Parents' literacy screen helps reduce costs

Alerts when parents need extra education

A pilot program in which parents or caregivers of patients were screened for health literacy reduced healthcare costs and emergency department use for patients at Cook Children's Medical Center in Fort Worth, TX. Parents and caregivers who did not successfully screen received additional comprehensive education on caring for the children during the pilot program initiated in March 2008.

The program generated an average savings of $3,545 per patient when costs were measured against those incurred by select group of members in the Cook Children's Health Plan, according to Margie Dorman-O'Donnell, RN, MSN, director of case management.

"We believed that poor literacy among the parents played a role in lack of compliance to the treatment plan following discharge, but we didn't know how to address the problem," O'Donnell says. "Our answer came when Cook Children's created a new 10-bed unit for children who need short stay observation or extended treatment, such as for asthma."

Working with their three physician advisors, the case management team researched ways to screen for healthcare literacy and selected the Newest Vital Signs screening tool to determine the literacy of the parents. Parents of every child admitted to the short-stay unit are assessed for healthcare literacy.

"Good literacy skills are paramount if we expect parents to understand the discharge plan," Dorman-O'Donnell says. "Parents need to follow at home what they learned in the hospital. For instance, they need to be able to read and understand prescription labels and to know that their children need to take their medicine at a certain time and how many pills or milliliters of liquid they need to take."

Parent and caregiver education at Cook Children's incorporates the teach-back method, which asks the parents to repeat what they have been told and the "Ask Me 3" tool to further determine parents' understanding of their child's hospital stay and discharge instructions. "Ask Me 3" questions are: "Do you know why your child is in the hospital?" "What do you need to do when you get home?" and "Why do you need to do that?"

Everyone on the unit, including the nurses, the interpreters, the pharmacist, the respiratory therapist, and the RN case manager, is trained on "Ask Me 3" and teach back. The two tools are used to assess each family's level of understanding, but the amount of time they spend teaching each family varies significantly. Those who did not successfully screen for healthcare literacy are enrolled in a special case management program that includes more focused teaching and post-discharge follow-up to assess their understanding and compliance with discharge instructions. The education is repeated frequently throughout the stay and again at the time of discharge.

"We want to make sure that the parent understands the child's condition and how to take care of it," Dorman-O'Donnell adds.

The unit's RN case manager calls the parents who did not successfully complete the literacy screen 5-7 days after discharge to determine if they are following the discharge instructions. During the call, the case manager reinforces hospital teaching, checks on follow-up appointments with primary care physicians, and arranges transportation if the family needs it.

"Initially, we called them back one or two days after discharge, but we determined that it was too early to get an accurate assessment of compliance with the medication regimen," Dorman-O'Donnell says. "A lot of parents stopped giving the children their medication after they started feeling better. Since most prescriptions are for a seven-day supply, by waiting, we can determine if they have taken all or almost all of the medication."

Simplifying teaching materials is an ongoing process, she says. "Medication administration is one area of improvement in Cook Children's discharge teaching process," Dorman-O'Donnell adds.

Working with the hospital pharmacists, the short-stay unit team developed a color-coded tutorial to instruct parents on how to give their children their medication. The instructions have a colored dot for each medication that corresponds with the color on the prescription label. Instead of using "morning," "noon," or "evening" to designate when the medication should be taken, the hospital uses a rising sun for early day, a full sun for mid-day, and a moon for evening. When patients fill their medication somewhere other than the hospital pharmacy, the case manager calls the pharmacy and asks that the label be color-coded as well. In special cases, such as when parents are color blind, the pharmacist pastes one pill on the bottle and another on the instruction sheet.

When members of the unit team use "teach back" and "Ask Me 3," they are not evaluating how much information the parents know. They are evaluating how well they are teaching the information, Dorman-O'Donnell says.

"Parents want to do what is right and what is best for their child," she says. "Some of the parents learn by seeing, some by hearing, and some by doing. Our challenge is to figure out the best method for delivering information to our parents at their level of understanding."


The Newest Vital Signs tool, available in English and Spanish, is based on a nutritional label from an ice cream container. The parents (or in the case of adults, the patients) are given the label and asked six questions about the label. Their answers enable the healthcare professional to determine their ability to read, understand, and act on healthcare information. For more information, see: Select "Physicians & Other Providers," then select "Risk Assessments & Screening," and "The Newest Vital Sign."