THE PATIENT NAVIGATOR OUTREACH AND DEMONSTRATION PROJECT funded by a grant received from HRSA

Transcription

1 THE PATIENT NAVIGATOR OUTREACH AND DEMONSTRATION PROJECT funded by a grant received from HRSA

2 BARRIERS TO CARE FOR LHFC PATIENTS Low Literacy Levels Language and Cultural Barriers (35% of Patients are Best Served in a language other than English) Low Socio-economic Status (75% of Patients are at or below the Federal Poverty Line) Lack of Health Insurance (28% of patients are insured) No Medical Home Immigration Status

3 STEP I: Defining the Primary Goals of Lutheran Family Health Center (LFHC) Patient Navigator Program To reduce the morbidity and mortality associated with diabetes among this high-risk patient population To improve health outcomes of diabetic patients by eliminating barriers to care and increasing patients access to medical care and other supportive services To help patients play an active role in the management of their condition and to empower them to sustain their ability to self manage their diabetes To prevent the occurrence of type II diabetes among children at risk due to obesity and family history

4 Step 2: Define Patient Navigator Interventions Provide a basic overview of the diabetes disease process Teach patients to use Blood Glucose Meters for self monitoring of diabetes Obtain free/discounted medications and testing supplies Help access community resources such as health insurance, public assistance, employment services and exercise programs Schedule medical and specialty appointments on a priority basis and accompany patients to appointments as needed Check in with patients on a regular basis to provide ongoing support Assist patients in adhering to existing self-management goals or developing new goals (working collaboratively with clinical providers)

5 Step 3: Define Patient Population Clearly define eligibility criteria for navigation based on need and your manpower resources Do NOT deviate from this criteria to the best of your ability Initial Eligibility Criteria Adults with Type II Diabetes and an A1c>9 Children at risk for developing Type II Diabetes (Family History or Obesity) Other Eligible Patient Cohorts Newly Diagnosed Patients Patients discharged from the ED/Hospital Patients identified as in need of intervention by providers/other staff Gestational Diabetics Target Capacity 650 patients with an added patients factoring in patient attrition

6 Step 4: Identification and Recruitment of Patients for Navigation Assess your patients interest in being navigated! This is critical to avoid attrition and to focus on patients that really need services Make face to face contact with patients at least once. Determine if patients can articulate specific needs that PNs can assist with Train staff to administer Readiness to Change assessment tools Reports generated by IT/QA departments of patients who are uncontrolled or have had no A1c in the past 6 months Reports of inpatient ED admissions Face-to-face meetings in clinic when patient arrives for a medical/specialty or lab appointment Referrals from providers and front-line staff

7 Step 5: Recruitment of Navigators Hire navigators with professional and personal qualifications that fulfill the objectives of the navigation program Profile of LFHC Navigators Residents of the communities served by LHFC Unique knowledge of the cultural, socio-economic and literacy needs of patients An understanding of the challenges faced by indigent patients in accessing healthcare and social services Ability to serve as peer educators and advocates

8 Profile of LFHC Patient Navigators A total of 7 patient navigators were hired, all of whom served as full-time employees 5 were second generation immigrants and 2 were first generation immigrants All were bilingual in English and either Spanish, Chinese or Creole 6 of 7 navigators had prior experience working with indigent populations 4 had served as national service volunteers working with underserved patients

9 Step 6: Initial Training The 70 hour training in core competencies and diabetes management was delivered over a period of 3 weeks Training was attended by 7 PNs and 15 AmeriCorps workers The course of study was designed to help community health workers PNs cultivate the core skills that have come to describe the field. The focus was on experiential learning methods that model the work PNs do. Participants completed a pre-training and post-training self assessments to evaluate their own understanding of their past training and their roles as PNs. PNs were issued a certificate of completion from the Columbia University Mailman School of Public Health.

10 TRAINING METHODS Adult learning theories Participatory and experiential Discovery process Liberating education Promotes critical thinking Shifts perspective from faults to strengths Changes approach from service to empowerment Strengths assessment first, needs assessment second

11 Training Comments Can this CHW training be offered as human being training? Of course it s directly applicable to my work but it s really about how we interact, respect and communicate with other beings it s about relationships. I am a new person. This training changed my life. I see things in a different way and this will help me in my work and in my life. I think that this is more than a training, this is a very good experience that I am going to remember every day of my life.

12 TRAINING COMMENTS (Continued) I have never attended a training like this. Never. This was the most fun, friendly, active training I have ever attended. I would not mind doing it again. Where I have been to some boring, long training and learned nothing, but this was a very special experience that I will never forget. The teaching techniques are awesome! This training transforms people! Keep up the good work! Do not surrender to any pressure to change the format. There is no way that you can prepare someone for so much change with traditional methods. This is TRANSFORMATIONAL!

13 TRAINING COMMENTS (Continued) The program helps and allows you to come in touch with your inner self. It challenges us emotionally and puts us to the test of asking ourselves some very serious questions. It allows us to look critically at ourselves and our work ethics. This program should be part of our schools curriculum. Our churches, youth groups, various places and the list goes on. This way everyone would be on one accord. Keep up the good work. You changed my life.

14 Additional Trainings Glucose Meter Teaching Nutritional Overview Domestic Violence Overview of Public Assistance Introduction to Pharmacy Assistance Programs and other resources for free and discounted medications/testing supplies for diabetics

15 Step 7: Setting Up Program Infrastructure: Navigation Model Note: In a system as large as LFHC having a central home base for navigators while simultaneously integrating the PN program into each primary care sites is essential for the success of this effort. 1. Patient Centered Approach a) Individualized telephonic or face-to-face contact b) Tailored to meet the needs of each individual patient, while keeping the overall goals of the PNDP program in mind. 2. Decentralized Model While part of the Disease Management Program which served as their central home, each navigator was assigned to one or two primary care sites, and developed relationships with patients and medical/other staff at that site 3. Use of The Electronic Medical Record a) To identify patient needs, review medical and visit history, etc b) To maintain relationships with clinical and administrative providers by sending electronic telephone messages c) Flagging disconnected numbers and change in contact information

16 Supervision of Patient Navigators and Integration of PN Program into the LFHC System LFHC has a main health center site and 6 satellite clinics. The project was decentralized, so each LFHC primary care clinic had a navigator assigned to it. Smaller sites share navigators Navigators were administratively supervised by the Director/Coordinator of the Disease Mgmt Program and by the Site Directors of each individual clinic Clinical oversight was provided at the site level by Medical Directors. Additional guidance was obtained from individual medical providers The overall guidance for PN activities came from The Network Care Management team that was responsible for creating network goals for self management, order sets, EMR registry functions and other templates for Chronic Diseases including diabetes

17 ASSIGNMENT OF PATIENT NAVIGATORS Caribbean American FHC Park Ridge FHC Family Practice FHC Brooklyn Chinese FHC Park Slope FHC Sunset Park FHC (Adult Medicine/Pediatrics/ Women s Health)

18 OUTCOMES: QUANTITATIVE AND QUALITATIVE SUCCESSES OF NAVIGATION Over 900 patients were enrolled into the program Approximately 25% (219) patients had been diagnosed with Gestational Diabetes. Approximately 10% (97) of enrolled patients were children at risk for developing type II diabetes due to obesity and/or family history A quarter of patients (258) were uninsured at the time of enrollment.

19 Outcomes of PNDP Program (cont) The success of PN intervention for Gestational Diabetics - defined by healthy birth outcomes- was over 85%. Of the 258 uninsured patients, 167 (65%) patients were enrolled in/ referred to Pharmacy Assistance Programs, resulting in increased compliance with medication regimens An additional 61 patients were enrolled into Pharmacy Assistance Programs to receive assistance with obtaining diabetic supplies and/or generic medications Of a random sample of 140 adult diabetic patients, 81 (58%) showed a decrease in A1c, while 22 (16%) patients who had not had an A1c in the year prior to enrollment, came in for their lab work due to PN outreach. (Note: 16 patients showed no change in A1c. 21 patients showed an increase.)

20 Establish Data Collection Systems! Clearly define data collection needs and outcomes Configure patient navigator activities on the Electronic Medical Record System if available Discuss the option/availability of a Disease Management Registry for tracking patients If the Electronic Health Record is unavailable, utilize a user friendly database such as MS Access or invest in tracking software

21 Results of Survey Administered to Patients LFHC created a survey tool to assess the impact of navigation on patients The survey was piloted on a small group of patients to gauge the simplicity of the questions and the ability of patients to understand and answers these. Modifications were made accordingly, and the final survey was telephonically administered over a four week period in August Surveys were administered telephonically in English, Spanish and Chinese by neutral third parties A total of 440 patients were called, of which 120 were not reachable, as patients were not home, had disconnected numbers, or no facility to leave a message. Only seven patients refused to answer the survey of which one patient had relocated to another state, while another patient no longer received services at LFHC.

22 Results of Survey (Cont) Of the 320 patients surveyed following are the results: Number of patients reporting less problems with the LFHC system since enrolling in navigation/number of patients finding it easier coming in for care after enrollment: 270 (87%) Number of patients who reported that they could talk to their navigator about their health and other issues (* aside from receiving diabetes education): 189 (60%) Number of patients reporting regular glucose monitoring: 262 (82%) Number of patients reporting increased glucose monitoring after meeting with navigators: 263(83%) Number of patients with self reported changes in knowledge of diabetes: 320 (100%)

23 Results of Survey (Cont) Number of patients with increased adherence to diet recommendations: 221 (69%) Number of patients with increased adherence to exercise recommendations: 159 (51%) Number of patients receiving assistance with appointment scheduling: 288 (91%) Number of patients receiving assistance with reminder calls: 292 (92%)

24 QUESTIONS/CHALLENGES What constituted enrollment of a patient in navigation? When was navigation considered completed? When was navigation considered a success? Strategies for minimizing patient attrition Creating a standard protocol for contacting patients. Every culture is unique and every patient within a particular culture is unique. Therefore it was hard to define how often to contact a patient and to create a standard protocol for communicating with patients, while respecting patients individuality.

25 LESSONS LEARNED Contrary to initial assumptions, the biggest barrier to obtaining medical care was Health Literacy and Cultural Norms and NOT lack of health insurance Support, encouragement and education in the above areas became the most important role of PNs Reminder calls and scheduling appointments have been identified by PNs as the two other essential services provided to patients Given the complexity of the Diabetes disease process, navigation for certain patient cohorts can be an ongoing long-term process, and may not always yield positive clinical short-term results

26 LESSONS LEARNED In larger health systems decentralizing and integrating PNs into primary care sites is integral to the success of the project During the early stages of implementation of the grant two essential tasks were: Reviewing the capabilities of ALL current systems for data collection and analysis Defining potential outcomes and methods to obtain the required data

27 BEST PRACTICES I. KNOW YOUR PATIENTS HISTORY! Successful Integration of PN activities into Patients Electronic Medical Record (EMR) - All navigators were trained extensively on the use of the EMR - PNs were assigned privileges to review and document on patient records - The EMR has a special configuration for PN activities. These can be reviewed by individual providers - For urgent matters, telephone encounters were sent through the EMR to providers - ALL patient contact was initiated after a review of patient s record. This enabled PNs to make informed outreach and follow up calls to patients and was a key to successful navigation

28 EMR: TEMPLATE FOR NAVIGATION

29 BEST PRACTICES (CONT D) 2. Recruitment of appropriate staff Depending on the structure of the program and the financial situation of the program, a professional such as social worker or RN may be hired as a PN. This makes reimbursement for services more feasible. If program is financially stable, then lay persons from the community can be hired as CHWs. The important criteria, irrespective of professional qualifications, remains the same: a) A thorough understanding of the cultural and social issues of the patient population they serve. b) Personal/Family History of dealing with a Chronic Disease c) Computer skills d) Knowledge of internal and external resources Your best staff often comes from within the organization

30 Future of Patient Navigation: Sustainability of PNDP Program Unionizing PN positions Since several key positions requiring patient interactions are unionized, PNs have increased opportunities to apply for these positions and use their navigation skills in different areas of patient service Reimbursement for CHW/PN serivices and Establishing PNs/CHWs as a job category

31 CHW Financing Public Sector Recommendations Medicaid administrative costs Medicaid care team integration PCMH, ACO, Health Homes Medicaid direct provider reimbursement 1115 Waiver Federal, state and local policy positions Federal grants and contracts Private Sector Recommendations Commercial insurance medical cost ratio direct reimbursement for CHW services outcomes-based payment Private sector organizations hospital, CHCs MCOs, providers plan for shifting revenue streams under health reform Philanthropies explicitly support HCW model

32 CHW Business Case Cost savings Maryland diabetes study $2, per patient per year cost savings 40% reduction in diabetes ED visits 33% reduction in diabetes hospitalizations 27% reduction Medicaid expenses Hawaii asthma study 97% reduction in per capita expenditures 83% reduction in ED visits Return on Investment $4.80 per dollar spent (Georgia) $2.28 per dollar spent (Denver)

33 Questions/Discussion