Low Health Care Literacy and the Older Patient in the Emergency Department

Michael L. Malone, MD and Adam Perry, MD, and Rebecca Weeks BSN, MSN

GED Newsletter, May 2019

Introduction

What is Health Care Literacy

Health Care literacy refers to an individual’s ability to understand his or her health and effectively navigate the health care system. An older patient with low health literacy might present to the emergency department with repeated visits, misunderstanding of or non-adherence to their medications, or exacerbation of their chronic illness.

Providers

Poor health literacy may be intertwined with the following provider issues:

  • poor communication skills and practices
  • inability to spend enough time with the patient
  • non-native speaking provider
  • incomplete understanding of patient’s recent testing, treatment, and transitions

Patients

In addition, poor health literacy may further be affected by patient characteristics of:

  • low education level
  • poverty
  • a new immigrant to this country
  • lack of health insurance
  • other priorities in one’s life
  • substance abuse disorder
  • self- neglect
  • anxiety and depression

Age-related changes

Sensory, perceptual, and cognitive abilities work together to help people process information; therefore, the processing of health information is intimately tied with sensory processes.

Age-related changes in vision, hearing and cognition, as well as, cognitive impairments with problems in executive function should be considered when communicating health related information.

Infographic from the CDC Centre for Preparedness and Response. Patients with low health literacy are more likely to visit an emergency room, have more hospital stays, less likely to follow treatment plans, and have higher mortality rates.

Ten Strategies to Address Low Health Literacy of an Older Emergency Department Patient

  1. Recognize patients with dementia and/or delirium and implement a system to screen for these conditions during ED evaluation. During the initial assessment, ask the patient their understanding of the problem they are facing and have them explain their medications and how they are taken.
  2. Adopt a supportive and unhurried manner to minimize patient anxiety. Anxiety impairs both understanding of the ED evaluation and ability to participate in shared decision making.
  3. Reduce the risk of adverse medication events by simplifying the medication regimen, encouraging use of a pill box, and assisting the patient to use a pharmacy which provides bubble pack medications.
  4. Engage the caregiver in the care plan and elicit their support in explaining the ED evaluation and discharge instructions.
  5. Record the care plan and your medical decision making in the electronic health record. Review the EHR to more fully understand the HPI in context of recent PMH.
  6. Consider a health navigator or a nurse case manager to assist with communication and coordination in the ED and to follow up after discharge.
  7. Assess the patient’s goals, so that the plan is consistent with those goals. Consider medical decision-making capacity and the need to contact a surrogate decision maker.
  8. Ensure patients have the appropriate sensory support, such as eyeglasses or hearing amplification devices, to ensure health information is communicated effectively.
  9. Use a “teach back” method to review the patient’s understanding of their discharge instructions.
  10. Provide a “warm handoff” written or verbal report to the patient’s next provider to communicate the concerns, the plan, and the follow up appointment.

References