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.

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.