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Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients
A special concern since the institution of hospital readmission penalties1 is the transitions in care of a patient from one care setting to another, often at hospital discharge. Burke et al.2 proposed a framework for an ideal transition in care (ITC) to study and improve transitions from the hospital to home. The features in the ITC were identified based upon their inclusion in the interventions that improved discharge outcomes.3-5 Inspired by the ITC and other patient risk tools,6 we identified 10 domains of transitional care needs ([TCN] specified below), which we define as patient-centered risk factors that should be addressed to foster a safe and effective transition in care.7
One particularly important risk factor in patient self-management at transition points is health literacy, a patient’s ability to obtain, understand, and use basic health information and services. Low health literacy affects approximately 26% to 36% of adults in the United States.8,9 Health literacy is associated with many factors that may affect successful navigation of care transitions, including doctor-patient communication,10,11 understanding of the medication regimen,12 and self-management.13-15 Research has also demonstrated an association between low health literacy and poor outcomes after hospital discharge, including medication errors,16 30-day hospital readmission,17 and mortality.18 Transitional care initiatives have begun to incorporate health literacy into patient risk assessments6 and provide specific attention to low health literacy in interventions to reduce adverse drug events and readmission.4,19 Training programs for medical students and nurses advise teaching skills in health literacy as part of fostering effective transitions in care.20,21
Although low health literacy is generally recognized as a barrier to patient education and self-management, little is known about whether patients with low health literacy are more likely to have other risk factors that could further increase their risk for poor transitions in care. A better understanding of associated risks would inform and improve patient care. We hypothesized that TCNs are more common among patients with low health literacy, as compared with those with adequate health literacy. We also aimed to describe the relationship between low health literacy and specific TCNs in order to guide clinical care and future interventions.
METHODS
Setting
The present study is a cross-sectional analysis of data from a quality improvement (QI) intervention that was performed at Vanderbilt University Medical Center, a tertiary care facility in Nashville, Tennessee. The QI intervention, My Health Team (MHT), was funded by the Centers for Medicare and Medicaid Services Innovation Award program. The overall MHT program included outpatient care coordination for chronic disease management as well as a transitional care program that was designed to reduce hospital readmission. The latter included an inpatient needs assessment (which provided data for the present analysis), inpatient intervention, and postdischarge phone follow-up. The MHT initiative was reviewed by the institutional review board (IRB), which deemed it a QI program and granted a waiver of informed consent. The present secondary data analysis was reviewed and approved by the IRB.
Sample
Patients were identified for inclusion in the MHT transitions of care program if the presenting problem for hospital admission was pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or decompensated heart failure, as determined by the review of clinical documentation by nurse transition care coordinators (TCCs). Adults over the age of 18 years were eligible, though priority was given to patients aged 65 years or older. This study includes the first inpatient encounter between June 2013 and December 31, 2014, for patients having a completed needs assessment and documentation of health literacy data in the medical record.
Data Collection
TCN assessment was developed from published patient risk tools and the ITC framework.2,6,22 The assessment has 10 domains composed of 49 individual items as follows: (1) caregiver support (caregiver support not sufficient for patient needs), (2) transportation (relies on public or others for transportation and misses medical care because of transportation), (3) health care utilization (no primary care physician, unplanned hospitalization in the last year, emergency department [ED] visit in the last 6 months, or home health services in the last 60 days), (4) high-risk medical comorbidities (malnutrition or body mass index <18.5, renal failure, chronic pain, diabetes, heart failure, COPD, or stroke), (5) medication management provider or caregiver concern (cannot provide medication list, >10 preadmission medications, high-risk medications [eg, insulin, warfarin], poor medication understanding, or adherence issue identified), (6) medical devices (vascular access, urinary catheter, wounds, or home supplemental oxygen), (7) functional status (weakness of extremities, limited extremity range of motion, difficulty with mobility, falls at home, or activities of daily living challenges), (8) mental health comorbidities (over the past month has felt down, depressed, or hopeless or over the past month has felt little interest or pleasure in doing things, high-risk alcohol use, or high-risk substance use), (9) communication (limited English proficiency or at risk for limited health literacy), and (10) financial resources (no health insurance, skips or rations medicines because of cost, misses medical care because of cost, or misses medical care because of job).
The 49 items of the TCN assessment were documented as being present or absent by nurse TCCs at the time patients were enrolled in the transitional care program, based on patient and family interview and chart review, and the items were later extracted for analysis. Patients were determined to have a domain-level need if they reported a need on any individual item within that domain, resulting in a binary score (any need present, absent) for each of the 10 TCN domains.
Health literacy was assessed by using the Brief Health Literacy Screen (BHLS), which is administered routinely by nurses at hospital intake and documented in the medical record, with completion rates of approximately 90%.23 The BHLS is a 3-question subjective health literacy assessment (scoring range 3-15) that has been validated against longer objective measures24 and shown to predict disease control and mortality.18,25 To improve the stability of scores (for patients who completed the BHLS more than once because of repeat hospitalizations) and to reduce missing values, we calculated the patient’s mean BHLS score for assessments obtained between January 1, 2013, and December 31, 2014. Patients were then categorized as having inadequate health literacy (BHLS ≤ 9) or adequate health literacy (BHLS > 9).18,25 Demographic information was extracted from patient records and included age, sex (male/female), marital status (married/without a partner), race (white/nonwhite), and years of education. Income level and primary language were not available for analysis.
Statistical Analysis
Patient characteristics and TCNs were summarized by using the frequency and percentages for categorical variables and the mean and standard deviation (SD) for continuous variables. We compared patient characteristics (age, sex, marital status, race, and education) between health literacy groups (inadequate vs adequate) by using χ2 or analysis of variance as appropriate. We assessed Pearson correlations among the 10 TCN domains, and we examined differences in reported needs for each of 10 TCN domains by the level of health literacy by using the χ2 test. Because the TCN domain of communication included low health literacy as one of its items, we excluded this domain from subsequent analyses. We then compared differences in the number of TCNs documented (scoring range 0-9) by using an independent samples Student t test.
Multivariate logistic regression models were then constructed to examine the independent association of inadequate health literacy with 8 TCN domains while controlling for age, sex, marital status, race, and education. Patients with incomplete demographic data were excluded from these models. Additionally, these analyses excluded 2 TCN domains: the communication domain for reasons noted above and the high-risk medical comorbidity domain because it ended up being positive in 98.4% of patients. Statistical significance was set at an alpha of 0.05. All analyses were performed by using SPSS Statistics for Mac, version 23.0 (IBM Corp., Armonk, New York)
RESULTS
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).
DISCUSSION
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.
CONCLUSION
In this sample of hospitalized patients who were administered a structured needs assessment, patients commonly had needs that placed them at a higher risk of adverse outcomes, such as hospital readmission. Patients with low health literacy had more TCNs that extended beyond the areas that we normally associate with low health literacy, namely patient education and self-management. Healthcare professionals should be aware of the greater likelihood of transportation barriers and inadequate caregiver support among patients with low health literacy. Screening for health literacy and TCN at admission or as part of the discharge planning process will elevate such risks, better positioning clinicians and hospitals to address them as a part of the efforts to ensure a quality transition of care.
Disclosure
This work was funded by the Centers for Medicare and Medicaid Services (1C1CMS330979) and in part by the National Center for Advancing Translational Sciences (2 UL1 TR000445-06). The content is solely the responsibility of the authors and does not necessarily represent official views of the funding agencies, which did not participate in the planning, collection, analysis, or interpretation of data or in the decision to submit for publication.
Dr. Dittus reports personal fees as a board member of the Robert Wood Johnson Foundation Medical Faculty Scholars Program National Advisory Committee; consultancy fees from the University of Virginia, Indiana University, University of Michigan, Northwestern University, Montana State University, and Purdue University; has grants/grants pending from NIH (research grants), PCORI (research grant), CME (innovation award), VA (training grant); payment for lectures including service on speakers bureaus from Corporate Parity (conference organizer) for the Global Hospital Management & Innovation Summit; and other from Medical Decision Making, Inc. (passive owner); all outside the submitted work. Dr. Kripalani has grants from NIH (research grant), PCORI (research grant), and CMS (QI grant); outside the submitted work. All other authors have nothing to disclose.
1. Rau J. Medicare to penalize 2,211 hospitals for excess readmissions. Kaiser Heal News. 2012;13(6):48-49.
2. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102-109. PubMed
3. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA. 1999;281(7):613-620. PubMed
4. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009;150(3):178-187. PubMed
5. Coleman EA, Parry C, Chalmers S, Min S. The Care Transitions Intervention. Arch Intern Med. 2006;166(17):1822-1828. PubMed
6. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. PubMed
7. Hatch M, Bruce P, Mansolino A, Kripalani S. Transition care coordinators deliver personalized approach. Readmissions News. 2014;3(9):1-4.
8. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175-184. PubMed
9. Kutner M, Greenburg E, Jin Y, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. Natl Cent Educ Stat. 2006;6:1-59.
10. Kripalani S, Jacobson TA, Mugalla IC, Cawthon CR, Niesner KJ, Vaccarino V. Health literacy and the quality of physician-patient communication during hospitalization. J Hosp Med. 2010;5(5):269-275. PubMed
11. Goggins KM, Wallston KA., Nwosu S, et al. Health literacy, numeracy, and other characteristics associated with hospitalized patients’ preferences for involvement in decision making. J Health Commun. 2014;19(sup2):29-43. PubMed
12. Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL, Kripalani S. Health literacy and medication understanding among hospitalized adults. J Hosp Med. 2011;6(9):488-493. PubMed
13. Evangelista LS, Rasmusson KD, Laramee AS, et al. Health literacy and the patient with heart failure—implications for patient care and research: a consensus statement of the Heart Failure Society of America. J Card Fail. 2010;16(1):9-16. PubMed
14. Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173-178. PubMed
15. Coleman EA, Chugh A, Williams MV, et al. Understanding and execution of discharge instructions. Am J Med Qual. 2013;28(5):383-391. PubMed
16. Mixon AS, Myers AP, Leak CL, et al. Characteristics associated with postdischarge medication errors. Mayo Clin Proc. 2014;89(8):1042-1051. PubMed
17. Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(sup3):325-338. PubMed
18. McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc. 2015;4(5):e001799. PubMed
19. Kripalani S, Roumie CL, Dalal AK, et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1-10. PubMed
20. Polster D. Patient discharge information: Tools for success. Nursing (Lond). 2015;45(5):42-49. PubMed
21. Bradley SM, Chang D, Fallar R, Karani R. A patient safety and transitions of care curriculum for third-year medical students. Gerontol Geriatr Educ. 2015;36(1):45-57. PubMed
22. Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-485. PubMed
23. Cawthon C, Mion LC, Willens DE, Roumie CL, Kripalani S. Implementing routine health literacy assessment in hospital and primary care patients. Jt Comm J Qual Patient Saf. 2014;40(2):68-76. PubMed
24. Wallston KA, Cawthon C, McNaughton CD, Rothman RL, Osborn CY, Kripalani S. Psychometric properties of the brief health literacy screen in clinical practice. J Gen Intern Med. 2013:1-8. PubMed
25. McNaughton CD, Kripalani S, Cawthon C, Mion LC, Wallston KA, Roumie CL. Association of health literacy with elevated blood pressure: a cohort study of hospitalized patients. Med Care. 2014;52(4):346-353. PubMed
26. Garcia CH, Espinoza SE, Lichtenstein M, Hazuda HP. Health literacy associations between Hispanic elderly patients and their caregivers. J Health Commun. 2013;18 Suppl 1:256-272. PubMed
27. Levin JB, Peterson PN, Dolansky MA, Boxer RS. Health literacy and heart failure management in patient-caregiver dyads. J Card Fail. 2014;20(10):755-761. PubMed
28. Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-479. PubMed
29. Graham CL, Ivey SL, Neuhauser L. From hospital to home: assessing the transitional care needs of vulnerable seniors. Gerontologist. 2009;49(1):23-33. PubMed
30. Foust JB, Vuckovic N, Henriquez E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res. 2012;34(2):194-212. PubMed
31. Hahn-Goldberg S, Okrainec K, Huynh T, Zahr N, Abrams H. Co-creating patient-oriented discharge instructions with patients, caregivers, and healthcare providers. J Hosp Med. 2015;10(12):804-807. PubMed
32. Hendrix C, Tepfer S, Forest S, et al. Transitional care partners: a hospital-to-home support for older adults and their caregivers. J Am Assoc Nurse Pract. 2013;25(8):407-414. PubMed
33. Rubin DJ, Donnell-Jackson K, Jhingan R, Golden SH, Paranjape A. Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869-873. PubMed
34. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976-993. PubMed
35. Wheeler K, Crawford R, McAdams D, et al. Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients. Ethn Dis. 2007;17(2):238-243. PubMed
36. Brega A, Barnard J, Mabachi N, et al. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition. Rockville: Agency for Healthcare Research and Qualiy; 2015. https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed August 21, 2017.
37. Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11(5):685-694. PubMed
38. Carlin B, Wiles K, Easley D, Dskonerwpahsorg DS, Prenner B. Transition of care and rehospitalization rates for patients who require home oxygen therapy following hospitalization. Eur Respir J. 2012;40(Suppl 56):P617.
39. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165(17):1946-1952. PubMed
40. Smith SG, O’Conor R, Curtis LM, et al. Low health literacy predicts decline in physical function among older adults: findings from the LitCog cohort study. J Epidemiol Community Health. 2015;69(5):474-480. PubMed
41. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015;175(4):559-565. PubMed
42. Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess (Full Rep). 2011;199:1-941. PubMed
43. Lincoln A, Paasche-Orlow M, Cheng D, et al. Impact of health literacy on depressive symptoms and mental health-related quality of life among adults with addiction. J Gen Intern Med. 2006;21(8):818-822. PubMed
44. Weiss BD, Francis L, Senf JH, et al. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med. 2006;21(8):823-828. PubMed
45. Goggins K, Wallston KA, Mion L, Cawthon C, Kripalani S. What patient characteristics influence nurses’ assessment of health literacy? J Health Commun. 2016;21(sup2):105-108. PubMed
46. Scarpato KR, Kappa SF, Goggins KM, et al. The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun. 2016;21(sup2):99-104.
PubMed
47. Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54(5):770-776. PubMed
48. Jacobson HE, Hund L, Mas FS. Predictors of English health literacy among US Hispanic immigrants: the importance of language, bilingualism and sociolinguistic environment
A special concern since the institution of hospital readmission penalties1 is the transitions in care of a patient from one care setting to another, often at hospital discharge. Burke et al.2 proposed a framework for an ideal transition in care (ITC) to study and improve transitions from the hospital to home. The features in the ITC were identified based upon their inclusion in the interventions that improved discharge outcomes.3-5 Inspired by the ITC and other patient risk tools,6 we identified 10 domains of transitional care needs ([TCN] specified below), which we define as patient-centered risk factors that should be addressed to foster a safe and effective transition in care.7
One particularly important risk factor in patient self-management at transition points is health literacy, a patient’s ability to obtain, understand, and use basic health information and services. Low health literacy affects approximately 26% to 36% of adults in the United States.8,9 Health literacy is associated with many factors that may affect successful navigation of care transitions, including doctor-patient communication,10,11 understanding of the medication regimen,12 and self-management.13-15 Research has also demonstrated an association between low health literacy and poor outcomes after hospital discharge, including medication errors,16 30-day hospital readmission,17 and mortality.18 Transitional care initiatives have begun to incorporate health literacy into patient risk assessments6 and provide specific attention to low health literacy in interventions to reduce adverse drug events and readmission.4,19 Training programs for medical students and nurses advise teaching skills in health literacy as part of fostering effective transitions in care.20,21
Although low health literacy is generally recognized as a barrier to patient education and self-management, little is known about whether patients with low health literacy are more likely to have other risk factors that could further increase their risk for poor transitions in care. A better understanding of associated risks would inform and improve patient care. We hypothesized that TCNs are more common among patients with low health literacy, as compared with those with adequate health literacy. We also aimed to describe the relationship between low health literacy and specific TCNs in order to guide clinical care and future interventions.
METHODS
Setting
The present study is a cross-sectional analysis of data from a quality improvement (QI) intervention that was performed at Vanderbilt University Medical Center, a tertiary care facility in Nashville, Tennessee. The QI intervention, My Health Team (MHT), was funded by the Centers for Medicare and Medicaid Services Innovation Award program. The overall MHT program included outpatient care coordination for chronic disease management as well as a transitional care program that was designed to reduce hospital readmission. The latter included an inpatient needs assessment (which provided data for the present analysis), inpatient intervention, and postdischarge phone follow-up. The MHT initiative was reviewed by the institutional review board (IRB), which deemed it a QI program and granted a waiver of informed consent. The present secondary data analysis was reviewed and approved by the IRB.
Sample
Patients were identified for inclusion in the MHT transitions of care program if the presenting problem for hospital admission was pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or decompensated heart failure, as determined by the review of clinical documentation by nurse transition care coordinators (TCCs). Adults over the age of 18 years were eligible, though priority was given to patients aged 65 years or older. This study includes the first inpatient encounter between June 2013 and December 31, 2014, for patients having a completed needs assessment and documentation of health literacy data in the medical record.
Data Collection
TCN assessment was developed from published patient risk tools and the ITC framework.2,6,22 The assessment has 10 domains composed of 49 individual items as follows: (1) caregiver support (caregiver support not sufficient for patient needs), (2) transportation (relies on public or others for transportation and misses medical care because of transportation), (3) health care utilization (no primary care physician, unplanned hospitalization in the last year, emergency department [ED] visit in the last 6 months, or home health services in the last 60 days), (4) high-risk medical comorbidities (malnutrition or body mass index <18.5, renal failure, chronic pain, diabetes, heart failure, COPD, or stroke), (5) medication management provider or caregiver concern (cannot provide medication list, >10 preadmission medications, high-risk medications [eg, insulin, warfarin], poor medication understanding, or adherence issue identified), (6) medical devices (vascular access, urinary catheter, wounds, or home supplemental oxygen), (7) functional status (weakness of extremities, limited extremity range of motion, difficulty with mobility, falls at home, or activities of daily living challenges), (8) mental health comorbidities (over the past month has felt down, depressed, or hopeless or over the past month has felt little interest or pleasure in doing things, high-risk alcohol use, or high-risk substance use), (9) communication (limited English proficiency or at risk for limited health literacy), and (10) financial resources (no health insurance, skips or rations medicines because of cost, misses medical care because of cost, or misses medical care because of job).
The 49 items of the TCN assessment were documented as being present or absent by nurse TCCs at the time patients were enrolled in the transitional care program, based on patient and family interview and chart review, and the items were later extracted for analysis. Patients were determined to have a domain-level need if they reported a need on any individual item within that domain, resulting in a binary score (any need present, absent) for each of the 10 TCN domains.
Health literacy was assessed by using the Brief Health Literacy Screen (BHLS), which is administered routinely by nurses at hospital intake and documented in the medical record, with completion rates of approximately 90%.23 The BHLS is a 3-question subjective health literacy assessment (scoring range 3-15) that has been validated against longer objective measures24 and shown to predict disease control and mortality.18,25 To improve the stability of scores (for patients who completed the BHLS more than once because of repeat hospitalizations) and to reduce missing values, we calculated the patient’s mean BHLS score for assessments obtained between January 1, 2013, and December 31, 2014. Patients were then categorized as having inadequate health literacy (BHLS ≤ 9) or adequate health literacy (BHLS > 9).18,25 Demographic information was extracted from patient records and included age, sex (male/female), marital status (married/without a partner), race (white/nonwhite), and years of education. Income level and primary language were not available for analysis.
Statistical Analysis
Patient characteristics and TCNs were summarized by using the frequency and percentages for categorical variables and the mean and standard deviation (SD) for continuous variables. We compared patient characteristics (age, sex, marital status, race, and education) between health literacy groups (inadequate vs adequate) by using χ2 or analysis of variance as appropriate. We assessed Pearson correlations among the 10 TCN domains, and we examined differences in reported needs for each of 10 TCN domains by the level of health literacy by using the χ2 test. Because the TCN domain of communication included low health literacy as one of its items, we excluded this domain from subsequent analyses. We then compared differences in the number of TCNs documented (scoring range 0-9) by using an independent samples Student t test.
Multivariate logistic regression models were then constructed to examine the independent association of inadequate health literacy with 8 TCN domains while controlling for age, sex, marital status, race, and education. Patients with incomplete demographic data were excluded from these models. Additionally, these analyses excluded 2 TCN domains: the communication domain for reasons noted above and the high-risk medical comorbidity domain because it ended up being positive in 98.4% of patients. Statistical significance was set at an alpha of 0.05. All analyses were performed by using SPSS Statistics for Mac, version 23.0 (IBM Corp., Armonk, New York)
RESULTS
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).
DISCUSSION
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.
CONCLUSION
In this sample of hospitalized patients who were administered a structured needs assessment, patients commonly had needs that placed them at a higher risk of adverse outcomes, such as hospital readmission. Patients with low health literacy had more TCNs that extended beyond the areas that we normally associate with low health literacy, namely patient education and self-management. Healthcare professionals should be aware of the greater likelihood of transportation barriers and inadequate caregiver support among patients with low health literacy. Screening for health literacy and TCN at admission or as part of the discharge planning process will elevate such risks, better positioning clinicians and hospitals to address them as a part of the efforts to ensure a quality transition of care.
Disclosure
This work was funded by the Centers for Medicare and Medicaid Services (1C1CMS330979) and in part by the National Center for Advancing Translational Sciences (2 UL1 TR000445-06). The content is solely the responsibility of the authors and does not necessarily represent official views of the funding agencies, which did not participate in the planning, collection, analysis, or interpretation of data or in the decision to submit for publication.
Dr. Dittus reports personal fees as a board member of the Robert Wood Johnson Foundation Medical Faculty Scholars Program National Advisory Committee; consultancy fees from the University of Virginia, Indiana University, University of Michigan, Northwestern University, Montana State University, and Purdue University; has grants/grants pending from NIH (research grants), PCORI (research grant), CME (innovation award), VA (training grant); payment for lectures including service on speakers bureaus from Corporate Parity (conference organizer) for the Global Hospital Management & Innovation Summit; and other from Medical Decision Making, Inc. (passive owner); all outside the submitted work. Dr. Kripalani has grants from NIH (research grant), PCORI (research grant), and CMS (QI grant); outside the submitted work. All other authors have nothing to disclose.
A special concern since the institution of hospital readmission penalties1 is the transitions in care of a patient from one care setting to another, often at hospital discharge. Burke et al.2 proposed a framework for an ideal transition in care (ITC) to study and improve transitions from the hospital to home. The features in the ITC were identified based upon their inclusion in the interventions that improved discharge outcomes.3-5 Inspired by the ITC and other patient risk tools,6 we identified 10 domains of transitional care needs ([TCN] specified below), which we define as patient-centered risk factors that should be addressed to foster a safe and effective transition in care.7
One particularly important risk factor in patient self-management at transition points is health literacy, a patient’s ability to obtain, understand, and use basic health information and services. Low health literacy affects approximately 26% to 36% of adults in the United States.8,9 Health literacy is associated with many factors that may affect successful navigation of care transitions, including doctor-patient communication,10,11 understanding of the medication regimen,12 and self-management.13-15 Research has also demonstrated an association between low health literacy and poor outcomes after hospital discharge, including medication errors,16 30-day hospital readmission,17 and mortality.18 Transitional care initiatives have begun to incorporate health literacy into patient risk assessments6 and provide specific attention to low health literacy in interventions to reduce adverse drug events and readmission.4,19 Training programs for medical students and nurses advise teaching skills in health literacy as part of fostering effective transitions in care.20,21
Although low health literacy is generally recognized as a barrier to patient education and self-management, little is known about whether patients with low health literacy are more likely to have other risk factors that could further increase their risk for poor transitions in care. A better understanding of associated risks would inform and improve patient care. We hypothesized that TCNs are more common among patients with low health literacy, as compared with those with adequate health literacy. We also aimed to describe the relationship between low health literacy and specific TCNs in order to guide clinical care and future interventions.
METHODS
Setting
The present study is a cross-sectional analysis of data from a quality improvement (QI) intervention that was performed at Vanderbilt University Medical Center, a tertiary care facility in Nashville, Tennessee. The QI intervention, My Health Team (MHT), was funded by the Centers for Medicare and Medicaid Services Innovation Award program. The overall MHT program included outpatient care coordination for chronic disease management as well as a transitional care program that was designed to reduce hospital readmission. The latter included an inpatient needs assessment (which provided data for the present analysis), inpatient intervention, and postdischarge phone follow-up. The MHT initiative was reviewed by the institutional review board (IRB), which deemed it a QI program and granted a waiver of informed consent. The present secondary data analysis was reviewed and approved by the IRB.
Sample
Patients were identified for inclusion in the MHT transitions of care program if the presenting problem for hospital admission was pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or decompensated heart failure, as determined by the review of clinical documentation by nurse transition care coordinators (TCCs). Adults over the age of 18 years were eligible, though priority was given to patients aged 65 years or older. This study includes the first inpatient encounter between June 2013 and December 31, 2014, for patients having a completed needs assessment and documentation of health literacy data in the medical record.
Data Collection
TCN assessment was developed from published patient risk tools and the ITC framework.2,6,22 The assessment has 10 domains composed of 49 individual items as follows: (1) caregiver support (caregiver support not sufficient for patient needs), (2) transportation (relies on public or others for transportation and misses medical care because of transportation), (3) health care utilization (no primary care physician, unplanned hospitalization in the last year, emergency department [ED] visit in the last 6 months, or home health services in the last 60 days), (4) high-risk medical comorbidities (malnutrition or body mass index <18.5, renal failure, chronic pain, diabetes, heart failure, COPD, or stroke), (5) medication management provider or caregiver concern (cannot provide medication list, >10 preadmission medications, high-risk medications [eg, insulin, warfarin], poor medication understanding, or adherence issue identified), (6) medical devices (vascular access, urinary catheter, wounds, or home supplemental oxygen), (7) functional status (weakness of extremities, limited extremity range of motion, difficulty with mobility, falls at home, or activities of daily living challenges), (8) mental health comorbidities (over the past month has felt down, depressed, or hopeless or over the past month has felt little interest or pleasure in doing things, high-risk alcohol use, or high-risk substance use), (9) communication (limited English proficiency or at risk for limited health literacy), and (10) financial resources (no health insurance, skips or rations medicines because of cost, misses medical care because of cost, or misses medical care because of job).
The 49 items of the TCN assessment were documented as being present or absent by nurse TCCs at the time patients were enrolled in the transitional care program, based on patient and family interview and chart review, and the items were later extracted for analysis. Patients were determined to have a domain-level need if they reported a need on any individual item within that domain, resulting in a binary score (any need present, absent) for each of the 10 TCN domains.
Health literacy was assessed by using the Brief Health Literacy Screen (BHLS), which is administered routinely by nurses at hospital intake and documented in the medical record, with completion rates of approximately 90%.23 The BHLS is a 3-question subjective health literacy assessment (scoring range 3-15) that has been validated against longer objective measures24 and shown to predict disease control and mortality.18,25 To improve the stability of scores (for patients who completed the BHLS more than once because of repeat hospitalizations) and to reduce missing values, we calculated the patient’s mean BHLS score for assessments obtained between January 1, 2013, and December 31, 2014. Patients were then categorized as having inadequate health literacy (BHLS ≤ 9) or adequate health literacy (BHLS > 9).18,25 Demographic information was extracted from patient records and included age, sex (male/female), marital status (married/without a partner), race (white/nonwhite), and years of education. Income level and primary language were not available for analysis.
Statistical Analysis
Patient characteristics and TCNs were summarized by using the frequency and percentages for categorical variables and the mean and standard deviation (SD) for continuous variables. We compared patient characteristics (age, sex, marital status, race, and education) between health literacy groups (inadequate vs adequate) by using χ2 or analysis of variance as appropriate. We assessed Pearson correlations among the 10 TCN domains, and we examined differences in reported needs for each of 10 TCN domains by the level of health literacy by using the χ2 test. Because the TCN domain of communication included low health literacy as one of its items, we excluded this domain from subsequent analyses. We then compared differences in the number of TCNs documented (scoring range 0-9) by using an independent samples Student t test.
Multivariate logistic regression models were then constructed to examine the independent association of inadequate health literacy with 8 TCN domains while controlling for age, sex, marital status, race, and education. Patients with incomplete demographic data were excluded from these models. Additionally, these analyses excluded 2 TCN domains: the communication domain for reasons noted above and the high-risk medical comorbidity domain because it ended up being positive in 98.4% of patients. Statistical significance was set at an alpha of 0.05. All analyses were performed by using SPSS Statistics for Mac, version 23.0 (IBM Corp., Armonk, New York)
RESULTS
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).
DISCUSSION
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.
CONCLUSION
In this sample of hospitalized patients who were administered a structured needs assessment, patients commonly had needs that placed them at a higher risk of adverse outcomes, such as hospital readmission. Patients with low health literacy had more TCNs that extended beyond the areas that we normally associate with low health literacy, namely patient education and self-management. Healthcare professionals should be aware of the greater likelihood of transportation barriers and inadequate caregiver support among patients with low health literacy. Screening for health literacy and TCN at admission or as part of the discharge planning process will elevate such risks, better positioning clinicians and hospitals to address them as a part of the efforts to ensure a quality transition of care.
Disclosure
This work was funded by the Centers for Medicare and Medicaid Services (1C1CMS330979) and in part by the National Center for Advancing Translational Sciences (2 UL1 TR000445-06). The content is solely the responsibility of the authors and does not necessarily represent official views of the funding agencies, which did not participate in the planning, collection, analysis, or interpretation of data or in the decision to submit for publication.
Dr. Dittus reports personal fees as a board member of the Robert Wood Johnson Foundation Medical Faculty Scholars Program National Advisory Committee; consultancy fees from the University of Virginia, Indiana University, University of Michigan, Northwestern University, Montana State University, and Purdue University; has grants/grants pending from NIH (research grants), PCORI (research grant), CME (innovation award), VA (training grant); payment for lectures including service on speakers bureaus from Corporate Parity (conference organizer) for the Global Hospital Management & Innovation Summit; and other from Medical Decision Making, Inc. (passive owner); all outside the submitted work. Dr. Kripalani has grants from NIH (research grant), PCORI (research grant), and CMS (QI grant); outside the submitted work. All other authors have nothing to disclose.
1. Rau J. Medicare to penalize 2,211 hospitals for excess readmissions. Kaiser Heal News. 2012;13(6):48-49.
2. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102-109. PubMed
3. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA. 1999;281(7):613-620. PubMed
4. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009;150(3):178-187. PubMed
5. Coleman EA, Parry C, Chalmers S, Min S. The Care Transitions Intervention. Arch Intern Med. 2006;166(17):1822-1828. PubMed
6. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. PubMed
7. Hatch M, Bruce P, Mansolino A, Kripalani S. Transition care coordinators deliver personalized approach. Readmissions News. 2014;3(9):1-4.
8. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175-184. PubMed
9. Kutner M, Greenburg E, Jin Y, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. Natl Cent Educ Stat. 2006;6:1-59.
10. Kripalani S, Jacobson TA, Mugalla IC, Cawthon CR, Niesner KJ, Vaccarino V. Health literacy and the quality of physician-patient communication during hospitalization. J Hosp Med. 2010;5(5):269-275. PubMed
11. Goggins KM, Wallston KA., Nwosu S, et al. Health literacy, numeracy, and other characteristics associated with hospitalized patients’ preferences for involvement in decision making. J Health Commun. 2014;19(sup2):29-43. PubMed
12. Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL, Kripalani S. Health literacy and medication understanding among hospitalized adults. J Hosp Med. 2011;6(9):488-493. PubMed
13. Evangelista LS, Rasmusson KD, Laramee AS, et al. Health literacy and the patient with heart failure—implications for patient care and research: a consensus statement of the Heart Failure Society of America. J Card Fail. 2010;16(1):9-16. PubMed
14. Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173-178. PubMed
15. Coleman EA, Chugh A, Williams MV, et al. Understanding and execution of discharge instructions. Am J Med Qual. 2013;28(5):383-391. PubMed
16. Mixon AS, Myers AP, Leak CL, et al. Characteristics associated with postdischarge medication errors. Mayo Clin Proc. 2014;89(8):1042-1051. PubMed
17. Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(sup3):325-338. PubMed
18. McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc. 2015;4(5):e001799. PubMed
19. Kripalani S, Roumie CL, Dalal AK, et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1-10. PubMed
20. Polster D. Patient discharge information: Tools for success. Nursing (Lond). 2015;45(5):42-49. PubMed
21. Bradley SM, Chang D, Fallar R, Karani R. A patient safety and transitions of care curriculum for third-year medical students. Gerontol Geriatr Educ. 2015;36(1):45-57. PubMed
22. Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-485. PubMed
23. Cawthon C, Mion LC, Willens DE, Roumie CL, Kripalani S. Implementing routine health literacy assessment in hospital and primary care patients. Jt Comm J Qual Patient Saf. 2014;40(2):68-76. PubMed
24. Wallston KA, Cawthon C, McNaughton CD, Rothman RL, Osborn CY, Kripalani S. Psychometric properties of the brief health literacy screen in clinical practice. J Gen Intern Med. 2013:1-8. PubMed
25. McNaughton CD, Kripalani S, Cawthon C, Mion LC, Wallston KA, Roumie CL. Association of health literacy with elevated blood pressure: a cohort study of hospitalized patients. Med Care. 2014;52(4):346-353. PubMed
26. Garcia CH, Espinoza SE, Lichtenstein M, Hazuda HP. Health literacy associations between Hispanic elderly patients and their caregivers. J Health Commun. 2013;18 Suppl 1:256-272. PubMed
27. Levin JB, Peterson PN, Dolansky MA, Boxer RS. Health literacy and heart failure management in patient-caregiver dyads. J Card Fail. 2014;20(10):755-761. PubMed
28. Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-479. PubMed
29. Graham CL, Ivey SL, Neuhauser L. From hospital to home: assessing the transitional care needs of vulnerable seniors. Gerontologist. 2009;49(1):23-33. PubMed
30. Foust JB, Vuckovic N, Henriquez E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res. 2012;34(2):194-212. PubMed
31. Hahn-Goldberg S, Okrainec K, Huynh T, Zahr N, Abrams H. Co-creating patient-oriented discharge instructions with patients, caregivers, and healthcare providers. J Hosp Med. 2015;10(12):804-807. PubMed
32. Hendrix C, Tepfer S, Forest S, et al. Transitional care partners: a hospital-to-home support for older adults and their caregivers. J Am Assoc Nurse Pract. 2013;25(8):407-414. PubMed
33. Rubin DJ, Donnell-Jackson K, Jhingan R, Golden SH, Paranjape A. Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869-873. PubMed
34. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976-993. PubMed
35. Wheeler K, Crawford R, McAdams D, et al. Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients. Ethn Dis. 2007;17(2):238-243. PubMed
36. Brega A, Barnard J, Mabachi N, et al. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition. Rockville: Agency for Healthcare Research and Qualiy; 2015. https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed August 21, 2017.
37. Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11(5):685-694. PubMed
38. Carlin B, Wiles K, Easley D, Dskonerwpahsorg DS, Prenner B. Transition of care and rehospitalization rates for patients who require home oxygen therapy following hospitalization. Eur Respir J. 2012;40(Suppl 56):P617.
39. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165(17):1946-1952. PubMed
40. Smith SG, O’Conor R, Curtis LM, et al. Low health literacy predicts decline in physical function among older adults: findings from the LitCog cohort study. J Epidemiol Community Health. 2015;69(5):474-480. PubMed
41. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015;175(4):559-565. PubMed
42. Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess (Full Rep). 2011;199:1-941. PubMed
43. Lincoln A, Paasche-Orlow M, Cheng D, et al. Impact of health literacy on depressive symptoms and mental health-related quality of life among adults with addiction. J Gen Intern Med. 2006;21(8):818-822. PubMed
44. Weiss BD, Francis L, Senf JH, et al. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med. 2006;21(8):823-828. PubMed
45. Goggins K, Wallston KA, Mion L, Cawthon C, Kripalani S. What patient characteristics influence nurses’ assessment of health literacy? J Health Commun. 2016;21(sup2):105-108. PubMed
46. Scarpato KR, Kappa SF, Goggins KM, et al. The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun. 2016;21(sup2):99-104.
PubMed
47. Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54(5):770-776. PubMed
48. Jacobson HE, Hund L, Mas FS. Predictors of English health literacy among US Hispanic immigrants: the importance of language, bilingualism and sociolinguistic environment
1. Rau J. Medicare to penalize 2,211 hospitals for excess readmissions. Kaiser Heal News. 2012;13(6):48-49.
2. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102-109. PubMed
3. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA. 1999;281(7):613-620. PubMed
4. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009;150(3):178-187. PubMed
5. Coleman EA, Parry C, Chalmers S, Min S. The Care Transitions Intervention. Arch Intern Med. 2006;166(17):1822-1828. PubMed
6. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. PubMed
7. Hatch M, Bruce P, Mansolino A, Kripalani S. Transition care coordinators deliver personalized approach. Readmissions News. 2014;3(9):1-4.
8. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175-184. PubMed
9. Kutner M, Greenburg E, Jin Y, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. Natl Cent Educ Stat. 2006;6:1-59.
10. Kripalani S, Jacobson TA, Mugalla IC, Cawthon CR, Niesner KJ, Vaccarino V. Health literacy and the quality of physician-patient communication during hospitalization. J Hosp Med. 2010;5(5):269-275. PubMed
11. Goggins KM, Wallston KA., Nwosu S, et al. Health literacy, numeracy, and other characteristics associated with hospitalized patients’ preferences for involvement in decision making. J Health Commun. 2014;19(sup2):29-43. PubMed
12. Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL, Kripalani S. Health literacy and medication understanding among hospitalized adults. J Hosp Med. 2011;6(9):488-493. PubMed
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