Caring for patients with cognitive accessibility needs (Case study)

Andy is a 33 year old man with Down syndrome who is being discharged from the hospital after being treated for a broken leg.

He is with his parent, Elena, who will be taking him home and helping with his care during recovery. His nurse, Cherise is preparing to review discharge instructions with Andy.

Before she enters Andy's room, she keeps in mind that some patients find discharge instructions overwhelming because the instructions contain input from multiple members of the healthcare team.

In Andy's case, the hospitalist, physical therapist, orthopedic physician assistant, pharmacist, and nurse were all involved in Andy's care.

To ensure Andy understands the instructions, physical therapy exercises, and follow-up appointments before he's discharged home, Cherise uses methods to increase cognitive accessibility by providing information in ways that make it easier for him to process, including use of plain language, slower pacing, repetition, and visual supports.

Now, Down syndrome is a genetic condition that can affect learning, memory, and processing of new information. For some patients, working memory may be reduced, so when too much information is presented at once or too quickly, it can be harder to understand and remember.

This can lead to cognitive overload, which can make Andy feel overwhelmed, confused and anxious, and make it harder for him to retain discharge information.

Cognitive overload can create problems after discharge. If Andy can't take his medications as prescribed, remember signs and symptoms of infection to watch out for, how and when to do his physical therapy exercises, or the date and time of his follow-up appointments, he's at risk of complications.

For patients like Andy, making accommodations when presenting information is critical for his safety, recovery, and overall well-being.

Nurse Cherise sits at Andy's bedside and begins his discharge teaching. She begins by explaining the discharge process by reading the first paragraph of the discharge instructions slowly and in plain language.

As she's talking, she notices that Andy starts to look out the window. When she asks him if he understands, he appears confused and doesn't really answer the question.

Cherise knows it's time to change her approach. She asks some questions to determine how to best support Andy.

Would it help if I explained this step by step? Yes, I think so.

No problem. Would you also like if I wrote this in a different way for you?

Yes, please. I'll be right back.

Let me grab a couple of things. Cherise then turns to Elena.

Will you be helping Andy at home with his medicines, appointments, and getting around? Yes, he'll be staying with me while his leg heals, and I'll help him keep track of everything.

Great. I'll review the instructions with both of you and I'll still check in with Andy as we go.

Cherise returns to the room with new written discharge instructions. Andy's follow-up appointments are at the top of the page, and the remaining instructions are listed in a bullet point format in plain jargon-free language.

Sam, the pharmacist, provided a list of each medication, listing them by name and dosage, along with pictures of each medication and instructions on when and how to take them.

Cherise points to the pain medication section. This line is your pain medication.

It can sometimes make you sleepy. You can take one pill, which is 5 mg every 4 to 6 hours as needed for your pain.

Your last dose was at 1:00 p.m. What time would you be able to take your pain medication again?

Since I took it at 1:00 p.m., it would be OK if I took it at 5:00 p.m. or later.

That's right. Do you have any other questions about your pain medication?

No, I have to wait at least 4 hours between taking it and it might make me sleepy. Exactly.

Elena, can you tell me what you'll watch for when Andy takes this medication at home? I'll make sure he waits at least 4 hours between doses, takes only the amount prescribed, and I'll watch to see if it makes him too sleepy.

Perfect. Cherise nods and continues through the discharge instructions.

She makes sure she keeps a moderate pace, speaks clearly, and pauses to ask Andy to repeat back the information. She also checks that Elena understands the plan for medicines, mobility, follow-up appointments, and when to get help.

After finishing this part of the discharge instructions, Jeff, the physical therapist, enters the room to review Andy's mobility and home exercise plan.

He tells Andy there are videos he can watch on his device through the hospital's website. He assists Andy with scanning the QR code on his device, shows him how to access the videos, and reassures him they can go over them together during his first physical therapy visit.

These videos are a great learning resource for patients like Andy because they were created in accordance with the Americans with Disabilities Act or ADA, Title II Digital Accessibility rule, and the European Accessibility Act or EAA which require accessible communication.

So digital technologies like websites, mobile apps, and routinely used platforms are accessible to individuals with all abilities.

The guidelines also include requirements for addressing cognitive accessibility in accordance with the Web Content Accessibility guidelines or WCAG standards that require design features such as clear language, easy to read fonts, and simple navigation.

When providing care to patients like Andy, using strategies to increase cognitive accessibility can improve patient outcomes by supporting their ability to adhere to treatment regimens, maintain their health and safety, and promote their overall well-being.

Including the patient support person in discharge teaching can also improve safety and follow-through at home. All right, as a quick recap, while providing discharge instructions for Andy, Cherise addressed Andy's needs by supporting cognitive accessibility.

Because of the way Andy processes new information and his decreased capacity of working memory, Cherise took steps to prevent cognitive overload and confusion.

To improve retention of information, she used methods like plain, jargon-free language, slower pacing, repetition, and visual support.

She also included Andy's parent in the teaching because Andy was being discharged home with her support during recovery.

These strategies improved accessibility, supported Andy's ability to adhere to his prescribed treatments, and promoted positive health outcomes.