Health Literacy Universal Precautions Toolkit, 2nd Edition

Connect Patients with Literacy and Math Resources: Tool #20

Select to download PDF Version (480.46 KB).


Research has shown that clinicians have trouble identifying patients with limited health literacy skills.1,2 Patients are unlikely to mention limitations in their literacy or math skills, unless you initiate a conversation about the issue. For these patients, referral to an adult learning center for literacy and math skill enhancement can be a life-changing event.

Practice Experiences
"I was surprised that patients were overwhelmingly receptive to questions like: 'Are you interested in improving your reading skills?' Our eyes were really opened up by the literacy resources in our community and how easy it is to talk to people about them."

—Rural family medicine practice


Address literacy and math skills.

  • Ask patients directly about their literacy skills. Using the DIRECT tool,3 developed by the American Medical Association, can make discussing reading difficulties with patients feel less awkward.
DIRECT—Asking Patients About Literacy Skills
D—Ask about difficulty reading: "Have you ever had a problem with reading?"
I—Ask if the patient has an interest in improving: "Would you be interested in a program to help you improve your reading?"
R—Have referral information for adults and family literacy programs ready to give to those identified with reading difficulty.
E—Ask everyone about their literacy skills. Let patients know it is your policy to ask everyone.
C—Emphasize that low literacy is a common problem and they are not alone: "Half of Americans have some difficulty reading."
T—Take down barriers to joining literacy classes (e.g., help with the initial phone call, have informational sessions at the clinic, make followup contact with patients to see if they were able to find the right class), to refer patients to local adult education classes to support everyday math skills.
  • Train staff to become comfortable using the DIRECT tool and talking about math skills. Plan a staff training about literacy and math that includes role playing such conversations.

Connect patients to literacy and math resources.

  • Identify community resources.
    • America's Literacy Directory is a site that identifies local resources to provide help with reading, math, GED, and English for speakers of other languages.
    • Contact resources in your community to verify their services and how to make referrals.
    • Regularly update resource information.
    • Obtain or create an easy-to-read handout, such as this Community Referral Form, with information about joining a literacy or math program. Ensure the instructions are easy to understand (e.g., use plain language, provide directions).
  • Offer help with the referral. Ask staff to help the patient by making the initial phone call. Tool 21: Make Referrals Easy provides further advice on how to offer patients help with referrals.
  • Document the referral. Identify a way of documenting referrals to literacy and math programs in your medical records, and train staff to document referrals consistently.

Track Your Progress

Test whether your community resource list is up to date. Call four service providers, and verify their contact information.

Track how many referrals are made in a month and then again 2, 6, and 12 months after implementing this tool. If you have an EHR, you can generate a tracking report from the system. Otherwise, collect copies of the Community Referral Forms to track referrals.

Note five literacy or math referrals you made. Check the medical record after 1 month to see if the outcome of the referral is documented.


  1. Bass PF, 3rd, Wilson JF, Griffith CH, Barnett DR. Residents' ability to identify patients with poor literacy skills. Acad Med Oct 2002;77(10):1039-1041.
  2. Dickens C, Lambert BL, Cromwell T, Piano MR. Nurse overestimation of patients' health literacy. J Health Commun 2013;18 Suppl 1:62-69.
  3. American Medical Association. "Health literacy and patient safety: Help patients understand. Reducing the risk by designing a safer, shame-free health care environment." 2007.

Return to Contents

Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Connect Patients with Literacy and Math Resources: Tool #20. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD.
Back To Top