Additional follow-up calls for heart failure patients with limited health literacy reduced hospital readmission rates significantly following discharge.
Does health literacy screening and targeted follow-up calls reduce hospital readmissions in adult patients with heart failure?
Implementing health literacy screening and targeted follow-up calls for heart failure patients with limited literacy significantly reduces hospital readmissions.
Absolute Event Rate: 0% vs 0%
Purpose of Study: This quality improvement project was designed to close a gap in capturing health literacy in adult patients with heart failure discharged from a hospital system. An opportunity existed to investigate if health literacy levels contribute to individuals’ social factors and overall health. A priority focus was evident across healthcare organizations to address the social determinants of health (SDOH) for the populations served. Throughout the literature, limited health literacy is associated with higher hospital readmission rates. Pre-implementation data included 2023 heart failure readmission rate (19.02%) and baseline SDOH screenings (9,500) which noted housing, food insecurities, and transportation as greatest needs. There was no prior data analysis of how social factors may have impacted readmissions. Primary Practice Settings: Patients with recent hospitalization in Acute Care Hospitals with a known heart failure diagnosis; received health literacy screenings by the Registered Nurse (RN) Transitional Care Managers (TCMs) during their post-hospital discharge follow-up calls. Methodology and Sample: Pre-implementation period began in August 2024. Project launched in November 2024 with RN TCMs conducting assessments using the BRIEF (Health Literacy Screening Tool) during post-hospital discharge calls. Additional follow-up calls were required as the intervention for patients with limited literacy during their 30-day post-hospitalization transition period. Data collection occurred from November 2024 through June 2025. Results: The 8-month period included 1,543 high-risk hospital discharges, among them 580 patients with heart failure screened for health literacy; 517 patients had adequate health literacy, 44 had marginal health literacy, and 19 had limited health literacy. The intervention of additional follow-up calls for patients with limited health literacy achieved statistical significance in reducing readmissions. Implications for Case Management Practice: By implementing the BRIEF screening tool within an existing RN TCM workflow, it allowed for RN TCMs to interview patients with important questions during a vulnerable time for patients – transitioning from hospital to home. Expansion of health literacy assessments is vital for patients with any chronic condition, not just heart failure. RN TCMs identify the necessary interventions needed to support their patients and develop care plans. It is especially important to understand the needs specifically for patients with limited health literacy. Care management plays a pivotal role in patient advocacy by providing education and coordinating directly with providers to support patients’ journey to better health.
Cooke et al. (Mon,) reported a other. Additional follow-up calls for heart failure patients with limited health literacy reduced hospital readmission rates significantly following discharge.