Authors: Kelly Dinh, DO (Kings County/SUNY Downstate Department of Emergency Medicine); Natalie Hernandez, MD, MPH, (Harbor-UCLA Medical Center Department of Emergency Medicine); Manpreet Singh, MD, MBE (Director, Undergraduate Medical Education, Harbor-UCLA Medical Center Department of Emergency Medicine) // Reviewed by: Summer Chavez, MD; Brit Long, MD (@long_brit)

Case:

A 45-year-old female presents to the emergency department (ED) with episodic right upper quadrant abdominal pain. She had been discharged the previous week with a diagnosis of biliary colic and was prescribed symptomatic treatment. She returns to the ED today because her moderate postprandial pain persists with no acute or worsening symptoms. Repeat imaging and laboratory studies reveal no evidence of obstruction or other acute findings.

The patient appears upset and expresses confusion regarding the etiology of her pain and the persistence of her symptoms. Although pain medications provided partial relief, intermittent pain continues. She does not understand why her condition has not fully resolved since her initial visit.

Upon further questioning, the patient demonstrates limited understanding of the etiology of gallstones, the anatomical location of the gallbladder, preventive strategies, pain management, and her outpatient follow-up instructions. She acknowledges not comprehending the discharge instructions and was unaware of the need to schedule a follow-up appointment at the surgery clinic.

What is health literacy? 

Health literacy can have a significant impact on patient outcomes and has been defined in numerous ways. Literacy commonly refers to reading and writing skills, as described by the National Literacy Institute.¹ The Institute of Medicine also proposes that health literacy includes numerical skills and quantitative reasoning. The Office of Disease Prevention and Health Promotion (ODPHP) has introduced a new definition of health literacy, which the Department of Health and Human Services has endorsed. Health literacy is divided into two main categories: personal and organizational.²

Personal health literacy is defined as “the extent to which individuals can locate, comprehend, and apply information and services that inform health decisions and actions for themselves and others.” ²

Organizational health literacy focuses on “the extent to which organizations fairly facilitate individuals in finding, understanding, and utilizing information and services to support health-related decisions and actions for themselves and others.”²

It is crucial to note that while language proficiency and health literacy can be related, they are distinct concepts. Language proficiency is the ability to understand, communicate, and perform tasks in a language across multiple modalities such as speaking, listening, reading, and writing. An individual may be health literate in one language but struggle in another. This underscores the need for translation and interpretation services to ensure effective communication in multilingual settings.3 Title VI of the Civil Rights Act of 1964 requires all organizations that receive federal funds to provide language-congruent services.4 For these patients, you can refer to this emDocs article on Improving Care for Patients with a Non-English Language Preference.

How does health literacy impact the ED? 

Approximately 40% of ED patients have health literacy skills assessed at or below the 8th-grade level. In contrast, patient materials designed for the ED are generally written at or above the 9th-grade level.⁵

According to the 2024-2025 health literacy statistics from the National Literacy Institute, 21% of adults in the U.S. are illiterate.¹  Limited health literacy disproportionately affects Medicaid members, with 60% classified as having “below basic” or “basic” health literacy, compared to 24% of those with employer-sponsored insurance.⁶  Limited health literacy can lead to various negative outcomes, including medication errors, difficulty understanding care plans, reduced utilization of preventive services, challenges in managing chronic conditions, longer hospital stays, increased rates of hospital readmissions, higher usage of the ED, confusion during public health emergencies, and ultimately higher mortality rates.⁷

Health literacy often impacts underserved and vulnerable populations, contributing to disparities in healthcare access and outcomes.⁸ In a cross-sectional study on the link between health literacy and the ED, patients with limited health literacy had a 2.3 times higher rate of potentially preventable ED visits that led to hospital admissions compared to those with adequate health literacy.⁹ It has also led to increased visits to the ED with higher rates of return after initial visits,¹⁰ reduced use of preventive care,¹¹ a greater burden of chronic health issues,¹² and less knowledge and self-management skills related to health conditions.^10,13,14 Adults aged 65 and older with lower health literacy are also more likely to use the ED and incur higher costs associated with it. ⁵

These findings suggest the ED is an opportune setting for implementing universal, literacy-sensitive practices and piloting interventions to reduce preventable visits, ultimately benefiting both patients and the healthcare system.

What are the barriers or limitations for implementing these strategies?

Practicing shared decision-making and improving health literacy are essential for addressing social determinants of health. However, several obstacles hinder their consistent implementation in the ED.¹⁵ These barriers and facilitators can be identified at three levels: ¹⁵

1. Patient Level: Emotional factors, health literacy levels, and patient engagement in managing their healthcare.
2. Clinician Level: Fear of medicolegal consequences, a lack of skills or knowledge in shared decision-making, and clinicians’ beliefs in the superiority of certain treatments.
3. System Level: Time constraints, institutional guidelines, and the availability of patient decision aids.

Addressing these barriers at each level can improve the effectiveness of shared decision-making and health literacy in the ED.

What are the strategies to improve health literacy in the ED?

Health literacy is essential for improving health outcomes and advancing health equity. Healthcare providers play a key role in assessing patients’ understanding of health information using methods such as the “teach-back” technique. Teach-back improves comprehension of post-ED care instructions, including medications, self-care, follow-up, and return precautions, but does not affect patient satisfaction or perceived comprehension.¹⁶  It benefits all ED patients, regardless of age or education.¹⁷ Using a multimodal approach that identifies patients’ preferred learning methods, such as written materials, conversations, or videos, can further enhance information retention.¹⁸

Healthcare providers and organizations should integrate health literacy practices to achieve systemic improvements in health equity.¹⁸ This includes:

• Testing health communication materials with target audiences
• Using clear and simple language in all communications
• Designing accessible websites for users
• Providing culturally relevant education
• Consider using health literacy and/or patient activation level measurement tools
• Engaging in shared decision-making
• Practicing the teach-back method
• Providing opportunities or simulated exercises for healthcare providers to practice skills such as the teach-back method, communication skills, and use of multimodal teaching
• Offering guidance on nutrition or lifestyle that respects patients’ cultural, dietary, and religious values
• Practicing cultural humility, utilizing cross-cultural communication techniques such as motivational interviewing, and offering information in multiple languages with professional interpreter services for diverse populations.¹⁸

Integrating assessments at a systems level will significantly enhance the quality of care and elevate the patient experience. Assessing patients’ health literacy in the ED enables the development of tailored strategies to enhance information comprehension and support shared decision-making.¹⁶  There are multiple tools for assessment of health literacy, including but not limited to:

• REALM-R (Rapid Assessment of Adult Literacy in Medicine)
• NVS (The Newest Vital Sign)
• PAM (Patient Activation Measure)

A systematic review found that REALM-R had the shortest administration time among health literacy assessment tools (1.06 min).¹⁹  Both REALM-R and NVS provide direct, objective measurement of individuals’ skills using empirically grounded data,²⁰ and are less prone to self-report bias compared to other tools.²¹ The Patient Activation Measure (PAM) also assesses an individual’s knowledge, skills, and confidence in managing their health.²² Limited REALM-R scores combined with low PAM were significantly associated with increased ED and hospital reutilization.²³ These measurement tools help healthcare systems identify patients with limited health literacy, improve patient-provider communication, enhance discharge planning, and support better health outcomes for vulnerable populations.

Health literacy tools can be completed during hospital registration, by triage nurses, or by medical providers prior to discharge.  After identifying patients’ health literacy levels in the ED, it is critical to ensure comprehension. Studies show that providers deliver insufficient information 17-42% of the time,^{23,24, 25} and most patients (41-78%) leave the ED with comprehension deficits.^{17, 23, 24, 26-29}  Most patients with comprehension deficits do not recognize them, indicating that many are unaware of their lack of understanding and may have unwarranted confidence.²⁵

Recent research has highlighted that the ED discharge process presents a significant opportunity for effective patient education.²⁹ Although there are challenges like overcrowding and fluctuating workloads, the ED visit should be seen as a crucial opportunity for boosting patient satisfaction and improving compliance with medical recommendations.²⁹ This could help mitigate complications and decrease the chances of early readmissions. Enhancing patient education and health information may serve as a valuable approach to improving the safety and quality of patient care. Further studies are needed to develop evidence-based guidelines for a thorough and effective patient education strategy.²⁹

By prioritizing these health literacy initiatives, health institutions can enhance communication and patient engagement across various populations, ultimately leading to better health outcomes and greater equity.³⁰

Conclusion: 

The frequent use of EDs for preventable conditions contributes to inefficiencies and frustrations within the U.S. healthcare system.³¹ These situations delay the care of patients who are experiencing true emergencies.³¹ The Agency for Healthcare Research and Quality suggests that quality and efficiency could be improved by reducing preventable visits to the ED.³¹ Focusing on patient education, shared decision-making, and enhancing health literacy at the patient, clinician, and systemic levels may help reduce the frequency of ED visits for preventable conditions.

Case Conclusion:

Explaining the pathophysiology of gallstones and the mechanism underlying the patient’s symptoms in simpler terms visibly eased her concerns. She expressed relief and indicated that her misunderstanding had prompted her return for clarification.

She was reassured after being informed that repeat imaging and laboratory results showed no acute findings. Through shared decision-making, she was assessed on whether she required admission for intractable pain, or if discharge with supportive care and outpatient follow-up was more appropriate. She acknowledged that her pain was not intolerable and had improved since discharge, but she returned because her symptoms had not fully resolved. She had not understood that her symptoms would likely recur without a cholecystectomy. Providing this information reassured her and clarified the importance of scheduling outpatient follow-up. The plan was for her to be discharged with instructions for outpatient follow-up.

Effective patient education depends more on the quality of information delivery and patient comprehension than on the duration of the encounter. If return precautions and discharge instructions had included a simplified explanation of her diagnosis and verified understanding through the teach-back method, her return to the ED might have been prevented, thereby reducing costs and time for both patients and providers. Her persistent symptoms, combined with the misconception that pain medications alone would resolve her condition, prompted her return. It remains essential to encourage patients to seek reassessment if symptoms do not improve, persist, or worsen.

Identifying her preferred method for receiving educational materials enhanced her understanding of cholelithiasis. Involving her in shared decision-making during this visit improved the comprehension of her diagnosis, understanding of the discharge instructions, awareness of the outpatient follow-up options, and supported the scheduling of an elective cholecystectomy.

Pearls:

• Low health literacy affects a substantial portion of the U.S. population, contributing to increased ED visits, hospital admissions, and adverse health outcomes.
• Addressing health barriers at personal, clinical, and systemic levels can improve health literacy and the impact of the ED visit.
• Implementing shared decision-making and cultural humility in patient encounters can improve understanding and outcomes.
• For patients with a non-English language preference, professional interpreter services should be readily accessible to ensure clear communication and understanding. 
• Measurement tools should be used to assess the health literacy of each ED’s patient population to help improve patient-provider communication, discharge planning, and health outcomes.
• Patients’ perception of their understanding may not match their actual comprehension of diagnoses and discharge instructions. Confirm understanding before discharge and provide multimodal resources.
• Using the “Teach-back” technique can improve comprehension of post-ED care instructions, including medications, self-care, follow-up, and return precautions.
• Further research is necessary to establish standardized, evidence-based approaches for improving health literacy in emergency care settings.

Supplemental Resources:

1. National Action Plan to Improve Health Literacy Overview  (Full PDF) 

The Office of Disease Prevention and Health Promotion created a National Action Plan to Improve Health literacy that is based on 2 core principles: 32 

• “All people have the right to health information that helps them make informed decisions”
• “Health Services should be delivered in ways that are easy to understand and that improve health, longevity, and quality of life” 

The action plan contains 7 goals to improve health literacy and develop strategies to achieve them: 21   

Learn about the Teach-Back Method
3. Health Literacy Improvement Toolkit
4. Health Literacy Professional Education and Training
5. Health Literacy overview by CDC
6. Updated Health Literacy Definition

References:

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2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. History of Health Literacy Definitions. Health.gov. Updated October 31, 2023. Accessed November 1, 2024. https://odphp.health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030/history-health-literacy-definitions
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