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Innovative Health Literacy Strategy Advances Health Equity: Perspectives of the Cambridge Health Alliance Past and Present Department Chiefs
Ryan S. Lee, DDS, MPH, MHA, is the chief of dental services at the Cambridge Health Alliance, a community health system serving Cambridge, Somerville and Boston’s metro-north communities. Conflict of Interest Disclosure: None reported.
Brian J. Swann, DDS, 2008, the Cambridge Health Alliance MPH, is the former chief (CHA) began a transformative journey. of dental services at the Cambridge Health Alliance. Conflict of Interest Disclosure: None reported.
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In 2008, the Cambridge Health Alliance (CHA) began a transformative journey. This journey not only ensured the survival of community health services in danger of being diminished or completely lost, but also improved health literacy for its peers and patients as well as utilizing core health literacy concepts to advance health equity. As the organization experienced a complete paradigm shift that involved new leadership, in-depth internal evaluation and assessments, personnel and policy changes and consistent emphasis on operational fitness, the CHA incorporated a steady focus on better educating its patients and peers as well as maintaining standards of excellence in its fair and equitable delivery of community health services.
The CHA was faced with myriad challenges resulting from the 2008 economic downturn, including the loss of state funding due to reallocations, an inefficient dental billing system and a major decrease in its revenue stream leading to reductions in staff and programs as well as decreased access to dental services and oral health education for patients. Committed to creating a healthliterate community and fair and equitable treatment for all, the CHA recognized the need for cultural sensitivity and input from the community regarding needed services. The CHA also recognized that health equity across all segments of the population required patient and provider health literacy. Despite the challenges, the CHA conducted its operations based on guidelines described in the Healthy People Initiative. The alliance managed to survive, created innovative and inclusive programs and continued to expand community services.
The mission and focus of the CHA remain constant and directly align with the central goals of the Healthy People 2030 initiative, [1] which is to eliminate health disparities, achieve health equity and attain health literacy to improve the health and welfare for all. The CHA has continued to maintain its standards of excellence and to focus on improving the overall health care of its community. The values of the organization are integrity, respect, compassion, learning, inclusion and excellence. Although these values may seem idealistic to some, they are exactly what are required to establish and maintain patient-provider trust, create health literacy and consistently deliver fair and equal care to all members of the community. The 2030 initiative provides the following new definitions of personal and organizational health literacy: [2]
- Personal health literacy is the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others.
- Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others.
In a change from the health literacy definitions used in Healthy People 2010 and 2020, the new Healthy People 2030 initiative definitions emphasize people’s ability to use health information rather than just understand it; focus on the ability to make “well-informed” decisions rather than “appropriate” ones; incorporate a public health perspective; and acknowledge that organizations have a responsibility to address health literacy. [3]
Simply put, health literacy on the part of the patient and the community of providers makes it possible for individuals and families to seek proper care, locate appropriate care, make good decisions and follow instructions for comprehensive treatment. Health literacy warrants that all members of the health care community clearly understand the need to embrace an integrative model of comprehensive health care that includes oral health services.
Health equity is achieved when each person has the chance to reach their full health potential without facing obstacles based on social position or other socially determined circumstances. [4] Health equity can only be achieved when obstacles within each community are neutralized, including language barriers. Equity requires an emphasis on the contextual circumstances and social determinants of health such as education, income, employment, race, age, gender, housing, environment, food, transportation, safety and more. It also requires an integrative health care model that includes medical and oral health care providers working collaboratively toward a common goal.
Background
Cambridge Hospital was founded in 1917 with the goal of being a primary care, safety-net, community hospital. The facility merged with Somerville Hospital in 1996, with Everett Hospital 2001 and eventually became the CHA, a nonprofit, academic, community hospital and safety-net organization.
According to the National Academies of Science, Engineering and Medicine, a safety-net organization delivers a significant level of health care and other needed services to the uninsured, underinsured and other vulnerable populations. [5] These populations include, but are not limited to, adults, children, the elderly, people with physical and psychiatric disabilities, medically compromised populations, people recently and long-term unemployed, immigrants, undocumented individuals, people without housing, survivors of abuse, members of the armed services and their spouses, veterans, those with addictions and the poor.
In the early 2000s, in collaboration with the dean of the Harvard School of Dental Medicine (HSDM) and the department chair of oral health policy and epidemiology, the chiefs of pediatrics and internal medicine recommended that an oral health department be included at the CHA. Based on a needs assessment of the city and input from Cambridge citizens, it was unanimously decided that the CHA needed to include a department that would provide oral health services. Since then, the number of dental sites has fluctuated based on a common theme of budget cuts and the rising cost of oral health care.
The Integrative Model Involving the Oral Physician
To survive its many challenges, the CHA needed to create a multidisciplinary environment of health care providers and administrators who could appreciate the value of integrating oral health as a component of comprehensive health care. The CHA team created a strategy to improve health literacy and ultimately help to achieve health equity that included improved access to care, cultural sensitivity, interdisciplinary bias minimization, enhanced and transparent communication and learning and role modeling. The team shared with colleagues across health disciplines that the inclusion of oral health care could play a pivotal role in providing primary preventive care and secondary care in the form of early detection.
A general practice residency (GPR) program that operated through an affiliation between the CHA and the HSDM was enhanced to provide awareness and recognition of the value that oral health brings to primary care. Every meeting with peers and executives became an opportunity to share the potential for oral health to build capacity within the patient-centered and comprehensive care system.
An emeritus Harvard professor suggested that the CHA team incorporate the oral physician model into our GPR residency program. [6] This concept basically called for oral health providers to work more comprehensively and at their level of training. This model would serve as an asset for the perennial and widespread shortages in primary care. Compounding the shortage of primary care providers, the fact that oral disease is a risk factor for systemic diseases necessitates awareness of the oral-systemic connection by all health care providers.
The team worked to ensure that patient visits occurred before their health conditions progressed or benefits expired and before children had to return to school. Our solution involved “group visits,” a concept that involves observations and treatment of multiple patients simultaneously in one locale. The modalities included group denture visits, whereby multiple patients received treatment for partial or full dentures grouped by appointment sequence (i.e., the border molding procedure was provided simultaneously for several patients at once, thereby increasing efficiency in communication and turnaround time); [7] pediatric group visits; periodontal disease prevention for diabetic groups and for suboxone groups in primary care; and pregnancy visits with patients and their partners to discuss prevention and best practices for mothers and newborns. Most of these visits involved dental, medical and other allied health providers.
The incorporation of the medical interview as a valuable and essential tool increased the opportunity for early detection, developed rapport and established patient-provider trust. Combined with the fact that a significant number of patients visit the dental office more often than their primary care office, [8] this creates an opportunity for the oral health provider to screen and refer potentially undiagnosed health conditions. As such, health literacy across disciplines is an important element in the earliest stages of training for the oral physician model of care. As the oral health department adopted the oral physician model, the perception for the oral health provider changed and justified creating a more robust experience for the residents. Their curriculum included rotations in oral medicine, oral pathology, orthodontics and oral surgery. Residents participated in presentations that included public health, peer communication, health IT system improvements and practical applications of oral anesthesia and other medications. Interdepartmental shadowing experiences were arranged for medical residents and undergraduate students, including dental assisting, hygiene and pharmacy students. GPR residents also supervised a monthly student-run pediatric clinic.
Looking beyond the head and neck, oral physicians are also cognizant of behavioral health relative to signs of abuse, attention deficit syndrome, depression and PTSD issues. At nearby elementary schools and local homeless shelters, residents screened patients and provided follow-up referrals to the CHA clinic site. They treated domestic abuse survivors and immigrants in various shelters, participated in outreach programs for Native Americans and taught prevention to Spanish- and Haitian Creole-speaking diabetic groups. These experiences coupled with research projects, recognized, emphasized and improved on a tripartite partnership between providers, patients and parent organizations to enhance health literacy resulting in increased capacity across disciplines. In this fashion, the oral physician model has shown early signs of directly impacting integrative care. [9,10]
Eventually, the chief of oral health and the GPR director were invited to become members of the CHA academic council. They participated in discussions regarding research and integrated learning opportunities to build capacity across disciplines and to ensure a more comprehensive and collaborative educational experience for the next generation of providers. Such discussions enabled dialogue regarding health communication and literacy across multiple health disciplines.
Upon graduation from the GPR program, each resident received two certificates: one for the general practice residency program and one for the oral physician certificate from both the CHA and the HSDM. Postgraduates have incorporated the oral physician concept in several ways. A recent graduate became the first oral physician to be accepted as a fellow to receive a master’s in health education through a partnership with the University of Dundee in Scotland. Other graduates of the program have pursued dual degrees in medicine and dentistry, while many others have reimagined and redesigned their clinics, both public and private, to reflect the integration of medicine and oral health.
The CHA Dental Implant Program
One new example of this innovation has been the CHA Dental Implant Program (CHADIP), which was implemented in January 2021. Considerations of dental implants in the past have posed a challenge for many underserved patients due to finances, time or logistics-related constraints. The program at the CHA now offers dental implant care for all patients, regardless of socioeconomic status or demographics. Any patient with missing dentition may receive an implant consultation and a cone beam CT scan. A patient in need can receive the entire package of services including:
■ Surgical placement of a dental implant fixture.
■ Prefabricated or customized abutment.
■ The final prosthodontic crown.
■ Associated procedures (e.g., bone grafting, sinus augmentation, soft tissue regeneration).
The cost is less than one-third of the average fees in comparison to practices in the region. [11] The CHADIP has expanded and developed implant services for patients in partner organizations such as Boston Healthcare for the Homeless, the Salvation Army, PACE elder care services and the Wampanoag Native American communities. Financial and educational support from industry partners with orthodontic, dental implant and technology sectors contributes to our ability to lower fees for those in need.
Beyond price innovation, however, clinical innovation remains a core mission for the CHADIP, which has continued its implementation of digital dentistry involving CBCT, intraoral scanning, 3D printing and open-source milling to deliver same-day printed dentures, provide guided implant surgery and ensure optimal pre-, peri- and postoperative care. To reflect the health literacy needs involving said new procedures and care modalities, the CHADIP has updated all relevant patient information, consent forms and interhospital documents. Because information regarding dental implants can be difficult to understand for patients, [12,13] plain-language concepts have been incorporated in all such documents.
Trainees at all levels, including dental students, undergraduate externs and GPR residents, have undertaken research projects supported by the implant program, some of which fall into health communication and health literacy arenas. Provider literacy, even at the attending oral physician level, must follow suit to provide excellent care, especially as these services seek to integrate oral health with other arenas of medicine. At the intersection of price innovation and clinical innovation, health literacy must play a pivotal role to ensure health equity for our underserved patients. The CHADIP is not simply about offering excellent treatment for all patients at an affordable cost; every consultation, treatment visit and postoperative appointment must be delivered in plain language that involves health literacy and communication as core concepts, which serve as a foundation for all clinical care.
Health care is multifactorial. All patients, regardless of background and culture, must be understood, must feel respected and must know that they are receiving the best treatment available. COVID-19 has demonstrated that all segments of our community need and must receive equal care and attention, lest we run the risk of devastating consequences.
The Future of Oral Health at the CHA
Today, primary care, specialty care, mental health and substance abuse programs exist across two hospitals and 12 associated community clinics, totaling more than 20 affiliated programs across five cities located north and west of Boston. Teaching affiliations include the Harvard Medical School, the HSDM, the Tufts School of Medicine and the Massachusetts College of Pharmacy and Health Sciences. Of note, the CHA recently won awards for its delivery of care and services in the areas of maternal health and psychiatry. [14]
Specific to oral health, the CHA’s department of dental medicine and oral health was awarded a $4.5 million expansion grant in 2020, during the height of the COVID-19 pandemic no less, serving as a testament to the organization’s commitment to oral health and its integration with primary care. The expansion will create a new hub site, triple the operational capacity, double the number of residents and share the same location with the primary care’s home office.
Another aim is to create a translational “innovation laboratory” based on best clinical and administrative practices to create, test and deliver novel models of care. This will explore access, enhance communication and integrate electronic health records, thereby improving health outcomes and reducing health costs. This expansion aims to improve and reinforce health literacy and equity by offering our patients a user-friendly and culturally sensitive environment in which the patient will be heard and will feel welcomed to receive quality care. With the creation of an integrated and diverse advisory committee, we will keep taking concrete steps to remain a health-literate organization.
As our regional, national and global communities emerge from the COVID-19 pandemic, safety-net organizations like the CHA must continue innovations to continue equitable care delivery for underserved patient populations. To that end, we have provided point-of-care COVID-19 testing in our dental facility to determine risk assessment for all patients needing care. For certain patients, telehealth visits are available to minimize any health risks. Every consent form for every new procedure we implement must meet the literacy, numeracy and overall language needs of each patient.
Undoubtedly, health communication and literacy have in the past and will continue to play a critical role in our mission to deliver innovative, customized, culturally sensitive and friendly care for all patients and families. The CHA offers translations in 60 languages online or in person throughout the entire system. As Healthy People 2030 now emphasizes the importance of health literacy at organizational levels, the CHA and its department of dental medicine and oral health seek to lead by example in the intersection of health literacy, health equity and oral health integration.
REFERENCES
1. U.S. Department of Health and Human Services. 2021. Health Literacy in Healthy People 2030. Accessed Oct. 9, 2021.
2. U.S. Department of Health and Human Services. 2021. History of Health Literacy Definitions. Accessed Oct. 9, 2021.
3. Ibid.
4. Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.
5. Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. Washington, D.C.: The National Academies of Press; 2020. doi.org/10.17226/9612.
6. Giddon DB. Should dentists become ‘oral physicians’? Yes, dentists should become ‘oral physicians.’ J Am Dent Assoc 2004 Apr;135(4):438, 440, 442 passim. doi: 10.14219/ jada.archive.2004.0208.
7. Chandrupatla SG, Thompson LA, Kuna S, Swann BJ. Denture group visits: A model to improve access to care and reduce treatment period for dentures. J Calif Dent Assoc 2018 Nov;26(9):707–713.
8. Vujicic M, Israelson H, Antoon J, Kiesling R, Paumier T, Zust M. A profession in transition. J Am Dent Assoc 2014 Feb;145(2):118–21. doi: 10.14219/jada.2013.40.
9. Giddon DB. Oral physicians. Br Dent J 2012;213(10):497–498. doi.org/10.1038/ sj.bdj.2012.1038.
10. Giddon DB, Swann BJ, Hertzman-Miller R. Oral physicians: An opportunity for dentists? Am J Public Health 2012 Jul;102(7):e8; author reply e8–9. doi: 10.2105/ AJPH.2012.300667. Epub 2012 May 17.
11. FAIR Health Consumer. Total cost related to surgical placement of a dental implant into the jaw bone D6010. Accessed Oct. 9, 2021.
12. Jayaratne YS, Anderson NK, Zwahlen RA. Readability of websites containing information on dental implants. Clin Oral Implants Res 2014 Dec;25(12):1319–24. doi: 10.1111/ clr.12285. Epub 2013 Oct 22.
13. Leira-Feijoo Y, Ledesma-Ludi Y, Seoane-Romero J, Blanco- Carrion J, Seoane J, Varela-Centelles P. Available web-based dental implants information for patients. How good is it? Clin Oral Implants Res 2015 Nov;26(11):1276–80. doi: 10.1111/clr.12451. Epub 2014 Jul 21.
14. Cambridge Health Alliance. 2021. Academic Scholarship and Research. Accessed Oct. 9, 2021.
THE CORRESPONDING AUTHOR, Ryan Lee, DDS, MPH, MHA, can be reached at ryalee@challiance.org.
