This week, we celebrate a post-Thanksgiving bounty for Attribute 7 of the Ten Attributes of Health Literate Health Care Organizations with the second in our 2-part discussion on this critical quality.

We caught up with HRHCare Community Health to learn how it has implemented health literacy strategies to ensure its information, services and system of 28 sites in the Hudson Valley and Long Island are easy to access, use and navigate.

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

Attribute 7: A health literate health care organization provides easy access to health information and services and navigation assistance.

Say Ah!: As a Federally Qualified Health Clinic (FQHC), providing easy access and navigation for the patients you serve is integral. I know that HRHCare Community Health launched their fully featured website a few years ago. Can you speak to what health literacy best practices went into that and some feedback you have received so far?

HRHCare: The main objective of redesigning the HRHCare Community Health website was to develop a website that is user friendly, simple to navigate, and easy to find what you are looking for. It is always our goal to help our patients and prospective patients learn about our comprehensive services and get connected to care. First, we spent a great deal of time developing a design and navigation that is simple, has as much white space as possible, and leads the user to what they are looking for. We developed user profiles for the key audiences of our website and customized the experience to the top needs of each user. A clean and simple layout was our goal.

Next, we focused on the written content and language. We worked with Say Ah to develop content that was written in plain, familiar language. Additionally, we used call outs to direct patients to the information they are looking for. Icons were integrated into the design as a secondary visual element to assist in navigation. The patient portal is easy to find with a bright orange button on the homepage. The website is available in many different languages and includes a full accessibility menu. We have received very good feedback on the website.

Say Ah!: What are some steps you take to ensure that your patients or clients understand the health information and services they receive both in person and online?

HRHCare: First and foremost, at HRHCare we embrace the universal approach to health literacy because it’s in everyone’s best interest to improve communication. Many of our providers use the “teach back” method for patients to share in their own words what they heard or ask the patient to describe how they will explain to their family or loved ones about today’s visit. Second, we encourage staff and patients alike to ask open ended questions at all points of patient care—at the front desk, as referrals are made by their Patient Navigators or discussing foot care problems with the Podiatrist. One step has been to integrate the “Ask Me 3” questions into our Health Center services brochures and patient education handbook. This helps to promote the message that questions are welcomed and provides a “script” for those who need some help getting conversations started with their health care team.

Our health system represents a diverse and growing population in the Hudson Valley and Long Island. The presence of our Outreach staff and Community Health Workers are instrumental players in patient engagement. They can relate and help bridge the gap to ensure our patients are using primary care health services and understand the benefits of knowing your numbers for blood pressure or prediabetes screenings. Having trained medical interpreters on our staff is key. We know we cannot rely solely on printed materials; having staff that reflect the diversity of the communities we serve is valuable in being able to relay information that patients can process and use to make informed decisions is paramount.

Say Ah!: Are there any distinct cues and layout elements strategically placed within the physical layout of your center(s) that helps direct patients with ease?

HRHCare: Absolutely. We developed a bilingual wayfinding system to help patients find the departments and services that they are looking for. The wayfinding system includes icons to help with literacy and quickly identify services for patients of all literacy levels. Additionally, the system acts as an educational tool to make patients aware of the full scope of services offered at our health centers. This is a great way to easily help patients navigate the health system and learn about all our health care offerings.

About HRHCare
Founded over 40 years ago as a Federally Qualified Health Center, HRHCare Community Health is one of the nation’s largest community health providers. The HRHCare network of 28 health centers throughout the Hudson Valley and Long Island provides affordable, accessible care to over 175,000 patients through more than 650,000 visits annually. Our 350 primary care practitioners and 700 specialists and support staff have made HRHCare a destination for convenient, high-quality care for all. www.hrhcare.org

Ahead of the Thanksgiving holiday, we are thankful for the many people who have helped make this Ten Attributes of Health Literate Health Care Organizations interview and discussion series a success.

This week, in particular, we are grateful to Dr. Douglas Reich, Chairman of the Department of Family Medicine at the Bronx Lebanon Hospital Center, who spoke to us about meeting the health literacy needs of patients facing multiple challenges in Part 1 of our 2-part pice on Attribute 7 .

We are also grateful for the reunion this interview brought with Arafat Omidiran, MPH, the Research and Data Analyst at Bronx Lebanon Hospital’s Department of Family Medicine. Ms. Omidiran, an original administrator of the Health Literacy NY, conducted the interview.

Attribute 7: A Health Literate Health Care Organization Provides Easy Access to Health Information and Services and Navigation Assistance.

Say Ah!: The Bronx has some of the most complex populations from a health literacy perspective, can you tell us about some of the challenges you face in providing easy access to health information and services and what you are doing to meet these challenges?

Dr. Reich: More than a third of adults in our community have not completed high school, and many of our patients have a general reading level between 3rd and 5th grade. As a result we have had to dramatically adjust how we provide information to our patients. Coupled with the fact that our patient population speaks a multitude of languages, communication can be difficult. We are aware of these complexities and as a result we hire physicians and staff that reflect the community we serve and are sensitive to the needs and issues of our clients. We are trying to elevate the Health Literacy of our community through our community health workers and community partnerships.

Say Ah!: How does Bronx Lebanon Hospital Center engage the community – individuals or community based organizations – in improving access to health information and services.

Dr. Reich: In 2012, the family medicine department and Healthfirst helped anchor a novel cross-sector collaboration known as the Claremont Healthy Village Initiative (CHVI). Community Partners include the Tenant Associations of Webster-Morrisania, Morris, and Butler Houses (NYCHA), Claremont Neighborhood Center, William Hodson Senior Center, Directions For Our Youth, GrowNYC, Street Soccer USA, Casita Maria Center for Arts and Education, Bronx Documentary Center, Bronx District Public Health Office and Claremont in Motion (bike program).

CHVI is focused on proactively addressing health disparities and sustaining a shared culture of health promotion and wellbeing in the Claremont community, one of the poorest neighborhoods of the Bronx. Each partner organization provides programs and services consistent with their expertise and mission. Through CHVI, these programs and services are integrated, which facilitates reinforcement of health-related messaging; as well as expanded outreach and impact. Though many partners are active on Social Media, CHVI has recently started utilizing social media to engage more individuals. Our mission is to improve the quality of life in the Bronx, one person at a time!

Say Ah!: Technology is playing an ever larger role in assisting patients navigate the system. What technology have you found to be effective, and what hasn’t worked (i.e. automated appointment reminders).

Dr. Reich: One of our most powerful tools has been Health Leads, an online resource that points us in the direction of the community-based resources our patients need. This gives patients information and access to services that help reduce the many socio-economic barriers that inhibit their quality of life. Our Electronic Medical Record has also been a powerful tool. It has helped us to manage population health and improve health screenings. Though telehealth has been a success among certain populations, it has been a struggle to use with others. This is also true of other technologies, i.e. automated appointment reminders text messages, telephone calls and emails. However, our department has Community Health Workers who are available to make home visits to the patients if we are unable to connect to them using technology.

Say Ah!: What are the top three lessons you would impart to a health care system trying to improve its own health literacy?

Dr. Reich: The top three lessons are:
You need to offer a variety of methods when educating your patients because when it comes to health literacy education one size certainly does not fit all. You need to consider culture, language, age, etc.
Keep the message as simple as possible with palpable and definable outcomes, goals, and results in mind
Utilize Peers to disseminate your information! It is very important that your language is understood by your patient population/demographic. Having peers that match the population is an extremely powerful resource. They will assist in both the development and implementation phases.

About Douglas Reich, M.D.
Dr. Reich has been practicing family medicine for more than 30 years, and has been Chair of the Department of Family Medicine at Bronx-Lebanon Hospital Center since 2006. As Chair, Dr. Reich serves as Medical Director for Family Medicine’s five clinic locations and the Dr. Martin Luther King, Jr. Health Center. Under Dr. Reich’s leadership, the Department of Family Medicine has been the recipient of numerous grants, from both public and private funding sources. Dr. Reich was previously the Program Director for the Family Medicine Residency Training Program, and the Medical Director of Bronx Lebanon Integrated Services System, a Federally Qualified Health Center. Prior to his current position, Dr. Reich worked at Wyckoff Heights Medical Center, The Brooklyn Hospital Center, and in private practice. In addition to his clinical practice, Dr. Reich has held multiple academic and professional appointments, including as an Adjunct Clinical Associate Professor of Family Practice at the New York College of Osteopathic Medicine. Dr. Reich continues to collaborate with attending and resident physicians to conduct research on a variety of topics related to Family Medicine including child asthma, opioid use disorder and pain management, community health, and creative interventions to improve the quality and delivery of healthcare.

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.