Modules

Thank you for your interest in the IDHEAL Social Emergency Medicine teaching modules. Here is how we suggested we use these modules with your learners. We are working on a more in-depth faculty teaching guide for each module that will be available by December, 2018.

Each Module consists of:

1. Objectives
2. A Clinical Case
3. Discussion Questions
4. Teaching Points
5. Practical Questions about Your Institution
6. Recommended Screening Question
7. A Paired Reading from the Literature
8. Discussion/Teaching Points from the Reading
9. Additional Reading Recommendations
    

For On-Shift Teaching (10-15 minutes)
Read the case aloud to the residents and medical students. Use the questions to stimulate a brief discussion. Use the discussion questions to stimulate discussion. Use the teaching points to summarize the discussion and take-home learning points. Finally, use the practical questions to make sure learners know how this case would be handled in your own institution (i.e. available local resources and how to access them).

For Small Group Teaching (30-45 minutes)
Distribute the Suggested Reading (s) in advance of the session with sufficient time for participants to read the paper. Initiate the session as above using the case and discussion questions.

Learners with a Strong Interest (Long term)
For those learners who approach the instructor after the session with the question, “how can I learn more about this?”, we have prepared the Additional Reading Recommendations section. You can encourage them to look at the additional readings and to engage with the authors of the modules and/or the authors of the additional readings. You can also suggest that they connect with emergency physicians with similar interests by joining the ACEP or SAEM sections of Social Emergency Medicine or by applying to the IDHEAL UCLA Emergency Medicine fellowship in Health Equity.

Module 1: Language

Breena R. Taira, MD, MPH
 

Objectives

1.  Increase awareness of needs and rights of Limited English Proficiency (LEP) patients.
2. Improve knowledge of policies and laws regarding language assistance use and best practices for the care of LEP patients.
3. Demonstrate how underutilization of language assistance leads to inappropriate care and contributes to health disparities.

Case

A 77-year-old male was sent from a skilled nursing facility for “continuous crying”. The resident noted a diagnosis code for dementia in the records from the nursing facility. On interview, the patient seemed to stare blankly when asked questions. Given his Japanese surname, they thought he might speak Japanese. The medical student on the team said she studied Japanese in college and offered to try speaking with him. She reported back to her superiors that the patient gave answers but they were unintelligible. They assumed that his dementia must be advanced stage and decided to cast a broad diagnostic net, sending a variety of lab tests and a chest x-ray to check for pneumonia.

The diagnostic tests resulted but nothing was remarkable. He was admitted for a cardiac workup and had been boarding in the emergency department for 10 hours waiting for a bed in the hospital to become available. At morning sign out, the on-coming team heard his story. On rounds, the attending called a Japanese interpreter who asked him in Japanese how he was feeling. To everyone’s surprise, he answered appropriately: “I’m in pain”. “Why are you crying?” “Because my heel hurts.” His right heel had a large decubitus ulcer that had not been noted previously. He recently suffered a broken hip and his nursing facility was not changing his position in the bed, therefore he developed the decubitus ulcer. In the 10 hours that he had been in the ED, this was the first attempt to communicate with him through an interpreter. He quickly disclosed that, not only was the source of his crying the intense heel pain, but also that he was suffering ongoing neglect at the skilled nursing facility. Further, he was having difficulty speaking clearly because his dentures were left in the rehab facility. His admission for cardiac workup was cancelled, the patient received wound care, and a social work consult was called to find a new rehabilitation facility.

Through social work, the initial rehabilitation facility was reported to the state ombudsman for the neglect the patient experienced. The patient’s chart happened to be chosen for audit as the hospital prepared for a Joint Commission survey and was flagged for lack of documentation of language assistance during the initial history and physical. The team that initially evaluated the patient was made to repeat their training on a patient’s right to language assistance under title VI of the 1964 Civil Rights Act.

Discussion Questions

1. What were some of the characteristics of this patient encounter that predisposed to a failure of communication?
2. What process failure must have occurred for this to happen?
3. How do you identify a patient’s need for language assistance?

Teaching Points

1. All patient interactions should begin by ascertaining the patient’s preferred language. The patient’s preference for language assistance should be given priority over the practitioner’s assessment of the patient’s English language skills.
2. We, as health care practitioners, have not only an ethical obligation, but also a legal one based on Title VI of the Civil Rights Act to provide language assistance to limited English proficiency patients. Language assistance should be provided by someone who has verified credentials to do so, such as a certified healthcare interpreter (CHI). Use of family members to interpret is discouraged and the use of minors to interpret is expressly forbidden in many institutions.
3. Clinician use of non-English language skills when non-fluent (such as those who have taken “medical Spanish”) leads to poor patient outcomes. A team member who states they have language skills, but are not certified by the hospital as bilingual may or may not have the ability to communicate clearly. Use of certified healthcare interpreters is recommended.

Practical Questions

(The responses are intentionally excluded from the module because they are meant to be specific to your own hospital environment.)

1. What options exist in your department for language assistance?
2. What type of certification is required before speaking a non-English language with patients at your institution?
3. Is there a specific policy regarding procedural consents for patients with Limited English proficiency? 

Recommended Screening Question(s)

1. What is the language (spoken and written) in which you prefer to receive your healthcare? (List of languages)
2. Would you like the assistance of an interpreter during your visit? (Yes/No) 

Paired reading

Diamond LC “Let’s Not Contribute to Disparities: The Best Methods for Teaching Clinicians How to Overcome Language Barriers to Health Care” J Gen Intern Med 25 (Suppl 2):189–93.

Discussion Points from the Reading

1. The persistent trend of underuse of interpreters by clinicians leads to poor quality of care and worse health outcomes for LEP patients that contribute to health disparities on the population level.
2. Short term language training programs such as “Medical Spanish” may contribute to disparities because interpreter use diminishes after these trainings, yet language fluency has not been achieved. A more inclusive curriculum about how to overcome language barriers including how to work with interpreters and how to identify problems in interpreted encounters is preferable to traditional “medical Spanish” classes.

Additional Readings

Basu G, Costa VP, Jain P. Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency. AMA J Ethics 2017;19:245-52.

Fernandez A, Quan J, Moffet H, Parker MM, Schillinger D, Karter AJ. Adherence to Newly Prescribed Diabetes Medications Among Insured Latino and White Patients With Diabetes. JAMA
Intern Med 2017;177:371-9.

Price-Wise G. An Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice: Center for Cultural Competence, Inc.

Taira BR. Improving Communication With Patients with Limited English Proficiency. JAMA Intern Med 2018 Mar 19 (Epub ahead of print).

Module 2: Culture

Kian Preston-Suni, MD

Objectives

1. Understand the connections between culture and health care.
2. Learn to consider an approach to providing patient-centered and respectful care when differences exist between patients, families and their physicians.

Case

A 64-year-old man originally from El Salvador presents to your Emergency Department complaining of fatigue, weakness and weight loss. You perform a history with the assistance of a Spanish interpreter, identifying, along with the above symptoms a vague, persistent abdominal pain and decreased appetite. You note a frail appearing man in no acute distress with scleral icterus. His daughter tells you in English that he’s never been sick and previously worked long hours in a warehouse until two weeks ago when his fatigue and weakness began to prevent him from working. He thought his symptoms were from empacho and visited a sobador for the abdominal pain but found no relief from the treatments provided.

A CT of the abdomen and pelvis shows a pancreatic mass with liver lesions and peritoneal enhancement. When you are about to enter the room, the daughter requests that you explain the findings to her, but not to your patient. You engage the daughter in discussion outside the room. She explains that her father tends to be very fatalistic and think that disease is God’s punishment. She is afraid that if you explain to her father that he has cancer that he will refuse treatment.

Notes

Empacho is a culture-bound syndrome, or folk illness, in which it is believed that food becomes stuck to the stomach or intestines and causes an obstruction. Symptoms may include abdominal pain, bloating, diarrhea, vomiting, or anorexia. It is generally treated with massage, herbal remedies, or dietary changes.

A sobador is an alternative medical provider used in various Latin American cultures to address aches, pains and other complaints. They provide varying combinations of massage, manipulation, creams and herbal remedies.

Discussion Questions

1. Have you encountered patients that seek treatment from traditional healers?
2. How would you address the daughter’s request to not inform the patient of the imaging findings?

Teaching Points

1. Recognizing cultural differences and providing care that is respectful of these differences is important in providing high quality medical care. This often requires humility on the part of the physician. Patient’s attribution of the cause of the disease may lead them to make different choices about types of healers and treatments than a physician might recommend. Healthcare providers should strive to attain cultural humility in order to create an atmosphere of open communication with patients of differing socio-cultural backgrounds.
2. Patient and family requests may differ from what you recognize as “appropriate”. In this case, the family is asking the physician to withhold information from the patient. In the U.S., we tend to value autonomy and choice and believe that the patient’s ability to make informed decisions trumps other priorities. This value may not be shared by patients and families. Some families may believe that shielding the family member from a bad diagnosis is more important to the patient’s overall well-being. This can be difficult for the provider to navigate. Interpreters can aid health care professionals by acting as a “cultural clarifier” in situations like this.
3. Patients may seek care from a combination of formal medical providers and from traditional or alternative sources. Patients may gain some physical or mental relief from suffering from seeing a traditional healer. Health care professionals should encourage patients to share this information openly and receive the information in a way that is free from judgement. Only if the health care professional establishes and open and trusting relationship will they learn what other types of treatment the patient is seeking and then can also assess concerns for treatment interaction and be assured that treatment plans are based on the entire picture.

Practical Questions

1. What resources are available in your hospital when providing care for patients whose cultures are different than your own?
2. How can you approach a patient or family request which differs from you view as acceptable?

Recommended Screening Question(s)

The LA County Health Agency SBDOH workgroup recommends cultural humility and understanding when working with all patients.

Paired Reading

Teal CR, Street RL. Critical elements of culturally competent communication in the medical encounter: a review and model. Soc Sci Med 2009;68:533-43.

Discussion Points from the Reading

1. A culturally competent health care professional has the capacity to recognize and reconcile sociocultural differences between provider and patient to achieve a patient-centered approach to care.
2. The authors describe a model of culturally competent communication with four components: communication repertoire, situational awareness, adaptability, and knowledge of core cultural issues. When using this model, a health care professional whose communication is based in empathy, caring and respect can provide culturally competent care for any patient, regardless of the provider’s specific knowledge of the patient’s culture. Invitation of the patient’s perspective on their symptoms and illness with non-judgmental reactions and follow-up questions are key elements of culturally competent communication.

Additional Readings

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.

Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/S0022-3476(00)90043-X

Many in Boyle Heights Look to Sobadores for Relief from Pain.
Available from: http://www.boyleheightsbeat.com/many-in-boyle-heights-look-to-sobadores-for-relief-from-pain-754/

Fadiman A. The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux; 1997.

Module 3: Race

Breena R. Taira, MD, MPH

Objectives

1. Discuss race as a social construct and understand the levels of racism.
2. Increase awareness of how racial bias contributes to health disparities.
3. To become aware of one's inherent biases and how these might impact your own behavior as a provider.

Case

A 39 year- old English-speaking Black male presents to an inner-city emergency department. He had spent the day moving into a new apartment. This evening as he unpacked his boxes, he started to feel some shortness of breath. He had noted earlier that there was a significant amount of construction dust covering the floors of the new apartment and he had been sneezing all day. He had a history of childhood asthma and had memories of many nights in his childhood spent in the emergency department for breathing treatments, but had mostly outgrown the asthma as he became older. Tonight was different as he felt gradually progressive dyspnea - he felt as if the childhood asthma had returned with a vengeance. Patient waited, hoping it would go away. He was hesitant to go to the hospital because he remembered the disparaging looks given to his mother when he presented to the ED as a child. They always seemed to imply that his uncontrolled asthma was her fault. He carried this negative feeling about healthcare into adulthood and tried to avoid medical care unless absolutely necessary. Finally, the patient could barely breathe and started to think he might die, so he went to the nearest ED.

He walked into triage and said that he needed help and couldn’t breathe. They told him to sit and wait his turn. He tried to explain repeatedly to the triage nurse that he could not breathe and was finally given a room in the ED. He was placed behind a curtain where he could not see anyone and no one came to evaluate him. He walked out of the curtain area to the desk and again said, “I can’t breathe, can you help me?” to which the clerk responded, “You’re walking so you must be breathing.” Finally, a white male physician appeared to evaluate him. He took the patient’s history and said,” You are fine; it's a panic attack, I will order some Ativan.” without listening to the patient’s heart or lungs. The patient replied that he did not feel anxious. The patient thought about the traumatic experiences he had in the past - surviving 9/11, two motorcycle accidents - and never had a panic attack. Could he be having one now? And wouldn’t it be a coincidence that it felt just like his asthma and occurred just after an environmental trigger? As the physician left the curtain area, he said to the nurse- “That guy looks fine, discharge him after the Ativan.” The patient decided to leave the ED and took an Uber to a nearby university hospital emergency department where he was evaluated and treated immediately with nebulizers for an asthma exacerbation. The patient, being highly educated with two Ivy League degrees, filed a formal complaint to the CMO of the initial hospital for poor quality care and disputed his bill. The CMO is puzzled as this provider usually has excellent Press Ganey scores and is known to be a competent clinician. This patient, however, denies ever being given a Press Ganey evaluation to fill out. On further investigation, the CMO learns that the clerks choose which patients receive the Press Ganey cards and generally choose based on "who looks educated enough to follow the instructions."

Discussion Questions

1. Was the care provided at the first hospital appropriate?
2. How did race impact care? Did it lead to different care? How did age play into the care?
3. How might this experience impact the patient's interactions with healthcare professionals in the future?

Teaching Points

1. Racism is not necessarily overt. Implicit bias describes the phenomenon of having a preference for or an aversion to a group of people without conscious awareness that the preference exists.
2. Health care professionals (just as all other individuals) are often unaware of their own implicit biases. In healthcare there is risk to the patient when a provider, unaware of his/her bias delivers a different type of care to a certain group based on his/her implicit bias. Often the discussion of implicit bias in the United States focuses on the negative implicit bias against Blacks harbored by other racial groups based on the years of racism that was normalized in our culture. This is an important example that is pervasive and has many societal and health repercussions. Implicit bias by definition, however, can be based on other group characteristics, not only skin color.
3. On the population level, the medical encounter is often cited as a potential source for persistent health disparities in the United States. Actions fueled by implicit bias on the part of the provider may be perceived as blatant racism by the patient. On the patient level, interactions like these contribute to continued mistrust of the healthcare system and worse patient outcomes for minority groups on the population level.

Practical Questions

1. Have you considered what your own implicit biases may be?
2. How can we become more cognizant of our own biases so that they do not influence medical decision making?

Consider recommending the Harvard Implicit Bias test that can be taken on-line free of charge:
https://implicit.harvard.edu/implicit/takeatest.html 

Recommended Screening Question(s)

The LA County Health Agency SBDOH workgroup has not developed any recommended screening questions for implicit bias. To screen for patient’s race and ethnicity, it recommends:

What is your racial and ethnic background?

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White
• Hispanic, Latino, or Spanish Origin
• Mexican, Mexican American, Chicano
• Puerto Rican, Puerto Rican American, or of Puerto Rican descent
• Cuban, Cuban American, or of Cuban descent
• Another Hispanic, Latino, or Spanish origin
• Multiple Race, including Mestizo
• Other

Paired Reading

Jones CP. Levels of Racism: A Theoretical Framework and a Gardener’s Tale. Am J Public Health 2000; 90:1212-1215.

Discussion Points from the Reading

1. The three levels of racism discussed in this article include: internalized, personally mediated and institutionalized.
   • Institutionalized: differential Access to the goods, services and opportunities of society by race.
   • Personally Mediated: prejudice and discrimination where prejudice means differential assumptions about the abilities, motive and intentions of others according to their race.
   • Internalized: acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.
2. How do the three levels of racism described in the paper relate to the case above?
   • Personally-mediated racism predominates in the interaction between the patient and provider. The provider provides substandard care, likely on the basis of his unconscious bias. Institutionalized racism exists in that the system of evaluating provider performance is limited to those who look "educated" according to the ward clerk, which very likely has a racial skew. This is an example of how an individual's (ward clerk's) implicit bias becomes institutionalized racism.
3. Can you think of examples of each from your own experience of the three levels of racism? How might they impact health outcomes?

Additional Readings

Hagiwara N, Slatcher RB, Eggly S, Penner LA. Physician Racial Bias and Word Use during Racially Discordant Medical Interactions. Health Commun 2017;32:401-8.

Black Man in a White Coat by Damon Tweedy, MD

Seeing Patients: Unconscious Bias in Health Care by Augustus A. White III, M.D.

The documentary 13th by Ava DuVernay (http://www.avaduvernay.com/13th/) 

Module 2: Gender Identity

Breena R. Taira, MD, MPH

Objectives

1. To recognize that the transgender population may have concerns about disclosing their gender identity and to discuss strategies to approach the subject when relevant to the ED visit.
2. To learn how to incorporate gender identity into clinical care.

Case

A 44-year-old English-speaking Latina female presented to the emergency department with chronic indolent left lower quadrant abdominal pain for 3 months. Patient says she has waited this long because of some bad experiences with the healthcare system in the past but today the pain was so bad she finally decided to come in. She gave a history of progressively worsening pain, localized to one specific point in the left lower quadrant without any bowel complaints such as diarrhea, or constipation. She denied nausea, fevers, dysuria or any other associated symptoms. After a history and physical, the initial physician decided the patient was a “rule out diverticulitis” workup. Lab work was normal. The patient was signed out to a second physician pending a CT scan of the abdomen. When the second physician received the read from radiology, it read “Left sided undescended testicle” with no sign of diverticulitis. The CT scan shows male genitalia. On receiving the read, the second physician thinks maybe she had misunderstood her sign-out and looked at the initial note. On review of the documentation, the note consistently refers to the patient as female and makes no mention of an exam of the genitalia. The second physician ponders how to best approach the situation with the patient, whom she has not yet met.

Discussion Questions

1. How would you approach this patient?
2. How do you typically initiate a discussion of gender identity?
3. Why is the second provider in the case uncomfortable about the pending discussion?
4. What measures can she take to facilitate a smooth and respectful interaction?

Teaching Points

1. Transgender patients may be uncomfortable disclosing their gender identity and not offer the information freely. Even if the transgender patient tries to disclose their gender identity, there may be no appropriate way to record a trans-person's gender in the electronic record. Most electronic health records only allow for "male" or female", which can make an awkward situation/choice for both the patient and the registration worker.
2. Discussing gender identity is something that all health care professionals should feel comfortable with. For those who have less experience talking with trans patients, thinking through respectful language and having a planned script in advance of the interaction can be helpful. It is okay to ask about gender identity when it relates to the medical problem at hand and encouraged to ascertain the patient's preferred pronoun. Providers should be weary of using judgmental or demeaning wording when asking about gender identity. It is also preferable to use unassuming terminology when referring to partners such as "significant other" when appropriate.
3. Transgender people may avoid ED visits and sometimes healthcare in general because of concern for lack of respect and knowledge amongst healthcare workers regarding gender identity.

Practical Questions

1. Do you know how gender is recorded in your electronic health record and what the answer options are?
2. What practical improvements could be made to processes in your ED to help minimize repeated questioning about gender identity and to make communication about gender identity more private?
3. Are there local resources available for transgender patients to obtain primary care in a supportive environment with providers who are expert in transgender care?

Recommended Screening Question(s)

1.  What is your gender identity? (Check all that apply)
   • Male
   • Female
   • Transgender male, trans man, female-to-male, trans-masculine
   • Transgender female, trans woman, male-to-female, trans-feminine
   • Genderqueer, neither exclusively male nor female, non-binary, or gender nonconforming
   • Additional gender category/Other (please specify): ____
   • Choose not to disclose
2. What is your identifying pronoun?
   • He
   • She
   • They
3. What sex were you assigned at birth, or was listed on your birth certificate?
   • Male
   • Female
   • Intersex
   • Other
   • Unknown
   • Choose not to disclose

Paired Reading

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. "Sometimes You Feel Like the Freak Show": A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients. Ann Emerg Med 2017.

Discussion Points from the Reading

1. Lack of privacy to disclose gender identity and repeated questioning from the healthcare team about gender identity is a source of distress and can produce a negative overall experience in the ED for transgender patients.
2. Basic education about trans patients is lacking in medical training curricula.
3. Clear communication about why sensitive questions and exams are necessary are helpful.
4. Binary gender documentation can be difficult to navigate for transgender patients and can cause confusion for the providers.

Additional Readings

Chisolm-Straker M, Jardine L, Bennouna C, et al. Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences. Transgend Health 2017;2:8-16.

Jalali S, Sauer LM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Ann Emerg Med 2015;66:417-23.

Maragh-Bass AC, Torain M, Adler R, et al. Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare. Acad Emerg Med 2017;24:655-67.

Maragh-Bass AC, Torain M, Adler R, et al. Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives. LGBT Health 2017;4:141-52.

Module 5: Health Literacy

Mohsen Saidinejad, MD, MBA
 

Objectives

1. To understand the importance of healthcare provider communication in improving health literacy for patients.
2. To understand the role of language fluency, education and culture in shaping health literacy.
3. To understand health literacy as a major contributor in medical decision-making.
4. To recognize the need to help patients find information and services needed to better care
   for their healthcare needs, including connecting the patients to their medical home.

Case

A 6-year old Hispanic male is brought by emergency medical services (EMS) in respiratory distress. His mom, who only speaks Spanish, states that the child may have asthma and was treated in the emergency department (ED) several times for the same problem, including a visit 2 days ago. The grandmother, who is the main caregiver to the child, was the one that brought him last time, so she is not sure what instructions the grandmother received. The grandmother did tell the child’s mother that a phone interpreter was used to communicate with her. The mother has an asthma inhaler for him, which was given to him a few months ago, and is now almost empty. She has a prescription for another asthma inhaler and another medication, which she has not had the time to fill. On arrival, the patient is in moderate respiratory distress, with tachypnea, and severe inspiratory and expiratory wheezing. He also has a persistent cough. His mother states that she is not sure who the child’s primary care provider is, because she usually brings him to the ED when she has a medical concern. She also states that she was given a color-coded paper during a prior ED visit, that was supposed to help her understand how bad the child’s asthma is, but she did not understand it, and she no longer has it. After a few rounds of treatment, the child is doing much better and is ready for discharge. Considering the history of this presentation, what can you do to help this family with their medical decision-making and disease outcome?

Discussion Questions

1. Why did the child come back to the emergency department?
2. How does having mom and grandmother take care of the child affect his care?
3. What can be done to improve this child's care at home and prevent him from bouncing back
   to the ED?

Case Discussion

Note: Health Literacy is defined in the Institute of Medicine report, Health Literacy: A Prescription to End Confusion as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." This is a very common presentation to the ED, where health literacy directly influences health behavior and disease outcome. This child, who likely has asthma, needs to be connected to several resources. First, he does not have an identified primary care provider (medical home). Second, he has multiple caregivers, which may augment the impact of communication issues. Third, his mother does not understand the instructions which may have been given to her. Fourth, his mother is describing the color coordinated form to help diagnose his asthma severity. This is the asthma action plan, which is an important resource for all asthmatics. Although she has the form, she does not understand it or know how to use it. This signals a failure of communication on the previous visit by the provider who gave her the sheet. Fifth, he is back in the ED within 2 days of his last visit, which suggests that the grandmother and mother likely were not able to follow the treatment plan. This could be due to a combination of provider communication (an essential component of patient health literacy) and lack of caregiver understanding (caregiver health literacy). When patients or their caregivers don’t understand the medical problem due to limited health literacy, they are not well-positioned to engage in shared decision making.

Teaching Points

1. Healthcare providers should take care to ensure that patients (and caregivers in the case of a minor) understand their care instructions. The material should contain simple language, be at a proper reading level (~ 5th grade education level), and make use of graphics and simple illustrations when possible.
2. When a language barrier is present, use of a trained interpreter is essential. In-person interpreters may be more effective than phone interpreters. Interpreters are just as important at discharge as they are during the initial history and physical to help the patient and family understand and increase the potential for treatment adherence. It is important to ensure that discharge instructions and prescription labels are in the patient's preferred language.
3. An important factor related to limited health literacy is the lack of access to a medical home. If the patient does not have a long-term relationship with a primary care provider, they have less opportunity to ask questions and receive less anticipatory guidance. This may increase ED recidivism.

Practical Questions

1. What are some practical things can you do at discharge to improve patient understanding?
2. Do you use pre-printed discharge instructions? If so, have you checked their reading level
   and their availability in other languages?

Recommended Screening Question(s)

1. How confident are you filling out medical forms by yourself?
   • Always
   • Often
   • Sometimes
   • Occasionally
   • Never

*Please note that when working in settings with a high prevalence of patients with limited health literacy, the LA County SBDOH Workgroup recommends not screening for health literacy but instead taking universal precautions, meaning ensuring that all materials and discussions are accessible to those with limited health literacy.

Paired Reading

Griffey RT, Shin N, Jones S, et al. The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: A randomized, controlled study. J Commun Health 2015;8:10-21.

Discussion Points from the Reading

1. Discharge from the Emergency Department is recognized as a high-risk transition of care that has potential for miscommunication with patients. Because of language barriers, limited health literacy and cultural differences, patients may not feel empowered to question providers when they do not understand their diagnosis or treatment plan.
2. The "teach-back" technique is a method of improving patient provider communication. The patient is prompted to "teach-back" to a provider the information conveyed to confirm comprehension. In this study, patients who received a discharge that included a teach-back had improved comprehension of their post-ED care instructions.

Additional Readings

Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press. https://doi.org/10.17226/10883.

U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, DC: U.S. Government Printing Office. Originally developed for Ratzan SC, Parker RM. 2000. Introduction. In National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.

Brabers AEM, Rademakers JJDJM, Groenewegen PP, van Dijk L, de Jong JD (2017) What role does health literacy play in patients' involvement in medical decision-making? PLoS ONE 12(3): e0173316. https://doi.org/10.1371/journal.pone.0173316 

Agency for Health Care Research and Quality (AHRQ). 2011. Health Literacy Interventions and Outcomes: An Update of the Literacy and Health Outcomes Systematic Review of Literature, 2011

National Library of Medicine. Health Literacy. https://nnlm.gov/priorities/topics/health- literacy. Retrieved Jan 20, 2018.