Amy Stewart, RN
Health literacy has always been an essential component of successful transitions of care, particularly at the point of discharge to the community. Limited health literacy is associated with a greater number of hospitalizations, more frequent emergency room visits, and an increase in adverse health behaviors.

Older adults tend to be more at risk for adverse events because of challenges with health literacy, according to the Cumulative Index to Nursing and Allied Health Literature Nursing Guide.

With the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) claims-based quality measure, Discharge to Community–Post Acute Care, which links successful discharge to payment, and the new publicly reported quality measure, Successful Discharge to the Community, ensuring residents’ health literacy is more important than ever for SNFs.

The Knowledge Gap

Health literacy is defined as the level at which one is able to gather, process, and comprehend basic medical information that is necessary for making appropriate choices about one’s health and treatment throughout life, according to the U.S. Department of Health and Human Services. Frequently, however, the health care professional providing discharge information to a resident or resident’s family member does not understand how best to communicate to that person, leaving him or her with a knowledge gap.

This gap can lead residents to poor outcomes, which often include hospital and emergency room visits within the 30-day window of discharge from a SNF.

Consider the following circumstance: Eighty-six-year-old Mrs. Smith is discharging home alone to her ranch house in the country following a three-week SNF stay. Mrs. Smith spent the last three weeks recovering from sepsis. She was newly diagnosed with hypertension and diabetes during her most recent hospitalization.

During her nursing facility stay, she received physical and occupational therapy and has now plateaued in therapy. Although she has not regained all of her strength, she has regained the ability to ambulate within her home with the use of a walker, which is new.

When the nurse reviews the medications list with her prior to discharge, Mrs. Smith voices concern about all the new medications she is taking and their cost; she has never had to take medications before. The nurse explains that the physician has ordered the medications and that they must be taken as prescribed. Mrs. Smith verbalizes understanding. Two weeks later, she is rehospitalized: Her blood sugar is over 500, and her blood pressure is 190/100. How did this happen? Didn’t Mrs. Smith take her medications as prescribed?

The Role of the Nursing Staff

Especially given the new quality measures, nurse leaders need to support staff in asserting their role of helping residents to understand their discharge orders and to plan appropriately to comply with them. Staff should be trained to recognize and minimize some of the challenges to health literacy that residents face.

Below are nine things that nursing staff should do:

1. Be attuned to cultural differences. It is not uncommon for residents with certain cultural barriers to respond yes without understanding, out of respect for the nurse. This is also true of residents who speak English as a second language.

2. Avoid elevated medical terminology when possible. Instead, staff should describe treatments and conditions to residents in a way that they will understand, for example, by saying sugar level instead of blood glucose, or high blood sugar instead of hypoglycemia.

3. Explain the impact of risky behavior on health status. For example, if explaining salt restrictions to a resident with high blood pressure, staff should describe types of high-sodium foods (such as individual frozen meals or canned foods) that the resident might be inclined to purchase but should avoid.

4. Ask how the resident plans to get prescriptions or travel to follow-up appointments once discharged. Asking directly forces the resident to start planning. A resident may not have a close support person, and even if there is such a person, the resident may mention not wanting to be a burden. The answer can be very telling, indicating a possible need for additional support.

5. Explain what each medication does, especially for chronic conditions. Residents may be less inclined to take a medicine consistently if they don’t understand how taking it—or not taking it—impacts their well-being.

6. Offer help in completing complex medical forms. If residents need to fill out complex forms to go see a specialist, gain access to medical transportation, or get discounted medication, they may give up and not do it.

7. Stress the importance of preventive care. Often, older adults don’t think they need to be seen for preventive care, instead waiting until there is a problem. Nursing staff should give residents the best phone number for the appropriate person at the facility and encourage them to call with questions.

8. Use teach-back methods. Residents should demonstrate that they have learned the information taught to them, for example, by demonstrating proper use of an inhaler or repeating medication instructions back.

9. Consider resident home situations, even when it’s difficult. It’s surprisingly easy to turn a blind eye to challenging home situations. Honing residents’ health literacy skills helps them identify personal challenges that may impede their completion of physician orders.

The Role of Nurse Leaders

Long term care nurse leaders and health care organizations can also commit to health literacy in a variety of ways. To start, make health literacy an organizational priority. Leadership teams may wonder why their rehospitalization rates are so high. When they identify health literacy gaps and address them, rehospitalization rates improve.

Then, leadership should implement ongoing workforce training and monitor progress.

Staff need to understand that their role communicating health information has an impact on residents’ health beyond the resident’s time in the nursing center. Ongoing training will help staff to educate residents on their health most effectively.

Learning by Evaluating

Discharge processes are key. Leaders should evaluate the processes, paying special attention to resident feedback. The population served by the health care organization should be considered in the design, implementation, and evaluation of health information and services. It is imperative to administer follow-up evaluations after care, asking residents whether they feel they were adequately prepared for home. This can help prevent the disconnect between what the organization thinks is happening when a resident prepares for discharge and what the resident experiences.

Finally, leadership should provide easy access to health information. If residents need help navigating health information platforms, leaders should be sure that help is available in the form of training or other community resources.

Health awareness campaigns can also be a great support. Print, audiovisual, and social media content can be designed and distributed in a way that is easy to understand and respond to.

For example, health literacy can be promoted through a Facebook campaign that distributes information to residents and their families about the signs of a stroke.

Benefits Abound

Providers have always been responsible for resident success in the community after discharge from the center, but now they are graded on it. Even more, providers that commit to ensuring that health literacy is addressed will see a ripple effect of benefits throughout their centers and in their measures.

In addition to seeing fewer emergency room visits after discharge to the community, these providers will have lower hospital readmission rates post-discharge (which impact value-based purchasing and the SNF QRP), a higher number of residents who are considered successfully discharged to the community (SNF QRP measure), positive publicly reported quality measures, and a lower Medicare cost per beneficiary.

As providers are increasingly paid for quality, these benefits will pay off for years to come.

Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is curriculum development specialist at the American Association of Directors of Nursing Services. She can be reached at