Health Literacy in Integrated Care Transitions: A Moderated Mediation Model Linking Family Engagement, Transition Preparedness, and Readmissions among Minority Patients

Background: Hospital-to-home transitions represent a critical phase in integrated care, particularly for patients from linguistic and cultural minorities who often struggle to understand discharge instructions and manage complex care after hospitalization. Family caregivers play a central role in bridging communication between patients and healthcare teams, ensuring comprehension, adherence, and coordination of care. Yet, their ability to support patients effectively depends on their own health literacy and level of engagement during hospitalization.

 

This study tested a moderated serial mediation model to determine whether family caregivers’ engagement in ensuring and explaining medical care (FCEEMC) and patients’ transition preparedness (CTM) mediate the relationship between minority status and 30-day readmission, while controlling for clinical and health-related covariates.

 

Methods: A prospective cohort study was conducted among 443 internal medicine patients in a tertiary hospital in Israel, each accompanied by a family caregiver. Minority status (Arabic or Russian speakers vs. Hebrew speakers) served as the independent variable. The FCEEMC scale measured family caregiver engagement through three items assessing the extent to which caregivers supervised medical care, communicated with the healthcare team, and ensured patient understanding of their condition and treatment.

 

Data on caregiver health literacy were collected during hospitalization, while patients’ transition preparedness (CTM) and 30-day readmission were obtained from follow-up surveys and hospital records. The moderated serial mediation model (PROCESS, Model 83) tested the conditional indirect effects of minority status on readmission via FCEEMC and CTM across levels of caregiver health literacy, using 5,000 bootstrap samples and controlling for patient health literacy, number of prior hospitalizations, number of diagnoses, and length of stay.

 

Results: The interaction between minority status and caregiver health literacy significantly predicted caregiver engagement (b = 0.58, p = 0.010). Among caregivers with high health literacy, minority patients exhibited significantly greater engagement scores (b = 0.47, p < 0.001), whereas no difference was observed among caregivers with low literacy. Higher caregiver engagement predicted greater transition preparedness (b = 8.60, p < 0.001), which in turn reduced the odds of 30-day readmission (b = -0.045, p = 0.012). The serial indirect effect of minority status on readmission through FCEEMC and CTM was significant only for caregivers with high health literacy (b = -0.18, 95% CI [-0.41, -0.04]). The index of moderated mediation confirmed this conditional process (b = -0.23, 95% CI [-0.59, -0.03]). These effects remained robust after adjusting for clinical covariates. All reported coefficients are unstandardized.

 

Implications: Findings highlight that family caregiver health literacy is a crucial determinant of effective integrated care transitions, particularly among minority populations. High-literate caregivers facilitate communication with healthcare teams, enhance patient preparedness, and significantly reduce readmission risk. Interventions should focus on identifying caregivers with limited literacy at hospital admission and providing culturally and linguistically tailored support to strengthen their engagement. While caregiver engagement benefits all patients, it plays an especially protective role among minority families, helping to overcome structural and linguistic barriers and promoting equitable, continuous, and safer transitional care.