An older patient with low health literacy might present with repeated provider visits or phone calls, misunderstanding of, or non-adherence to, their medication plan, or exacerbations of chronic illness. 

Patient characteristics may contribute to low health literacy: 

• Cognitive impairment including dementia and delirium
• Cultural beliefs surrounding medicine and health  
• Health a more minor life priority
• Lack of health insurance
• Low educational level
• Mental illness, including anxiety and depression 
• Poverty 
• Recent immigration
• Self- neglect 
• Substance abuse 
• Vision and hearing loss

Provider characteristics may exacerbate low health literacy:

• Brief patient contact time
• Incomplete knowledge of recent testing, treatment, and care transitions 
• Poor communication skills 
• Provider and patient difference in primary language spoken

Ten Ways to Address Low Health Literacy of Older Patients:

1. Adopt a supportive and unhurried manner to minimize patient anxiety.  Decreased anxiety improves the patient’s ability to understand information and participate in shared decision making.
2. Ensure patients have the appropriate sensory support, such as eyeglasses or hearing amplification devices, to ensure health information is communicated effectively.
3. Recognize when a patient may have cognitive impairment, whether from dementia, delirium or psychiatric illness. Brief initial screening questions (e.g., “what is your understanding of your health problem”, “what are some of your medications”), may be revealing.
4. Review the medical records carefully to more fully understand the current illness in the full context of the patient. Record your medical decision making and care plans in the electronic health record. 
5. Consider medical decision-making capacity and the potential need to contact a surrogate decision maker. Assess the patient’s goals, aiming towards care plans consistent with those care and life goals.
6. Engage the family and/or caregiver in the health care plan and elicit their support in emphasizing and carrying out the care plan and discharge instructions.
7. Reduce the risk of adverse medication events in the home setting.  Simplifying the medication regimen, encouraging use of a pill box or pharmacy that provides “bubble packed” medications, and caregiver support can all be helpful.
8. Use a “teach back” method to review the patient’s understanding of their discharge instructions.
9. Consider a health navigator or a nurse case manager, if available, to assist with communication and coordination before and after clinic appointments or hospital discharge.
10. Provide a “warm handoff” written or verbal report to the patient’s next provider to communicate the concerns, the plan, and the follow up appointment.