International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

Social Emergency Medicine Teaching Modules
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Module 5
Mohsen Saidinejad, MD, MBA


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.


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

1. Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press.

2. 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.

3. 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.

4. 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

5. National Library of Medicine. Health Literacy. literacy. Retrieved Jan 20, 2018.