Closing the loop, also known as teach back, is a health coaching intervention that should be used with all patients. Research has suggested that patients remember and understand as little as 50 percent of what the provider says.  Regardless of a patient's health literacy level, it is important that staff ensures that patients understand the information they have been given.

What is closing the loop? 

This method involves asking patients to retell, in their own words, the information you provided regarding what they need to know or do about their health. It is a way to confirm that you have explained things in a way your patients understand. The approach is to use the Ask-Tell-Ask health coaching technique, which was the topic of the previous Health Coach newsletter, to check—re-explain—and check again the patient’s understanding of the information you provided. Using open-ended questions rather than yes/no is key to confirming the patient’s understanding of his/her care plan (see example below).

Additionally, once you are certain the patient correctly understands the information provided, it is important to assess whether the patient agrees with the information and is confident in doing the new behavior. The care team needs to be know if the patient has barriers to following through with the care plan. Asking the patient on a scale of 1-10 how confident he/she is in doing the new behavior is a way to identify potential barriers. The rule of thumb is that a confidence level less than seven is indicative of barriers that need to be explored.

Although primary care clinic staff has limited time for additional work, health coach experts highly recommend a follow-up call to patients to check how things are going with the new behavior. The call is an opportunity to address patient concerns that may prevent them from following the plan, adjust medications, and schedule clinic follow-up visits, if needed.     

Closing the loop should be done in a way that patients don’t feel they are being tested or quizzed on the information provided. 

The following phrases are suggestions for beginning the conversation of closing the loop:

• “Just to make sure we are on the same page, can you tell me …”
• “I want to make certain I was clear, can you tell me …”
• “So I know that I made sense, can you tell me …”

Overall, closing the loop will help:

• Improve patient understanding and adherence, especially with medications  
• Decrease call backs and cancelled appointments
• Improve patient satisfaction and outcomes

An example of closing the loop:

• Coach: Mrs. Jones, you have been making progress to improve your diet and exercise and your HbA1c has come down from 10 to 8.5. We would like your HbA1c to be 7 or below. Dr. Smith thinks adding a new medication should bring your HbA1c down to where we’d like it. What do you think?
• Mrs. Jones: I’m willing to try the new medication.
• Coach: Great. Did Dr. Smith explain how to take the new medication, Metformin?
• Mrs. Jones: Yes.
• Coach: Just to make sure we are on the same page, can you tell me how you will take the Metformin? (open-ended question)
• Mrs. Jones: Starting tonight, I’m going to take it twice a day.
• Coach: And when will you take it?
• Mrs. Jones: After breakfast and dinner.
• Coach: Yes, that’s correct. What will you do if you have problems with your stomach or bowels? (open-ended question)
• Mrs. Jones: Oh, I almost forgot. I’ll take only 1 a day for a week. After breakfast?
• Coach: Yes. Then go back to 2 a day, 1 after breakfast and 1 after dinner, and see how things go. Can I call you in a week to see how you are doing?
• Mrs. Jones: Please do. 

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The Hennepin County health coach trainers offer a one-hour refresher session to review highlights of the training curriculum and talk about how you and your clinic are using health coaching techniques with your patients.  With a small group of clinic staff, the refresher session is an opportunity to share your successes and challenges and brainstorm solutions to any challenges. 

The refresher session can also be an introduction to health coaching.  Schedule a refresher for your clinic to learn about the training curriculum and decide if the full-day training session is something that would be valuable for your patients. Some of the clinic staff or the entire care team can learn how to better engage patients in self managing their health concerns. 

The following is the health coach refresher agenda. The agenda can be tailored to meet your needs:

Introductions

Review health coach principles

• Ask-Tell-Ask (open-ended questions, the four questions)
• Closing the Loop
• Setting the agenda
• Action planning—patient centered action plans

Scenario practice

How and when to document goals

Successes and challenges

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