Low Health Literacy and Transitional Care Needs: Beyond Screening

Health literacy (HL) is the ability of individuals to obtain, process, and understand health information in a way that enables them to make health decisions.¹ Approximately one-third of adults in the United States are considered to have inadequate HL,² and its prevalence is even higher among hospitalized patients.³ Low HL has been associated with higher rates of hospital readmission⁴ and higher mortality.^5,6 Inadequate HL has been identified as a barrier to communication and is associated with poorer outcomes for communication-sensitive behaviors, such as adherence to medications, chronic disease self-efficacy and self-management,^7-10 and understanding hospital discharge instructions.^11,12 It has been largely understood that the association between HL and hospital outcomes has been mediated by these communication challenges.

In this issue of the journal, Boyle et al.¹³ demonstrate that inadequate HL is not only a communication barrier but also an indicator of other social support needs during a transition from the hospital. In particular, the authors found that hospitalized patients with inadequate HL had needs in more social support domains than those with adequate HL. After multivariable adjustment for sociodemographic factors that likely impact social support, such as age and marital status, inadequate HL remained associated specifically with insufficient caregiver support and transportation barriers. These findings suggest that, along with the more direct comprehension barriers previously associated with inadequate HL, the identified social support needs may mediate prior established associations between inadequate HL and poor health outcomes.

The authors concluded that screening for HL along with transitional care needs will allow hospitals to ensure a quality care transition. Indeed, screening for these gaps is the first step in identifying important postdischarge social needs and will be necessary in order to track improvements for at-risk populations. However, screening alone will not likely change outcomes; for this, we will need effective interventions.

In fact, it remains an open question how best to intervene to improve care transitions for patients with social needs and low HL. The recent focus of HL interventions in the literature has been on “universal precautions,” such as the teach-back technique, to ensure patient comprehension of information, and writing patient informational materials at a low literacy level.¹⁴This approach to make all materials and communication accessible to all patients, rather than to tailor HL interventions, has become more prevalent in efforts to address the adverse communication and resultant health impacts of inadequate HL.^15-17

Meanwhile, the focus of care transition interventions has been on transition coaching or case management in the hospital, medication reconciliation prior to discharge, and postdischarge telephone calls from pharmacists or nurses, often utilizing the HL “universal precautions.”^18-20 While these approaches have been impactful to improve discharge preparedness and decrease readmission rates,²¹ they may not adequately address individual social support and social service needs when the patient leaves the hospital.

Recently, the National Academy of Medicine published the Accountable Health Community Screening Tool, designed to screen for the following 5 areas of unmet social need that are known to be impactful for health: housing stability, food insecurity, transportation needs, utility needs, and interpersonal violence.²² This screener is being used as part of the Center for Medicare & Medicaid Services’ Accountable Health Communities Model and is being tested by the Center for Medicare and Medicaid Innovation (CMMI). The goal of the CMMI evaluation is to test whether systematically identifying social service needs and closing the gap between clinical care and community services for patients with the highest levels of need will improve health outcomes.

Screening for HL and social determinants in the hospital will not, in and of itself, improve the quality of care transitions or prevent subsequent readmissions, morbidity, or mortality. However, measurement is the first step toward identifying individuals with the greatest need and can help direct hospitals’ utilization of limited resources, such as transition managers. The CMMI Accountable Health Communities Model evaluation will provide hospital and healthcare systems with best practices for building clinical–social services networks and connecting at-risk patients with high levels of need to appropriate services in the community.

No longer can a patient’s hospital care end with writing prescriptions and scheduling follow-up appointments. For some, using teach-back and low literacy-appropriate discharge materials will be enough; others will require a postdischarge telephone call to review medications and symptoms and ensure follow-up. But for those highest-risk patients, connection to a network of ongoing community social support will be necessary to guide their transition back to health in the community.