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COVID-19 Applications and Perspectives

Organizational Health Literacy: Opportunities for Patient-Centered Care in the Wake of COVID-19

Sentell, Tetine PhD; Foss-Durant, Anne MSN, MBA; Patil, Uday MA; Taira, Deborah ScD; Paasche-Orlow, Michael K. MD, MA, MPH; Trinacty, Connie Mah PhD

Author Information
Quality Management in Health Care: January/March 2021 - Volume 30 - Issue 1 - p 49-60
doi: 10.1097/QMH.0000000000000279
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Abstract

The coronavirus disease-2019 (COVID-19) pandemic has strained and disrupted health care in the United States and elsewhere,1–3 pushing emergency departments well beyond capacity in some areas,4 while critical health safety net organizations are furloughing workers and are at risk of closure.5 The human connections that are so critical for health and well-being have been diminished, altered, and reinvented through technology in health care delivery even during the most intense moments of life.6–8 Nationally, a massive and innovative move into remote medical care delivery and reimbursement has happened virtually overnight.8–12 Despite considerable stimulus funding for the health care sector, many health systems face significant financial, logistical, and workforce challenges that may last well into the future.13,14

By forcing hospitals and clinics to curtail face-to-face elective services, the COVID-19 pandemic is transforming the health care sector, reshaping health care institutions, priorities, and provider roles. Meanwhile, enormous segments of our populations have lost jobs and health insurance.15,16 Needs for nutrition, housing, health insurance, and other necessities that impact current and future health outcomes and health service use are deep, vast, and likely to grow.17–19 While we have seen temporary moratoriums on actions such as evictions, foreclosures, and stoppage of utilities, these will likely resume well before the economy improves. Chronic conditions that have not been well managed due to logistics, stress, or financial distress in this time of crisis may result in higher rates of health services use, morbidity, and mortality.20–22 Mental health challenges are likely to grow due to the stress of this pandemic, exacerbated by social isolation and stress.23,24 These outcomes are falling hardest on many of our most vulnerable populations, highlighting fault lines of power and privilege in our society.25–28

As health care organizations move from crisis mobilization29,30 to a new paradigm that will include an urgent need to ensure solvency, rebuild a workforce, integrate care with social and behavioral health needs, and respond to these health disparities,31 organizational health literacy offers practical building blocks to provide high-quality, efficient, and meaningful health care even in the face of financial and workforce disruption and social distancing. Even when we are past this pandemic, the effects may be long lasting, or the possibilities of another global pandemic may sustain or warrant organizational health literacy infrastructural changes, such as automatic opt-in mail order pharmacy or telehealth as a first line of treatment.

In particular, organizational health literacy can provide ways to ensure health care is more patient-centered by facilitating personalized, collaborative, and understandable care.32–34 Putting patient preferences, needs, and values at the center of organizational design, workflow, and decision-making has been a goal for many years.35–37 Improving how patients are seen, heard, and cared for via such innovation can improve organizational quality, efficiency, and outcomes as well as attenuate existing, underlying health disparities.35,38,39 The need for patient-centered care has been felt acutely during the time of COVID-19, as providers have struggled to connect, touch, engage, and communicate with their patients from behind their (too often inadequate) personal protective equipment or by remote communication and in a time of information overload and increased responsibility for patients and caregivers.40–43 In this time of extraordinary crisis and health system disruption, there is strong justification and new opportunity to advance patient-centered care using the principles of organizational health literacy.

METHODS

This article synthesizes insights from organizational health literacy in the context of current major health care challenges and toward the goal of innovation in patient-centered care. It is designed to provide guidance for systems and inform decisions around resource allocation and organizational priorities to best meet the needs of their patient populations in this transformative moment. We first provide a brief overview of the origins and outlines of organizational health literacy research and practice. Second, using an established patient-centered innovation framework,35 we show how the existing work on organizational health literacy can offer a menu of effective, patient-centered innovative options for care delivery systems to improve systems and outcomes. Finally, we consider the high value of management focusing organization health literacy efforts specifically for patients in health care transitions and in the new transformation of care to a distance model. Definitions of key terms used in the article can be found in Table 1.

Table 1. - Key Definitions Used
Key Terms Definitions
Health literacy The degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.44
Organizational health literacy The degree to which an organization implements policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health.45
Patient-centered care Patient preferences, needs, and values are central to organizational design, workflow, and patient decision-making.35
Health care innovation The implementation of new or altered products, services, processes, systems, policies, organizational structures, or business models that aim to improve one or more domains of health care quality or reduce health care disparities.46
Care transition When patients move between health care practitioners, settings, and home as their condition and care needs change.47

Organizational health literacy

Organizational health literacy considers “the degree to which an organization implements policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health.”48,49(p1) This perspective considers the health care organization responsible for understanding and addressing patient health information needs, rather than putting this responsibility on individual patients and caregivers.49–52 A health literate organization would not just be easy to navigate, but also truly transformative—empowering individuals across cultural, linguistic, economic, and educational backgrounds to meet their health and wellness needs.52 As we create virtual care networks, we must do so with organizational health literacy principles in mind.

While organizational health literacy is a relatively new area of research and practice, it already has strong national and international standards, active momentum in the health care sector, and an innovative and growing evidence base in research and practice.45,48–58 Choosing health literacy as an organizational priority with which to rebuild or reimagine a health system is a management decision with considerable potential, practical guidance, and clear metrics for success.49–52

Brief history of organizational health literacy

Organizational health literacy grew from the field of health literacy, an active research area for the past 30 years. Across varying definitions and conceptualizations of health literacy, it has become clear that only a small minority of Americans have proficiency in the full array of skills and capacities to be “health literate” in our current systems.59,60 Those who are poor, elderly, live in rural areas, have chronic conditions, have poor self-reported health, have limited English proficiency, and are of a minority race/ethnicity are more likely to have low health literacy.59,60 Even those with “adequate” health literacy may struggle to obtain, process, and understand basic health information under the stress of a new diagnosis or when they are not feeling well.61 Low health literacy has been associated with a myriad of poor health outcomes of interest to health care systems including health care quality, equity, and cost.62–64

Health care organizations, and the providers who practice within them, play a major role in building, promoting, and sustaining health literacy for individuals, caregivers, and families.39 Given the ubiquity of health literacy challenges, including the current “infodemic,”65 the strong associations with critical health outcomes, and the disproportionate impact on certain groups,60 addressing health literacy at the organizational level has the potential to achieve the Triple Aim of higher health care quality, reduced costs, and improved population health.51,54,66

Many conceptual models, guidelines, and resources exist for health literacy approaches by health care organizations.45,49,52–55,66 The Institute of Medicine (IOM; now, the Health and Medicine Division of the National Academies) and other key national agencies, accreditation bodies, and international organizations have provided influential guidance on becoming a health literate organization, including toolkits to achieve these goals and measure progress.45,49,52–55,66 Particularly seminal are the Ten Attributes of a Health Literate Organization (“Ten Attributes”) described in 2012 by the IOM.49 These include strong leadership support; health literacy embedded in organizational planning, practice, evaluation, and quality improvement; meeting patient needs without stigmatizing them; and all health information content being easy to access and easy to understand across cultural and linguistic preferences. Critically, these goals align with institutional efforts to reduce health disparities with a recognition that the patient is a partner in their care and that literacy, language, and culture are intertwined.49

Following organizational health literacy principles can reduce inefficiency and duplication while achieving patient-focused goals of engagement, understanding, and support across prevention, decision-making, and self-management.48,49,51 There is hope it can build better patient-provider relationships and deepen trust and communication.32,34 On a deeper level, shifting an organization toward these goals can upend the ways in which health systems and their complexities disempower patients and their families, particularly those who are already vulnerable to health inequities.50,52

Organizational health literacy as a patient-centered innovation

This section identifies synergies between the organizational health literacy perspective and patient-centered quality improvement.67 These are organized according in the Hernandez et al. framework,35 which describes 5 attributes supporting patient-centered innovation: leadership, internal and external motivation, mission and culture, capacity and resources, and feedback loops. Organizational health literacy is considered within and across these domains, especially threading the links between the seminal Ten Attributes of a Health Literate Organization in support of patient-centered care. This is a unique contribution of this article. While these topics are often discussed together, they are not explicitly linked together within existing conceptual models. We also highlight practical guidance throughout this section.

Organizational leadership

Strong leadership with a clear vision to make health literacy an organizational priority is the first of the Ten Attributes.49 Without meaningful leadership buy-in, specifically a choice by executives to use their resources and power toward ambitious and demanding goals, patient-centered innovation is not possible, practical, or sustainable.35,49 Organizational health literacy has clear priorities, training, and resources toward achieving a health literate organization,45,49,52–55,66 all of which can provide useful guidance and benchmarking for pioneering leadership, especially in a time of stress and uncertainty. Health care leaders have been challenged, exhausted, and frustrated by the uncertainties and demands of COVID-19.68,69 They have critical responsibilities not only for obtaining personal protective equipment, managing risk, and supporting their workforce,29,30 but also for empowering patients to understand social distancing, self-care, and telemedicine.70,71

Empowering patients is a patient-centered, health-literate action that can help flatten the curve for use of health services for COVID-19 and decrease health care utilization for many diseases and health emergencies.71,72 Patients need to understand the balance between social distancing and knowing when to seek care given their preexisting conditions. Patients need to have the skills, knowledge, and confidence to manage their health concerns, including chronic diseases. Providers and public health professionals are concerned that these patients are at even greater risk during this time, due to exposure to COVID-19 and lack of access to care equally.73 Patients now have an even greater responsibility to self-navigate through a health care system that is not as accessible. These are all critical to helping the health system through the crisis. There is hope that on the other side of this pandemic, a more integrative and equitable health care system may be possible.68,69,74

Internal and external motivation to change

Health care organizations are not easy to change. Becoming a patient-centered, health literate organization will necessitate not only major changes in workflow and expectations, but may also add considerable costs.54 Health care organizations have always been complex, extremely busy, and resource constrained. Such a transformative journey must be necessary and worthwhile. Yet, COVID-19 has shown that massive, rapid change can happen. We are making transformative changes now, particularly in telemedicine, that were previously unthinkable.10,11,75 To make this possible, outside forces (eg, economic, cultural, political, technological, and ecological) must support and incentivize this process. Similar forces have been pushing organizations toward models that are both patient-centered and health literate even before COVID-19 and these forces have become even more urgent in this time. This disruption presents incentives toward major change. Table 2 considers this synergy in more detail across these factors generally and in relation to the COVID-19 pandemic.

Table 2. - Synergistic External Forces Incentivizing Both Patient-Centered Innovation35 and Health Literate Organizations
External Forces Background Forces—Pre-COVID-19 Additional Background Forces—Post-COVID-19
Economic forces New models of payment are incentivizing teams to address health care needs with patients at the center, including medical homes and accountable care organization. Financial incentive structures prioritize addressing factors as pervasive, as low health literacy not just to improve health outcome and reduction of medical errors, but also patient's experience of being seen, heard, and understood as improved patient quality and experience. These are associated with financial rewards and penalties. Decisions on these topics may impact position in market competition and organizational survival. Systems are under strain and need to innovate. Telehealth and related products are now reimbursable, providing new opportunities. The system is in flux as much care, including elective surgical procedures, has been halted to respond to this crisis and other funds are needed to sustain health care. Funding will come to health care from stimulus packages.
Political forces Recent health reform legislation has influenced the prioritization of both health literacy and patient-centered care. The Affordable Care Act (ACA) made plain language critical to health insurance information. This is related to one of the goals of becoming a health literature organization in the Ten Attributes—being clear about what is covered and what is not. Health care is an extremely visible economic sector and critical community asset in this pandemic. This brings considerable political attention and tremendous public support. Still, patients may be fearful to engage with the health care system due to concerns about contracting COVID-19. Patient-centered, health literate care can build trust, understanding, and empowerment.
Ecological factors Community initiatives to improve public health are growing. Initiatives to address health literacy fit into the larger efforts (also driven by economic and policies forces) to address social factors in health care more generally even from acute care facilities, health insurers, and others who have not typically engaged with population health and social factors. These include efforts to understand and measure patient's social vulnerabilities but then address them, necessitating changed workflows and new electronic medical record systems.76,77 Health disparities are deeply visible. The need for social factors to integrate into health care to achieve both individual and population-level health will be vast and continue well into the foreseeable future. The need for materials translated in other languages and understandable to all around health care empowerment and access to resources to meet social and behavioral health needs are a matter of clear personal and community health. Patient-centered, health literate care can provide this information.
Technological forces Advancements in technology, including in electronic medical records, can incentivize organizational efforts to address health literacy, including making community-clinical linkages more plausible. Ensuring health literacy is not simply the demands of health but may include the ability to access needed services to ensure health such as legal, social, and other services. In the health literate care model, community-clinical linkages are critical to help patients manage their vulnerabilities.52 Communications on telehealth, mail order pharmacy, and use of online patient portals to communicate with their providers are central and will certainly grow at this time, but are not necessarily patient-centric. Automatic opt-in mail order pharmacy or telehealth may become the first line of treatment. These innovations will have new opportunities, as many patients across all demographics become more familiar with remote options and these options adjust to the particular needs of health care privacy, functionality, and connectivity. A health literate health care system will ensure that all patients can engage with these technologies and feel seen and known.
Cultural motivators The shift toward patient-centered care, team-based models of care, population health, and reducing health disparities in the health care system have all been incentivized by factors such as new funding models and ACA rules, fundamentally changing the perspective and leadership directions needed for many high-level health care managers. This is a dramatic cultural norm shift. Addressing low health literacy as an organization can help not only to achieve these goals, but support this cultural norm change in practice.78 There is hope and possibility for true transformation of the health care system in this moment. By paying attention to the patient's pathways and informational needs at this time, management can see where the gaps lie and where patient-centered needs exist in their organization now and in the future.

Organizational mission and culture

Organizational health literate communication and practices should be vertically integrated into health care systems. With COVID-19, organizations have struggled to protect the workforce especially in the context of personal protective equipment shortages not only for doctors and nurses but for everyone in the health system (eg, food service personnel, maintenance workers, therapists, chaplains, and pharmacists).79,80 And it takes more than the immediate safety of the workforce to fulfill the mission.81 A mission and culture of organizational health literacy helps remind people to keep patient and family empowerment in decision-making at all levels.

For some health care organizations, making patient needs and preferences a central principle of their missions demands a massive shift from traditional models of health care systems, which typically prioritize provider and organizational needs, effectively changing the power dynamic.78 Changing this may take major investment and thoughtful, practically minded insights into how systems are disempowering to patients. The Ten Attributes49 offer a number of concrete strategies to revitalize an organizational mission and culture to be more patient-centered. This includes a key directive: “Being a health literate organization is more than initiating a few projects that address health literacy; it means that health literacy is an organizational value. Health literacy strategies are infused throughout the organization and embraced as part of the organization's core business.”49(p4)

Patient-centered innovation thrives in organizations that create a culture in which learning and experimentation occur at all levels.35,78 Other activities can promote a cultural shift toward health literacy. Patient- and family-centered councils are becoming a popular strategy across health systems as part of institutional efforts to ensure partnerships with patients to improve communications and align care with patients and supportive family needs and preferences.82,83 As health care organizations begin to envision their future directions and continue to develop remote health care options and tools, patients and families should be part of health system transformation and redesign. In this case, councils will need to continue in a remote fashion. Some health systems have continued to support these councils to meet virtually,82 a critical step to keep these voices in decision-making in this dynamic time. These councils can potentially support and target organizational health literacy efforts to meet the needs of individual patients, their families, and community needs. However, they need autonomy, investment, and independent leadership to allow truly visionary goals and to ensure they do not just rubber-stamp the status quo. While organizational health literacy centers on strong communication, communicating remotely has many challenges. Still, the disruption of COVID-19 may open space for truly transformative action and innovation, as we identify the critical portions of our health care relationships that are missing and those pieces that were not necessary.10,11,75 During this time, the need for organizational health literate communication that is also patient-centered has often been hard to address; however, this will be critical in the long run for patients, especially those with chronic disease.12 Telehealth appointments are great, but these must have human connectivity in the virtual space to be meaningful. Strong collaborations with community organizations toward connectivity, resources, and cultural relevance are critical; patients and their own voices should be at the table as well in these redesigns toward organizational health literacy.

Capacity and resources

An organization's ability to become a health literate organization will be constrained by its capacity and resources, including variation in staff, size, location, design, and technology. In times of financial strain, it will be important to leverage resources that organizations already have in place or can create. Innovation in the face of need has become very visible in the COVID-19 response (eg, ventilators with multiple patients and impromptu personal protective equipment).84,85 A focus on patient-centered care is critical to resource allocation, as it can guide treatment decisions and inform resource prioritization as health systems will need to continue to innovate going forward, in what will hopefully be somewhat less dire circumstances.

Supporting the health literacy of the workforce itself is one of the Ten Attributes.49 Provider training on low health literacy and strategies to address this relevant to patient populations are useful.39,48,50 Simplifying health care facilities and systems navigation is also crucial. The system should build in points of communication and engagement with patients and their “support teams” to ensure they understand the patient's condition and how to manage it.86 These encounters with patients and families should include teach-back and mutual respect. Investing in community health workers and patient navigators, especially with cultural relevance, can better link patients to resources and lead to improved health.87–90 Diversifying the health care workforce to resemble the demographic and cultural mix of the patient population can ultimately support broad organizational health literacy and patient-centered goals.

Feedback loops

For innovation to be both sustained and effective, continuous feedback loops are needed to realign strategies and ensure they are meeting patients' health needs, preferences, and values. This is an ongoing process; there is no full attainment and systems are always learning.49,52 A recent literature review and expert panel found 22 measures that organizations can use to monitor their health literacy quality improvement efforts (eg, number of staff trained in the teach-back method) that were useful, meaningful, feasible, and had face validity computed from clinical, administrative, quality improvement, or staff-reported data.48 These could complement data collected by patients around their health literacy-related experiences or collected in tools such as the Consumer Assessment of Healthcare Providers and Systems.91,92 Feedback loops can be difficult, taxing, and even politically inconvenient, revealing findings that are hard to address. Also, while a variety of measures exist, best practices on measuring organizational health literacy and marking improvements are still emerging.48,53–55,66 Thus, the comprehensive impacts of large-scale initiatives are often loosely assessed or missing altogether from operational workflows. However, these are critical to understand and to see progress relative to benchmarks. Internal and external recognition programs tied to these can also be a motivator for organizational innovation.49,93

Overarching model

The 5 domains described previously work together. For instance, leadership strives to improve capacity in response to internal and external pressures. From a management perspective, there are many important, sometimes competing agendas and initiatives. Addressing these separately divides resources and attention. A focus on organizational health literacy as a patient-centered innovation presents an opportunity to align not only strategic goals and efforts, but also the quality improvement metrics to measure meaningful progress. Integrating measures for key metrics such as health literacy, language access, and cultural competence could prevent duplication and confusion and could allow leadership to expend efforts and capital synergistically.94

Health care transitions for patients with complex health needs

Care transitions for complex, high-needs patients may be an area for a practical first step toward implementing health literacy into the care systems and can test system readiness for this form of patient-centered innovation. These issues have been deeply considered over time in light of health literacy and patient-centered care. We provide a brief, practical synthesis of this literature here and links to additional useful literature.

Patients in care transitions are among the high-need, high-cost patients who comprise only 5% of the US population, but account for 50% of the US annual health care spending.95 In care transitions, patients and their families are faced with more opportunities for confusion, miscommunication, and significant adverse outcomes in health, cost, and quality.45,60,96–101 Patients in these care transitions are perhaps the most susceptible to adverse outcomes resulting from a systems failure to account for health literacy.102–104 And ignoring health literacy in care transitions initiatives may exacerbate inequalities.96–101 Thus, a considerable amount of useful research exists at the nexus of health literacy, care transitions, and patient-centered care toward understanding and addressing care transitions generally and reducing readmissions specifically.96–101,105–111

Project RED is one seminal project designed to reduce readmission and improve health care quality, built with health literacy principles in mind, and supported by a strong evidence base.108,111,112 Practical toolkits from this project and others with similar goals are available for health system use.108–110,113 These include efforts in medication reconciliation, improved patient education, and ensuring that patients leave the hospital with an appointment with their primary care provider within a week of discharge. These are often now part of typical practice, helping to promote health literacy and providing links with a supportive health care system to answer questions and reduce complexity. Table 3 considers health literacy concerns in care transitions and evidence-based, patient-centered resources for organizational health literacy efforts to address them, providing practical guidance.

Table 3. - Justification of Health Literacy Efforts in Care Transitions and Examples of Evidence-Based Interventions
Care Transition Needs Health Literacy Challenges Options for Evidence-Based Patient-Centered Innovation to Address Health Literacy Challenges
Discharge planning Patients with low health literacy are more likely to lack understanding of key elements of transitional care, including diagnosis and medications97 Universal precautions and plain language, which can benefit all patients61
Project RED provides comprehensive, mutually reinforcing strategies to promote patient safety and reduce rehospitalization rates108,111,112
BOOST Risk Assessment Tool identifying 8 modifiable risk factors that guide discharge planning114
Using the teach-back method to review this information with the patient115
Educate patients on red flags signaling complications116
Include strong interdisciplinary patient engagement and rapid primary care follow-up117
Protected time for discharge teaching with patients and families to review the information and allow them to ask questions
Streamline the discharge paperwork making it complete concise and easy to read
Use visuals, checklists, and itineraries when appropriate in printed materials
Additional resources (care coordinators, clinical cardiologist, care management, insuring follow-up appointments) if patients at risk99
Medication reconciliation Poor ability to take medications appropriately118,119 Personal health record to document medication issues120
Medication reconciliation worksheet121
Patient and family communication People with low health literacy often draw upon the health literacy skills of others to seek, understand, and use health information122,123 Family Caregiver Activation in Transitions (FCAT) Tool124
Sending reminders on medication refills, appointments, and important time-sensitive tasks
DECAF Family Caregiver Tool: D = Direct Care Provision, E = Emotional Support, C = Care Coordination, A = Advocacy, and F = Financial125
Stop and watch early warning sign tool126
Primary care provider communication People with low health literacy have difficulty navigating the health care system127 Personal health record to create list of questions for provider128
Providers may not be aware of the challenge patients face in health literacy and health communication129 How to Talk to Your Doctor HANDbook130
There may be inequity in health communication by race/ethnicity, income, gender, and other factors associated with health literacy, which may exacerbate health disparities131 Patient-centered care and shared decision-making132
Patients with low health literacy may be less satisfied with their care132

Health care transitions for remote care

Remote care, telehealth, telemedicine, and mobile care are also areas where attention to health literacy from an organizational perspective is critical to ensuring that care remains patient-centered, especially for those who are not familiar with such technology or do not own these tools.133–138 Remote management of many chronic diseases can be improved by adding tools such as scales, blood pressure monitoring, pulse oximetry, glucose monitoring, heart rate monitor apps, video, thermometers, and digital electrocardiograph systems.139,140 Responsive health systems may be able to pivot to provide these, but getting the devices to the patients is only part of the puzzle. An organizational health literate system must empower patients to utilize the devices, understand the information,137 and use the information in calls with providers and for self-care. Patients will develop their own skills in self-monitoring and learn to recognize for risk factors such as leg swelling, shortness of breath, wheezing, and fever that would indicate health system contact would be needed. To empower patients in these ways has become newly urgent in the time of COVID-19.

Other than materials translated in other languages, patient-centric interventions include infographics provided by the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, and other public health agencies.141–144 Communications on the use of telehealth, mail order pharmacy, and online patient portals are central but not necessarily patient-centric. Patients in systems that followed organizational health literacy principles may have transitioned better than those systems that have not subscribed to these principles. Home blood pressure readings and mailed colorectal cancer screening kits already exist, but we expect to see an influx of initiation and sustained use in the wake of COVID. Patients must understand why they are using them, and how to do so, for best results.

Investment in information technology (IT) has the potential to improve health care and access, including transitions for patients with complex conditions. At the same time, greater use of even the most innovative IT (eg, smartphone-based applications to improve care coordination, interactive patient-centered discharge toolkits to promote self-management, and access to personal health records) can present patients with new complex information with fewer personal touchstones, potentially exacerbating digital divides, health literacy challenges, and health disparities.35,145–147 Communication in the digital realm must follow patient-centered and organizational health literacy principles.86

DISCUSSION

Focusing on organizational health literacy is a useful, transformative patient-centered innovation that can provide meaningful goals, activities, and metrics in this time of disruption and strain. The article contributes to the literature on this topic by weaving together existing lines of research and practice around organizational health literacy and patient-centered innovation in a practical document designed to be informative and useful to practice generally and also specifically relevant to concerns in the COVID-19 pandemic around care transitions and the rapid transformation to remote care.

Toolkits, momentum, and measurement tools for organizational health literacy exist as described in detail previously. The research on the need for organizational health literacy, especially in priority groups and populations, is clearly articulated. Efforts to improve organizational health literacy should improve patient safety and quality of care, which yields both financial and nonfinancial benefits.49 Other benefits include lower emergency department visits, fewer preventable admissions, fewer medical errors, reduced disparities, and higher patient satisfaction. Newer payment models have incentivized these efforts. The need for health care systems to innovate and change from the status quo is even more urgent and visible in this crisis. The system is in flux, presenting an opportunity for change. As we have created a shift from in-person and emergency department care to the same care over telephone or video calls, we may need to build innovative structures between hospitals and health care systems and home and community to keep patients known, engaged, and healthy in this time of physical distancing.

Pioneering efforts can move a health system to be more patient-centered, using strong existing guideposts to set the conversation and agenda. Changing organizational culture is not simple, no matter how strong the need or logic for improvement. Barriers to wholesale change to improve organizational health literacy include the presence of competing initiatives, limited staff availability, the length and complexity of organizational health literacy assessment tools, lack of organizational leadership, prioritization of patient care over implementation, and lack of qualified staff and supervision.148 Yet because health literacy impacts so many components of health and health care access and cuts across departments, organizations, and needs, addressing this comprehensively presents a critical opportunity to meet the Triple Aim and reduce health disparities. Bringing an organizational health literacy mindset to all initiatives is the key goal.

Next steps

While this article focuses on hospitals and health care systems, many lessons could be relevant to nursing homes, primary care, and other health care settings, which are also under significant logistical and financial strain from COVID-19 pandemic. Although research evidence is building across locations and care settings, a deeper evidence base for strategies and interventions to address organizational health literacy and the cost implications would also be welcome in the field.148–150 More research is needed around measurement of organizational health literacy initiatives and the practical realities of putting organizational health literacy initiatives in place, especially drawing upon implementation theory. While this is an active area of practice, many of these initiatives, like many organizational changes, take place in the context of practice, not research, and thus are not systematically evaluated nor are the results disseminated to peers. Research that considers health information comprehension and longitudinal health outcomes for individuals or populations following the implementation of organizational health literacy initiatives would also be useful.

CONCLUSIONS

Organizational health literacy principles and guidelines provide a road map for promoting patient-centered care. In this time of crisis, change, and transformation, health system leaders seeking innovative approaches can have access to well-established tool kits, guiding models, and materials toward many organizational health literacy goals across treatment, diagnosis, prevention, education, research, and outreach. Organizational health literacy can be used as an innovation by a health system to meet the Triple Aim and reduce health disparities.52 We have synthesized existing literature to provide updated guidance for systems looking for a short list and a narrowing of options to inform decisions needed around resource allocation and organizational priorities to best meet the needs of their patient populations even in this uncertain time. As they engage in telehealth, patient-centric organizational health literacy makes it more effective and efficient.

REFERENCES

1. Cavallo JJ, Donoho DA, Forman HP. Hospital capacity and operations in the coronavirus disease 2019 (COVID-19) pandemic—planning for the Nth patient. JAMA Health Forum. 2020;1(3):e200345. doi:10.1001/jamahealthforum.2020.0345.
2. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lan-cet. 2020;395(10231):1225–1228. doi:10.1016/S0140-6736(20)30627-9.
3. Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ. 2020;368:m1090. doi:10.1136/bmj.m1090.
4. Ouyang H. I'm an E.R. Doctor in New York. None of Us Will Ever Be the Same. The New York Times. https://www.nytimes.com/2020/04/14/magazine/coronavirus-er-doctor-diary-new-york-city.html. Published April 14, 2020. Accessed April 30, 2020.
5. Gabler E, Montague Z, Ashford G. During a Pandemic, an Unanticipated Problem: Out-of-Work Health Workers. The New York Times. https://www.nytimes.com/2020/04/03/us/politics/coronavirus-health-care-workers-layoffs.html. Published April 3, 2020. Accessed April 30, 2020.
6. Brody JE. Take Steps to Counter the Loneliness of Social Distancing. The New York Times. https://www.nytimes.com/2020/03/23/well/family/coronavirus-loneliness-isolation-social-distancing-elderly.html. Published March 23, 2020. Accessed April 30, 2020.
7. Sashin D. Portraits on COVID-19 protective gear reveal human faces providing care. Scope. https://scopeblog.stanford.edu/2020/04/10/portraits-on-covid-19-protective-gear-reveal-human-faces-providing-care/. Published April 10, 2020. Accessed April 30, 2020.
8. Daley J. How a Denver Family Found Itself Saying Goodbye to Their Coronavirus-Infected Father Over Video Chat. Colorado Public Radio News. https://www.cpr.org/2020/04/01/denver-coronavirus-death-family-mike-farley-maybe-to-goodbye/.d Published April 1, 2020. Accessed April 30, 2020.
9. American Academy of Family Physicians. Using Telehealth to Care for Patients During the COVID-19 Pandemic. https://www.aafp.org/patient-care/emergency/2019-coronavirus/telehealth.html. Published March 2020. Accessed April 30, 2020.
10. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26(5):309–313. doi:10.1177/1357633X20916567.
11. Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: a call to action. JMIR Public Health Surveill. 2020;6(2):e18810. doi:10.2196/18810.
12. Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract. 2020;8(5):1489–1491. doi:10.1016/j.jaip.2020.03.008.
13. Schulte F. COVID-19 bonanza: stimulus hands health industry billions not directly related to pandemic. Kaiser Health News. https://khn.org/news/covid-19-bonanza-stimulus-hands-health-industry-billions-not-directly-related-to-pandemic/. Published March 30, 2020. Accessed April 30, 2020.
14. Moore KA, Lipsitch M, Barry JM, Osterholm MT. The Future of the COVID-19 Pandemic: Lessons Learned from Pandemic Influenza. Minneapolis, MN: Center for Infectious Disease Research and Policy, University of Minnesota; 2020. https://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap-covid19-viewpoint-part1.pdf. Accessed May 2, 2020.
15. Wolfers J. The Unemployment Rate Is Probably Around 13 Percent. The New York Times. https://www.nytimes.com/2020/04/03/upshot/coronavirus-jobless-rate-great-depression.html. Published April 3, 2020. Accessed April 30, 2020.
16. Woolhandler S, Himmelstein DU. Intersecting U.S. epidemics: COVID-19 and lack of health insurance. Ann Intern Med. 2020;173(1):63–64. doi:10.7326/M20-1491.
17. McKee M, Stuckler D. If the world fails to protect the economy, COVID-19 will damage health not just now but also in the future. Nat Med. 26(5):640–642. doi:10.1038/s41591-020-0863-y.
18. Benfer E, Wiley L. Health Justice Strategies to Combat COVID-19: Protecting Vulnerable Communities During A Pandemic. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20200319.757883/full/. Published March 19, 2020. Accessed April 30, 2020.
19. Artiga S, Hinton E. Beyond health care: the role of social determinants in promoting health and health equity. Health (N Y). 2019;20(10):1–13.
20. CDC COVID-19 Response Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019—United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382–386. doi:10.15585/mmwr.mm6913e2.
21. Kasanagottu K. Don't delay care for chronic illness over coronavirus. It's bad for you and for hospitals. USA Today. https://www.usatoday.com/story/opinion/2020/04/14/coronavirus-chronic-illness-avoidable-hospital-admissions-column/5134473002/. Published April 14, 2020. Accessed April 30, 2020.
22. Parekh A. This Policy Expert Explains Why The United States Will See an Increase in Non-Coronavirus Deaths (And How We Can Stop It). Forbes. https://www.forbes.com/sites/coronavirusfrontlines/2020/04/08/a-healthcare-policy-expert-warns-the-coronavirus-pandemic-is-a-double-whammy-for-americans-with-chronic-illnesses/. Published April 8, 2020. Accessed May 1, 2020.
23. Panchal N, Kamal R, Orgera K, et al. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Published 2020. Accessed April 30, 2020.
24. Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N Engl J Med. 2020;383(6):510–512. doi:10.1056/NEJMp2008017.
25. Artiga S, Orgera K, Pham O, Corallo B. Growing Data Underscore That Communities of Color Are Being Harder Hit by COVID-19. Kaiser Family Foundation. https://www.kff.org/coronavirus-policy-watch/growing-data-underscore-communities-color-harder-hit-covid-19/ Published 2020. Accessed April 30, 2020.
26. Dorn AV, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet. 2020;395(10232):1243–1244. doi:10.1016/S0140-6736(20)30893-X.
27. Wang Z, Tang K. Combating COVID-19: health equity matters. Nat Med. 2020;26(4):458–458. doi:10.1038/s41591-020-0823-6.
28. Ahmed F, Ahmed N, Pissarides C, Stiglitz J. Why inequality could spread COVID-19. Lancet Public Health. 2020;5(5):e240. doi:10.1016/S2468-2667(20)30085-2.
29. Chopra V, Toner E, Waldhorn R, Washer L. How should U.S. hospitals prepare for coronavirus disease 2019 (COVID-19)? Ann Intern Med. 2020;172(9):621–622. doi:10.7326/M20-0907.
30. Adalja AA, Toner E, Inglesby TV. Priorities for the US health community responding to COVID-19. JAMA. 2020;323(14):1343–1344. doi:10.1001/jama.2020.3413.
31. Weil AR. Integrating social services and health. Health Aff (Millwood). 2020;39(4):551–551. doi:10.1377/hlthaff.2020.00180.
32. Australian Commission on Safety and Quality in Health Care. Consumers, the Health System and Health Literacy: Taking Action to Improve Safety and Quality. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2013. https://www.safetyandquality.gov.au/sites/default/files/migrated/Consumers-the-health-system-and-health-literacy-Taking-action-to-improve-safety-and-quality2.pdf.
33. NEJM Catalyst. What is patient-centered care [published online ahead of print January 1, 2017] NEJM Catal. doi:10.1056/CAT.17.0559.
34. Meggetto E, Kent F, Ward B, Keleher H. Factors influencing implementation of organizational health literacy: a realist review [published online ahead of print March 19, 2020]. J Health Organ Manag. doi:10.1108/JHOM-06-2019-0167.
35. Hernandez SE, Conrad DA, Marcus-Smith MS, Reed P, Watts C. Patient-centered innovation in health care organizations. Health Care Manage Rev. 2013;38(2):166–175. doi:10.1097/hmr.0b013e31825e718a.
36. Clancy CM. How patient-centered healthcare can improve quality. Patient Saf Qual Healthc. 2008;5(2):6–7.
37. Fredericks S, Lapum J, Schwind J, Beanlands H, Romaniuk D, McCay E. Discussion of patient-centered care in health care organizations. Qual Manag Health Care. 2012;21(3):127–134. doi:10.1097/qmh.0b013e31825e870d.
38. Kressin NR, Chapman SE, Magnani JW. A tale of two patients: patient-centered approaches to adherence as a gateway to reducing disparities. Circulation. 2016;133(24):2583–2592. doi:10.1161/CIRCULATIONAHA.116.015361.
39. Wynia MK, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15(suppl 2):102–115. doi:10.1080/10810730.2010.499981.
40. Rappleye H, Lehren A, Strickler L, Fitzpatrick S. ‘This system is doomed’: doctors, nurses sound off in NBC News coronavirus survey. NBC News. https://www.nbcnews.com/news/us-news/system-doomed-doctors-nurses-sound-nbc-news-coronavirus-survey-n1164841. Published March 20, 2020. Accessed April 30, 2020.
41. Back A, Tulsky JA, Arnold RM. Communication skills in the age of COVID-19. Ann Intern Med. 172(11):759–760. doi:10.7326/M20-1376.
42. Sonis JD, Kennedy M, Aaronson EL, et al. Humanism in the age of COVID-19: renewing focus on communication and compassion. West J Emerg Med. 2020;21(3):499–502. https://escholarship.org/uc/item/802655ws.
43. Aboumatar H. Three reasons to focus on patient and family engagement during the COVID-19 pandemic. Qual Manag Healthc. 2020;29(3):176–177. doi:10.1097/QMH.0000000000000262.
44. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004. https://books.google.com/books?id=ifohUt4ZHC8C.
    45. Schillinger D, Keller D. The other side of the coin: attributes of a health literate health care organization. In: Institute of Medicine of the National Academies, ed. How Can Health Care Organizations Become More Health Literate? Workshop Summary. Washington, DC: National Academies Press; 2012:13402. doi:10.17226/13402.
    46. Agency for Healthcare Research and Quality. About the AHRQ Health Care Innovations Exchange. https://innovations.ahrq.gov/about-us. Published September 26, 2016. Accessed March 8, 2020.
      47. Naylor M, Keating SA. Transitional care. Am J Nurs. 2008;108(9 suppl):58–63. doi:10.1097/01.NAJ.0000336420.34946.3a.
      48. Brega AG, Hamer MK, Albright K, et al. Organizational health literacy: quality improvement measures with expert consensus. Health Lit Res Pract. 2019;3(2):e127–e146. doi:10.3928/24748307-20190503-01.
      49. Brach C, Keller D, Hernandez L, et al. Ten attributes of health literate health care organizations [published online ahead of print June 19, 2012]. NAM Perspect. doi:10.31478/201206a.
      50. Paasche-Orlow MK, Schillinger D, Greene SM, Wagner EH. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006;21(8):884–887. doi:10.1111/j.1525-1497.2006.00544.x.
      51. Brach C. The journey to become a health literate organization: a snapshot of health system improvement. Stud Health Technol Inform. 2017;240:203–237.
      52. Koh HK, Brach C, Harris LM, Parchman ML. A proposed “health literate care model” would constitute a systems approach to improving patients' engagement in care. Health Aff Proj Hope. 2013;32(2):357–367. doi:10.1377/hlthaff.2012.1205.
      53. Dietscher C, Pelikan J, Bobek J, Nowak P, World Health Organization. Regional Office for Europe. The Action Network on Measuring Population and Organizational Health Literacy (M-POHL): a network under the umbrella of the WHO European Health Information Initiative (EHII). Public Health Panor. 2019;05(01):65–71. https://apps.who.int/iris/handle/10665/325113.
      54. Farmanova E, Bonneville L, Bouchard L. Organizational health literacy: review of theories, frameworks, guides, and implementation issues. Inq J Med Care Organ Provis Financ. 2018;55:46958018757848–46958018757848. doi:10.1177/0046958018757848.
      55. Trezona A, Dodson S, Osborne RH. Development of the Organisational Health Literacy Responsiveness (Org-HLR) self-assessment tool and process. BMC Health Serv Res. 2018;18(1):694–694. doi:10.1186/s12913-018-3499-6.
      56. Trezona A, Dodson S, Fitzsimon E, LaMontagne AD, Osborne RH. Field-Testing and Refinement of the Organisational Health Literacy Responsiveness Self-Assessment (Org-HLR) Tool and Process. Int J Environ Res Public Health. 2020;17(3):1000. doi:10.3390/ijerph17031000.
      57. Mastroianni F, Chen Y-C, Vellar L, et al. Implementation of an organisation-wide health literacy approach to improve the understandability and actionability of patient information and education materials: a pre-post effectiveness study. Patient Educ Couns. 2019;102(9):1656–1661. doi:10.1016/j.pec.2019.03.022.
      58. Henrard G, Vanmeerbeek M, Buret L, Rademakers J. Dealing with health literacy at the organisational level, French translation and adaptation of the Vienna health literate organisation self-assessment tool. BMC Health Serv Res. 2019;19(1):146–146. doi:10.1186/s12913-019-3955-y.
      59. Kutner M, Greenburg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483. Published 2006.
      60. Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “crisis care.” Health Aff Proj Hope. 2012;31(2):434–443. doi:10.1377/hlthaff.2011.1169.
      61. DeWalt DA, Broucksou KA, Hawk V, et al. Developing and testing the health literacy universal precautions toolkit. Nurs Outlook. 2011;59(2):85–94. doi:10.1016/j.outlook.2010.12.002.
      62. Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess (Full Rep). 2011;(199):1–941.
      63. Barton AJ, Allen PE, Boyle DK, Loan LA, Stichler JF, Parnell TA. Health Literacy: essential for a culture of health. J Contin Educ Nurs. 2018;49(2):73–78. doi:10.3928/00220124-20180116-06.
      64. Batterham RW, Hawkins M, Collins PA, Buchbinder R, Osborne RH. Health literacy: applying current concepts to improve health services and reduce health inequalities. Public Health. 2016;132:3–12. doi:10.1016/j.puhe.2016.01.001.
      65. Zarocostas J. How to fight an infodemic. Lancet. 2020;395(10225):676. doi:10.1016/S0140-6736(20)30461-X.
      66. Kripalani S, Wallston D, Cavanaugh K, et al. Measures to Assess a Health-Literate Organization. Washington, DC: Institute of Medicine; 2014:52. http://www.nationalacademies.org/hmd/Activities/PublicHealth/HealthLiteracy/∼/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Commissioned-Papers/Measures_to_Assess_HLO.pdf.
      67. Niehaus K, Epstein C, Temple L, Sepkowitz K. A Patient and Family Advisory Council for Quality: Making Its Voice Heard at Memorial Sloan Kettering Cancer Center. NEJM Catal. 2017;3(5). https://catalyst.nejm.org/doi/abs/10.1056/CAT.17.0379. Accessed April 30, 2020.
      68. NEJM Catalyst. Lessons from CEOs: health care leaders nationwide respond to the COVID-19 crisis [published online ahead of print April 22, 2020]. NEJM Catal. doi:10.1056/CAT.20.0150
      69. NEJM Catalyst Insight Council Members. What Health Care Leaders and clinicians say about the COVID-19 pandemic [published online ahead of print April 2020]. NEJM Catal. doi:10.1056/CAT.20.0177.
      70. Van Bavel JJ, Baicker K, Boggio P, et al. Using social and behavioural science to support COVID-19 pandemic response [published online ahead of print Mar 24, 2020]. doi:10.31234/osf.io/y38m9.
      71. Van den Broucke S. Why health promotion matters to the COVID-19 pandemic, and vice versa. Health Promot Int. 2020;35(2):181–186. doi:10.1093/heapro/daaa042.
      72. Sentell T, Vamos S, Okan O. Interdisciplinary perspectives on health literacy research around the world: more important than ever in a time of COVID-19. Int J Environ Res Public Health. 2020;17(9):3010. doi:10.3390/ijerph17093010.
      73. Sentell TL, Irvin L, Pirkle C, Ching L. Those With Health Vulnerabilities Are Now Deeper At Risk. Honolulu Civil Beat. https://www.civilbeat.org/2020/04/those-with-health-vulnerabilities-are-now-deeper-at-risk/. Published April 24, 2020. Accessed May 1, 2020.
      74. Wang X, Bhatt DL. COVID-19: an unintended force for medical revolution? J Invasive Cardiol. 2020;32(4):E81–E82.
      75. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679–1681. doi:10.1056/NEJMp2003539.
      76. Cantor MN, Thorpe L. Integrating data on social determinants of health into electronic health records. Health Aff (Millwood). 2018;37(4):585–590. doi:10.1377/hlthaff.2017.1252.
      77. Trinacty CM, LaWall E, Ashton M, Taira D, Seto TB, Sentell T. Adding social determinants in the electronic health record in clinical care in Hawai'i: supporting community-clinical linkages in patient care. Hawaii J Med Public Health. 2019;78(6, suppl 1):46–51.
        78. Bokhour BG, Fix GM, Mueller NM, et al. How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation. BMC Health Serv Res. 2018;18(1):168. doi:10.1186/s12913-018-2949-5.
        79. Pirkle C. A Health System Is More Than Just Hospitals. Honolulu Civil Beat. https://www.civilbeat.org/2020/04/a-health-system-is-more-than-just-hospitals/. Published April 1, 2020. Accessed May 1, 2020.
        80. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020;323(15):1439–1440. doi:10.1001/jama.2020.3972.
        81. Fraher EP, Pittman P, Frogner BK, et al. Ensuring and sustaining a pandemic workforce. N Engl J Med. 2020;382(23):2181–2183. doi:10.1056/NEJMp2006376.
        82. Institute for Patient- and Family-Centered Care. PFCC and COVID-19. Bethesda, MD: Institute for Patient- and Family-Centered Care. https://www.ipfcc.org/bestpractices/covid-19/index.html. Accessed May 1, 2020.
        83. Institute for Patient- and Family-Centered Care. Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals. Bethesda, MD: Institute for Patient- and Family-Centered Care; 2018. https://www.ipfcc.org/bestpractices/NYSHF_2018_PFAC_Online_v3.pdf. Accessed May 1, 2020.
        84. Jacobs A. Fears of Ventilator Shortage Unleash a Wave of Innovations. The New York Times. https://www.nytimes.com/2020/04/17/health/ventilators-coronavirus.html. Published April 17, 2020. Accessed April 30, 2020.
        85. Ip G. Shoes to Masks: Corporate Innovation Flourishes in Coronavirus Fight. Wall Street Journal. https://www.wsj.com/articles/american-companies-innovate-to-fight-the-coronavirus-in-echo-of-world-war-ii-11587045652. Published April 16, 2020. Accessed April 30, 2020.
        86. Poureslami I, Nimmon L, Rootman I, Fitzgerald MJ. Health literacy and chronic disease management: drawing from expert knowledge to set an agenda. Health Promot Int. 2017;32(4):743–754. doi:10.1093/heapro/daw003.
        87. Kim JK, Garrett L, Latimer R, et al. Ke Ku'una Na 'au: A Native Hawaiian Behavioral Health Initiative at The Queen's Medical Center. Hawaii J Med Public Health. 2019;78(6, suppl 1):83–89.
        88. Nishizaki LK, Negrillo AH, Ho'opai JM, Naniole R, Hanake'awe D, Pu'ou K. “It starts with ‘Aloha...’” Stories by the Patient Navigators of Ke Ku'una Na'au Program at The Queen's Medical Center. Hawaii J Med Public Health. 2019;78(6, suppl 1):90–97. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603887/
        89. Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers: integral members of the health care work force. Am J Public Health. 1995;85(8, pt 1):1055–1058. doi:10.2105/AJPH.85.8_Pt_1.1055.
        90. Javanparast S, Windle A, Freeman T, Baum F. Community health worker programs to improve healthcare access and equity: are they only relevant to low- and middle-income countries? Int J Health Policy Manag. 2018;7(10):943–954. doi:10.15171/ijhpm.2018.53.
        91. Weidmer BA, Brach C, Hays RD. Development and evaluation of CAHPS survey items assessing how well healthcare providers address health literacy. Med Care. 2012;50(9, suppl 2):S3–S11. doi:10.1097/MLR.0b013e3182652482.
        92. Weidmer BA, Brach C, Slaughter ME, Hays RD. Development of items to assess patients' health literacy experiences at hospitals for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey. Med Care. 2012;50(9, suppl 2):S12–S21. doi:10.1097/MLR.0b013e31826524a0.
        93. Prince LY, Schmidtke C, Beck JK, Hadden KB. An assessment of organizational health literacy practices at an academic health center. Qual Manag Health Care. 2018;27(2):93–97. doi:10.1097/qmh.0000000000000162.
        94. Bau I, Logan RA, Dezii C, et al. Patient-centered, integrated health care quality measures could improve health literacy, language access, and cultural competence [published online ahead of print February 11, 2019]. NAM Perspect. doi:10.31478/201902a.
        95. Cohen SB, Yu W. Statistical Brief 354: The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the US Population, 2008-2009. Rockville, MD: Agency for Healthcare Policy and Research; 2012. https://meps.ahrq.gov/data_files/publications/st354/stat354.shtml.
        96. Cawthon C, Walia S, Osborn CY, Niesner KJ, Schnipper JL, Kripalani S. Improving care transitions: the patient perspective. J Health Commun. 2012;17(suppl 3):312–324. doi:10.1080/10810730.2012.712619.
        97. Marcantoni JR, Finney K, Lane MA. Using health literacy guidelines to improve discharge education and the post-hospital transition: a quality improvement project. Am J Med Qual. 2014;29(1):86. doi:10.1177/1062860613508905.
        98. Samuels-Kalow M, Rhodes K, Uspal J, Reyes Smith A, Hardy E, Mollen C. Unmet needs at the time of emergency department discharge. Acad Emerg Med. 2016;23(3):279–287. doi:10.1111/acem.12877.
        99. Rymer JA, Kaltenbach LA, Anstrom KJ, et al. Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction. Am Heart J. 2018;198:97–107. doi:10.1016/j.ahj.2017.08.024.
        100. Innis J, Barnsley J, Berta W, Daniel I. Measuring health literate discharge practices. Int J Health Care Qual Assur. 2017;30(1):67–78. doi:10.1108/ijhcqa-06-2016-0080.
        101. Cox SR, Liebl MG, McComb MN, et al. Association between health literacy and 30-day healthcare use after hospital discharge in the heart failure population. Res Soc Adm Pharm. 2017;13(4):754–758. doi:10.1016/j.sapharm.2016.09.003.
        102. Myers LC, Faridi MK, Hasegawa K, Hanania NA, Camargo CA. The Hospital readmissions reduction program and readmissions for chronic obstructive pulmonary disease, 2006-2015. Ann Am Thorac Soc. 2020;17(4):450–456. doi:10.1513/AnnalsATS.201909-672OC.
        103. Smith TB, English TM, Naidoo J, Whitman MV. The hospital readmissions reduction program's impact on readmissions from skilled nursing facilities. J Healthc Manag Am Coll Healthc Exec. 2019;64(3):186–196. doi:10.1097/JHM-D-18-00035.
        104. Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(suppl 3):325–338. doi:10.1080/10810730.2012.715233.
        105. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796–1803. doi:10.1161/CIRCULATIONAHA.114.010270.
        106. Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232–1237.
        107. Sentell TL, Seto TB, Young MM, et al. Pathways to potentially preventable hospitalizations for diabetes and heart failure: a qualitative analysis of patient perspectives. BMC Health Serv Res. 2016;16:300. doi:10.1186/s12913-016-1511-6.
        108. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187.
        109. Williams MV, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J. 2014;107(7):455–465. doi:10.14423/smj.0000000000000140.
        110. Westat. Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative. (Prepared by Westat Under Contract No. HHSA 290200900023I). Rockville, MD: Agency for Healthcare Research and Quality; 2013:27. https://digital.ahrq.gov/sites/default/files/docs/page/findings-and-lessons-from-improving-management-of-individuals-with-complex-health-care-needs-through-health-it-grant-initiative.pdf.
        111. Berkowitz RE, Fang Z, Helfand BKI, Jones RN, Schreiber R, Paasche-Orlow MK. Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. J Am Med Dir Assoc. 2013;14(10):736–740. doi:10.1016/j.jamda.2013.03.004.
        112. Mitchell SE, Martin J, Holmes S, et al. How hospitals reengineer their discharge processes to reduce readmissions. J Healthc Qu-al. 2016;38(2):116–126. doi:10.1097/JHQ.0000000000000005.
        113. Levine C, Rutberg J, Jack B, Cancino R. Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re- Engineered Discharge. http://www.bu.edu/fammed/projectred/Project%20RED%20Revised%20Toolkit%209-2012/REDTool7FamilyCaregiversUnitedHospital%20Fund.pdf. Published 2012.
        114. Project BOOST. The 8P Screening Tool: Identifying Your Patient's Risk for Adverse Events After Discharge. Society of Hospital Medicine. https://www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/8ps_riskassess-1.pdf.
          115. Institute for Healthcare Advancement. Using the Teach-back Toolkit. Teach-back Training. http://www.teachbacktraining.org/using-the-teach-back-toolkit. Published 2020.
            116. American Hospital Association, Partnership for Patients, Health Research & Educational Trust. Readmissions Change Package: Improving Care Transitions and Reducing Readmissions. https://www.hqinstitute.org/sites/main/files/file-attachments/ar_6_hret_readmission_change_package.pdf. Accessed March 8, 2020.
              117. Bailey JE, Surbhi S, Wan JY, et al. Effect of intensive interdisciplinary transitional care for high-need, high-cost patients on quality, outcomes, and costs: a quasi-experimental study. J Gen Intern Med. 2019;34(9):1815–1824. doi:10.1007/s11606-019-05082-8.
              118. Wolf MS, Davis TC, Osborn CY, Skripkauskas S, Bennett CL, Makoul G. Literacy, self-efficacy, and HIV medication adherence. Patient Educ Couns. 2007;65(2):253–260. doi:10.1016/j.pec.2006.08.006.
              119. Ngoh LN. Health literacy: a barrier to pharmacist–patient communication and medication adherence. J Am Pharm Assoc. 2009;49(5):e132–e149. doi:10.1331/japha.2009.07075.
              120. Pignone MP, DeWalt DA. Literacy and health outcomes: is adherence the missing link? J Gen Intern Med. 2006;21(8):896–897. doi:10.1111/j.1525-1497.2006.00545.x.
              121. MED-PASS, INTERACT. Medication Reconciliation Worksheet for Post-Hospital Care. https://www.med-pass.com/medication-reconciliation-worksheet-for-post-hospital-care-version-4-0-100-pad.html. Published 2020.
                122. Edwards M, Wood F, Davies M, Edwards A. “Distributed health literacy”: longitudinal qualitative analysis of the roles of health literacy mediators and social networks of people living with a long-term health condition. Health Expect. 2015;18(5):1180–1193. doi:10.1111/hex.12093.
                123. Sentell T, Pitt R, Buchthal OV. Health literacy in a social context: review of quantitative evidence. Health Lit Res Pract. 2017;1(2):e41–e70. doi:10.3928/24748307-20170427-01.
                  124. Coleman EA, Ground KL, Maul A. The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy. Jt Comm J Qual Patient Saf. 2015;41(11):502–507. doi:10.1016/s1553-7250(15)41066-9.
                  125. The Care Transitions Program. All Tools and Resources. The Care Transitions Program. https://caretransitions.org/all-tools-and-resources/. Accessed March 8, 2020.
                    126. Florida Atlantic University, INTERACT. Stop and Watch: Early Warning Tool. https://pathway-interact.com/wp-content/uploads/2018/09/INTERACT-Stop-and-Watch-v4_0-June2018_June-2018.pdf. Published 2014.
                      127. Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Atlanta, GA: US Department of Health and Human Services; 2010. http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf.
                        128. The Care Transitions Program. Person Health Record. https://caretransitions.org/wp-content/uploads/2015/08/phr.pdf. Published 2015.
                          129. Cornett S. Assessing and addressing health literacy. Online J Issues Nurs. 2009;14(3):2.
                            130. Washburn L, Hadden KB, Prince LY, McNeill C, Moon Z. Development and Implementation of the How to Talk to Your Doctor HANDbook Health Literacy Program in Rural Counties. HLRP Health Lit Res Pract. 2019;3(3):e205–e215.
                              131. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med. 2006;21(6):667–669. doi:10.1111/j.1525-1497.2006.0512.x.
                              132. Altin SV, Stock S. The impact of health literacy, patient-centered communication and shared decision-making on patients' satisfaction with care received in German primary care practices. BMC Health Serv Res. 2016;16(1):450. doi:10.1186/s12913-016-1693-y.
                              133. Schwamm LH. Telehealth: seven strategies to successfully implement disruptive technology and transform health care. Health Aff (Millwood). 2014;33(2):200–206. doi:10.1377/hlthaff.2013.1021.
                              134. Ito M. Chapter 6—Patient-centered care. In: Gogia S, ed. Fundamentals of Telemedicine and Telehealth. London, England: Academic Press; 2020:115–126. doi:10.1016/B978-0-12-814309-4.00006-9.
                              135. Daniel H, Sulmasy LS. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians Position Paper. Ann Intern Med. 2015;163(10):787–789. doi:10.7326/M15-0498.
                              136. Dinesen B, Nonnecke B, Lindeman D, et al. Personalized telehealth in the future: a global research agenda. J Med Internet Res. 2016;18(3):e53. doi:10.2196/jmir.5257.
                              137. Dunn P, Hazzard E. Technology approaches to digital health literacy. Int J Cardiol. 2019;293:294–296. doi:10.1016/j.ijcard.2019.06.039.
                              138. Triantafyllidis A, Kondylakis H, Votis K, Tzovaras D, Maglaveras N, Rahimi K. Features, outcomes, and challenges in mobile health interventions for patients living with chronic diseases: a review of systematic reviews. Int J Med Inf. 2019;132:103984. doi:10.1016/j.ijmedinf.2019.103984.
                              139. Vegesna A, Tran M, Angelaccio M, Arcona S. Remote patient monitoring via non-invasive digital technologies: a systematic review. Telemed E-Health. 2016;23(1):3–17. doi:10.1089/tmj.2016.0051.
                              140. Debon R, Coleone JD, Bellei EA, De Marchi ACB. Mobile health applications for chronic diseases: a systematic review of features for lifestyle improvement. Diabetes Metab Syndr Clin Res Rev. 2019;13(4):2507–2512. doi:10.1016/j.dsx.2019.07.016.
                              141. Otten JJ, Cheng K, Drewnowski A. Infographics and public policy: using data visualization to convey complex information. Health Aff (Millwood). 2015;34(11):1901–1907. doi:10.1377/hlthaff.2015.0642.
                              142. McCrorie A, Donnelly C, McGlade K. Infographics: healthcare communication for the digital age. Ulster Med J. 2016;85(2):71–75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920488/
                              143. Centers for Disease Control and Prevention. Infographics. Social Media at CDC. https://www.cdc.gov/socialmedia/tools/InfoGraphics.html. Published December 27, 2019. Accessed May 1, 2020.
                              144. Centers for Medicare & Medicaid Services. Medicaid Program Integrity Education Infographics. Program Integrity: Medicaid Integrity Education. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/infographics. Published November 18, 2019. Accessed May 1, 2020.
                              145. Bailey SC, O'Conor R, Bojarski EA, et al. Literacy disparities in patient access and health-related use of Internet and mobile technologies. Health Expect. 2015;18(6):3079–3087. doi:10.1111/hex.12294.
                              146. Azzopardi-Muscat N, Sørensen K. Towards an equitable digital public health era: promoting equity through a health literacy perspective. Eur J Public Health. 2019;29(suppl 3):13–17. doi:10.1093/eurpub/ckz166.
                              147. Norman CD, Skinner HA. eHEALS: The eHealth Literacy Scale. J Med Internet Res. 2006;8(4):e27. doi:10.2196/jmir.8.4.e27.
                              148. Lloyd JE, Song HJ, Dennis SM, Dunbar N, Harris E, Harris MF. A paucity of strategies for developing health literate organisations: a systematic review. PLoS One. 2018;13(4):e0195018. doi:10.1371/journal.pone.0195018.
                              149. Adsul P, Wray R, Gautam K, Jupka K, Weaver N, Wilson K. Becoming a health literate organization: formative research results from healthcare organizations providing care for undeserved communities. Health Serv Manage Res. 2017;30(4):188–196. doi:10.1177/0951484817727130.
                              150. Weaver NL, Wray RJ, Zellin S, Gautam K, Jupka K. Advancing organizational health literacy in health care organizations serving high-needs populations: a case study. J Health Commun. 2012;17(suppl 3):55–66. doi:10.1080/10810730.2012.714442.
                              Keywords:

                              health literacy; healthcare organization and administration; patient transitions; patient-centered care

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