Lauren W. Johnston, RN, M.P.A., NEA-BC, FACHE
New York City Health and Hospital Corporation
The mission of the New York City Health and Hospital Corporation (HHC) is to provide comprehensive health services regardless of a patient’s ability to pay. In fulfilling its mission, Johnston said, HHC seeks to promote the fullest meaning of health: total physical, mental, and social well-being. HHC is the largest municipal organization in the country, she said. It has revenues of about $7 billion, and it includes 11 acute-care facilities, 4 long-term care facilities, 6 diagnostic and treatment centers, 80 other community health clinics, and a home care agency. HHC also has its own managed care health plan and 40,000 employees. It uses an employed physician model.
Annually, HHC has about 1 million emergency department visits, 5 million clinic visits, and 25,000 babies delivered. About 70 percent of the behavioral health population being cared for in New York City is cared for at HHC. The population it serves is ethnically and culturally diverse, with many patients being recently arrived immigrants. During 2010 HHC had 450,000 uninsured visits, and approximately 40 percent of those seen were undocumented immigrants. Translation services are routinely provided in more than 100 languages.
No two hospitals or facilities have the same distribution of languages or culture. Many HHC hospitals have been the cornerstones of their
communities for more than a century, and many of them are the largest employers in their areas. HHC provides a safety net not only for health care, but many times also for financial counseling, legal issues, and family support. This is important because if a patient does not know where he is going to sleep that night or isn’t sure whether he will eat, he is not listening to instructions about such things as weighing himself every day.
Health literacy includes more than just health information and health services, Johnston said. It is about helping people live their lives. For example, about two years ago the contractor handling the HHC health information system experienced a breach in the security of information for about 150,000 people. That contractor offered the 150,000 patients a toll-free number to call for information and free credit reports for a year. But the offer was all in English. Of course, the patients immediately came to HHC staff with the letter—an entire page all written in legalese and barely understandable to English speakers—and said, What are we supposed to do with this?
HHC set up a system to help the patients. Staff members explained what the letter meant and provided telephone support because the contractor was unaware of the patients’ language needs and only offered telephone support in English. Then, when the credit reports were delivered, the patients brought them in to HHC to find out what those reports meant. That is an example of health care literacy, Johnston said.
HHC has attempted to address many of the attributes described in the commissioned paper. Although not fully successful, the organization is on the path described. HHC sees the following attributes as top priorities:
• Establish promoting health literacy as an organizational responsibility.
• Foster an augmented and prepared workforce to promote health literacy.
• Distribute resources to better meet the needs of the populations served.
Several initiatives are important as the base from which HHC will help provide the support patients need to become health literate, including initiatives aimed at transparency and patient-centeredness. One of HHC’s cornerstones is transparency, Johnston said. In 2007 HHC president Alan Aviles wrote an article explaining why HHC publishes patient outcomes and patient satisfaction results on its website—it is part of becoming a transparent organization, to which HHC is fully committed. Furthermore, all of the ambulatory care sites are approved by the National Committee for Quality Assurance at Level 3, the highest level of approval, as patient-centered medical homes, delivering high-quality primary care.
In terms of the attribute “leverage accessible health information technology (IT) to embed health literacy practices and support providers and patients,” HHC meets the information technology meaningful use requirements, which include education of patients. Medication and patient medication communication have been made a priority (Attribute 11), and there are well-established offices for culturally and linguistically appropriate services (CLAS) with translation services at all points of care.
HHC is also moving forward with workforce development and is currently undertaking an assessment concerning workforce development. It is probable that there are not enough educators. A number of staff members could provide education, but they are currently prevented from doing so because of the press of daily tasks. The aim of the assessment is to be sure that staff members are being used most effectively. It will be important to include all staff in this effort—physicians, nurses, other health care disciplines, volunteers, and peer coaches.
There are many challenges that HHC faces in its efforts to improve the literacy of its patients and staff. In the area of information technology, for example, many vendors can offer programs only in English and Spanish, so those programs have to be supplemented. While the organization has an office of CLAS and translation services at every facility, this does not mean that staff members are aware of all important cultural perspectives. But one must be able to talk with patients before one can understand their cultures. Efforts are also being made to raise everyone’s expectations about the ability of staff members to communicate with patients. Unfortunately, the organization was faced with a $1 billion deficit which definitely affects what can be achieved in educating the workforce and providing the time needed to increase effective communication with patients. Other challenges include the transitory nature of the patient population—as individuals improve their financial status, they move to other places—as well as the need to overcome the inherent lack of trust among many patients in anyone functioning in an official capacity.
While there may be incentives for moving forward with programs and policies to become a more health literate organization, the main difficulty is really one of complexity, Johnston said. What should be the priorities? How does one choose what to work on first? What do we know about what will work and what will not work? Just because a program works in one community or one hospital doesn’t mean it will work the same in another. How do we know what to change? Return on investment is an important criterion in making decisions about what to do.
There is not anything in the commissioned paper that is undesirable, Johnston said, although there is a great deal that will be a challenge to implement at this time. “Develop a culture of active inquiry, partner in innovation, invest in rigorous evaluations of operations improvements”
is a difficult attribute to implement, she said. The immediate focus is to get everyone to do what is needed at the time it is needed. Another attribute, “Provide patient training and assistance around personal health records and health IT tools,” is a stretch for the population served by the organization since people do not always have reliable access to technology. And other than during patient visits, it is extremely difficult to “continually assess and track patient comprehension, skills, and ability to problem-solve around health conditions,” another worthwhile but difficult attribute. With the patient-centered medical home,1 the intention is to add to patients’ choices on how the organization communicates with them. Rather than just relying on face-to-face communication with physicians, for example, if a patient says the best way to communicate is by cell phone, that is how communication will be conducted.
There is enormous need to improve health literacy. From HHC’s point of view the attributes would benefit from specificity, prioritization, and identification of costs. This would help organizations develop plans for implementing programs to achieve these attributes. Of course, Johnston concluded, there will always be the question of how much can be done, given the resources available and the benefit expected. Changing the organization and workforce culture requires major effort, but it is effort that HHC is committed to giving.
Debra Dever, RN, BSN, MN
Loudon Community Health Center
Loudon Community Health Center in Leesburg, Virginia is a federally qualified health center (FQHC).2 The FQHC model has existed for 45 years in the United States. It is a model designed to provide access to health care services for low-income, uninsured, and underinsured people. The program began in inner-city urban areas and in extremely rural areas
1 “A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes.” http://www.medscape.com/viewarticle/589670 (accessesd April 1, 2012).
2 “Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act, certain tribal organizations, and FQHC Look-Alikes. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits.” Five requirements of an FHQC are that they serve an underserved area or population; offer a sliding fee scale; provide comprehensive services; have an ongoing quality assurance program; and have a governing board of directors. http://www.raconline.org/topics/clinics/fqhc.php (accessed December 15, 2011).
where there was no access to health care services. Today there are more than 1,000 FQHCs across the United States (Kaiser Family Foundation, 2011).
Loudon County is the richest county in the nation, Dever said. A large influx of immigrants over the past 10 years has contributed to the 800 percent growth in population. It is currently estimated that there are 40,000 uninsured residents in Loudon County, many of whom are undocumented immigrants.
Loudon Community Health Center is four years old. It began with a staff of five and one physician. The center has served 10,000 patients and has 7,000 active patients at two sites. The population served by the center is very poor. Ninety percent of those served are at 200 percent or less of the federal poverty level (FPL); of those, about 60 percent are under 100 percent of the FPL. Those served come from over 80 different countries; 55 percent are Hispanic, and 45 percent of patients require an interpreter or other language assistance. The most common diagnosis among the adult population is diabetes, followed by hypertension, then hyperlipidemia, with depression as the fourth most common diagnosis.
The center provides primary medical care and preventive care. It has family practice, board certified providers, and some mid-level providers. There is a psychiatrist on staff and two mental health counselors to provide mandated mental health services. The mandated dental care is provided through a referral system, and access to radiology services is accomplished through agreements with off-site providers. There is a professor of pharmacy from a school of pharmacy who is on site half time, and the school’s senior pharmacy students rotate through the center. There is a medications program to provide access to needed medications and an in-house laboratory.
The mission of the center is to provide all of the residents of the community, especially those who are uninsured and medically underserved, with access to comprehensive, cost-effective, high-quality, culturally competent primary and preventive health care. The center is committed to being culturally competent. Its vision is to be a model primary health care organization, to eliminate health disparities in the community, and to become the medical home of choice in Loudon County. To accomplish its mission and vision the center provides whatever enabling services are needed to overcome barriers to obtaining services. In Loudon County the number-one barrier is a lack of transportation, and the second is the language barrier.
Which attributes are more relevant to the center? Of major importance is the attribute “Provide the infrastructure to avail frontline providers, patients, and families with a package of appropriate, high-quality educational supports and resources.” This is a major challenge. The center has
educational materials in English and Spanish; the challenge is instead with other languages. To prepare materials in other languages takes time, and that is one thing that is a major barrier for center staff: There just isn’t enough time.
Another important attribute is “Leverage accessible health information technology (IT) to embed health literacy practices and support providers and patients.” The center is working very hard to effectively use its electronic health record, but the demands of time and resources and the need to standardize across the Virginia health centers made it impossible to involve the community in the development of the system. The center is investigating the establishment of a portal to overcome some of the difficulties, and to that end staff members wrote a grant to obtain resources to hire an informatics person. Because it will be very difficult to identify all the data needed to become a certified medical home, informatics expertise will be critical.
One top priority is medication safety and medication communication. The center currently asks all patients to bring their medications with them to their appointments. Given the center’s relationship with the school of pharmacy, a knowledgeable person is generally available to meet with the patients to explain their medications or to act as consultants to the center’s other providers. The center is also eligible for what is called a 340B pharmacy.3
The challenge is the diversity of the population served. How does one ensure that individuals from all the different cultures that make up the center’s patient population really understand how to take their medications appropriately or recognize that it is important to do so? Furthermore, some patients who have just entered the United States have been taking herbs or other unknown medications. It can take more than one visit and several hours to decipher what they have been taking and try to develop plans for their future medication use. Another challenge is creating a climate in which asking questions is encouraged and expected. The teach-back method and Ask Me Three are very intriguing approaches that will be helpful as the center educates its providers and nursing staff.
The center is absolutely committed to undertaking activities to become a health literate organization. The challenge in implementing
3 “Section 340B of the Public Health Service Act (created under Section 602 of the Veterans Health Care Act of 1992), which requires pharmaceutical manufacturers participating in the Medicaid program to enter into a second agreement with the Secretary under which the manufacturer agrees to provide discounts on covered outpatient drugs purchased by specified government-supported facilities, called ‘covered entities,’ that serve the nation’s most vulnerable patient populations.” http://www.cjaonline.net/events/SustSeries/Calls/Call20080918/OverviewSection340B2.pdf (accessed December 16, 2011).
these attributes is that the center has significant productivity expectations that have to be met. The question then becomes how, even with support staff, can what needs to be done be accomplished in a 15-minute visit. Other challenges include resources, manpower, expertise, and money. The federal budget for community health centers was cut earlier this year by $330 million. That meant a $215,000 cut for the center.
In terms of incentives to implement activities, the major one is financial resources, but another thing that would help would be to be able to learn about the types of programs and services that have worked in other facilities. It would be helpful if there were standardized education materials and checklists available so that each facility would not be reinventing everything.
None of the attributes listed in the paper are undesirable. Some of them are more difficult than others, such as developing metrics, particularly in the center setting. And there is no way the center would have the resources to employ a health literacy officer.
Dever concluded by saying that the attributes are in line with the center’s mission and vision and that the commitment is there to implement programs and activities to achieve these attributes. What it comes down to, she said, is possessing adequate resources.
Roundtable member Patrick McGarry noted that both speakers highlighted the attribute related to a workforce prepared to promote health literacy. How is such a workforce developed? Are there job descriptions that have health literacy included? Are there criteria used to assess whether a workforce is health literate? Are continuing medical education (CME) credits or continuing education units (CEUs) required?
Johnston responded that HHC is still in the assessment stage. The organization is trying to support the workforce. It does not require CME credits but is working to assure that CME programs are available. It is important to emphasize that the need for a health literate workforce is not confined to physicians. Health literacy is important for everyone. HHC also provides CEUs for nurses and has the ability to include other professions in continuing education. But, again, the organization is still at the point of determining not only what staff is able to do, but also what they are actually doing. The assessment has found, for example, that just about everyone on staff answers the telephone or makes appointments. Yet some staff should be focusing elsewhere, such as on medication education and teach-back. The organization is in the process of revising the job descriptions so that they better reflect what members of each profession should be doing to work at the peak of their licensure. The problem
is one of resources: The work has to be done yet there are not enough people to do it.
Dever said that at Loudon Community Health Center cultural competence and cultural sensitivity are built into the job descriptions at every level. When staff go through hiring interviews, questions are asked to ascertain how the interviewee might react in certain situations requiring a cultural perspective. There is also mandated cultural competency training for which the clinic is closed for a day so that staff members can attend the training session. Health literacy is the next area to be targeted. Finances are the limiting factor because it is financially difficult to close the clinic in order to conduct the training. There is online training available, and staff members are encouraged to participate in that.
Roundtable member Winston Wong complimented the organizations of both speakers for being dedicated to serving the needs of the underserved. It appears that both organizations think not only of the patients that enter the facilities but also about overall community needs. To what extent, he asked, does each of the organizations think about the health literacy needs of the community? Is there a way in which that can be systematically assessed? And how can those needs be addressed?
Johnson responded that HHC is grounded in its communities. Currently every facility has a community advisory board, and each of those tends to be politically active locally. However, sometimes that means that the information that reaches the organization has been screened. Therefore, in an effort to reach out to the communities themselves, many of the facilities have begun holding patient forums and including patients in root cause analysis4 and on patient safety rounds. One of the facilities, for example, has begun work on community-oriented patients care, but it is a long process. The patients and the community must trust the facility. Many patients and community members are not ready to talk about the issues they think are important, so efforts at establishing partnerships with individuals and community organizations are under way. There are also efforts aimed at determining patient satisfaction.
Dever said that FQHCs are required to conduct a complete community needs assessment every 5 years. While the Loudon center’s assessment has not focused specifically on health literacy, it has looked at the diversity and the cultural needs of the community. Furthermore, the satisfaction surveys include questions about whether patients understood what their problem was, whether they received explanations they understood,
4 A reoccurring problem makes it is important to determine the actual cause of the problem so that that cause can be removed, thereby preventing the situation from occurring again. This is called root cause analysis. http://www.systems-thinking.org/rca/rootca.htm. (accessed December 21, 2011).
and if they know their treatment plans. FQHCs are also required to have a board of directors of which at least 51 are percent community members. This means that the board is incredibly diverse, with low-income individuals from many different countries. They are, therefore, able to identify challenges in access and other barriers.
Schillinger noted that both Johnston and Dever had been talking about safety net systems—one of which is immense and the other smaller. Both have taken the universal approach to health literacy and other challenges, since nearly everyone in both facilities is facing those challenges. On the one hand, these attributes fit with the missions of each organization, thereby making it easier to build the attributes into the system because those attributes align with the mission. On the other hand, there is a great challenge because achieving the attributes requires reallocating resources, but the major challenge both organizations face is the amount of resources coming into the system. Other organizations, Schillinger continued, are not explicitly safety-net organizations and may have more leeway in discretionary decision making.
Isham said that the entire health care system is at a challenging point. The commissioned paper presents a set of recommendations that could be viewed as optional add-ons or as critical and important. Which view an organization takes, which choices it makes, is all the more important in terms of determining what the organization currently is doing versus what it could do to be more effective in meeting patients’ needs.
Kaiser Family Foundation. 2011. Number of Federally Funded Federally Qualified Health Centers, 2010. Available at http://www.statehealthfacts.org/comparemaptable.jsp?cat=8&ind=424 (accessed December 15, 2011).