health care home spotlight: early lessons and results from chw integration promoting patient...
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Health Care Home Spotlight: Early Lessons and Results from CHW Integration Promoting Patient Centered Care and Community Health. Tara M. Nelson Intercultural Mutual Assistance Association Community Health Worker Jean M. Gunderson Mayo Clinic Employee Community Health - PowerPoint PPT PresentationTRANSCRIPT
HEALTH CARE HOME SPOTLIGHT:EARLY LESSONS AND RESULTS FROM CHW INTEGRATION PROMOTING PATIENT CENTERED CARE AND COMMUNITY HEALTH
Tara M. Nelson Intercultural Mutual Assistance Association
Community Health Worker
Jean M. Gunderson Mayo Clinic Employee Community Health
Community Engagement Coordinator
Minnesota Community Health Worker Alliance Statewide Meeting
June 5, 2014
OBJECTIVES
Illustrate the impact of CHW home visits on the understanding of the patient experience through descriptions of goal setting, self-management, and acts of resiliency
Review the collaborative infrastructure and funding aligning CHW capacities promoting community health
Describe the building of teams integrating CHWs in a certified Health Care Home
Examine the community based co-supervisory CHW model integrating patient centered team based care
PATIENT STORY …
CHALLENGE AS OPPORTUNITY 1990’s influx of immigrant and refugee
populations Public program and funding transitions Unmet and uncoordinated patient/consumer
needs across a continuum of care Recognition of the social determinants of
health and community oriented primary care Navigation, communication and engagement
History
LOCAL COLLABORATIVE RESPONSE The Multicultural Health Care Alliance (1997) The Olmsted County Health Care Access
Taskforce in 2005 (access; context) The Olmsted County Community Health Care
Access Collaborative in 2007 (community priorities; workgroups)
The Coalition of Community Health Integration in 2012 (formalization of systems, policy and funding)
The United Way of Olmsted County (alignment of early intervention: behavioral health, oral health, medical home) History
LOCAL CHW WORKFORCE DEVELOPMENT Standardized, competency-based CHW
curriculum offered at Rochester Technical & Community College (2006 and 2012)
CHW Workgroup (2008); small study (2009) 90 hour CHW internships at lead partner sites
(2006 and 2012) MN CHW Employer Forum in Rochester (2009) CHW Employer Consortium (2011) Community Based Co-Supervisory CHW Pilot
(2013)
History
CHW CURRICULUM Standardized, competency based 11 credit
curriculum (2003-2005) Revised to 14 credits (2010) Core competencies (9 credit hours) Health promotion competencies (3 credit
hours) Internship (2 credit hours) CHW certificate upon graduation
Curriculum
COMPETENCIES CHW Role, Advocacy and Outreach,
Organization and Resources, Teaching and Capacity Building, Legal and Ethical Responsibilities, Coordination and Documentation, Communication and Cultural Competency
Healthy Lifestyles, Heart Disease and Stroke, Maternal and Child/Teen Health, Diabetes, Cancer, Oral Health, and Mental Health
Curriculum
FUNDING The United Way of Olmsted County The Mayo Clinic Office of Population Health
Management Potential: Team based care in the
Accountable Care Organization Model Potential: Care Coordination/HCH Testing: Minnesota Health Care Program
(MHCP) Medicaid fee-for-service option
Funding
CHW PILOT:CO-CREATING TRANSDISCIPLINARY TEAM BASED CARE Internship and Pilot aligned and co-created with lead
Care Coordinators and leaders in Mayo Clinic Employee and Community Health (ECH) Health Care Home
Specific service areas: Primary Care Internal Medicine (PCIM), Integrated Behavioral Health (IBH) and Community Pediatric & Adolescent Medicine (CPAM)
Referral Criteria: complex care needs, eligible for or enrolled in care coordination (recognizing health determinants)
Expanded programming: DIAMOND, EMERALD, COMPASS, and EPSDT (C&TC) complex care needs utilizing two lead Care Team RNs
Infrastructure
CHW ROLE Navigator Advocate Liaison Knowledge- Bearer: community relationships,
local lived experiences, cultural, linguistic and language needs
Connector to community resources Educator: reinforcement and support Walker of the Margins
Role
CHW STORY…
QUALITY DIMENSIONS:ASSET BASED AND HOLISTIC TEAM BASED CARE Community based co-supervisory CHW model Order by Proxy options (Primary Care
orientation) Team huddles, patient conferences and
consults Telephonic support Patient home visits and at other community
based sites Non Visit Care coordination supports
QUALITY DIMENSIONS:ASSET BASED AND HOLISTIC TEAM BASED CARE Social Determinants data identified in
partnership and reported utilizing patient language
Patient centered visit schedule (service, frequency & number)
Referral, patient goals, and self-management skills tracking
Transdisciplinary teaming (relational practice) Secondary partner sites reporting every 3
months
CHW PILOTCURRENT STATUS Total patients served: 181 Total Visits: 452 (since July 1, 2013) Active patients: 103; Average CHW caseloads: 50
patients Average number of visits per patient: 2.5
CHWs working with ECH teams: 2-3 FTE Care Coordinators in the Pilot: 24 Lead Care Team RNs: 2 (EPSDT)
Weekly reporting 5-19-2014
WHO ARE WE SERVING?
17 55
56
39
1
Age Group
0--910--1415-1718-6465+NR
83
39
1
Gender
FemaleMaleNR
WHO ARE WE SERVING ?WORKING ACROSS CULTURES, LANGUAGE AND LITERACY
99
714
1 111
Languages
EnglishSomaliSpanishLaotianKhmerArabicASL
WHO ARE WE SERVING ?
59
47
17
Insurance Type
GovermentCommercialNot doc-umented
* Documentation and tracking are challenging due to insurance enrollment status,patient and internal reporting, and when multiple payers per patient exist
WHO ARE WE SERVING?
45
620
134
4
33
Primary Diagnosis
DepressionCOPDDiabetesAsthmaHypertensionCHFOther
• Often multiple comorbid conditions exist
WHO ARE WE SERVING ?
30
3524
26
Social Determinates Score
Tier One (18-24)Tier Two (25-29)Tier Three (30+)NR
Multiple reasons for (NR) not reporting including,patient refusal of assessment, limited visits number and attention to urgent needs
Minnesota Department of Human Services and the Hennepin County Ryan White Program HIV/AIDS Medical Case Management Standards (Appendix C, HIV/Aids Acuity Assessment, pages 24-26)
WHAT ARE WE DOING?TOP DIRECT CARE THEMES-PATIENT DIRECTED GOALS Daily Living Healthy Living Independence Care of Chronic Conditions Social Support Public Programs Safety Spiritual Needs
NON VISIT CARE THEMES: AREAS OF IMPACT Basic Human Needs Patient Engagement/Communication Insurance/Coverage of Services Referrals to Direct Health-Related Services
SELF-MANAGEMENT THEMESo Budgeting: figure out expenses, find bills, set-up a
financial consult, track bank accounto Social Activity: get outside more, call churches,
volunteer, get involved in an activity, obtain a computer, find a buddy system for the Laundromat
o Goal setting and Planning: use a journal, calendar, or a list
o Advocating for Self: communicate with teams, home care agencies, and PCAs, being assertive and setting rules
o Gaining Independence: organize paper work, find a home, schedule transportation, go to work regularly, understand care plan
o Managing health: check BP, journal, relaxation breathing
LEAD PATIENT EDUCATION TOOLS PHQ-9 Asthma Control Test Asthma Control Assessment Asthma Action Plan Peds Quality of Life Form Goal Setting Goal Map Journaling Log books (BP, Diabetes, Activity)
CARE COORDINATOR STORY…
SATISFACTION AND ASSURANCE DATA Patients , Care Coordinators and CHW
satisfaction data collected using surveys (mail and on-line, interview option with CHW team)
Integration of human stories/cultural narratives Review of lead reporting tool: CHW Visit Form Monthly case consultation with CHWs & ECH
teams Bi-monthly co-supervisory meetings at IMAA
site MN CHW Alliance & MN CHW Alliance
Supervisor Roundtable
PATIENT EXPERIENCE Cultural narrative
LESSONS LEARNED:THE ART FORM OF HOLISTIC CARE WITHIN RELATIONSHIPo A fillable PDF CHW Reporting Form would create
improved outputs in reporting and in-direct time.o Home visits are critical in understanding
patient/family experiences, assets, needs, and health determinants
o Use of one’s language, literacy, and culture remain significant factors within care, healing, and health outcomes
o Mixed methods analysis is important when reviewing and reporting patient data
o Community based CHW services are essential in the integration of community contexts within team based care.
REFLECTION ON THE “A-HA” MOMENTS Market community based non-profits Integrate collaborative funding Recognize the impact of team champions Living the mantra: systems, tools, teams,
processes (process outputs/the collective flow)
Model how specialized training impacts observation, interviewing, documentation, reporting and referral (the transdiciplinary practice lens)
Align resources to envision and deliver Recognize transformation as both challenge
and opportunity
NEXT STEPSo Continue to develop CHW billing processes,
integrating both fee-for-service and shared revenue cost saving options
o Maintain the evaluation of CHW programming addressing complex care needs and the social determinants of health
o Expand the CHW reporting and referral pathways to include additional Care Team RN leads and Social Workers.
o Build the SE MN CHW Regional Pipeline with collaborative partners and expand local CHW programming
o Maintain CHW specialized training and cross-training across the care continuum
