2013 Grant Award from CDC Grant Award from CDC. 5 year period Needs Assessment Pilot Programs Tuition Coverage Statewide Advisory Committee

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2 Community Health Workers are frontline public health workers who are trusted members of and/or have an unusually close understanding of the communities served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. Community Health Workers are liaisons with resources in the communities they serve. They play a vital role in improving Missourian s health by providing a connection between health systems and community resources, as well as education on how to reduce behavioral health risk factors. ( (

3 2013 Grant Award from CDC 5 year period Needs Assessment Pilot Programs Tuition Coverage Statewide Advisory Committee 2018 Grant Award from CDC Certification Association Sustainability

4 Purposes Membership Meetings Quarterly Certification Association

5 Core Competencies Professionalism and Conduct Self-awareness Service Coordination and System Navigation Education to Promote Healthy Behavior Change Advocacy Individual and Community Capacity Building Effective Communication Strategies Cultural Responsiveness Documentation and Reporting Use of Public Health/Community Health Concepts and Approaches Individual Assessment Community Assessment

6 Locations Metro Community College Kansas City St. Louis Community College Ozarks Technical Community College Southeast Missouri State University State Fair Community College Moberly Area Community College

7 238 Individuals by June 2018 Pre and post surveys Female 146 / Male 29 Age ranges from 18 to over 66 years Majority have some college African American 73 / Caucasian 73 / Hispanic 19 / Asian 4 / Other 12

8

9 Statewide CHW ECHO: Spring 2018 Conference Statewide Payer Engagement Group (St. Louis/Kansas City) Regional Mid America Regional Council Kansas City Integrated Health Network St. Louis MO HealthNet Primary Care Health Home Diabetes Management in Senior Population Local Public Health Agencies

10 Barbara Brendel, Health Program Representative III Bureau of Cancer and Chronic Disease Control Missouri Department of Health and Senior Services 920 Wildwood Jefferson City, MO

11 Community Health Worker Activities At Central Ozarks Medical Center DawnElyn Schneider

12 Location, Location, Location Central Ozarks Medical Center (COMC) has at least 1 Community Health Worker located in each clinic location as well as 2 area school districts where we provide services. We have a total of 6 CHW s at this time and have plans to add additional school based CHWs.

13 Referral Paths Provider Referrals occur not only from our Medical Providers. Just as frequently our Behavioral Health and Dental Providers refer patients to us for additional resources and assistance. Schools we have Behavioral Health Staff imbedded in 10 school districts 2 now have CHW s on site and the others refer to the COMC CHW that is geographically closest. Counselors, nurses, administrators and teachers are all sources of these referrals.

14 Referral Paths continued Community Partnerships - Community Action Agencies, Churches, Shelters, FSD, Local Hospitals, Schools, Childcare Facilities etc. Other patients and community members (open access).

15 Panel Size Flexible Panel Sizes dependent on risk stratification levels. Each CHW informs me of when their panel is full and we need to flex patients to other CHWs. This process allows us to stay agile. There is a vast difference in 20 patients that are high risk versus 20 who are low to moderate risk.

16 Panel Population Currently we do not focus on a specific chronic disease panel of patients, however, by default we tend to Case Manage a great deal of pregnant women and children due to some of our specialty services offered at COMC. CHWs do assist in any quality initiatives we may be focusing on as an organization (Ex: 2 year old Immunizations or Controlled Hypertension in Diabetes).

17 Tools Utilized to Assess Patient Needs We utilize the PRAPARE Form to assess Social Determinants of Health as well as old fashioned conversation!

18 Common Needs Patients most commonly need assistance with Insurance Assistance Transportation Rx or Medical Services Assistance Connecting to additional resources Grandparents raising grandchildren, navigating the process.

19 Greatest Struggles/Ongoing Hurdles Transportation Educating Patients on Health Care Processes Documentation Meeting the Need

20 Advice Hiring the right person. What are the skills you can t train for? Community involvement, not just for work purposes Flexibility/Thinking outside the box Faces of the organization

21 You called for help?

22 We are committed to improving the health of the medically underserved of greater southwest Missouri through direct services and collaborative efforts.

23 ACCESS DIRECTORS AND LOCATIONS Anderson Medical & Dental Neosho Medical Aurora Medical Corporate Neosho Dental Lamar Medical Carthage Dental Joplin Medical & Dental Nevada Dental Cassville Medical & Dental Dr. Prater, CMO Don, McBride, CEO

24 Community Health Workers Angela, Aurora Karla, Joplin Emily, Joplin

25 Core Values CARE Compassion. We demonstrate compassion for our patients by being sensitive to their socio-economic status and ethnic diversity by providing the healthcare they need through the best and most efficient delivery methods which includes the chronic care model. ACCESS We create access to primary dental and medical healthcare by seeing patients with or without insurance or who have Medicare or Medicaid. We offer sliding fee discounts for those who qualify financially. Respect We respect our patients. No matter what their background or circumstance, we provide the services they need with equal respect. We as staff respect one another as we diligently serve our patients as servantleaders. Excellence We seek excellence in all we do. We are committed to continuous improvement through review, evaluation, and a performance improvement program that involves all levels of leadership.

26 A Little About Access We are a FQHC that is patient centered medical home Out of approximately 26,000 unduplicated patients served each year the CHW team works with approximately 225 patients, 75 for each of the three of us In general, most of the CHW patients come from the High Utilizer MO Medicaid Population Morning huddles are essential to maintain team communication and collaboration to serve the patient needs Initial patient interaction is important for building trust Maggie, Med. Assistant Cassville Community partnerships are a vital part of serving the patients and helping them meet their needs Rhonda & Marsha, Cassville Front Desk

27 Prapare (mapping and Social Determinant needs) Red Cap (state reporting) Assessment Tools DRVS (data reporting system) Karie, RN Care Mgr. Milly & Megan, Adult Hall Staff Rachel & Donna Joplin Dental Staff Tina Reeves, WHNP

28 Hope, Behavioral Health Resources Identified Transportation Food & Clothing Housing Cost effective medication and DME Referrals to other medical professionals Insurance applications Adaptive equipment Lindsey, Lamar Nurse Lilly, Lab Christina & Kelsi Joplin Pharmacy Staff

29 Team work is essential Recommendations Be aware of surroundings and safety needs Person centered approach for communication Terry & Regina Joplin Nurses Meeting the patient at their level of cognitive and physical function Build a working relationship by reaching small goals Megan & Kirsten Joplin Children's Hall Maribel, Maria A. & Maria O. Joplin Women s Hall Joplin Front Staff

30 Health Care Collaborative of Rural Missouri

31 Mission: Cultivate partnerships and deliver quality health care to strengthen rural communities.

32 Health Care Collaborative of Rural Missouri and Live Well Community Health Centers Community Health Workers We currently have four Community Health Workers which have completed the CHW Certification online class through State Fair Community College. Two of the CHW s are located on the Network side and one in our clinic and one in our school based telehealth clinic. We are in the process of hiring three additional CHW s to be placed in our clinics to work with patients on a dayto-day basis. Health Care Collaborative of Rural Missouri

33 Health Care Collaborative of Rural Missouri Assessment Tools Used PRAPARE Connector Form

34 Health Care Collaborative of Rural Missouri Common Resources Needed 340B Discount Prescription Drug Program Transportation Social Determinants of Health Needs ie: personal hygiene items, laundry detergent, mattresses, bedding, etc. Medicaid/Medicare/Food Stamps

35 Health Care Collaborative of Rural Missouri Housing Utility Assistance Prescription Drug Assistance Difficult Resources to find

36 Health Care Collaborative of Rural Missouri Missouri Telehealth ECHO Advice for other CHW s

37 Building Communities Suzanne Smith Chris Carney Director of Network Development CHW

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