By Elaine Christie, Author


To ensure optimal outcomes for patients from all backgrounds, review your materials and communications to ensure they include all literacy levels.

• For patients with low health literacy, it’s advised to keep communication materials on a third- to fifth-grade level.

• Studies have found that patients with higher education levels also can have poor or limited health literacy when faced with unfamiliar medical situations or terminology.

• The Agency for Healthcare Research and Quality recommends keeping all materials for all patients at or below the sixth-grade level.

How can RN case managers ensure that patients truly comprehend what they need to know?

A patient’s literacy level refers to the number of years of education required to understand oral and written materials. According to the National Institutes of Health (NIH), it’s best to aim for a level that is two to five grades lower than the highest average grade level of an intended audience. The NIH says this method accounts for a probable decline in reading skills over time.

For patients who have acknowledged low literacy, it’s best to keep discharge materials and other communication on a third- to fifth-grade level. (For more on health communication goals, visit:

Communication Failures and Heart Disease

Currently, only 12% of Americans have the health literacy skills to successfully navigate the healthcare system, according to a new report by the American Heart Association.1

Patients with limited health literacy may not understand that a "positive" stress test is not a good result, or may have difficulty sticking to a low-sodium diet if they do not understand nutrition labels.

Those are two scenarios analyzed in the AHA report, which suggests that limited healthy literacy is a major barrier to achieving good cardiovascular health or benefiting from effective treatment for heart attacks, heart failure, strokes, and other cardiovascular diseases.

“Many patients do not understand the written materials they receive as part of healthcare, or do not have the numeric skills to understand quantitative information. Also, medical care uses a considerable amount of specialized terminology, which some call jargon,” said Jared W. Magnani, MD, MSc, co-author of the AHA report and associate professor of medicine at the University of Pittsburgh School of Medicine.

Diabetic patients with low health literacy are more likely to develop disease complications such as diabetic retinopathy, according to the report. They also are 1.7 times less likely to use an online patient portal — a fast-growing technology for patient communication and disease management.

The authors emphasized that even patients with higher education may have poor or limited health literacy if they are not familiar with health terminology and face situations beyond their normal experience.

SMOG: Simple Measure of Gobbledygook

It's important to communicate clearly and keep discharge planning as simple as possible to increase comprehension.

But how can case managers communicate effectively if even highly educated patients face health literacy stumbling blocks?

One idea is to assess the “readability” level of patient materials with a commonly used formula called SMOG (Simple Measure of Gobbledygook). This readability formula was developed more than 40 years ago and is appropriate for fourth- grade to college-level readers.2

The SMOG formula calculates a patient’s reading level using the following four steps:

1. Count off 30 sentences — 10 near the beginning, 10 near the middle, and 10 near the end of the text.

2. From this sample, circle all words containing three or more syllables (polysyllabic), including repetitions of the same word, and total the number of words circled.

3. Estimate the square root of the total number of polysyllabic words counted (find the nearest perfect square and take its square root).

4. Add a constant of three to the square root. The resulting number is the SMOG grade, or the reading grade level, that a person needs to fully understand the text being assessed.

An Eye Toward Optimal Outcomes

The Agency for Healthcare Research and Quality’s Health Literacy Universal Precautions Toolkit recommends implementation of “health literacy universal precautions by making systematic, practicewide changes to simplify communication and reduce the complexity of healthcare for all patients.”3

For example, the "Design Easy-to-Read Material" tool offers several recommendations for evaluating and creating appropriate patient materials, such as avoiding jargon, integrating pictures as teaching tools, and encouraging patient feedback.

When it comes to patient feedback, be alert for red flags or responses to receiving written information.

Potential red flags could include patients who say “I forgot my glasses,” or "I'll have someone read this to me at home.”

Likewise, if a patient has trouble completing forms or makes frequent errors, it may indicate limited health literacy.

To obtain the best health outcomes, it’s critical that team members create understandable forms and informed consents, and always take into account that patients come from a wide variety of literacy backgrounds.

The toolkit also gives the following advice:

• avoid jargon;

• integrate pictures as teaching tools;

• create understandable forms, informed consents, and brochures;

• improve patient follow-up and phone access;

• ask patients to bring in all of their medications so that the healthcare provider can assess medication adherence and safety;

• consider the patient’s culture, customs, and beliefs in their care.


1. American Heart Association. Limited health literacy is a major barrier to heart disease prevention and treatment. ScienceDaily, 4 June 2018. Available at:

2. Pruthi A, Nielsen ME, Raynor MC, Woods ME, Wallen EM, Smith AB. Readability of American Online Patient Education Materials in Urologic Oncology: a Need for Simple Communication. Urology. 2015;85(2):351-356. doi:10.1016/j.urology.2014.10.035.

3. Agency for Healthcare Research and Quality. Health Literacy Universal Precautions Toolkit, 2nd Edition. Available at: