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MDH HCH Learning Days 2018April 3, 2018 from 1:30 pm to 2:30 pm
St. Paul, MN
Partnering to PilotCommunity Health Worker Services
Made possible through support from theMinnesota Department of Health and the
Centers for Disease Control and Prevention(Community Wellness Grant)
Kristin Erickson, MS, APHN-BC, RNHealthcare Initiatives CoordinatorPartnerSHIP 4 Health
Jody Lien, BSN, RN, PHNAssistant Public Health DirectorOtter Tail County Public Health
Megan Nieto, Certificate-Holding CHWConsultant/President, CHW ServicesCHW Solutions
Panelists
Following this session, participants will be able to:• Detail how the partnership emerged and
developed the CHW Pilot• Identify the successes of the Otter Tail County
Public Health CHW Pilot• Recall lessons learned during the Otter Tail
County Public Health CHW Pilot
Learning Objectives
• Local Public Health and Community Partners in West Central Minnesota
• Statewide Health Improvement Partnership (SHIP) Grantee since 2009
• Centers for Disease Control and Prevention -Community Wellness Grant (CWG) Grantee since 2014– Address prediabetes and hypertension– Priority populations
• low-wage earners• ethnic minorities
PartnerSHIP 4 Health
Com
mun
ity H
ealth
Wor
kers
Increase engagement of Community Health Workers to promote linkages
between health systems and community resources for
adults with high blood pressure or prediabetes or at high risk for type 2 diabetes.
One of Fifteen CWG Strategies
No CHWs in our regionMinimal knowledge of CHW services
How?
• What is a Beta Test?• PartnerSHIP 4 Health contracted with CHW Solutions
CHW Beta Test
• Develop and implement a beta test work plan• A workflow based on best practices• CHW service reimbursement• Referral and communication mechanisms • Improved Client Self-Management Skills
Desired Beta Test Outcomes
A willing community partner… Enter Otter Tail
County Public Health Fergus Falls, MN
Lacked One Thing
• Establish Project Team• Define beta test location(s)• Identify target group(s)• Determine outcome measures• Develop short-term and long-term goals• Evaluate Beta Test• Prepare for Sustainability
Beta Test Tasks (7)
• PartnerSHIP 4 Health– Kristin Erickson, Jason Bergstrand, Carol Hagel
• CHW Solutions– Megan Nieto and Megan Ellingson
• OTCPH– Diane Thorson and Jody Lien
• MDH EHDI Grantees - Guests– Maryann Harris and Aline Muhimpundu
Establish Project Team
Define Locations
• Low-income and/or Somali or Latino– At risk for diabetes and/or hypertension
• Referred from organizations serving Fergus Falls and/or Otter Tail County clients:– Lake Region Healthcare - IHP Population– Ringdahl EMS Community Paramedics– Otter Tail County Public Health – Lakeland Mental Health Center
ID Primary Target Group(s)
• Low-income and/or Somali or Latino– At risk for diabetes and/or hypertension
• Referred from:– Sanford Health Clinic, Pelican Rapids– Essentia Health Clinic, Pelican Rapids– Otter Tail County Community Organizations
ID Secondary Target Group(s)
• # clients served and which services by: language, payer, referral source, condition
• Omaha System Knowledge, Behavior, Status Ratings and/or Ohio Pathways Completion
• # and amount of claims submitted• # and amount of reimbursement received• Staff perspectives on project
Determine Outcome Measures
SHORT-TERM GOALS (ten months): CHWs employed and embraced CHWs establish trust between communities and
organizations CHWs empower priority populations CHW interventions organized, measured, and
communicated using Electronic Health Records CHW services reimbursed
Develop Short-term Goals
LONG-TERM GOALS (3-5 years): CHWs employed in health and social service
agencies, and included and embraced as valuable team members CHWs viewed as a valuable resource to deliver
value-based care and address workforce shortages
Develop long-term Goals
Draft a brief summary of the beta test:• Experience• Outcomes • Proposed next steps
Evaluate Beta Test
• July 25, 2017:– Five Project Team
Members completed initial assessment
– www.sustaintool.org• Next Steps:
– Review July results– Complete a second
assessment– Draft Sustainability Plan
Prepare for Sustainability
• Original Timeline (Dec 1, 2016 – Sept 29, 2017)• Revised Timeline (Dec 1, 2016 – Oct 31, 2017)
Beta Test Revised Timeline
Boots on the Ground -How is this all going to work?Is this even going to work?How about a CHW Pilot?
Otter Tail County Public Health to the rescue!
Beta Test Reveals a Need
• PartnerSHIP 4 Health contract with Otter Tail County Public Health
• Engage CHW(s) to link priority populations to promote prevention of type 2 diabetes and self-management of high blood pressure
• Timeline: April 2017 - September 2017
CWG CHW Pilot Contract
Otter Tail County Public Health (OTCPH)• Lead Organization• Partners with Beta Test Project Team
OTCPH CHW Pilot Team
• Recruit CHW(s)• Identify CHW supervision and orientation and
training needs • Develop referral relationships and processes • Articulate staff roles• Develop service delivery and billing
workflows, including standing orders• Document interventions and outcomes
OTCPH CHW Pilot
Recruitment
Supervision - OrientationResource Summary
MCDPH CHW online training modules
COST: $80 - Topics: chronic conditions, HTN, diabetes and prediabeteshttps://chwtraining.mcdph.org/
MDH/ WellShare CHW HTN 90-minute video of training -https://www.youtube.com/watch?v=-kAiwHuJ-jM
MDH CHW Toolkit (2016) “Hiring, Onboarding and Supervision” (pages 30-39)http://www.health.state.mn.us/divs/orhpc/workforce/emerging/chw/2016chwtool.pdf
Ramsey County Email connection made with OTCPHIMPaCT Model and Manual Evidence-based CHW model (clinic-based) from
PhiladelphiaDownloadable http://chw.upenn.edu/toolkit
Volunteers of America CHW manual
Resources from IMPaCT and Ohio Pathways models, and VoA internal policies
CDC Prediabetes Screening Test
https://www.cdc.gov/diabetes/prevention/pdf/prediabetestest.pdf
COMMUNITY RESOURCES (MAKE A LIST FOR CHWs TO USE AND BUILD ON)
Plan A: Develop referral relationships and processes with local clinic
Plan B: Outreach to Community Organizations
Referrals
• PHN: supervision; clinical oversight; ordering provider; develops health messaging; mentor regarding outreach and client visit practices; quality improvement
• CHW: provide and document direct CHW services and outreach activities
• Billing: submits CHW claims to payers; troubleshoots claims processing practices and denied claims with payers
Staff Roles for CHW Success
• Standing orders• Best practice guideline for prediabetes• Best practice guideline for hypertension• Educational resources• Self-management resources• Competencies• Billing Workflow
Service Delivery - Workflow
• Client narrative drafted• Omaha System Excel Spreadsheet constructed • CHW practice and outcomes documented
using the spreadsheet• Documentation transferred into electronic
health records system (PH-Doc)– Goal: CHWs chart interventions and outcomes
directly into PH-Doc
Practice Documentation
Lived Experience
Practice Documentation
• CHW Solutions certificate-holding CHW• OTCPH CHWs
Pilot CHWs
• Meetings with Healthcare Settings
• Prediabetes Screenings in the Community
• Outreach at Community Organizations
• Individual Client Visits
Pilot Activities
• Trust and Connections• Referrals Lake Region Healthcare Otter Tail County Public Health Lakeland Mental Health
CHW Pilot Successes
CHW visit
Referral back to County Programs
Assist with process
Client Connected to Community Resources
Ongoing supports secured
CHW Pilot Successes
CHW Pilot Successes
Knowledge Behavior StatusBaseLine 1 1 1Discharge 3 3 2
0
1
2
3
4
5
KBS
Ratin
g
KBS Category
Omaha System Outcome RatingsNutrition
BaseLine Discharge
CHW Pilot Successes
Knowledge Behavior StatusBaseline 2 3 3Discharge 3 4 3
0
1
2
3
4
5
KBS
Ratin
g
KBS Category
Omaha System Outcome RatingsMental Health
Baseline Discharge
CHW Pilot Successes
Knowledge Behavior StatusBaseline 2 1 2Discharge 2 2 2
2 2 2
0
1
2
3
4
5
KBS
Ratin
g
KBS Category
Omaha System Outcome RatingsResidence
Baseline Discharge
CHW Pilot Successes
Time spent planning pays off Time spent learning pays off Start small
CHW Pilot - Lessons Learned
Be ready with Plan B Be ready to readjust your goals Make sure your outcome measures
are…measurable
CHW Pilot - Lessons Learned
Don’t go it alone Make connections Learn from others
CHW Pilot - Lessons Learned
CHW Pilot - Lessons Learned
Wrap Up• Questions?
ReferencesMartin KS. (2005). The Omaha System: A key to practice, documentation, and information management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.
Minnesota Department of Health. Office of Rural Health and Primary Care (2016). CHW Toolkit: A Guide for Employers. Retrieved from http://www.health.state.mn.us/divs/orhpc/workforce/emerging/chw/2016chwtool.pdf
Kristin Erickson, MS, APHN-BC, RNHealthcare Initiatives CoordinatorPartnerSHIP 4 Healthkerickso@co.ottertail.mn.us
Jody Lien, BSN, RN, PHNAssistant Public Health DirectorOtter Tail County Public Healthjlien@co.ottertail.mn.us
Megan Nieto, Certificate-Holding CHWConsultantPresident, CHW ServicesCHW Solutionsmegannieto@chwsolutions.com
Contact Information
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