1. How can we involve the populations that we serve in improving the health literacy environment of health care organizations? Nadia Ali, M.D, M.B;B.S, MPH, FACP Associate Program Director, Internal Medicine Residency Program Clinical Assistant Professor, School of Medicine of Temple University, Crozer Chester Medical Center, Upland, PA. www.healthliteracynow.org

2. No conflicts of interest  No employment relationships outside of my primary affiliation  No memberships on a Board of Directors or other leadership position  No research funding received.  No paid consultant positions or membership in an advisory board or review panel  No membership in a speaker's bureau  No major stock or investments relevant to your position  No Other sources of income, including relationships and company name

3. Objectives  To identify the different levels of community participation in a health care organization.  To analyze the structures and processes needed to involve populations in identifying, assessing and eliminating health literacy barriers  To reflect upon potential challenges and opportinities in involving populations at the organizational level.

4. Outline  What is ‘ Health Literacy Environment ’ ?  Components of ‘ Health Literacy Environment of a health care organization.  Defining the characteristics of a population  Relationship between population and health literacy environment.  Defining the different levels of community involvement

5. Outline…(cont)  What structures are needed for community involvement?  What processes are needed for community involvement?  Challenges in involving communities.

6. What is ‘Health Literacy’?  Health literacy emerges when the expectations, preferences, and skills of individuals seeking health information and services meet the expectations, preferences, and skills of those providing information and services. Health Literacy: A Prescription to End Confusion. Institute of Medicine, 2004

7. What is ‘Health Literacy Environment’?  The health literacy environment of a healthcare facility represents the expectations, preferences, and skills of those providing health information and services.

8. Figure 1: Hospital Health Literacy Environment -human resources Skills Doctors Nurse Staff Social worker Case Manager Intern Med student Resident ??? Expectations Preferences

9. Figure 2: Hospital Health Literacy Environment -Material resources signs Technology Consents Advance directives Info Booklet Rights & Res Payment calculation Preferences Skills Expectations

10. What are the components of the health literacy environment?  Navigation  2. Print Communication  3. Oral Exchange  4. Technology  5. Policies & Protocols

11. Navigation  Telephone System  Entrance  Lobby  Staff Assistance  Hallways Navigation Ease  Service and specialty areas

12. Print Communication  Writing style  Organization and design  Type Style, Size of Print, and contrast with Paper  Photographs, Illustrations, Symbols, and Diversity

13. Oral Exchange  Provision of assistance  Translation services  Use of plain language  Use of audio and/or video tapes for patient education.

14. Technology  Televisions  Telephones  Computers  Kiosks

15. Policies & Protocols  Use of Print  Oral exchange  Staff orientation  Staff skills building (print communication and oral exchange)

16. Defining the characteristics of a population  A population is defined as a collection of human beings living in the same area.  The population being served by a health organization may consist of several communities.  Each community is characterized by its unique needs, risks, preferences, beliefs, values, language and resources.

17. Relationship between population and HL environment. Navigation Print Communication Oral Exchange Technology Policies Needs Beliefs expectations Values Preferences Language Resources

18. Activity 1  Each group will be assigned an at risk target population. Each group will come up with creation of an optimal health literacy environment for its target population in an office setting. How can each of the different component of the HL environment address the need of the target population. You have 10 minutes for discussion followed by a short presentation from each group.

19. Target Populations A. Elderly population with difficult sight and hearing. B. Chinese (Mandarin) speaking population consisting of large families. C. African American population with limited reading and writing skills and less than high school education.

20. Defining Population Involvement Inclusion of individuals who are adult learners or limited health literacy in the design, implementation and evaluation of health information and services. Attributes of a health literate organization: IOM Roundtable on Health Literacy Jan 2012

21. Levels of Population Involvement Level 1: Raising awareness about potential HL barriers. Level 2: Assessment of HL barriers. Level 3: Development of interventions to address HL barriers.

22. Level 1: Raising Awareness  Basic level  Specific examples of patients with poor outcomes secondary to HL barriers.  Main objective is raising awareness

23. Example:  36 year old African American female admitted second time with shortness of breath.  Patient recently delivered a normal baby about 1 months ago.  Post partum hospital stay for 2 weeks and diagnosed with post partum cardiomyopathy.

24. Example cont…  Visited her PCP 3 days post hospital discharge.  ED visit 1 week following the PCP visit. Sent out with same meds.  Second hospital admission with same symptoms as post discharge because family upset about symptoms not resolving and the first hospital not ‘ good enough ’

25. Example cont….  Audio

26. Level 1: Raising Awareness  Identifying key HL barriers through involvement of the population  Identifying key stake holders of organization  Meeting with key stake holders to specific examples indicating the need for improvement.

27. Level 1: Raising Awareness  Identify interested stakeholders and get their feedback on potential solutions.  Convene interested stake holders to form a taskforce or an interest group to deal with the situation

28. Example of Level 1: HL task force for a community Hospital  Collection of specific patient examples pertinent to oral exchange component of the HL environment.  Supplementation with a survey that indicated low knowledge amongst residents and nurses regarding HL

29. Example of Level 1: HL task force for a community Hospital  Stake holders identified Residents-Noon conference Nurses-Monthly nurse managers meeting and floor nurse assemblies Senior Leadership- Director for patient safety Culture committee and patient education committee- representation Librarian

30. Level 2 Population involvement: Assessment of HL Environment Essential to determine the populations  Needs  Expectations  Preferences  Perceptions of our services  Resources  Values

31. Level 2 Population involvement: Assessment of HL Environment Tools for assessment include  HL Environment Assessment Survey  HCAHPS  Staff, patients and their families, and community observations.

32. HCAHPS Questions How often did staff explain about medicines before giving them to patients?  How often did hospital staff tell you what the medicine was for? (Q16)  How often did hospital staff describe possible side effects in a way you could understand? (Q17)

33. Level 2 Population involvement: Assessment of HL Environment  Identify community resources and partnering with them  Involve community members in identifying a barrier using available tools.  Use community input to get a better understanding of the HL barriers and population needs.

34. Example of Level 2: Assessment of Hospital’s navigation system  Pharmacy representation on the task force.  Use of new student volunteers to fill out the navigation assessment on Day 1  Collection of forms and data entry

35. Example of Level 2: Assessment of Hospital’s navigation system  Discussion of the results with the sign committee.  Discussion with senior hospital executives regarding budget.  Roll out of the intervention at the beginning of next year.

36. Level 3: Development of interventions to address HL barriers.  Involving the population in the design of the intervention.  Pilot testing in the population  Post intervention follow-up

37. Example of Level 3: New Medication Form  Development of the form  Piloting the form  Post intervention follow-up

38. What structures are needed for population involvement? Review organizational structure to identify existing resources  Volunteers  Students  Community Organizations  Patient families

39. What processes are needed for population involvement?  Identify interested stakeholders  Involve them from the beginning  Lay down ground rules  Follow-up at regular intervals

40. Activity 2  How would you involve your target population in assessing and improving the HL environment?

41. Target Areas A. Elderly population with difficult sight and hearing –Providing consent for transfusions and surgical procedures B. Chinese (Mandarin) speaking population consisting of large families- hospital to home discharge. C. African American population with limited reading and writing skills and less than high school education- providing education about chronic diseases

42. Challenges…..brainstorm  What challenges do you expect during the process of population involvement?

43. Challenges  Involvement of stake holders Common ground follow-up  Incentives for stake holders time material incentive recognition

44. Challenges…continue  Choice of the HL barrier. Low hanging fruit Short steps feasibility Realistic timeline

45. Thank you