DISMISSED: Patient Literacy and Effectively Communicating Discharge Instructions

Guest Blog by Andrew Jesse Brown (CUNY SPH)

at the doctor's office

at the doctor’s office


In a recent podcast, Dr. Martin Zielinski, trauma surgeon and Assoc. Professor of Surgery at the Mayo Clinic (Rochester, NY) discusses the results of his research on effective patient discharge communication. He studied how well trauma patients understand discharge instructions. Dr. Zielinski’s study of trauma patients at discharge hypothesizes that the presentation of concussion may effect a patient’s ability to comprehend discharge instructions.

I propose that health communicators ought to be sensitive to a variety of factors when designing discharge materials for a target audience such as audience demographics (e.g., age, preferred language, level of educational attainment, religious/spiritual preference), situational attributes (e.g., what settings is the care transition involving, who are the agents involved in the patient’s care), and socio-environmental factors (e.g., is the patient willing and able to follow the care instructions they are given). What other factors could health communicators be sensitive to when designing messages, specifically discharge materials, for a target audience?

If you’re attending our Communicating Public Health class this semester at Hunter, this podcast episode may have seemed particularly resonant with our discussions in Class 2 and 3 about health literacy and models of effective communication.  The podcast also ties in with the Zarcadoolas, Pleasant, & Greer article regarding an expanded model of health literacy. Readers seeking additional information on the topic may also be interested in the research of Eric A. Coleman, an expert who has performed quality assessments of the patient discharge experience. The discussion with Dr. Zielinski underscores an important consideration in health communication: the ability of the audience to understand.  The audience’s ability to understand cannot be overestimated by those who intend to facilitate effective discharge instruction.  Communicators should never assume they are always understood.

Readability — the level at which material is prepared for the general public — is typically qualified by grade level of educational attainment.  The American Medical Association recommends that material prepared for the public should be readable at a 6th to 8th grade “reading level”. As a result of Dr. Zielinski’s disciplinary analysis of the readability of their discharge materials, the Mayo Clinic now targets its trauma discharge instructions to be readable at a 6th grade literacy level. In fact, the study’s results has led other departments at the Mayo Clinic (plastic surgery, for example) to revise their discharge materials with the end-users’ readability in mind.

Considering communication through the lens of a dynamic constructivist model allows for the development of appropriate, informative, multidisciplinary, multifaceted, high-touch, consistent and repetitive communication through which effective discharge and care coordination may be realized.  The commentators in the discussion suggest this could be positive or negative.  On the one hand, a more integrated system provides greater aptitude for change.  On the other, more cooks in the kitchen leads to a higher likelihood of mishandling, more cracks for patients and patient care to fall through, and so on.

What is your impression on the issue?

Have you ever been bewildered by discharge materials after an encounter with an inpatient situation? If there was one thing you could change when it comes to discharge materials, what would it be and why?

9 replies
  1. Milan Siemens
    Milan Siemens says:

    Prescribing providers should educate patients about each medication, including its name, appearance, purpose, and effect. This education should include any potential adverse effects and interactions of each medication, as well as the importance of contacting a healthcare provider should any questions or concerns arise

  2. Sarah Goldberg
    Sarah Goldberg says:

    The solution to the problem AJ posits of lack of understanding by patients upon discharge has been (in some situations) solved by using Community Health Workers for follow-up care in person. (Nevilla mentions using medical personnel for follow-up in person or over the phone.) As Chris points out – doing some of the work upon admittance means doing risk assessment early and then assigning CHWs to the most vulnerable cases. This system has been in place since S. Josephine Baker began developing the Nurse-Family Partnership in the late 1800s. We have evidence-based data supporting in-person follow-ups – we just don’t have the funds to support it. (Moreover, we don’t always have support of the patients themselves.)

    Horizontal integration – as AJ also brings up – can solve the money problem of paying for CHWs (and dealing with their powerful union) by allowing for economies of scale and with the additional benefit of the being able to integrate EMRs (Juan’s and Chris’s issue).
    This of course – is why Columbia and Cornell merged; why NYP just bought Queens, why Mt. Sinai and Community Health Partners merged in 2013, and why Health + Hospitals is such a large network. I struggle to come up with the negatives of horizontal integration beyond the immediate loss of jobs when eliminating repetitious services. Vertical integration seems dangerous – causing monopolies and leading to a perpetuation of unneeded services.

    Is horizontal integration the solution used by other countries with public hospital networks and single-payer systems?

    (Nurse-Family Partnership – http://www.nytimes.com/2015/03/09/health/program-that-helps-new-mothers-learn-to-be-parents-faces-broader-test.html)

  3. Juan Lopez
    Juan Lopez says:

    Thanks for writing a wonderful blog entry AJ! I find it amazing that in such an overpriced system as is American healthcare, we cannot provide patients with something a bit more substantive and hands-on than a generic list of mundane instructions. As Liam and others pointed out, discharged patients aren’t exactly ‘tip top,’ which makes the lack of a more personalized discharge experience mind-boggling. I understand that it is nearly impossible to provide all patients with a one-on-one, personalized follow-up after discharge, particularly in the massive institutions we know in the city, but limiting ourselves to nothing more than a cookie-cutter list of instructions is unacceptable.
    AJ and Chris referred to hospital integration, which is limited by the lack of integrated electronic medical record (EMR) systems. When it rains it pours, and a hodgepodge healthcare system like ours will always be more prone to problems such as these, keeping providers from supporting one another in the best way possible.

    At the end of the day, this is just one noticeable piece of a system that has always been a mess. Sick people aren’t pieces of Ikea furniture, and that’s exactly how hospitals treat them. We are all responsible for fixing it.

  4. Nevila Bardhi
    Nevila Bardhi says:

    Very good points AJ, Clarissa and ChrisZ!
    Discharging of patients is a delicate point, perhaps more delicate than admitting them at the hospital in the first place. Imagine a person who had just had surgery, cannot move and the last thing he wants to hear is how to take his medication, clean his wound or in what position is best to sleep. This becomes even harder if the patient is discharged earlier. There is also the matter of readmission. A person that does not follow discharge instructions is more likely to be readmitted, although this phenomenon is somehow being diminished by the establishment of ACA. Started in 2012, all hospitals that get readmission of patients due to preventative causes are not being paid anymore for their services by Medicaid and Medicare(see link below). This measure has made many hospitals follow up with their patients after discharge and even send medical personnel at patient’s residences to make sure they are recovering smoothly. Isn’t this some green light on the horizon! I think it is…

  5. Liam
    Liam says:

    Great blog AJ! I really enjoyed reading it and appreciate you bringing up this important topic. I definitely agree that there are so many factors to take into consideration when designing discharge materials. However, it’s not only the materials that patients take home that need to be more sensitive to their needs, but also the process of discharge as well- specifically how they are being educated on such materials. From my own experience, when working at the hospital with patients, I always felt that they were not always in the right state of mind for receiving education. During their time at the hospital they are either in pain, sedated, weak, and uncomfortable for so many reasons, which does not really encourage or help in obtaining any kind of education. Also, as Prof. Zarcadoolas mentioned earlier, they tend to go home still weak and not completely fit to understand and implement the instructions they just received. I agree that the process could begin when they are admitted, but I also feel that there should be a strong component of a follow up, either by phone or home visit if possible since the time from admission to discharge may be too long to retain such information. Also, when doing follow ups, a good practice for educating patients is the teach-back method. It is basically having the patient show you what they just learned by teaching it back to you. By doing so the audience’s ability to understand cannot be overestimated because they demonstrate to you what they understand and able to implement at home.

  6. ChrisZ
    ChrisZ says:

    You raise some dense issues that go far beyond the scope of the Communications class. That said, one of the things that still would be problematic in vertical and horizontal “integration” is that each hospital ( for instance) is using its own electronic medical record system. That’s a huge problem.
    There is no way to currently share patient data across various institutions. Unless two hospitals buy and install the same EMR – they can’t effectively share patient information.

  7. Clarissa Padilla
    Clarissa Padilla says:

    Thank you AJ for being the guest blogger this week and providing us with this insightful article. It certainly has tied together much of what we have learned these last few weeks in class. This article reminds me of a film called “Escape Fire the Fight to Rescue American Healthcare” which states 187,000 people die each year from harmful care in the U.S and doctors get paid roughly 1,500 dollars for a something like a stent but just talking to a patient to assess for root causes get them 15 bucks! As the film notes, this is related to ineffective communication as our fee-for service system allows medical doctors to get paid for delivering more care as opposed to keeping patients healthy with simple consultations. One medical doctor states, “our healthcare system is silent and specialized”, leading to massive medical errors and deadly infections. I believe we can view discharge instructions on the same continuum. How well patients understand health information keeps them in this “revolving door system. As professor Zarcadoolas lecture states, “the strongest predictor of health over factors such as employment, education and race is health literacy”. It is by definition our ability to process health information in a meaningful way and apply it towards our overall health. If we cannot provide effective communication on medications and health management, we are adding this fee-for-service system. Some other factors which are important to consider are science literacy and fundamental literacy as noted by Zarcadoolas, Pleasant and Greer (2005). These factors expand on how individuals process scientific concepts and basic reading, writing, speaking and math levels. These are also essential when processing discharge information which, even in its simplest terms, may contain warnings or dosage levels which may not be readily understood. We must also be mindful of vulnerable populations. People who have any form of trauma (physical, emotional, mental) coupled with their own levels of health literacy will certainly need more clear discharge information. If I could change one thing about the discharge materials I would suggest more visual items, step by step processes instead of small, print paragraphs and a contact sheet with various languages for those who need further explanation. However, I still feel the healthcare system would need to support any and all attempts to improve health from an ecological perspective. Providing discharge information even with respect to health literacy doesn’t mean people will comply. Other factors, like doctors talking instead of always treating will ultimately support any need for discharge instructions and long term health. This seems to be the upstream factor for changing health related material.

    Zarcadoolas, C. Pleasant, A Greer, D. Understanding health literacy: an expanded model. Health Promotion International. (June 2005) 20 (2): 195-203.
    Kravetz, L. Escape Fire the Fight to Rescue American Healthcare. YouTube.com. https://www.youtube.com/watch?v=g1uEnXtykbU. Published August 12, 2015. Accessed March 2, 2016.

    • ChrisZ
      ChrisZ says:

      Thank you for your thoughts – it reminded me of something else I learned when I was interviewing patients about their discharge experience. And that is, if one has been ill enough to be hospitalized, chances are they’re not going home quite fit as a fiddle. With hospitals discharging patients earlier, they often go home still weak and ill and needing care. In this diminished state they are given discharge instructions. The worst time to have to focus on specifics. Family caregivers try to pick up the responsibility – but this is also hard.
      To focus on improving the discharge process from a patient communication and education perspective – more often now you hear critiques saying that the process MUST begin when the patient is admitted.
      See AHRQ link below.

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