Health Literacy and Cardiac Medication Education: A Quality Improvement Study Using Teach-Back

Supplemental Digital Content is Available in the Text.

ABSTRACT

Background:

Limited qualitative research has explored clinician behaviors that enhance communication with patients who have limited health literacy (HL). Teach-back is a patient-centered strategy used to confirm understanding and close HL gaps.

Purpose:

This quality improvement initiative aimed to improve patient understanding of newly prescribed cardiac medications at discharge on a telemetry unit in a university-affiliated community hospital in New York. The goal was to increase the percentage of patients who understood the indication and side effects of their new medications to at least 85% by January 2024, using the Plan-Do-Study-Act framework.

Methods:

Fifty eligible patients (mean age 71.7 years) admitted between November 2023 and January 2024 were considered. Inclusion criteria included a newly prescribed cardiac medication, intact cognition, English fluency, and discharge to home. Patients completed a baseline questionnaire assessing knowledge of medication purpose and side effects. Those with knowledge gaps received tailored education using plain language, followed by a teach-back session. Patients were asked to explain the medication's purpose and risks in their own words. Follow-up interviews 2–4 weeks postdischarge reassessed retention using the same framework.

Results:

At baseline, 54% of patients understood the medication's purpose, and only 26% were aware of potential adverse effects. After the intervention, 92% accurately explained both indication and side effects, and 74% retained the information at follow-up. Standardized protocols and blinded follow-up interviews helped minimize selection and reporting bias.

Conclusions:

The teach-back method significantly improved patient comprehension and short-term retention of discharge medication instructions. It is a feasible, low-cost strategy that can be effectively implemented in inpatient cardiology settings to address HL-related communication gaps and support safer transitions of care.

Introduction

Effective communication between healthcare providers and patients is essential for ensuring safe and high-quality care, particularly during critical transitions such as hospital discharge. This is especially relevant for patients with cardiac conditions, who are frequently prescribed new medications that require clear understanding of indications, dosing, and potential side effects. Cardiac patients are particularly vulnerable due to the complexity of their medication regimens and the high risk of readmission after acute cardiac events, making them an ideal population for evaluating communication strategies (Figure 1).

Figure 1.

This graphical abstract summarizes a quality improvement project to enhance patient understanding of new cardiac medications using the teach-back method. It illustrates the problem of limited discharge education, outlines the intervention with 50 telemetry patients, and shows how teach-back was used to confirm comprehension. Results demonstrate improved understanding from 54% at baseline to 92% postintervention, supporting teach-back as a feasible and effective strategy in inpatient cardiology care.

However, communication challenges are often compounded by limited health literacy (HL), which places patients at increased risk for nonadherence, medication errors, and avoidable readmissions.^1,2 Health literacy is not only an individual issue but is deeply influenced by broader social determinants of health (SDOH).³ Factors such as educational attainment, socioeconomic status, language barriers, and access to healthcare services significantly affect a patient's ability to understand and manage their health.³ In underserved populations, these structural challenges may further widen communication gaps between clinicians and patients, especially during high-stress events such as hospitalization for acute cardiac illness.³ To address these challenges, strategies such as the teach-back method have been developed to promote patient-centered communication. Teach-back involves asking patients to restate information in their own words, allowing clinicians to assess understanding and provide clarification. Recommended by the Agency for Healthcare Research and Quality, this method is particularly useful for patients with limited HL and has been associated with improved patient outcomes across various settings.⁴

In this initiative, teach-back education was conducted by medical students, medical residents, and nursing staff, based on staffing structure and availability during patient discharge workflows. According to the existing literature, nurses and pharmacists are the most commonly reported disciplines conducting teach-back for medication education, particularly during transitions of care. Physicians and advanced practice providers are involved less frequently due to time constraints and competing clinical responsibilities.^1,5 Existing studies suggest that pharmacist-led teach-back interventions tend to yield higher rates of medication adherence and comprehension, particularly when integrated with medication reconciliation and postdischarge follow-up.⁶ Nursing-led interventions, meanwhile, have demonstrated strong patient satisfaction outcomes, likely due to longer and more consistent bedside interactions.⁷ However, multidisciplinary models combining pharmacists, nurses, and physicians show the most promise in sustaining long-term comprehension and reducing readmissions.⁸

Baseline comprehension of discharge medication instructions was assessed using a combination of methods: postdischarge follow-up calls in the affiliated primary care clinic, internal analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and informal bedside observations by nursing and clinical staff. The initiative was reportedly motivated by patient communication scores related to discharge education. These scores were drawn from HCAHPS data, specifically from the question: “During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “Did you understand the purpose of taking each of your medications?” Before the intervention, the institution's scores for these items averaged 63% and 58%, respectively, which were below both national and state benchmarks. These metrics informed the need for a structured, teach-back based approach to discharge education, particularly for cardiac patients at elevated risk of readmission.

Despite its potential, the teach-back method remains underused in inpatient care, particularly in cardiology units, where clinical complexity, time constraints, and variability in provider communication styles can hinder its implementation. This QI initiative aimed to evaluate the use of the teach-back method to enhance patients' understanding of newly prescribed cardiac medications during hospitalization. By acknowledging the influence of HL and SDOH, this QI study sought to explore strategies to close communication gaps and improve patient preparedness at discharge.

Methods

This quality improvement (QI) initiative was conducted at a university-affiliated community hospital in New York, targeting the telemetry floor where patients with various cardiac conditions are admitted and monitored. The primary aim was to increase the percentage of hospitalized patients who demonstrate understanding of the indication and potential adverse effects of newly prescribed cardiovascular medications to at least 85% by the end of January 2024, using the teach-back method. The initiative was guided by the SMART framework (Specific, Measurable, Achievable, Relevant, Time-bound).

Patients admitted between November 6, 2023, and January 29, 2024, were eligible if they met the following inclusion criteria: prescribed at least one new cardiac medication, alert and oriented to person, place, and time (A&Ox3), residing at home, and without cognitive impairment or significant psychiatric illness. A total of 50 patients (28 males, 22 females; mean age 71.72 ± 11.59 years) met these criteria. Patients were excluded if they had limited English proficiency without access to interpreter services, were discharged to rehabilitation or hospice, or were medically unstable at the time of discharge.

Understanding was assessed using a structured evaluation framework. Patients were initially asked two Yes/No screening questions: “Do you know why this medication was prescribed?” and “Do you know the adverse effects of this medication?” However, an affirmative response alone was not considered sufficient. Patients were required to explain, in their own words, the purpose and potential side effects of the newly prescribed medication(s) (Figure 2). Interviewers used a standardized reference list of commonly prescribed cardiac medications, including their indications and adverse effects, to validate responses in real time. Only patients who accurately articulated both indication and adverse effects were recorded as “Yes” responses.

Figure 2.

This figure shows the Teach-Back Questionnaire used to assess patient understanding of newly prescribed cardiac medications. Although it begins with two Yes or No questions about medication purpose and side effects, patients were required to explain both in their own words. The figure includes interviewer prompts, a reference list of common cardiac medications with their indications and adverse effects, and space for documenting responses. This format ensured accurate assessment of comprehension and supported consistent data collection.

Although the initial data collection form included binary Yes/No questions for tracking, structured open-ended responses were also collected and analyzed. These responses formed the basis for determining the accuracy of comprehension. A standardized checklist was used to ensure consistent judgment across interviewers, and answers were recorded in electronic documentation. The same approach was used during the follow-up phone call 2–4 weeks after discharge, where patients were asked the same questions using the same teach-back framework to evaluate retention of understanding. Before the intervention, discharge education was unstructured, with inconsistent assessment of patient understanding. This QI initiative followed the Plan-Do-Study-Act cycle to structure iterative improvement.

Teach-back education was delivered by medical students, medical residents, and nursing staff who were assigned to the unit during the intervention period. These educators were selected based on their availability during discharge processes and direct patient interaction. All educators underwent formal training on the teach-back method, which included instructions and a standardized teaching script and checklist to ensure consistency in content delivery. Educators were trained to use plain language and verification prompts. Oversight was provided by the hospital's QI department and the project manager, who periodically conducted random audits of documentation and observed interactions to ensure fidelity to the teach-back method.

For future scale-up and sustained implementation beyond the pilot phase, the goal is to embed teach-back education within routine discharge workflows. Medical students, residents, attending physicians, and nursing staff will all be involved in delivering education. Onboarding will include training on HL principles and teach-back technique, with competency assessed through observed structured interactions and periodic retraining. Integration into electronic discharge checklists is also under development to support long-term sustainability and accountability.

This project was reviewed by the Institutional Review Board (IRB) of our institution and was determined to be exempt from formal IRB approval, as it met criteria for a nonresearch, QI initiative focused on internal process enhancement.

Results

Among the 50 patients interviewed, 54% (n = 27) demonstrated an understanding of the reason for their newly prescribed cardiac medication at baseline, whereas only 26% (n = 13) were aware of the potential serious adverse effects (Figure 3). After the application of the teach-back method during hospitalization, there was a marked improvement in comprehension: 92% (n = 46) of participants were able to accurately describe both the indication and associated risks of their medications (Figure 4). During follow-up telephone interviews conducted 2–4 weeks after discharge, 74% (n = 37) of patients retained key information regarding the purpose and adverse effects of their prescribed medications (see Supplemental Figure 1, Supplemental Digital Content 1, http://links.lww.com/JHQ/A283).

Figure 3.

This figure illustrates a pie chart of the percentage of patients who demonstrated baseline knowledge of their newly prescribed cardiovascular medications, including understanding of the indication, dosage, and potential side effects, before the implementation of the teach-back method.

Figure 4.

This figure illustrates a bar graph of the percentage of patients who demonstrated knowledge of their newly prescribed cardiovascular medications, including understanding of the indication, dosage, and potential side effects, after the implementation of the teach-back method.

The “marked improvement in comprehension” is based on descriptive comparisons only; no formal statistical tests were performed. This decision was made given the small sample size (n = 50) and the project's classification as a QI initiative rather than a hypothesis-driven clinical study. The emphasis was placed on practical, observed changes in patient outcomes to inform future process implementation and scalability. To minimize selection bias, all eligible patients admitted with newly prescribed cardiac medications during the study period were consecutively approached for inclusion, rather than selected through random sampling. Reporting bias was addressed by implementing a standardized interview protocol for all participants, with predefined questions focused on medication indication and adverse effects. Importantly, interviewers conducting the postintervention and follow-up assessments were blinded to the baseline responses, helping to reduce the risk of expectation bias or interviewer influence on participant answers.

Limitations

This QI study has several limitations. It was conducted at a single center with a relatively small sample size (n = 50), which may limit the generalizability of findings to other inpatient cardiology settings. The assessment of understanding relied on patient self-reported responses during structured interviews, which may be influenced by recall or social desirability bias. In addition, the follow-up period was limited to 2–4 weeks, which restricts the evaluation of long-term knowledge retention, medication adherence, or clinical outcomes such as readmissions.

Although a standardized script and checklist were used, all teach-back sessions and follow-up interviews were conducted by a single trained interviewer. This may introduce bias due to variability in communication style or interpretation of patient responses. In future implementation, multiple team members including nursing staff, residents, and pharmacists will be trained to deliver and assess teach-back education. The project team plans to evaluate inter-rater reliability through periodic calibration sessions and consistency checks to ensure standardized assessment.

Data were collected through structured telephone interviews. This method was selected for feasibility during the pilot phase and was intended as a temporary measure. For future scale-up, a longer-term evaluation plan will involve integrating comprehension assessments into discharge documentation and linking follow-up to routine outpatient care. This will allow for better monitoring of sustained understanding and medication adherence, while minimizing reliance on telephone-based follow-up alone.

Discussion

The teach-back method significantly improved patient understanding of newly prescribed cardiac medications, with strong short-term retention postdischarge. In the cohort of 50 participants, 92% demonstrated an enhanced understanding of the reasons behind the initiation of the medication and its potential adverse effects after employing the teach-back method. In comparison, only 26% of patients understood the adverse effects, and 52% understood the indication behind the prescription of the medication before the implementation of the teach-back method. The teach-back method was also shown to support moderate retention of this knowledge, with 74% of patients being able to retain the information provided on a follow-up telephone interview 2–3 weeks postdischarge. The current guideline set by the American College of Cardiology/American Heart Association for discharge after an acute coronary syndrome (ACS) recommends the integration of the teach-back method into patient education to confirm an understanding of the importance of medication adherence and the treatment regimen.⁹

These results align with prior studies demonstrating the value of teach-back in outpatient and primary care settings, while emphasizing its utility in inpatient cardiology units during discharge planning. A study conducted on 120 patients showed that adding the teach-back method to standard written and verbal discharge instructions significantly improved patient understanding of postdischarge needs, with the most significant gains observed in medication comprehension (45.8% improvement, 95% Confidence Interval (CI), 0.40–0.67; p < .0001).¹⁰ Further supporting the importance of integrating the teach-back method into discharge planning surrounding new medications.

The teach-back method is a low-cost, high-yield strategy that warrants being embedded into discharge protocols. The teach-back method has been shown to decrease hospitalization for an ambulatory care-sensitive condition such as congestive heart failure and angina Relative Risk (RR), 0.85; 95% CI, 0.71–0.99).¹¹ The improved understanding translates to better adherence to cardioprotective treatment regimens after ACS.¹¹ Adequate integration of the teach-back method would require a significant investment of time and resources to allow adequate patient learning. Nursing staff and pharmacists can be trained to implement it consistently and efficiently during patient education opportunities. Not only does the teach-back method enhance patient knowledge and comprehension, but it can also be a tool to increase patient–provider trust.¹¹

The teach-back method has many aspects to consider when being used, as patients commonly struggle with medical terminology, anxiety about discharge, and inadequate explanation of medication risks.¹² It requires an educator with a comprehensive understanding and practical application of the teach-back method as an essential tool to enhance patient knowledge and retention of information regarding their medications.¹² The teach-back method relies on patient engagement, HL, and language proficiency, among several other factors, to be an effective teaching tool.¹²

To ensure sustainability, the teach-back method will be incorporated into standard discharge workflows, with plans to train additional nursing staff and providers to deliver consistent patient education. A structured in-service training program is being considered to expand implementation hospital-wide, particularly on high-risk units such as cardiology and internal medicine. Barriers to broader rollout, including time constraints, variability in staff communication skills, and competing discharge priorities, will be addressed through streamlined education tools and reinforcement during clinical and interdisciplinary rounds. Ongoing monitoring and feedback mechanisms will support long-term adoption and continuous QI.

Conclusions

This QI study highlights the significant impact of the teach-back method in enhancing patient understanding of newly prescribed cardiac medications during hospitalization. By engaging patients in a structured, interactive communication process, clinicians were able to identify and address gaps in comprehension, leading to a marked improvement in both immediate understanding and short-term retention postdischarge. These findings highlight the importance of patient-centered communication strategies in promoting HL, especially among older adults managing complex cardiovascular therapies. Integrating teach-back into routine discharge planning offers a simple yet powerful tool to support medication safety and adherence. As healthcare continues to evolve, combining traditional communication methods with innovative technologies such as artificial intelligence (AI)-driven education platforms may offer new opportunities to deliver personalized, scalable, and effective patient education.

Implications

Although this study demonstrated the effectiveness of the teach-back method in improving short-term understanding and retention of cardiac medication information, several opportunities exist for further research, innovation, and system-wide implementation. The teach-back method is both feasible and promising for enhancing medication comprehension, but successful large-scale implementation will require deliberate planning. Our system-level strategy includes training a multidisciplinary team composed of medical students, residents, nurses, and attending physicians, especially those involved in discharge processes. Training resources will include simulation-based scenarios, instructional videos, structured role-play exercises, and a standardized checklist to reinforce consistent delivery. Educational modules will be incorporated into onboarding and annual competency assessments to ensure continued fidelity to the method.

Competency will be evaluated regularly through observed interactions, documentation audits, and feedback sessions led by the QI team. Ongoing education will be reinforced through integration into departmental in-services, Electronic Health Record (EHR)-embedded reminders, and performance dashboards to maintain awareness and accountability. To evaluate the broader impact of the intervention beyond self-reported understanding, a more robust set of outcome metrics will be monitored in future phases of implementation: 30-day readmissions related to medication mismanagement or nonadherence, emergency department visits associated with adverse drug effects or confusion about medication, documentation compliance in the electronic health record, including structured discharge medication education and teach-back confirmation, and correlation with HCAHPS discharge-related communication domains, specifically the items addressing clarity of medication instructions and overall preparedness for discharge.

These outcomes will help establish whether improvements in communication translate to measurable gains in clinical care quality and patient safety. As part of continuous QI, data will be reviewed monthly and used to refine educational processes and identify opportunities for targeted intervention. Emerging technologies, particularly AI, present promising avenues to complement human-delivered teach-back. Artificial intelligence–powered tools such as personalized discharge summaries, natural language processing–driven education modules, and interactive virtual health assistants can help tailor information delivery to patients' literacy levels, cognitive load, and learning preferences. Integration of these technologies into EHR workflows may support consistent, scalable, and patient-centered education, especially in high-volume cardiac units.

Future QI initiatives may explore hybrid models that blend human-led teach-back with AI-enhanced communication strategies to further strengthen patient understanding, promote adherence, and reduce preventable readmissions.

Authors' Biographies

Inderbir Padda, MD, MPH, MSc, is an internal medicine physician and cardiology-focused researcher. He is affiliated with the Department of Internal Medicine at Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Sneha A. Sebastian, MD, is an internal medicine resident physician and cardiology-based researcher. She is affiliated with the Department of Internal Medicine at Augusta Health in Fishersville, VA, USA.

Khushal Choudhary, MD, is a general cardiologist and interventional cardiology fellow. He is affiliated with the Department of Cardiology at SUNY Downstate Medical Center in Brooklyn, NY, USA.

Paul Karroum, MD, is the chief quality improvement resident physician and a critical care fellow. He is affiliated with the Department of Internal Medicine at Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Inderjeet Bharaj, MD, is the chief academic and quality improvement resident physician. He is affiliated with the Department of Internal Medicine at Abrazo Health in Scottsdale, AZ, USA.

Harshan Atwal, MD, is a medical graduate and research scholar. He is affiliated with the Department of Internal Medicine at Saint James School of Medicine.

Sonam Chandi, DHA, MPH, MPA, is the Director of Behavioral Health and Quality. She is affiliated with the Department of Behavioral Health, Quality, and Patient Safety at Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Charles Sineri, DO, MHA, MBA, FACC, FSCAI, is an assistant professor of medicine and an interventional cardiologist. He is affiliated with Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Philip Otterbeck, MD, MBA, is the Chief Medical Officer and Chief of Endocrinology. He is affiliated with the Department of Endocrinology at Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Robert Macfadyen, JD, is the Vice President of Regulatory Affairs, Quality, Patient Safety, Infection Prevention, Language Services, and Patient Relations. He is affiliated with Richmond University Medical Center/Mount Sinai in Staten Island, NY, USA.

Supplementary Material

jhq-48-e0497-s001.pdf ^{(406.6KB, pdf)}

Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at www.nahq.org/journal/ce. This continuing education offering, JHQ 322 (48.2 May 2026), will provide 1 hour to those who complete it appropriately.

Core CPHQ Examination Content Area

Domain 3—Performance and Process Improvement

CE Objectives and Posttest Questions: Health Literacy and Cardiac Medication Education: A Quality Improvement Study Using Teach-Back

Objectives

1. Describe the role of the teach-back method in improving patient comprehension of cardiac medication instructions during hospital discharge.

2. Describe the impact of health literacy and social determinants of health (SDOH) on medication adherence and discharge education outcomes.

3. Describe the effectiveness of using a Plan-Do-Study-Act (PDSA) framework to implement a structured discharge education intervention in a cardiac telemetry unit.

Posttest Questions

1. What is the primary goal of the quality improvement (QI) initiative described in the article?

   1. To reduce hospital readmission rates by 50%

   2. To ensure all patients receive printed medication instructions

   3. To increase patient understanding of new cardiac medications or from what to what %

   4. To decrease provider workload during discharge

2. The teach-back method is best described as

   1. A memorization technique using visual cues

   2. A written checklist for providers

   3. A strategy where patients restate information in their own words

   4. A formal lecture delivered before discharge

3. Which population was specifically targeted for the intervention?

   1. Pediatric cardiac patients

   2. Patients with multiple comorbidities

   3. Non–English-speaking patients only

   4. English-speaking cardiac patients discharged home with new medications

4. What was the baseline percentage of patients who understood the adverse effects of their new medication?

   1. 10%

   2. 26%

   3. 54%

   4. 74%

5. What improvement was observed in medication comprehension postintervention?

   1. No change

   2. Improved from 26% to 54%

   3. Improved from 54% to 92%

   4. Improved from 74% to 100%

6. What framework guided the development and evaluation of this QI initiative?

   1. SWOT

   2. Six Sigma

   3. DMAIC

   4. Plan-Do-Study-Act (PDSA)

7. Which healthcare professionals delivered the teach-back education during the pilot phase?

   1. Only attending physicians

   2. Only pharmacists

   3. Medical students, residents, and nurses

   4. Volunteers

8. What method was used to reassess patient knowledge retention after discharge?

   1. In-person follow-up visit

   2. Medication refill tracking

   3. Blinded telephone interview 2–4 weeks postdischarge

   4. Online survey

9. What key limitation was noted in the study?

   1. Lack of funding

   2. Single-interviewer bias and small sample size

   3. Absence of a teaching script

   4. Poor patient feedback

10. How does this initiative plan to sustain and scale the intervention?

    1. Hire external consultants

    2. Eliminate patient follow-up

    3. Train multidisciplinary teams and integrate teach-back into discharge workflows

    4. Focus only on high-readmission patients