Health Literacy in the ED: A Quick Guide

Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform these same health-related decisions.

Health literacy also incorporates numeracy, which is the ability to read and understand numbers.¹

Low health literacy is very common. According to the CDC, nearly 9 out of 10 adults struggle to understand and use personal and public health information when it’s filled with unfamiliar or complex terms.² Those with lower educational attainment, the elderly, underserved minorities, and those with limited English proficiency are at higher risk of low health literacy.^3,4

Risk Factors, Clinical Outcomes
Poor health literacy is one of the most common social determinants of health that we encounter daily in the ED.

Limited health literacy results in higher rates of morbidity and mortality. One 2017 research study found that after adjusting for covariates, patients with limited health literacy had 2.3 (95% CI 1.7–3.1) times the number of potentially preventable ED visits resulting in hospital admission, 1.4 (95% CI 1.0–2.0) times the number of treat-and-release visits, and 1.9 (95% CI 1.5–2.4) times the number of total preventable ED visits when compared to individuals with adequate health literacy.⁶

Limited health literacy increases costs for the health-care system. Through its impact on medical errors, increased illness and disability, loss of wages, increased ED utilization, and compromised public health, low health literacy is estimated to cost the U.S. economy up to $236 billion annually. Improving health literacy nationwide could prevent nearly 1 million hospital visits and save health care more than $25 billion a year.⁵

Bedside Awareness
As emergency physicians, we are responsible for adequately communicating with patients about everything from why we are performing certain tests to the risks of specific interventions. Clear communication in our specialty is imperative, and it is therefore very important that we know how to best assess and address low health literacy in the ED.

We can help reconcile health inequities at the bedside for individuals with low health literacy by:

• Leading with the assumption that patients do not understand what is happening to them or why. Patients often do not understand how the history and events they report determines our workup or medical decision-
• Asking patients what they understand about their evaluation and testing. This gives a sense of where key misunderstandings exist, what needs to be re-explained, and how to best guide the patient through the rest of the ED visit.
• Documenting concerns of low health literacy and any mitigation steps you will employ throughout the visit. (Consider implementing the ICD-10 code “Problems related to health literacy” to flag future health-care providers.)
• Carefully considering your discussions of risk, percentages, or options. Avoid using non-medical language or terminology. Be mindful of bias in your language when employing methods such as shared decision-making or expressing recommendations during goals-of-care conversations.
• Considering a history of poorer patient outcomes, increased rates of morbidity, and higher rates of ED return visits throughout the patient interview and again when discussing disposition with patients.

Key Actions
As emergency physicians, we can address these social/structural determinants of health by actively engaging in the following actions.

Skills training. Consider effective communication of test results, risks and benefits, procedural consents, or end-of-life discussions to be a key skill that you can and will become competent in during your training. As such, using role play or simulation can be a useful tool to help you, your co-residents, and other members of your department improve communication skills. If you keep the patient with low health literacy in mind at all times, all of your patients will benefit from more effective communication.

Care coordination and social work. Involve care coordination and/or social work often and early, especially if you will be relying on outpatient providers to continue care after the visit, such as when referring a patient to urology after they had a foley placed in the ED for acute urinary retention. This can be key in preventing loss to follow-up care and ED return visits.

When handling discharge:

• Use the teach-back method as a way of checking understanding by asking patients to state in their own words what they know or need to do about their health. It is a way to confirm that you have explained things in a manner that patients understand. With the teach-back method, remember to “chunk and check.” Chunk information into small segments rather than employing teach-back at the end of a lengthy and complicated medical discussion.⁷ A wealth of practical information on teach-back strategies can be found at teachbacktraining.org.
• Use simple language handouts for common ED discharge diagnoses. These are premade in most EMRs.
• For uncommon diagnoses or care plans, consider the readability of your instructions. Write out anticipatory guidance and return precautions with simple sentence structure, using no more than 1 noun and 1 verb per sentence. Use videos when possible. For example, many EMR handouts contain video options for explaining to patients how to care for splints.
• If available in your ED, always use patient navigators (or other institutional resources), who are instrumental in helping patients navigate the complex health-care system. ED patient navigators are associated with higher rates of initiation of primary care following an ED visit, higher rates of attending follow-up visits, and lower rates of ED return visits.^8,9 If patient navigators are not available in your ED, be part of the solution! Talk to your operational leaders about starting a patient navigator program at your institution.

When prescribing medication, explain to patients why it is important that they take the medicine you are prescribing. Specify the timeframe you want them to take it. Is this a potentially lifelong prescription for fluticasone for their poorly controlled persistent asthma, or is this a 7-day course of doxycycline for an infection? Be sure to also explain the specific outcome intended from the medication you are prescribing. If a medication is meant to cure an infection, for example, be sure to clarify that the patient’s symptoms should improve while taking the medicine. If a medication is instead intended for the prevention of symptoms, be sure to clearly state this and verify patient understanding.

Return ED visits. If a patient returns to the ED, make an extra effort to understand why. Allow the patient to explain what has happened since their last ED visit. Was there something regarding the previous workup, diagnosis, or treatment that they did not understand? Was there an issue picking up necessary medications or accessing follow-up care? Involve social workers and patient navigators early in order to help these patients get the support they need to be successful managing their care after ED discharge.

This article is part of an EMRA Social EM Committee initiative to disseminate information about social EM topics encountered in the emergency department. More information can be found in the EMRA MobilEM app’s Patient Conversation Toolkit, available for download via iTunes and Google Play.

References 

1. Centers for Disease Control and Prevention. What is Health Literacy? https://www.cdc.gov/healthliteracy/learn/index.html. Accessed November 1, 2023.
2. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.
3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author.
4. Institute of Medicine (US) Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington (DC): National Academies Press (US); 2004. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK216033/ Accessed November 1, 2023.
5. Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications for national health policy. Washington, DC: Department of Health Policy, School of Public Health and Health Services, The George Washington University.
6. Balakrishnan MP, Herndon JB, Zhang J, Payton T, Shuster J, Carden DL. The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study. Acad Emerg Med. 2017;24(9):1042-1050. doi:10.1111/acem.13244
7. AHRQ Health Literacy Universal Precautions Toolkit. Content last reviewed September 2020. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/health-literacy/improve/precautions/index.html Accessed on October 20, 2023.
8. Peretz PJ, Vargas H, D'urso M, et al. Emergency department patient navigators successfully connect patients to care within a rapidly evolving healthcare system. Prev Med Rep. 2023;35:102292. Published 2023 Jun 23. doi:10.1016/j.pmedr.2023.102292
9. Bakshi S, Carlson LC, Gulla J, et al. Improving care coordination and reducing ED utilization through patient navigation. Am J Manag Care. 2022;28(5):201-206. doi:10.37765/ajmc.2022.89140