Role of Community Health Workers in Preventing Avoidable Readmissions Minnesota Community Health Worker Alliance Joan Cleary, MM Executive Director Interim & Spectrum Health System Patricia A. Duthie, RN, BSN February 26, 2013
Today’s Agenda Objectives: • Define the role and scope of practice of community health workers • Identify work settings and target populations for community health workers • Describe how community health workers could be used to help reduce avoidable readmissions
The Role of Community Health Workers in Preventing Hospital Readmissions Overview of the field and promising opportunities RARE Campaign Webinar February 26, 2013 Joan Cleary, Executive Director - Interim Minnesota Community Health Worker Alliance
Presentation Outline • Introduction to the Minnesota CHW Alliance • Overview of the CHW Role & Building Blocks of Minnesota’s CHW Field • Contributions to Preventing Hospital Readmission • Considerations and Outlook • Selected resources
Minnesota CHW Alliance We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a 16 -member nonprofit board, who work together to address health disparities, help achieve the triple aim and foster healthier communities http: //www. mnchwalliance. org/
Education Objective: Improve access to coverage and care Workforce Development Objective: Foster policies that promote healthy people and healthy communities MN CHW Alliance Help achieve the Triple Aim, address health disparities, expand & diversify the health care workforce and foster healthier communities through CHW strategies Policy Objective: Advance CHW knowledge & skillset and interprofessional education to better serve Minnesota communities Research Objective: Raise awareness of CHW impacts through research & evaluation
CHWs: An Emerging Profession • Educate and connect underserved communities to care, coverage and support • Work under different titles & in many settings • Provide outreach, advocacy, patient education, care coordination, navigation, social support and informal counseling • Trusted members of the communities they serve, with shared culture and life experiences
CHW Strategies: Evidenced-based best practices • Effectively address barriers related to culture, language, literacy, ability, place, socioeconomic and other factors • Increase access and improve quality, cost- effectiveness and cultural competence of care • Expand diversify our health care workforce • Organize and advocate for healthier communities • Well-documented outcomes: asthma, diabetes, HIV/AIDs, hypertension, maternal and child health as well as cancer outreach and immunizations
CHW Roles CHWs help patients of all ages: • Prevent costly health conditions, diseases and injuries • Access needed care, coverage & services • Avoid unnecessary ER and hospital visits • Navigate our complicated health care system • Manage chronic illness and maintain quality of life • Improve individual and family capacity • Foster healthy homes and communities
CHW Roles, continued CHWs help health providers, health plans & public health: • • Produce better outcomes Coordinate care and reduce costs Find coverage options for the uninsured Educate, empower and activate patients for better health Deliver culturally-sensitive services Reach those who are vulnerable, underserved or isolated Effectively tackle health disparities Link to community services and organizations
CHW employer types in Minnesota • Community-based Nonprofits • Clinics and Hospitals • Federally Qualified Health Centers • Public Health Departments • Dental Services • Mental Health Centers • Faith-based Networks
CHW Profession & Benefits: Recognized by Leading Public & Private Authorities • American Public Health Association (APHA) • Centers for Disease Control (CDC) • Health Affairs • Health Resources and Services Administration (HRSA) • Institute of Medicine (IOM) • U. S. Dept. of Labor Standard Occupational Classification (DOL)
CHWs & Healthcare Reform • Centers for Medicare and Medicaid Services Workforce Innovation Grants • Patient-Centered Medical Homes • Health Insurance Exchanges • Three sections of the Affordable Care Act –CDC grant (section 5313) to promote positive health behaviors and outcomes in medically underserved communities through Community Health Workers. –National Health Care Workforce Commission (Sec 5101) includes CHWs as primary care professionals –Area Health Education Centers (sec. 5403 Sec. 751) add CHWs to mandate for interdisciplinary training of health professionals
MN CHW Building Blocks Recently recognized by the Agency for Healthcare Research & Quality http: //innovations. ahrq. gov/content. aspx? id=3700 • CHW scope of practice developed (2004) • Standardized, competency-based 11 credit curriculum created by Healthcare Education Industry Partnership, leading to certificate (2003 -2005); revised to 14 credit program (2010) • Minnesota CHW Peer Network formed (2005) • CHW payment legislation successfully introduced (2007) in followup to commissioned research on sustainable funding strategies (2006) • Minnesota CHW Alliance formed as outgrowth of CHW Policy Council (2010) and incorporated as nonprofit (2011)
Minnesota CHW Scope of Practice • Role 1: Bridge the gap between communities and the health and social service systems. • Role 2: Promote wellness by providing culturally appropriate health information to clients and providers. • Role 3: Assist in navigating the health and human services system. • Role 4: Advocate for individual and community needs. • Role 5: Provide direct services. • Role 6: Build individual and community capacity.
MN CHW Curriculum • Model curriculum was updated in 2010 to a required 14 credit certificate program • Mn. SCU curriculum offered at no charge to postsecondary schools in Minnesota • Sold to over 30 organizations outside of Minnesota; now available in online format • Credits provide educational pathway for CHWs interested in other health careers
MN CHW Curriculum • Role of the CHW – Core Competencies (9 credit hours) – – – Role, Advocacy and Outreach - 2 Organization and Resources - 1 Teaching and Capacity Building - 2 Legal and Ethical Responsibilities - 1 Coordination and Documentation - 1 Communication and Cultural Competency - 2 • Role of the CHW – Health Promotion Competencies (3 credit hours) • Role of CHW – Practice Competencies – Internship (2 credit hours)
CHW Certificate Program • Currently five schools offer the certificate program: – Minneapolis Community and Technical College – Rochester Community and Technical College – St. Catherine University, St. Paul – South Central College, Mankato (online version) – Summit Academy OIC, Minneapolis • Normandale Community College and Northwest Technical College, Bemidji to introduce the program in 2013 -2014 • Over 500 graduates to date
CHW Peer Network Co-chaired by CHWs & sponsored by Wellshare International Established in 2005 in follow-up to CHW focus group research commissioned by the Blue Cross Foundation identified peer support and professional growth as priorities of practicing CHWs Goals: • Improve resource sharing and information exchange among CHWs • Create opportunities for peer mentoring and support • Offer continuing education and professional development http: //www. wellshareinternational. org/chwpeernetwork
Overview: MN CHW Payment Legislation • 2007 Legislation – 12/19/07: Federal approval received – Minnesota Health Care Program (MHCP) enrollment criteria: • CHW certificate from school offering Mn. SCU-approved curriculum • Supervised by a physician/advanced practice registered nurse • Grandfathering provision • 2008 Legislation – 3/18/09: Federal approval of expansion of CHW supervision to the following provider types: • Certified public health nurses operating under the direct authority of an enrolled unit of government • Dentists • 2009 Legislation – Federal approval of supervision by Mental Health Professionals
MHCP CHW Payment Legislation Minnesota Statute (MS 256 B. 0625, Subd. 49)
Covered Services • Signed diagnosis-related order for patient education in patient record • Face-to-face services, individual and group • Standardized education curriculum consistent with established or recognized health or dental care standards • Document all services provided
Provider Types Authorized to Bill for CHW Services Advanced Practice Nurses Hospitals Clinics Indian Health Services Facilities Critical Access Hospitals Mental Health Professionals Dentists Physicians Family Planning Agencies Public Health Clinic Nurses Tribal Health Facilities To learn more about MN CHW coverage policy, contact: Susan. Kurysh@state. mn. us
Looking Ahead • Fully integrate the CHW role into state-funded health and human services programs, local public health and human services, and health care systems redesign efforts • Incorporate CHW workforce into: - Health care home program - Health Insurance Exchange (as assistors and navigators) - ACO models • Build greater awareness of the role and its impacts
Models that integrate CHW strategies to reduce avoidable hospital utilization • Pathways Model, Community Health Access Project, • Duke University Health System, Division of Community Health, Durham, NC • Camden Coalition of Health Care Providers, Camden, NJ • Spectrum Health System, Grand Rapids, MI • Montana Frontier Community Health Coordination Network, Helena, MT
Minnesota Examples • Mayo Clinic: We’re closely investigating the opportunity of aligning CHWs with our healthcare teams as an 18 month pilot to promote holistic patient -centered care, address complex care needs, invest in modifiable health determinants, and divert ED and hospitalization utilization to primary care. • HCMC Health Care Home: Patients who are enrolled in health care home have a designated CHW. It is an expectation that they call the patient within 48 hours and go through a four question work flow. CHWs are also very involved with hospitalized patients that are high risk for readmission. An order referral is sent to the CHW by the Clinical Care Coordinator to make an appointment with the PCP within 2 -3 days post discharge. The CHW then will attempt to enroll them into the health care home when they come in for a visit.
Integrating CHW Services for Improved Transitions Patient and Caregiver Factors to Consider • 2+ chronic illnesses • Behavioral health issues • Disability • History of repeat ED visits and/or admissions Generational poverty/ACEs • Lack of trust and “low activation” • Urban or domestic violence/war trauma • No transportation • Lives alone or caregiver issues • Language differences • Cultural barriers • Low SES • Low literacy; lack of HS diploma • New to locale/socially isolated • Unstable housing /homeless •
Upstream Issues, Downstream Consequences Readmission sensitive to social conditions • Recent BMJ study finds strong link between income inequality and readmission risk • Patients exposed to greater levels of income inequality were at increased risk for readmission for within 30 days of discharge for heart attack, heart failure and pneumonia • Implications for care coordination and CHW strategies
Team-based CHW approaches help hospitals reach outside their walls to make a difference • Data-driven approaches target high risk cases • No one fix but non-medical challenges often top the list • Outreach and post-discharge care coordination begin at bedside • CHWs provide warm connection, coaching, navigation and follow-up • Cross continuum hand-offs & communication key • Designing sustainable delivery models that work
Trends that Impact the Future of the CHW Field • Move from volume-oriented payment to pay for performance/outcomes and total cost of care • Workforce needs related to expanded coverage and primary care shortages • Demographic shifts with aging baby boomers and growth in populations of color • New care delivery and financing models such as health care homes and accountable care organizations • Focus on team-based, patient-centered care with everyone “working at the top of their license”
Trends, cont. • Greater recognition of social, environmental and economic determinants of health and use of tools such as community assessments and HIA • Need for proven, integrated, lower cost models • Increased accountability for reporting and outcomes, leading to wider adoption of best practices to address health disparities • Growing body of outcome-based studies that point to effectiveness of CHW strategies to reduce health disparities and improve cultural competence
Conclusion CHW strategies are an integral part of the response to the challenges facing our nation’s health. They contribute to cost-effective team-based interventions for effectively reducing avoidable hospital readmissions. Let’s work together to integrate and implement CHW approaches to reduce health disparities and help achieve the Triple Aim!
Selected Resources • • Brownstein JN et al. Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach. CDC. 2011. Cleary J, Lee J and Itzkowitz V. CHWs in Minnesota: Bridging Barriers, Expanding Access, Improving Health. 2010. www. bcbsmnfoundation. org Johnson, D, Saavedra, P, Sun, E, Stageman, A, Grovet, D, Alfero, C, Kaufman, A. 2011. Community Health Workers and Medicaid Managed Care in New Mexico. Journal of Community Health. doi: 10. 1007/s 10900 -011 -9484 -1 Fisher et al. A Randomized Controlled Evaluation of the Effect of CHWs on Hospitalization for Asthma: The Asthma Coach. Archives of Pediatrics & Adolescent Medicine. Jan 2009. 163, 3 Lindenauer P et al. Income Inequality and 30 day outcomes after acute myocardial infarction, heart failure and pneumonia. BMJ 2013; 346: f 521. doi: http: //dx. doi. org/10. 1136/bmj. f 521 Pathways Model http: //www. innovations. ahrq. gov/content. aspx? id=2040 Wilder Research Center CHW Assessment and ROI http: //reg. miph. org/2012 Cancer. Summit/presentationpdfs/Diaz. pdf
For more information: Joan Cleary, Executive Director-Interim Minnesota Community Health Worker Alliance 612 -250 -0902 joanlcleary@gmail. com Thank you!
Optimizing Your Investment in Community Health Pat Duthie, RN, BSN February 26, 2013
Spectrum Health System § Health system § Hospitals § Medical group § Health plan § Quality care § Community partner
Spectrum Healthier Communities § Overview § Philosophy § Community outreach § Outcomes driven § Community health worker model
Successful Programs § § School Health Advocacy Program Core Health Programa Puente Mothers Offering Mothers Support (MOMS)
Speaking the language § § § “Cost avoidance” “Population health” “Triple Aim” “Affordable Care Act” “Return on investment"
The First Step: Most important § What are you trying to achieve? § Decreased emergency department visits § Decreased hospitalizations § Decreased premature births § Decreased absenteeism rates in schools
Second Step: What do you know? § Where can you find data? § Information systems § ED visits & hospital admissions § Self reported versus claims data
Third Step: Can you compare? § Before and after § Is this program is successful? § Pre-program vs. program enrollment § Compare to other programs
Fourth Step: Analysis § Cost avoidance per patient total estimated program savings § Divide by the cost of the program to determine the ROI
The First Step: Core Health § What are we trying to achieve? § Diabetes and Congestive Heart Failure § Decreased ED visits § Decreased hospitalizations
Second Step: What do you know? Emergency department visits # of patients Hospital cost (per patient) Diabetes only Heart failure w/wo diabetes 482 $223, 486 $464 107 $61, 606 $576 545 $5, 232, 316 $9, 601 1114 $13, 212, 146 $11, 860 Hospital admissions Diabetes only Heart failure w/wo diabetes
Third Step: Can you compare? • Emergency department visits Core Health Participants Enrolled Usage Rate for Before Core Health Experience Diabetes 458 16. 4% 7. 4% Heart Failure 196 35. 9% 11. 4% 47
Third Step: Can you compare? • Inpatient admissions Core Health Participants Enrolled Usage Rate for Before Core Health Experience Diabetes 458 8. 5% 2. 8% Heart Failure 196 43. 5% 9. 1% 48
Third Step: Can you compare? • Emergency department Core Health Estimated Participants Emergency Enrolled Visits “Saved” Cost Avoidance Diabetes 458 248. 1 $115, 118 Heart Failure 196 206 $118, 656 49
Third Step: Can you compare? • Inpatient admissions Core Health Hospitalization Cost Participants “Saved” Avoidance Enrolled Diabetes 458 158. 6 $1, 522, 719 Heart Failure 196 272. 4 $3, 230, 664 50
Fourth Step: Analysis § Cost savings for diabetes of $1. 64 M § Cost savings for heart failure of $3. 35 M § Total estimated program savings $5 M § Core Health returned $2. 53 in savings for every $1. 00 of cost
Lessons learned § Time in the program § Patient selection § Patient engagement § Efficiency and effectiveness
Framework for the future § § Creativity Innovation Collaboration Integration of care
Contact information § Pat Duthie, BSN, RN § Pat. duthie@spectrumhealth. org
Questions ?
Upcoming RARE Events…. • RARE Webinar, Health Care Homes – Improving Care Transitions, Friday March 15, 2013, 12 noon -1 p. m. • RARE Rapid Action Learning Day, April 23, 2013, (8: 30 a. m. – 3: 30 p. m. ) Mpls. Marriot Northwest, Brooklyn Park, MN
Future webinars… • To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, kcummings@icsi. org
Resource Contacts For Community Health Workers De. Ann Rice, RN, PHN Manager, Care Coordination Ambulatory Administration Hennepin County Medical Center Direct: 612 -873 -2350 Fax: 612 -904 -4484 deann. rice@hcmed. org Jean M. Gunderson, DNP Community Engagement Coordinator Primary Care Internal Medicine-ECH~BA 1 B Mayo Clinic Phone: 507. 538. 8458 Pager: (53) 8 - 8758 Fax: 507. 266. 0036 E-mail: gunderson. jean@mayo. edu
Resource Contacts For Community Health Workers Jason Turi, RN, MPH Clinical Manager, Care Management Camden Coalition of Healthcare Providers 808 Cooper Street, 7 th Floor Camden, NJ 08102 856. 261. 0699 mobile 856. 365. 9510 ext. 2017 856. 365. 9520 fax www. camdenhealth. org/programs/caremanagement-program/ "Jason Turi" <jason@camdenhealth. org>, Heidi Blossom MSN RN Care Transition Coordinator MHA…An Association of Montana Health Care Providers 406 457 -8025 heidi@mtha. org Sarah Redding, MD sarah. redding@me. com Community Health Access Project Mansfield, OH Pathways Model http: //www. innovations. ahrq. gov/conte nt. aspx? id=2953 419 -525 -2555
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