We are thrilled to inform you that our series on the Ten Attributes of Health Literate Health Care Organizations will live beyond its original Health Literacy Month lifespan, and continue into the holiday season.

We are celebrating with an important interview on how to ensure the sustainability of health literacy.

This week we corresponded with Juanita Lyde, the senior project manager leading the Cultural Competency/Health Literacy efforts at Finger Lakes Performing Provider System (FLPPS), to learn about how to lay a strong foundation for Attribute 6.

As always, these interviews are meant to spark discussion. Please join Health Literacy NY and be part of the conversation. Thank you!

Attribute 6: A Health Literate Health Care Organization Uses Health Literacy Strategies in Interpersonal Communications and Confirms Understanding at All Points of Contact.

Say Ah!: The Finger Lakes PPS covers an incredibly diverse region, both by population and geography. Can you give us an overview of the populations served, and how the PPS is organized to meet their needs.

Juanita: The Finger Lakes PPS covers a 13-county region that includes 300,000 Medicaid members and an additional 100,000 individuals that are uninsured. To meet the needs of the various populations, the Finger Lakes PPS is divided into five geographic sub-regions, termed Naturally Occurring Care Networks (NOCN). These Networks represent the full continuum of care and organizational leadership within a shared geographic service area.  Each NOCN is led by a participant workgroup that represents the healthcare providers and community based organizations in their area. Within each NOCN region we have identified vulnerable populations based on the community needs assessment. Those vulnerable groups consist of: African Americans, Latino(a), Deaf/Hard of Hearing, LGBT, Those Living in Poverty, Mothers, Infants and Children, and the Mental Emotional and Behavioral Health Population, Migrants, Refugees, Mennonites and the Amish.

Say Ah!: How do you work across these NOCN, et al, to promote health literacy to both medical and non-medical staff?

Juanita: The Finger Lakes PPS is taking a multi-pronged approach to promoting health literacy within our network.  Our approach includes education and training that targets the organizational infrastructure, workforce, patients/consumers and community stakeholders.  We are taking this approach because we believe it to be the most effective with ensuring successful outcomes and sustainability.

Organizational: The Finger Lakes PPS is devoted to ensuring that the health literacy practices that we employ are sustainable. To ensure sustainability the entire organization must have an understanding of health literacy, be educated on health literacy practices, and operationalize those practices within the organization.  The understanding and education must include the leadership team (including the board of directors) and all other staff, even staff that may have no direct contact with patients.  Our health literacy goals include operationalizing health literacy practices in 100% of our contracted partner organizations.  We aim to accomplish this by offering an organizational assessment that evaluates the cultural competency and health literacy standards and practices of the organization. We will then work with our partner organizations to develop a 3-year strategic plan and workplan that builds on their identified strengths and areas of improvement. Many of the assessment questions encompass health literacy components and there is an entire section dedicated to health literacy practices in the assessment. Examples of this are:

• Asking if the practice/organization has a consumer advisory board: Consumer advisory boards are important to providing feedback to the practice/organization. Examples: reviewing patient/consumer documentation for literacy levels.

• Knowledge of Communities and data collected: Knowing the race/ethnicity of those you serve can help you understand your patient needs and respond appropriately. Example: large Hispanic/Latino(a), Asian, Russian, African, Refugee, Migrant, Deaf/Hard of Hearing, etc. these patient populations may indicate a need to ensure that documents are translated into these languages and that providers have access to appropriate translation services. How the cultural diet, cultural taboos (related to taking certain meds/other medical practices) and other cultural nuances may affect the recommended treatment plan.

To alleviate the burden that this work may place on many of our partners that are small, have limited resources and time, the Finger Lakes PPS has teamed up with approximately 10 CBO across the NOCN regions to hire and train Cultural Competency and Health Literacy (CCHL) Operation Specialists to support the work that we are asking of our partners.  This work has already started and approximately 40% of our contracted partners are engaged in the work to operationalized health literacy practices in their organization. The remaining partners will begin the work in 2018.

Workforce: The Finger Lakes PPS will work with each of our contracted partners to ensure that CCHL training plans are in place and includes CCHL training for each staff in the organization. Training also includes board members. The Finger Lakes PPS will offer in-person and online health literacy trainings to meet the needs of the various staff in each organization. These include:

• Trainings for Organizations: Best Practices of a Health Literate Organization (universal precautions approach, data collection, language access, how to assess health literacy/red flags for low literacy, etc.)

• Trainings for the Workforce: Teach Back Method/Use of Visuals/Need to Know, Motivational Interviewing (promotes successful 2-way communication, the training helps trainees to adopt in interview style that is conducive to making  individuals feel comfortable enough to disclose information that is critical to their care, e.g., low literacy level, disclose reason for not taking medication, other health and health literacy needs)

The Finger Lakes PPS understands that in order to improve health literacy and health outcomes training the workforce and ensuring health literacy practices are operationalized in organizations will not be enough. The patients/consumers must also receive education and training. Education promotes awareness and awareness promotes empowerment. The Finger Lakes PPS has a Cultural Competence Health Literacy (CC/HL) committee that was established in 2014. There are 25 members from various health and community-based organizations and two patient/consumer representatives.  We will use the input from our patient/consumer representatives, the other members of the CC/HL committee and our partner organizations to determine the best way to implement the curriculum developed for the patients/consumers in our region. We have also conducted community forums and patient focus groups to gain insight into the needs of patients/consumers and found communication to be one of the most significant challenges.

Say Ah!: What are the top three lessons you have learned working in health literacy that you would pass along?

Juanita: (1) Staff, especially those working directly with patients should receive ongoing and up-to-date training in health literacy.  Clinicians and other staff should be familiar with the various tools and methods that promote health literacy and 2-way communication.

(2) Every patient should have access to interpreting services if needed but because of the expense associated with the service this does not always take place. More should be done in this area to support health care and non-health care providers to ensure that they are able to offer interpreting and other language access services to their patient/consumer population.  Using family, friends and untrained staff is not appropriate.

(3) Workflows should be designed to support health literacy practices. Physicians have limited time with the patient so other members of the medical team should be trained on health literacy practices and these practices should be incorporated into the workflow to maximize efficiency and ensure that health literacy practices are taking place.

About Juanita Lyde

Juanita Lyde, M.S., is the project manager for cultural competency and health literacy at the Finger Lakes Performing Provider System. She has over 15-years of experience working with low-income, at-risk and vulnerable populations and managing programs and services for healthcare and community based organizations.

We are thrilled to share a special Halloween installment of our series on the Ten Attributes of Health Literate Health Care Organizations in celebration of National Health Literacy Month.

In honor of this scary day, we learned from New York City Poison Control’s Director of Public Education Lauren Schwartz about why you should never be frightened of engaging the people you serve.

This series is meant both to inform and spark discussion. Please feel free to comment, ask questions, and contribute. Thank you!

Attribute 4:  A health literate health care organization includes populations served in the design, implementation, and evaluation of health information and services.

Say Ah!: Poison Control has been an early adopter of health literacy best practices. The Health Education Literacy Program was one of the first initiatives to engage a broader audience in both health literacy and medication safety. How did you engage target audiences in developing these materials?

Lauren: We were fortunate to collaborate with Literacy Partners on the Health Education Literacy Program (HELP). We developed the materials together and were able to field-test all of the curriculum components with their adult learners to ensure that the materials were engaging and understood by our target populations. This included the brochures and the lessons. In addition, we were able to observe a number of adult education instructors at the Queens Public Library use the materials with their English as a Second Language (ESL) students. Working with the adult education students, we were able to incorporate the feedback from focus groups. We then showed them the revised version of the materials. The students were able to again give feedback and stated how much the materials had improved and how much of their own suggestions they saw incorporated into the new versions.

Say Ah!: Your written materials are great models of plain language writing. Thank you. How do you handle and resolve conflicts of opinion when they arise between what professionals want to communicate and what patients and consumers want and need from the materials?

Lauren: I always sit down with the content experts at the Poison Control Center when beginning materials development to help establish the key messages and ensure that the content is rooted in clinical evidence. Materials are then field tested using a discussion guide that incorporates CeCi Doak and Len Doak’s Learner Verification and Revision technique, which asks questions of the target audience to ensure that the material is understood and allows any concerns or questions to be addressed before the piece is printed. See Chapter 10 (chapters 8, 9 and 10 appear in this link).

Say Ah!:  Do you have different models for evaluating information and services based on the many unique populations? If so, can you tell us about some and to what populations they apply? And if not, can you tell your process for evaluating the health literacy of the health information and services you design and implement?

Lauren: Any new program is piloted with a sample of the target population we are aiming to reach. For example, when we developed the medicine safety for parents program in English, Spanish and Chinese, our health educators piloted it with these audiences. We collected a pre-test from participants and then conducted follow-up calls two weeks after the session to obtain their feedback about the program and gather information about changes in knowledge, attitudes and behaviors. Building knowledge, attitude and behavior change questions into the assessments helps to evaluate outcomes. Knowledge based questions assess using a dosing instrument rather than a kitchen spoon and knowing the active ingredient; attitude is often measured through comfort calling the Poison Control Center after the workshop; and behavior often asks about using the medication management tools and saving the Poison Center number in the cell phone.

Say Ah!:  In the many years you have been doing this, what are the top 3 three lessons you have learned to better engage and empower populations served in the development of consumer-facing materials and services.

Lauren: First and foremost, always listen to the needs and feedback of those communities you are trying to reach. Ask about any barriers for accessing a service or engaging in a health behavior change. Focus groups conducted with parents at WIC showed that barriers for calling the Poison Control Center included a preference for 911, a fear of being reported to child welfare, and low self-efficacy when presented with a child’s poisoning. This led to creating programs that addressed these issues with caregivers (read more here).  Second, field test all new programs and materials developed in every language to ensure that the messages are understood and address any concerns. Third, be open to change and continue the learning process.

About Lauren Schwartz, MPH
Ms. Schwartz is the Director of Public Education at the New York City Poison Center, where she has worked since 1999. In her role, she coordinates the community education and outreach efforts for New York City and Nassau, Suffolk and Westchester counties. Ms. Schwartz is responsible for all aspects of the multilingual health education programs created to raise awareness about prevention of unintentional poisonings, medicine safety and utilization of the NYC Poison Control Center. She is also an Assistant Professor of Emergency Medicine at New York University School of Medicine. She received a master’s degree in Public Health from Hunter College.

The NYC Poison Control Center is available 24 hours a day, 7 days a week for treatment advice about exposures to poisons or questions about medicine safety. Pharmacists and nurses certified in poison information are there to give advice. All calls are free and confidential. Translator services are provided in more than 150 languages. Call any time at 1-800-222-1222 or 212-POISONS (212-764-7667).