthly meetings may be necessary initially, but it should be possible to decrease the frequency of the meetings as everyone becomes familiar with the program.

Step 5) Make patient-education materials readily available. Staff should have access to a main storage area where these materials are kept. Posters and other written materials should be placed in all waiting areas, examination rooms, and restrooms. Post signs urging patients to ask for help or materials if they have questions.

Step 6) Train the trainers. Teaching the staff how to teach is paramount in the success of your patient-education program. Once your team has decided on what material(s) will be presented to patients, schedule staff seminars and make sure the seminars are at convenient times to boost attendance. For example, try “lunch and learn” sessions for your staff and invite in all others involved with your patients, such as home care providers your patients use.

Whether your program is all-inclusive (for instance, with a full-fledged CPAP desensitization program and classes for compliance), or a scaled-down version where staff deliver simple education material, your available dollars for this venture will set the path. When setting a budget, patient education need not be costly—as little as $1,000 per year is enough in many practices—but money must be set aside specifically for this purpose. One consideration that is friendly to all budgets is the fact that excellent free or low-cost resource materials are available from a number of sources, so operating a program on a shoestring budget is very possible.

It is also a good idea to include patients in the planning. Every sleep laboratory has at least one model patient that could boost your education program by contributing input to your team from a patient’s perspective. Maybe this person is the leader of your patient support group, if you already have one, or a patient that has overcome difficult obstacles with the treatment regimen. It is a good idea for the staff to collectively identify this patient (or patients).

Creating Scripts for the Team
If your facility is already affiliated with a DME provider, patient-education methods and the verbiage used to teach patients are probably already synchronized. If these discussions have not taken place, begin with a get-together to determine what is being done presently and then decide as a team what each person’s new role will be and how patients will be taught going forward. It is good practice for your team to create scripts for all those who will be talking to patients diagnosed in your sleep laboratory. Scripts need not be memorized, per se, but the overall messages and vocabulary used should be consistent.

Support-group meetings are a good backup to patient education, but that should not be relied upon solely for education and support delivery. It is important to catch problems with CPAP in the first weeks of the treatment regimen, and some months can pass before another patient-support-group meeting occurs. Patients in the first stages of treatment sometimes cannot afford to wait that long.

We are all aware of the fact that each patient is unique. Patients with all manner of health literacy levels come to your laboratory, and great care should be taken to introduce material to them that fits their individual learning styles. Your program should employ various stages of appropriate methods for teaching every literacy level. An excellent resource to learn more about the health literacy dilemma our nation faces and tools to assist your program can be found through the IOM’s 2004 report, “Health Literacy: A Prescription to End Confusion,” at www.iom.edu/?id=19750.

Program-Component Outline
Education classes provide patients with information, skills, and coping mechanisms to better care for themselves and make informed decisions.2 Family members or caregivers should be welcome to attend. Your team might consider the following class or module topics for components of your educational program:

• Structure of the upper airway while awake and asleep. It is imperative that patients understand basic physiology principles of the airway while they are awake versus while they are asleep. Explaining this alone is sometimes too confusing, and even visual-learner patients are sometimes intimidated by intricate diagrams. However, if there is access to the Internet in your facility, there are simple teaching tools available. The American Academy of Sleep Medicine (AASM) provides “Sleep Education.com,” a comprehensive patient-education Web site. In the section of the site titled “CPAP Central,” there is a link called “Tools for Success” that, in turn, leads to a link called “About Sleep Apnea.” where an excellent, patient-friendly diagram is posted. By clicking through the diagram menu, patients can see various views of the airway in situations including normal breathing, open airway, snoring, sleep apnea, and using CPAP.

• Classes for patients’ families or support systems. Family members should be taught that it is important not to make fun of the “look” of their loved one wearing a CPAP system. Sometimes they do not realize that these actions could make the patient feel so ashamed that he or she stops using the treatment.

• The “What You Can Do About Treatment Side Effects” class. This class can teach patients and family members how to manage side effects, such as nasal dryness and congestion or mask irritation.

• Equipment care. No patient should ever leave the laboratory without equipment care instructions, even if they hear this content again from DME representatives. Patients must be taught that bacteria forms in humidifiers that are not cleaned. Also, because natural oils on the face cause a breakdown of CPAP mask materials, cleaning of masks and mask-replacement schedules should be covered

• CPAP and anxiety/claustrophobia complaints. Make extra sure that someone discusses mask options with these patients. Exposure—introducing clients to controlled amounts of the thing they fear—is the treatment of choice for anxiety-based responses, such as claustrophobia.3 In addition, other methods for dealing with anxiety problems in patient therapy might be available in the future. For example, psychiatrists are exploring visual and tactile virtual-reality procedures to treat a number of phobias.4

• SDB exacerbation by alcohol intake. Teach a simple explanation of the increase in muscle relaxation that occurs when alcohol is consumed, and how this can worsen SDB.

• Supplemental videos explaining SDB. These can be helpful, but remember, even the best-produced videos will not be effective educational tools if your patients do not have the opportunity to discuss the content with you and ask questions afterward.

• Discover the Internet. Offer a class or module designed to help patients locate the plethora of learning materials available on the Web. Classes could be held by appointment, or, if this is not possible, you could distribute simple printed guides containing Internet addresses for basic learning sites. If some patients do not own computers, encourage visits to the public library where staff may assist them in Internet exploration. Remind them to take along any resource sheets that include Internet addresses you may have provided.

• Nontreatment risks overview. A positive approach to patient education has proven to help patients understand the scope of their problems,5 but they also need to know the risks and consequences that result from nontreatment and nonadherence to SDB treatment, including drowsy driving, hypertension, and diabetes.

Referrals
Once your team has honed in on what the program includes—and after it has been determined that your efforts are successful—it would behoove the team to involve referral physician practices. Start with your medical director making initial phone calls to your referring physicians to let them know that you have formed a team to provide augmented patient education, and that your program has been very successful. Your medical director should ask the referring physician if he or she is interested in having a member of your team present an overview of the program. By showing the referring practice staff your program and providing them with simple screening tools6 and associated patient-education materials, your referral sources will not only feel confident about sending their sleep patients to your facility, but will also feel a sense of ownership in being the first step in a consistent, coordinated patient-education program.

Engaging Payors
Now that you have planned out your program, be sure that your marketing or public relations department representatives help ensure that the fruits of your labors have far-reaching successful publicity. Be sure to engage your institution’s business development department. It might be a good time to set yourself apart in the eyes of your contracted payors, or potential contracted payors. Let them know what a great job you are doing in serving patients by assisting in decreasing the risks for untreated sleep-related breathing disorders. Your augmented patient-education program will go a long way in convincing payors that you have improved quality of care, improved patient satisfaction, increased compliance, improved staff satisfaction, and ensured more effective use of health care resources.

Theresa Shumard is a polysomnographic technician; the editor for A2Zzz magazine, a membership publication of the Association of Polysomnographic Technologists (APT); a member of the APT Board of Directors; North American Manager of Sleep Strategic Planning for DeVilbiss, Sunrise Medical Inc; and an international lecturer on sleep-related topics. She is a member of the Sleep Review editorial advisory board.

References
1. Ley P. Doctor-patient communication: some quantitative estimates of the role of cognitive factors in non-compliance. J Hypertension. 1985;3:51-5.

2. Walker LM. Patient education: do it right, and everyone wins. Med Econ. 1992;69:155-158, 160-163.

3. McCrae CS, Ingmundson PT. Using graduated in vivo exposure to treat a claustrophobic response to nasal continuous positive airway pressure. Clinical Case Studies. 2006;5:71-82.

4. Rothbaum BO, Davis M. Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy. 2006;37(1):80-90.

5. Gold DT, McClung B. Approaches to patient education: emphasizing the long-term value of compliance and persistence. Am J Med. 2006;119(4 suppl 1): S32-S37.

6. Ashtyani H, Hutter D. Collateral damage: the effects of obstructive sleep apnea on bed partners. Chest. 2003;124:780-781.