Health Literate Healthcare Organizations and their Role in Future Healthcare

There is a growing need for a system change towards more patient-centred and health literate healthcare systems. One valuable approach for change on the system-level is the redesign of health organizations to health literate healthcare organizations (HLHO). This process requires sufficient efforts in teamwork, committed leadership and outcome monitoring. Nurses could make major contributions to the overall system change by integrating their expertise in the redesign of health care organizations in health literate ones.

Nowadays, most healthcare systems face a rapid transformation of care processes and structures due to fast-moving technological developments in the fields of medical research and health information technology leading to advances in healthcare coverage and delivery system design [1]. These changes constantly increase the complexity of healthcare systems demanding more patient engagement and broader patient capacities to navigate through healthcare systems [2,3]. To achieve the latter, patients need much more health literacy skills such as to access and understand health information, interact with health professionals and apply health information to make appropriate health decisions [4]. Unfortunately, many patients are not sufficiently equipped with competencies that are vital to health literacy. They experience difficulties when reading, writing and communicating efficiently as well as understanding numbers [5]. As a consequence, patients feel challenged to use health information in a way that they can navigate the healthcare system better [1,6]. Thus, increasing body of research demonstrates that limited health literacy affects large parts of the US and European population and ultimately contributes to undesirable outcomes including limited ability to take medication appropriately and manage own health, more hospitalizations and greater use of emergency care [5,7,8]. As a consequence, the Institute of Medicine as well as the US Department of Health and Human Services propose to address the challenges of limited health literacy by transforming healthcare systems to more health literate ones by integrating elements of patient-centred care and health literacy into processes and structures of healthcare organizations [9,10]. In order to be health literate, healthcare organizations need to implement structures that ensure that patients understand relevant health information and are capable to act upon these information in order to make thorough health decisions. The approach of health literate healthcare organizations (HLHO) receives considerable support from healthcare stakeholders and policy makers around the world arguing that patients have the right to receive health information that helps them make informed choices [11,12]. For them, system change towards increasing patient safety, healthcare quality and equity can only be achieved by implementing Health Literate Healthcare Organizations (HLHO) and putting the patient and his informational needs and preferences first [1].

What is a Health Literate Healthcare Organization and why does it Matter?
Since health literacy is the product of individual capabilities and the health literacy related demands emerging from the complexity of healthcare systems, HLHO represent a valuable way to align healthcare demands better with patients and public skills and capacities [13,14]. In this regard, a HLHO supports patients to navigate, understand, and use information and services to take care of their health [11]. It is denoted as an organization that enables patients to read and comprehend instructions, adhere to directions of health professionals, seek care early when required, recognize warning signs and ask questions whenever needed. According to the Institute of Medicine there are ten attributes that characterize a health literate healthcare organization as presented in Table 1 [11]. These characteristics include the implementation and monitoring of an organizational mission, operations and interventions that put aspects of health literacy in the centre of the organizational culture, the delivery of easy to understand written and oral health information as well as the provision of patientcentred communication strategies. Since the different health professions (e.g. physicians, nurses, pharmacists in in-and outpatient care settings) in a healthcare organization are operating as change agents and guiding the redesign of processes and structures towards a HLHO, it is of major importance to put these in the centre of the change process by assigning them specific work profiles and agentroles [12]. So far, research on HLHO reveals that certain health literacy interventions used in the clinical context do have an impact on patient outcomes. In this regard, there is evidence that communication training for health professionals enhances patient understanding, reduces medicine-taking errors and increases cancer screening rates [15][16][17]. An intervention in the coordination of care reveals that a reengineered discharge process including patient education and better organized hospital transition reduces hospitalization rates by thirty percent [18]. These findings demonstrate that the organizational approach to focus more on the informational needs of patients is a valuable strategy to improve patient outcomes and healthcare quality.

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Attributes of a health literate health organization Examples of nurse role

How can Healthcare Organizations be Redesigned and what Role do Nurses Play?
To become health literate, organizations need to undergo an organizational self-assessment to identify health literacy-based barriers and facilitators [11]. After that, organizations can start to address the attributes of a HLHO by focusing on organizational structures and the qualification of the workforce. They can start training their staff in clear communication techniques, in securing language assistance for speakers of foreign languages, and providing needed assistance to patients without stigmatizing them. Further, they can design and distribute written/audio/visual health information tailored to the differing health literacy levels and needs of patients. In addition, they can plan and implement monitoring systems that continuously identify patient's health literacy needs and the effectiveness of implemented health literacy interventions from the patient perspective by using already available assessment tools [11]. In this process, especially nurses who are at the forefront of educating patients and serve as vocal advocates for vulnerable groups play a pivotal role in taking over certain responsibilities as change agents [19][20][21]. As depicted in Table 1, there are several tasks nurses can perform to support organizational change to a HLHO. First of all, they can serve as multipliers of the overall vision and strategy and support the organization in developing, implementing, monitoring and evaluating health literacy interventions. Further, they can participate in training programs for communication and information brokerage, use the knowledge gained in routine care and training of other peers.
Recently, there are sophisticated concepts and tools in place that are appropriate to initiate system-level changes in healthcare organizations. Nurses should be encouraged to participate in the implementation of concepts such as the "Health Literacy Universal Precautions". The concept aims to enable health professionals to approach all patients who are likely to be at risk of not understanding information relevant to improving their own health. According to the universal precautions approach, HLHO need standard procedures for clear and actionable information and communication and easy to understand patient education materials [22]. The Health Literacy Universal Precautions Toolkit recently developed by the AHRQ serves as a guideline for the step-by-step implementation of interventions integrating health literacy elements into the health care organization [23]. It includes interventions on clear provider communication (e.g. teach-back method), interventions on information brokerage (e.g. design and distribution of easy to read/understand health information/ education materials) as well as interventions on care coordination and self-management support such as the application of patient follow-up, medication review, action plans and appointment scheduling. Nurses could play a pivotal role in the implementation and evaluation of the interventions recommended in the toolkit and could serve as leaders of organizational change. Already existing evidence reveals that the integration of nurses in health literacy interventions yields promising results [24,25]. Future research should evaluate the effectiveness of recommended low health literacy strategies in health organizations, identify best practices, and determine how different health professions might contribute best to organizational change.