Abstract
After hospital discharge, patients commonly suffer potentially avoidable adverse events and hospital readmissions. As hospitals implement interventions to improve discharge transitions, it is important to understand patients' perspectives on which intervention components are most beneficial. This study examined a sample of 125 patients randomized to the intervention arm of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease study who completed a telephone survey about the helpfulness of different components of the intervention, which included medication reconciliation, inpatient counseling, simple adherence aids, and telephone follow-up. The majority of patients indicated that it was “very helpful” to speak with a pharmacist about their medications before discharge (72.8%), particularly about how to take the medications and how to prevent and manage side effects. Receiving an illustrated medication list (69.6%) and a follow-up phone call after discharge (68.0%) were also considered very helpful. Patients with limited health literacy indicated the greatest benefit. Patients also reported feeling more comfortable speaking with their outpatient providers about their medications after receiving the intervention. In conclusion, patients—particularly those with limited health literacy—found a hospital pharmacist-based intervention to be very helpful and empowering.
Care transitions have been identified as a major point of confusion and miscommunication for patients, families, and healthcare providers (Bodenheimer, Citation2008; Coleman & Berenson, Citation2004). In particular, the transition from hospital to home is a vulnerable time (Kripalani, Jackson, Schnipper, & Coleman, Citation2007). During the sometimes chaotic discharge period, many patients are sent home without adequate instruction on medication management, follow-up appointments, and other necessary information to ensure a successful postdischarge (Cua & Kripalani, Citation2008; Greenwald, Denham, & Jack, Citation2007). Consequently, patients often feel ill-prepared to provide appropriate self-care during the transition to home (Graumlich, Novotny, & Aldag, Citation2008). Incomplete or delayed communication between inpatient and outpatient providers further complicates postdischarge care (Kripalani et al., Citation2007). In this context, it is not surprising that adverse events and unplanned hospital readmissions are common, each affecting approximately 20% of patients during the first few weeks after discharge (Forster, Murff, Peterson, Gandhi, & Bates, Citation2003; Jencks, Williams, & Coleman, Citation2009).
Growing recognition of these problems and mounting policy pressures (Axon & Williams, Citation2011) have prompted hospitals and health systems to implement a number of interventions that seek to improve care transitions. These include medication reconciliation, enhanced discharge counseling, health coaching, and timely follow-up. Many of these interventions focus on reducing readmission to the hospital (Hansen, Young, Hinami, Leung, & Williams, 2011), while others seek to improve medication management, quality of life, and satisfaction (Preen et al., Citation2005; Schnipper et al., Citation2010). It is unfortunate that despite positive results from a few well-conducted studies (Coleman, Parry, Chalmers, & Min, Citation2006; Jack et al., Citation2009; Naylor et al., Citation1999), most care transition interventions have not proven efficacious in reducing readmission (Hansen et al., Citation2011).
In the available literature, patient perspectives about care transition interventions have been conspicuously absent. Particularly given the mixed results of published studies, a better understanding of patients' views on different types of assistance could help guide the development and implementation of future care transition interventions. Moreover, as patients' health literacy likely plays a crucial role in their ability to navigate the transition from hospital to home, it would also be valuable to understand how patients' needs and perceptions differ according to their level of health literacy.
Despite numerous published studies on health literacy (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011), surprisingly few have focused on the vulnerable transition period from hospital to home (Chugh, Williams, Grigsby, & Coleman, Citation2009). Kripalani and colleagues surveyed patients 2 weeks after discharge and found that individuals with inadequate health literacy gave lower ratings to the clarity of their physicians' communication in the hospital (Kripalani et al., Citation2010). Lindquist and colleagues found that, 48 hours after hospital discharge, elderly patients with limited health literacy were more likely to have unintentional nonadherence to their medications, often related to not understanding their discharge instructions (Lindquist et al., Citation2011). On the basis of these findings and others in the outpatient arena (Berkman et al., Citation2011), it is likely that patients with limited health literacy have distinct needs and would benefit from different forms of assistance when returning home from the hospital.
We recently performed a randomized controlled trial of a multicomponent, health literacy-sensitive care transition intervention to reduce medication errors during the 30-day period after hospital discharge (Schnipper et al., Citation2010). Here, we describe participants' assessment of the different components of the intervention, and how this varied according to their health literacy level.
Method
Participants
Subjects were participants in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study. The PILL-CVD study was a two-site randomized controlled trial of patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Patients were eligible for the trial if they spoke English or Spanish, were at least 18 years of age, and managed their own medications prior to admission. A more detailed description of the study design and primary outcomes has been reported elsewhere (Kripalani et al., Citation2012; Schnipper et al., Citation2010). All study procedures were approved by the Institutional Review Board at each site.
The present follow-up study was conducted among a sample of participants in the PILL-CVD study who had been randomized to the intervention, spoke English, had completed their 30-day period of participation, and were willing to complete an additional interview by telephone to provide their opinions about the intervention components.
PILL-CVD Intervention
The PILL-CVD intervention consisted of pharmacist-assisted medication reconciliation and counseling, low-literacy tools for medication management, and postdischarge phone follow-up (Schnipper et al., Citation2010). The pharmacists and staff who delivered the intervention were trained in clear health communication (Kripalani & Jacobson, Citation2007). Medication reconciliation involved the pharmacist taking a detailed medication history using multiple sources (e.g., electronic health records, family, community pharmacy records). An initial counseling session after enrollment allowed the pharmacist to evaluate and address the individual needs of each patient, focusing on the patient's understanding of the medication regimen, comprehension of medication labels, daily medication adherence, refill adherence, social support, and any other patient-specific problems. During a separate hospital discharge counseling session, pharmacists provided intervention patients with an illustrated discharge medication list that included dosing instructions, timing, important side effects, and any special instructions (Schnipper et al., Citation2010). Patients were offered a pill box and taught how to fill it. Pharmacists also attempted to engage family members and caregivers when possible and encouraged patients to get their help with managing medications after discharge. One to four days after discharge, a study coordinator contacted intervention patients by telephone to assess any new or worsening symptoms, medication discrepancies or nonadherence, and other concerns. Issues were forwarded to a study pharmacist who followed up with patients as needed. Sometimes, if the pharmacist was unable to provide discharge counseling in the hospital, the pharmacist conducted the postdischarge phone call to perform discharge counseling and complete the postdischarge follow-up simultaneously.
Data Collection
During the baseline interview for the PILL-CVD study, research assistants collected demographic information from the patient and the number of preadmission medications from the medical chart. They also administered the short test of Functional Health Literacy in Adults (Nurss, Parker, Williams, & Baker, Citation1998), the Mini-Cog (Borson, Scanlan, Watanabe, Tu, & Lessig, Citation2005), the Medication Understanding Questionnaire (Marvanova et al., Citation2011), and the Morisky Medication Adherence Survey (Morisky, Green, & Levine, Citation1986). Scores on the short test of Functional Health Literacy in Adults range from 0 to 36 and classify respondents' health literacy as inadequate (0–16), marginal (17–22), or adequate (23–36). The Mini-Cog, which is a 3-item recall test with a clock-draw distraction task, provides scores ranging from 0 to 5, with ≤2 indicating cognitive impairment. In the Medication Understanding Questionnaire, an interviewer provides the generic and brand names of up to five of the participant's preadmission medications and asks the participant to report the indication, dose, and frequency for each medication; scores range from 0 to 3, with 3 indicating perfect understanding. The Morisky Medication Adherence Survey is a 4-item test with scores ranging from 4 to 8; a higher score indicates better medication adherence.
The PILL-CVD participants in this follow-up study completed a 5–7-min telephone survey within approximately 2 months of having completed their 30-day participation in the trial (i.e., within 3 months of the index hospital discharge). Eleven survey items assessed the utility of different components of the intervention, including the pharmacist counseling, illustrated medication list, pill box, and follow-up phone call. Response options included “very helpful,” “somewhat helpful,” and “not helpful at all.” A response of “not applicable” was recorded if participants indicated that they either did not receive or did not recall receiving a given intervention component. Six additional questions assessed if receiving the intervention had affected patients' level of comfort in communicating with their outpatient providers about their medications. Response options included “much more comfortable,” “slightly more comfortable,” “about the same,” “slightly less comfortable,” and “much less comfortable.” A response of “not applicable” was recorded if patients indicated that they either did not discuss or did not need to discuss a specific topic with their providers. Survey data were collected and managed using Research Electronic Data Capture (REDCap), which is a secure, web-based application designed to support data entry for research studies (Harris et al., Citation2009).
Analyses
Patient characteristics were summarized using frequencies, medians, and interquartile ranges. We used frequencies to summarize patient responses to survey items about the utility of various intervention components and provider communication. We then conducted a series of bivariate analyses (i.e., chi-square tests with categorical variables and independent sample t tests with continuous variables) to determine the relationship between patient characteristics, including health literacy, cognitive function, medication understanding, medication adherence, and number of preadmission medications, and each survey item. For these analyses, survey responses were grouped into the following categories: very helpful vs. somewhat/not at all helpful, and much more/slightly more comfortable vs. same/slightly less/much less comfortable. Invalid responses (i.e., not applicable) were excluded from bivariate analyses. All analyses were performed in SPSS version 19.0 for Windows. Two-sided p values<.05 were considered statistically significant.
Results
Of the patients enrolled in the PILL-CVD study between May 2008 and September 2009 (N = 862), 430 were randomized to the intervention arm. Of these, 236 (54.9%) met inclusion criteria for this follow-up study. The primary reason for exclusion was that greater than 2 months' time had elapsed since their study participation. We had resources to attempt to contact 179 of these patients, and 135 agreed to participate (75.4% of attempted). Reasons for not participating included being unreachable by phone (n = 36), declining to participate (n = 5), or being deceased (n = 3). Among those who agreed to participate, 10 were excluded from the analyses, including 9 who did not sufficiently recall their experience with the intervention and 1 who had an incomplete call.
Patients completing the survey (N = 125) were primarily male (55.2%), White (81.6%), and insured (91.3%); the median age was 63 (interquartile range = 54 to 73; Table ). While the majority (97.6%) of patients had completed high school, 23.2% had marginal or inadequate health literacy and 12% had impaired cognitive function. These characteristics did not differ meaningfully from those of the overall PILL-CVD study participants.
Table 1. Patient characteristics (N = 125)
When assessing the utility of different forms of care transition assistance, the components of the intervention that received the most favorable responses were speaking to the pharmacist (72.8% rated as very helpful), receiving an illustrated medication schedule (69.6%), and receiving a follow-up phone call at home (68.0%; Table ). Just under half of patients (44.0%) rated getting help from friends and family as very helpful, though most (73.5%) had a family member or friend present during discharge instructions.
Table 2. Utility of different forms of assistance in hospital discharge transition (N = 125)
Regarding specific topics covered during pharmacist counseling, those rated most helpful included exactly how to take the medicines (71.8%) and how to prevent or manage side effects (62.6%). A smaller percentage of patients rated discussion of problems like cost or transportation to obtain medicines as very helpful (40.3%).
Between hospital discharge and the telephone survey, 110 of 125 patients (88.7%) had spoken with a doctor or nurse about their medications, either at a follow-up appointment or by phone. Overall, patients reported feeling more comfortable discussing medications with outpatient providers after having participated in the intervention (Table ). Specifically, patients reported improvements in being able to discuss drug indications (53.7% reported feeling much more comfortable with this), side-effect management (53.3%), the names of new medicines (49.6%), and any problems they were having with following the treatment plan (48.0%). Fewer patients reported improving their comfort level in the discussion of what to do with their old medications after returning home from the hospital (35%).
Table 3. Comfort level with patient–provider communications (N = 125)
In subgroup analyses (Table ), patients with marginal or inadequate health literacy were significantly more likely than patients with adequate health literacy to report various components of the intervention were very helpful (vs. somewhat or not at all helpful). Specifically, patients with limited health literacy were more likely than those with adequate health literacy to report that speaking with a pharmacist about their medications (p = .03), and receiving a follow-up phone call 1 to 4 days after discharge (p = .01) were very helpful. Among the pharmacists' counseling topics, patients with limited health literacy were more likely than those with adequate health literacy to report that talking with the pharmacist about always filling their prescriptions on time was very helpful (p = .05). Participants with limited health literacy tended to rate other discussion topics as very helpful compared with those with adequate health literacy, including reading and understanding medication labels (p = .07), preventing and managing drug side effects (p = .08), and taking their medications every day without missing any doses (p = .09), though these differences were not statistically significant. Patient responses to survey questions did not differ according to other variables, including patients' baseline medication understanding, medication adherence, cognitive function, or number of preadmission medications.
Table 4. Patients reporting “very helpful” for each item, by health literacy level
Patients with limited health literacy had a similar likelihood as patients with adequate health literacy to report feeling much more comfortable talking to their doctors or nurses about the names of their new medications, what the new medicines are for, what to do with their old medicines after discharge, any problems they might have taking their medicines daily, dealing with side effects of medicines, and specific problems they were having such as the cost of their medicines or transportation (data not shown).
Discussion
In this study of patients' perspectives on a care transition intervention, we found that the majority of participants perceived the pharmacist-led intervention to be very helpful. The intervention was health literacy-sensitive and tailored to each patient, providing patients with easy-to-understand instructions and strategies to manage their postdischarge medication regimens. Patients with limited health literacy tended to perceive greater intervention benefits.
Many studies have quantified the efficacy of multifaceted care transitions interventions (Hansen et al., Citation2011), and professional societies have recommended implementation of specific initiatives (“Executive Summary of the Continuity of Care in Medication Use Summit,” Citation2008; Snow et al., Citation2009). However, this is one of the first studies to evaluate the patient perspective regarding the utility of different components of a care transition intervention. As hospitals select from numerous possible interventions to improve hospital discharge transitions, they may wish to consider that patients responded very favorably to receiving inpatient pharmacist counseling, an illustrated discharge medication list, and a postdischarge phone call. Patient satisfaction is an important outcome, as is patient empowerment to communicate with providers and manage their own conditions.
Specifically, patients reported that it was very helpful to discuss with a pharmacist the exact instructions for taking their medications after discharge and how to prevent and manage side effects, as well as other aspects of their medication self-management. Other research has shown that hospitalized patients, especially those with limited health literacy skills, often have a poor understanding of their own medication regimen (Marvanova et al., Citation2011). Confusion about the medication regimen, medication nonadherence, and adverse drug events are common after patients return home from the hospital (Cua & Kripalani, Citation2008). Therefore, efforts to enhance medication understanding and self-management among hospitalized patients are needed. These results suggest that inpatient pharmacist counseling and a patient-centered medication list may be beneficial in this regard. Others have also found patient-centered medication instructions to be useful adjuncts to discharge counseling (Jack et al., Citation2009).
It is important to note that patients indicated that this intervention had an enduring effect; they reported feeling much more comfortable discussing their medications with outpatient providers after discharge. This effect was similar among patients with either limited or adequate health literacy, suggesting that pharmacist counseling may have a durable effect in promoting patient engagement regardless of health literacy status. Others have found a hospital discharge intervention to have similar efficacy across levels of health literacy (Jack et al., Citation2009). However, the majority of care transition studies have not examined whether intervention effects may differ according to health literacy, and more research is needed given the important role health literacy may play in this context (Kripalani et al., Citation2007).
The main limitation of this study is that it was conducted among a relatively small sample of patients who were participating in a randomized trial, had taken part in other follow-up calls, and were willing to complete this assessment. They may have had more positive experiences to report. It is unlikely, however, that a large response bias was present, given the high response rate.
A second limitation is that, to help address the ceiling effect common in patient satisfaction studies, we analyzed responses by reporting the top response category (very helpful) versus other responses (somewhat or not at all helpful), though we recognize that this approach is imperfect. We also are cautious to not overinterpret the order of intervention components that patients rated most helpful, as patients with positive experiences may have difficulty separating out the value of different components. Moreover, an intervention component that is deemed valuable by only a minority of patients (e.g., discussion of costs and transportation) should not necessarily be dropped, because it may have a large impact on those patients for which it is relevant.
Third, by excluding patients from the parent trial who did not manage their own medications, the overall sample may have been biased toward patients who had higher medication self-management skills. This may have affected, for example, the percentage of patients replying “not applicable” to the component of receiving help from friends and family in managing their medications. Fourth, responses of “not applicable” for discussing cost and transportation issues may be a result of the demographics of the study sample, as most patients were insured, which may indicate a higher average socioeconomic status than other populations or settings. Fifth, the prevalence of limited health literacy (23.2%) in our study sample was lower than has been estimated for the U.S. population in general (Kutner, Greenberg, Jin, & Paulsen, Citation2006), and this may have affected the statistical power of our subgroup comparison. Sixth, because of the modest sample size, we did not adjust for other factors that may have influenced patient ratings, such as study site, which individual pharmacist delivered the intervention, the duration of the counseling sessions, and whether patients were called by a pharmacist after discharge. A final limitation relates not to the study design, but rather to the applicability of our findings. Though patients found this pharmacist intervention to be helpful, hospitals will have to make their own cost-benefit assessment of inpatient pharmacist counseling based on its effects on patient satisfaction as well as other patient outcomes. Because these limitations affect the generalizability of the study, additional research should be conducted to replicate our findings.
Conclusions
During discharge, a significant amount of information about medication management must be conveyed. The care transition period requires thorough communication between patients, family members, and providers. The PILL-CVD intervention provided inpatient pharmacist counseling, medication adherence aids, and telephone follow-up, and patients perceived it to be very helpful. By educating patients on self-care and empowering them to have a more informative discourse with their providers, it may be possible to improve patient self-management after hospital discharge, though further study is required to assess the effect on health outcomes.
Acknowledgments
This study was funded by grants R01 HL089755 and 3R01 HL0890755-02S2, and in part by K23 HL077597, K01 DK087894, and K08 HL072806. REDCap is supported through the Vanderbilt Institute for Clinical and Translational Research by the National Center for Research Resources (1 UL1 RR024975).
Additional information
Notes on contributors
Sunil Kripalani
Sunil Kripalani is a consultant to and holds equity in PictureRx, LLC, which makes patient education tools to improve medication management. PictureRx did not provide materials or funding for this study.Notes
*Median (interquartile range).
*Items 3–9 and 11 were missing one response each, and Item 10 was missing three responses.
*Items 1–4 were missing three responses each, and Items 5 and 6 were missing two responses each.
*N for each item varies on the basis of the number of people who (a) had missing responses, (b) reported the item as “not applicable,” or (c) had a missing value for a covariate.
Related Research Data
References
- Axon , R. N. , & Williams , M. V. ( 2011 ). Hospital readmission as an accountability measure . JAMA , 305 , 504 – 505 .
- Berkman , N. D. , Sheridan , S. L. , Donahue , K. E. , Halpern , D. J. , & Crotty , K. ( 2011 ). Low health literacy and health outcomes: An updated systematic review . Annals of Internal Medicine , 155 , 97 – 107 .
- Bodenheimer , T. ( 2008 ). Coordinating care—A perilous journey through the health care system . New England Journal of Medicine , 358 , 1064 – 1071 .
- Borson , S. , Scanlan , J. M. , Watanabe , J. , Tu , S. P. , & Lessig , M. ( 2005 ). Simplifying detection of cognitive impairment: Comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample . Journal of the American Geriatrics Society , 53 , 871 – 874 .
- Chugh , A. , Williams , M. V. , Grigsby , J. , & Coleman , E. A. (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management , 25, 11–32.
- Coleman , E. A. , & Berenson , R. A. ( 2004 ). Lost in transition: Challenges and opportunities for improving the quality of transitional care . Annals of Internal Medicine , 141 , 533 – 536 .
- Coleman , E. A. , Parry , C. , Chalmers , S. , & Min , S. ( 2006 ). The Care Transitions Intervention: Results of a randomized controlled trial . Archives of Internal Medicine , 166 , 1822 – 1828 .
- Cua , Y. M. , & Kripalani , S. ( 2008 ). Medication use in the transition from hospital to home . Annals of the Academy of Medicine, Singapore , 37 , 136 – 141 .
- Executive Summary of the Continuity of Care in Medication Use Summit . ( 2008 ). American Journal of Health-System Pharmacy , 65 , e3 – e9 .
- Forster , A. J. , Murff , H. J. , Peterson , J. F. , Gandhi , T. K. , & Bates , D. W. ( 2003 ). The incidence and severity of adverse events affecting patients after discharge from the hospital . Annals of Internal Medicine , 138 , 161 – 167 .
- Graumlich , J. F. , Novotny , N. L. , & Aldag , J. C. ( 2008 ). Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties . Journal of Hospital Medicine , 3 , 446 – 454 .
- Greenwald , J. L. , Denham , C. R. , & Jack , B. W. ( 2007 ). The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process . Journal of Patient Safety , 3 , 97 – 106 .
- Hansen , L. O. , Young , R. S. , Hinami , K. , Leung , A. , & Williams , M. V. ( 2011 ). Interventions to reduce 30-day rehospitalization: A systematic review . Annals of Internal Medicine , 155 , 520 – 528 .
- Harris , P. A. , Taylor , R. , Thielke , R. , Payne , J. , Gonzalez , N. , & Conde , J. G. ( 2009 ). Research Electronic Data Capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support . Journal of Biomedical Informatics , 42 , 377 – 381 .
- Jack , B. W. , Chetty , V. K. , Anthony , D. , Greenwald , J. L. , Sanchez , G. M. , & Johnson , A. E. , … Culpepper , L. ( 2009 ). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial . Annals of Internal Medicine , 150 , 178 – 187 .
- Jencks , S. F. , Williams , M. V. , & Coleman , E. A. ( 2009 ). Rehospitalizations among patients in the Medicare fee-for-service program . New England Journal of Medicine , 360 , 1418 – 1428 .
- Kripalani , S. , Jackson , A. T. , Schnipper , J. L. , & Coleman , E. A. ( 2007 ). Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists . Journal of Hospital Medicine , 2 , 314 – 323 .
- Kripalani , S. , & Jacobson , K. L. ( 2007 , October ) . Strategies to improve communication between pharmacy staff and patients: A training program for pharmacy staff. Curriculum guide . (AHRQ Publication No. 07(08)-0051–1-EF) . Rockville , MD : Agency for Healthcare Research and Quality . Retrieved from http://www.ahrq.gov/qual/pharmlit/pharmtrain.htm
- Kripalani , S. , Jacobson , T. A. , Mugalla , C. I. , Cawthon , R. C. , Niesner , K. J. , & Vaccarino , V. ( 2010 ). Health literacy and the quality of physician–patient communication during hospitalization . Journal of Hospital Medicine , 5 , 269 – 275 .
- Kripalani , S. , LeFevre , F. , Phillips , C. O. , Williams , M. V. , Basaviah , P. , & Baker , D. W. ( 2007 ). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care . JAMA , 297 , 831 – 841 .
- Kripalani , S. , Roumie , C. L. , Dalal , A. K. , Cawthon , C. , Businger , A. , & Eden , S. K. , … Schnipper , J. L. ( 2012 ). Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: A randomized controlled trial . Annals of Internal Medicine , 157 , 1 – 10 .
- Kutner , M. , Greenberg , E. , Jin , Y. , & Paulsen , C. ( 2006 ). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483) . Washington , DC : U.S. Department of Education, National Center for Education Statistics .
- Lindquist , L. A. , Go , L. , Fleisher , J. , Jain , N. , Friesema , E. , & Baker , D. W. (2011). Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. Journal of General Internal Medicine , 27, 173–178.
- Marvanova , M. , Roumie , C. L. , Eden , S. K. , Cawthon , C. , Schnipper , J. L. , & Kripalani , S. ( 2011 ). Health literacy and medication understanding among hospitalized adults . Journal of Hospital Medicine , 6 , 488 – 493 .
- Morisky , D. E. , Green , L. W. , & Levine , D. M. ( 1986 ). Concurrent and predictive validity of a self-reported measure of medication adherence . Medical Care , 24 , 67 – 74 .
- Naylor , M. D. , Brooten , D. , Campbell , R. , Jacobsen , B. S. , Mezey , M. D. , Pauly , M. V. , … Schwartz , J. S. ( 1999 ). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial . JAMA , 281 , 613 – 620 .
- Nurss , J. R. , Parker , R. M. , Williams , M. V. , & Baker , D. W. ( 1998 ). Short Test of Functional Health Literacy in Adults . Snow Camp , NC : Peppercorn Books and Press .
- Preen , D. B. , Bailey , B. E. , Wright , A. , Kendall , P. , Phillips , M. , Hung , J. , … Williams , E. ( 2005 ). Effects of a multidisciplinary, postdischarge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: A randomized controlled trial . International Journal for Quality in Health Care , 17 , 43 – 51 .
- Schnipper , J. L. , Roumie , C. L. , Cawthon , C. , Businger , A. , Dalal , A. K. , Mugalla , I. , … Kripalani , S. ( 2010 ). The rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study . Circulation: Cardiovascular Quality & Outcomes , 3 , 212 – 219 .
- Snow , V. , Beck , D. , Budnitz , T. , Miller , D. C. , Potter , J. , Wears , R. L. , … Williams , M. V. ( 2009 ). Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine . Journal of Hospital Medicine , 4 , 364 – 370 .