Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients

Older age was independently associated with more needs related to medical devices (OR, 1.02; 95% CI, 1.00-1.04), functional status (OR, 1.03; 95% CI, 1.02-1.05), and fewer financial needs (OR, 0.93; 95% CI, 0.91-0.96). Being married or living with a partner was associated with fewer needs related to caregiver support (OR, 0.37; 95% CI, 0.19-0.75) and more device-related needs (OR, 1.60; 95% CI, 1.03-2.49). A higher level of education was associated with fewer transportation needs (OR, 0.89; 95% CI, 0.82-0.97).

A structured patient risk factor assessment derived from literature was used to record TCNs in preparation for hospital discharge. On average, patients had needs in about half of the TCN domains (4.6 of 9). The most common areas identified were related to the presence of high-risk comorbidities (98.4%), frequent or prior healthcare utilization (76.6%), medication management (76.3%), functional status (54.9%), and transportation (48.7%). Many of the TCNs were significantly correlated with one another. The prevalence of these needs highlights the importance of using a structured assessment to identify patient concerns so that they may be addressed through discharge planning and follow-up. In addition, using a standardized TCN instrument based on a framework for ITC promotes further research in understanding patient needs and in developing personalized interventions to address them.

As hypothesized, we found that TCNs were more common in patients with inadequate health literacy. After adjustment for demographic factors, inadequate health literacy was significantly associated with transportation barriers and inadequate caregiver support. Analyses also suggested a relationship with needs related to medical devices, functional status, and mental health comorbidities. A review of the literature substantiates a link between inadequate health literacy and these needs and also suggests solutions to address these barriers.

The association with inadequate caregiver support is concerning because there is often a high degree of reliance on caregivers at transitions in care.^3-5 Caregivers are routinely called upon to provide assistance with activities that may be difficult for patients with low health literacy, including medication adherence, provider communication, and self-care activities.^26,27 Our finding that patients with inadequate health literacy are more likely to have inadequate caregiver support indicates additional vulnerability. This may be because of the absence of a caregiver, or in many cases, the presence of a caregiver who is underprepared to assist with care. Prior research has shown that when caregivers are present, up to 33% have low health literacy, even when they are paid nonfamilial caregivers.^26,28 Other studies have noted the inadequacy of information and patient training for caregivers.^29,30 Transitional care programs to improve caregiver understanding have been developed³¹ and have been demonstrated to lower rehospitalization and ED visits.³²

Patients with inadequate health literacy were also more likely to have transportation barriers. Lack of transportation has been recorded as a factor in early hospital readmission in patients with chronic disease,³³ and it has been shown to have a negative effect on a variety of health outcomes.³⁴ A likely link between readmission and lack of transportation is poor follow-up care. Wheeler et al.³⁵ found that 59% of patients expected difficulty keeping postdischarge appointments because of transportation needs. Instead of expecting patients to navigate their own transportation, the Agency for Healthcare Research and Quality recommends identifying community resources for patients with low health literacy.³⁶

In this sample, inadequate health literacy also had near significant associations with TCNs in the use of medical devices, lower functional status, and mental health comorbidities. The use of a medical device, such as home oxygen, is a risk factor for readmission,³⁷ and early reports suggest that interventions, including education related to home oxygen use, can dramatically reduce these readmissions.³⁸ Lower functional capacity and faster functional decline are associated with inadequate health literacy,³⁹ which may have to do with the inability to appropriately utilize health resources.⁴⁰ If so, structured discharge planning could alleviate the known connection between functional impairment and hospital readmissions.⁴¹ A relationship between low health literacy and depression has been demonstrated repeatedly,⁴² with worsened symptoms in those with addiction.⁴³ As has been shown in other domains where health literacy is a factor, literacy-focused interventions provide greater benefits to these depressed patients.⁴⁴

The TCN assessment worked well overall, but certain domains proved less valuable and could be removed in the future. First, it was not useful to separately identify communication barriers, because doing so did not add to information beyond the measurement of health literacy. Second, high-risk comorbidities were ubiquitous within the sample and therefore unhelpful for group comparisons. In hindsight, this is unsurprising because the sample was comprised primarily of elderly patients admitted to medical services. Still, in a younger population or a surgical setting, identifying patients with high-risk medical comorbidities may be more useful.

We acknowledge several limitations of this study. First, the study was performed at a single center, and the TCN assessments were conducted by a small number of registered nurses who received training. Therefore, the results may not generalize to the profile of patient needs at other settings, and the instrument may perform differently when scaled across an organization. Second, the needs assessment was developed for this QI initiative and did not undergo formal validation, although it was developed from published frameworks and similar assessments. Third, for the measure of health literacy, we relied on data collected by nurses as part of their normal workflow. As is often the case with data collected during routine care, the scores are imperfect,⁴⁵ but they have proven to be a valuable and valid indicator of health literacy in our previous research.^18,24,25,46 Fourth, we chose to declare a domain as positive if any item in that domain was positive and to perform a domain-level analysis (for greater clarity). We did not take into account the variable number of items within each domain or attempt to grade their severity, as this would be a subjective exercise and impractical in the discharge planning process. Finally, we were unable to address associations among socioeconomic status,⁴⁷ primary language,⁴⁸ and health literacy, because relevant data were not available for this analysis.