Make sure your patients understand discharge plan

Low health literacy contributes to readmissions

As a case manager, you're likely to be one of the last people to see patients before they leave the hospital. This gives you the opportunity to make sure they understand their treatment regimen, their follow-up appointment, how to take their medicine, and other components of the discharge plan that can help them recuperate rapidly and avoid readmissions or emergency department visits.

Low health literacy, or lack of understanding of the treatment regimen, costs the health care system an estimated $58 billion a year, according to the Institute of Medicine in its 2004 report Health Literacy: A Prescription to End Confusion.

Low health literacy is associated with more hospitalization and emergency department use, increased adverse drug reactions, and a decrease in the use of preventive services, according to the report.

Health literacy is the degree to which individuals are able to obtain, process, and understand basic health information and services needed to make appropriate health decisions, according to the U.S. Department of Health and Human Services.

The National Assessment of Adult Literacy by the U.S. Department of Education, conducted on more than 19,000 adults, showed that about one in 20 adults in the U.S. could not answer simple test questions or could not take the test because of language barriers.

Even among college graduates, 3% demonstrated "below basic literacy," meaning that they couldn't perform skills such as locating easily identifiable information in a short paragraph or reading a prescription label.

But even people who are highly literate can have low health literacy and not understand complex medical terms, points out Gloria Mayer, RN, EdD, president and chief executive officer of the Institute for Healthcare Advancement (IHA) based in La Habra, CA.

"Health literacy is a huge problem. Many times case managers may feel like their patients aren't compliant, but it's a health literacy problem. They simply don't understand what they are supposed to do," Mayer adds.

"An increasingly important trend is to give patients more ownership of their own health care outcomes and to make them understand that they are responsible, in part, for how things go for them medically. This puts a higher burden on us to provide education in clear English that they are capable of understanding," says John Rogers, MD, chairman of the department of medicine for Good Samaritan Hospital in Baltimore.

Put yourself in your patient's place and remember what it's like when you deal with someone in another profession, such as a computer technician or an automobile mechanic who uses terms you don't understand.

Age, disability, language, culture, or the sheer stress of being in the hospital can block a patient's understanding of health information, says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, a Natick, MA, firm.

Don't make an assumption of literacy, no matter how bright the patient seems to be, Rogers advises.

While it may seem that the immigrant population or people with low-level jobs would be the ones affected by low health literacy, middle class people with good jobs may have trouble understanding, Mayer points out.

Rogers tells of a patient with diabetes he followed for a year. She seemed to understand her instructions on how to give herself insulin shots and fill out a flow sheet showing blood sugar levels. "I found out she was filling out the flow sheet into the future, recording her blood sugar levels for a week or two ahead of time, trying to please me. She didn't understand why she was doing it," he said.

Patients' lack of understanding of their condition and the health care system often starts at admission, when the patient is the primary source of his or her medical history.

"We've looked at medication history as provided by different people and have found a big variation," Rogers says.

For instance, a patient comes into the emergency department and tells the admissions person what medications he or she is taking. Later, the spouse comes in and brings a bag with the medication. The two versions are likely to be different and may not include herbal medicine or over-the-counter drugs.

"Every hospital and health care system should be trying to educate people to get into the habit of bringing medication lists or the actual medications with them," Rogers says.

Discharge instructions are particularly crucial to patients' well-being after they leave the hospital, and it's an area where case managers have the potential for the biggest impact.

"With the current time crunch in health care, the decision to discharge a patient is made; and an hour later, we're in the middle of the discharge process. We need to think ahead and make sure the discharge instructions are clear and have the patient or a responsible caregiver demonstrate that they understand them," Rogers says.

Osborne points out that while most hospital literature is written for people at the seventh- to 12th-grade reading level, millions of adults in the United States can't read above the fifth-grade level.

Even the signs in the hospital pose difficulties for some patients, Mayer adds. "A patient may know he's going to see Dr. Smith but he can't read 'radiology' or 'neurology,'" she says.

Make sure your patient education material is simple and easy to understand, with a lot of illustrations. Examine all written materials you give to patients. Mayer points out that materials produced by drug companies may be too complicated for the average patient to understand but so may hospital discharge instructions.

For instance, directions for medication may say, "take with food" rather than "take with water and food."

Patients who take direction literally, particularly the elderly, may believe it means the medication should be folded into food, Mayer points out.

Test materials on intended readers first

When you develop written materials, test them on the intended readers as you go along. Test your initial draft of the materials, then make revisions and test it again.

"No writer, no matter how clever he or she is, can be sure the reader will understand," Osborne points out.

Use formal focus groups to test your materials or just ask people sitting in the waiting room to look them over and answer questions.

"In our book, we use 'pee' instead of 'urine.' We had five focus groups look at the material and they all recommended using 'pee' because everybody understands what that is," Mayer says.

If your word processing software has a spell-checking function, look for words that are highlighted because they're not in the software's dictionary and eliminate those.

Case managers should work with other professionals within the hospital as well as outpatient providers to make sure that everyone who works with patients uses the same wording and language, Osborne suggests.

For instance, it may confuse patients if one person says his or her condition is "hypertension" and another calls it "high blood pressure."

Use pictures and a model to show your patients what they need to do after discharge. Make sure they understand, and if not explain it in other ways until they do.

Use large type for your older patients and adjust the content to meet their learning needs, Osborne suggests.

Never ask patients, "Do you understand?" It's too easy for them to say yes when they do not understand.

One way to make sure you're getting through when you give oral instructions is to use the "teach-back" method, asking your patient to explain each key point, "to make sure I explained it correctly," Osborne advises.

Preface your questions by putting the burden on yourself, rather than suggesting that the patient may not understand, she adds.

For instance, ask the patients how they would explain their medication regimen to someone else or to show you the suggested exercises.

If you find that the person doesn't understand completely or correctly, go over it again until he or she understands.

Take a patient's age into consideration and do your education of elderly patients in short sessions, repeating the information, and confirming their understanding along the way, Osborne suggests.

"As people go through the life cycle, their way of learning changes; their hearing and eyesight may not be as good; their tactile senses may not be as good; and they tend to learn in shorter bursts," Osborne explains.

Suggest that your older patients bring along someone else when you do patient teaching.

"Older people have a harder time reading and comprehending, as well as poorer eyesight," Mayer says.

Keep in mind that while you talk about the same types of information all day long as a professional, the patient you're talking to is hearing it for the first time.

"Clinicians shouldn't use medical jargon. In a study by Dean Schillinger, MD, assistant professor of medicine at the University of California, San Francisco, a doctor explained dialysis to a patient, but when he was asked to repeat what he learned, he said he just knew he had to do something daily," Mayer says.

"Health professionals tend to have their own jargon, their own way of talking in shorthand to each other. It's an efficient way to communicate with other clinicians but it's not effective when they talk to patients," Osborne says.

"For instance, PET scan is an easy way to say 'positive emission tomography' and is understood by people in the medical profession, but someone in your emergency department who's been hit by a car might think of a furry little animal when they hear the term. Drawing blood has nothing to do with crayons, but the medical profession uses it in a certain way and assumes people will understand" Osborne says.