In addition, she says, “hospital patients usually are more complicated than patients seen in an office practice. They may have chronic conditions and several comorbidities, and the information and discharge instructions the physicians give them can be pretty complex.”
Indeed, “a patient may come in thinking she had no issues and leave the hospital with four or five complaints. We’ve rocked her world, and that can be overwhelming for even the most motivated person,” says Dr. Halasyamani, who cautions that any chronic illness that requires a significant amount of ongoing self-care, such as diabetes or heart failure, can tax a patient’s ability to completely understand her situation and coordinate her care effectively.
Fragmented Care
Patients with multiple and complex morbidities also are likely to be cared for by several physicians, who prescribe numerous drugs, tests, and procedures, and who don’t necessarily know what the other members of the care team are doing. Even highly sophisticated people can get the feeling that they’re caught in an ever-changing kaleidoscope of medical visits and jargon, in which the various fragments never coalesce into a comprehensible whole. As Dr. Powers and coauthor Hayden Bosworth, PhD, wrote in a recent editorial: “ … there may be specific physician and health system organizational factors that exacerbate or mitigate the impact of low literacy. Literacy may matter more for patients who are cared for in a chaotic and discontinuous system that is not organized around delivering high quality care in a multidisciplinary setting.”7
This is more than a subjective impression: There is evidence supporting the importance of coordinated care for people of limited literacy skills. Dr. Powers and Bosworth recently compared the impact of low literacy on blood pressure control in patients in the Veterans Affairs (VA) system and those who attended local community clinics.
“Although the prevalence of low literacy was high in both populations, there was a significant association with low literacy and poor blood pressure control in the community clinics but not the VA,” Dr. Powers tells The Hospitalist. “In other words, literacy seemed to be an important predictor of good blood pressure control in one healthcare setting but not in another.”
In hospitals, “the frequency of handoffs among doctors, nurses, caseworkers, and social workers may all contribute to the fragmented nature of a patient’s care,” warns Dr. Halasyamani. This may be exacerbated even further should the patient have the misfortune to be admitted during a transitional period, such as a weekend or the end of the month when staff members rotate.
Red Flags
Literacy limitations are easy to miss: Patients rarely announce that they can’t read forms or comprehend a clinician’s instructions. “Just asking, ‘Do you understand?’ rarely works, because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively,” says Dr. Williams.
Usually, the clues are subtle. “Most physicians do encounter such patients, but we’re not trained to detect literacy problems and respond appropriately,” says Sunil Kripalani, MD, MSc, who, like Dr. Williams, is an Emory University hospitalist with a special interest in patient literacy issues. Dr. Kripalani suggests looking for red flags, including:
- Vague or evasive answers to questions. For example, “the patient who is taking a host of medications but can’t name them or tell you what time of day he’s supposed to take them;”
- Few, if any, questions or discussions of concerns: “Patients with limited literacy are less prone to ask questions, and the questions they do ask may not be as deep as those asked by a patient with greater literacy skills. The patient may use very simple terminology and not integrate any of the concepts discussed during the appointment;” and
- Missed appointments and repeated crises and hospitalizations resulting from the patient’s inability to read appointment cards or manage his illness. “Limited literacy skills may be a contributor to the exacerbations that put the patient in the hospital,” says Dr. Kripalani.