Partnering to Pilot Community Health Worker Services

Transcription

1 Partnering to Pilot Community Health Worker Services Made possible through support from the Minnesota Department of Health and the Centers for Disease Control and Prevention (Community Wellness Grant) MDH HCH Learning Days 2018 April 3, 2018 from 1:30 pm to 2:30 pm St. Paul, MN

2 Panelists Kristin Erickson, MS, APHN-BC, RN Healthcare Initiatives Coordinator PartnerSHIP 4 Health Jody Lien, BSN, RN, PHN Assistant Public Health Director Otter Tail County Public Health Megan Nieto, Certificate-Holding CHW Consultant/President, CHW Services CHW Solutions

3 Learning Objectives 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

4 PartnerSHIP 4 Health 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

5 One of Fifteen CWG Strategies Community Health Workers 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.

6 How? No CHWs in our region Minimal knowledge of CHW services

7 CHW Beta Test What is a Beta Test? PartnerSHIP 4 Health contracted with CHW Solutions

8 Desired Beta Test Outcomes 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

9 Lacked One Thing A willing community partner Enter Otter Tail County Public Health Fergus Falls, MN

10 Beta Test Tasks (7) 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

11 Establish Project Team 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

12 Define Locations

13 ID Primary Target Group(s) 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

14 ID Secondary 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

15 Determine Outcome Measures # 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

16 Develop Short-term Goals 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

17 Develop long-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

18 Evaluate Beta Test Draft a brief summary of the beta test: Experience Outcomes Proposed next steps

19 Prepare for Sustainability July 25, 2017: Five Project Team Members completed initial assessment Next Steps: Review July results Complete a second assessment Draft Sustainability Plan

20 Beta Test Revised Timeline Original Timeline (Dec 1, 2016 Sept 29, 2017) Revised Timeline (Dec 1, 2016 Oct 31, 2017)

21 Beta Test Reveals a Need 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!

22 CWG CHW Pilot Contract 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 September 2017

23 OTCPH CHW Pilot Team Otter Tail County Public Health (OTCPH) Lead Organization Partners with Beta Test Project Team

24 OTCPH CHW Pilot 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

25 Recruitment

26 Supervision - Orientation Resource MCDPH CHW online training modules Summary COST: $80 - Topics: chronic conditions, HTN, diabetes and prediabetes MDH/ WellShare CHW HTN 90-minute video of training - MDH CHW Toolkit (2016) Hiring, Onboarding and Supervision (pages 30-39) merging/chw/2016chwtool.pdf Ramsey County IMPaCT Model and Manual Volunteers of America CHW manual CDC Prediabetes Screening Test COMMUNITY RESOURCES connection made with OTCPH Evidence-based CHW model (clinic-based) from Philadelphia Downloadable Resources from IMPaCT and Ohio Pathways models, and VoA internal policies testest.pdf (MAKE A LIST FOR CHWs TO USE AND BUILD ON)

27 Referrals Plan A: Develop referral relationships and processes with local clinic Plan B: Outreach to Community Organizations

28 Staff Roles for CHW Success 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

29 Service Delivery - Workflow Standing orders Best practice guideline for prediabetes Best practice guideline for hypertension Educational resources Self-management resources Competencies Billing Workflow

30 Practice Documentation 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

31 Practice Documentation Lived Experience

32 Pilot CHWs CHW Solutions certificate-holding CHW OTCPH CHWs

33 Pilot Activities Meetings with Healthcare Settings Prediabetes Screenings in the Community Outreach at Community Organizations Individual Client Visits

34 CHW Pilot Successes Trust and Connections Referrals Lake Region Healthcare Otter Tail County Public Health Lakeland Mental Health

35 CHW Pilot Successes CHW visit Referral back to County Programs Assist with process Client Connected to Community Resources Ongoing supports secured

36 CHW Pilot Successes 5 4 Omaha System Outcome Ratings Nutrition KBS Rating Knowledge Behavior Status BaseLine Discharge KBS Category BaseLine Discharge

37 CHW Pilot Successes 5 4 Omaha System Outcome Ratings Mental Health KBS Rating Knowledge Behavior Status Baseline Discharge KBS Category Baseline Discharge

38 CHW Pilot Successes KBS Rating Omaha System Outcome Ratings Residence Knowledge Behavior Status Baseline Discharge KBS Category Baseline Discharge

39 CHW Pilot Successes

40 CHW Pilot - Lessons Learned Time spent planning pays off Time spent learning pays off Start small

41 CHW Pilot - Lessons Learned Be ready with Plan B Be ready to readjust your goals Make sure your outcome measures are measurable

42 CHW Pilot - Lessons Learned Don t go it alone Make connections Learn from others

43 CHW Pilot - Lessons Learned

44 Questions? Wrap Up

45 References Martin 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 ce/emerging/chw/2016chwtool.pdf

46 Contact Information Kristin Erickson, MS, APHN-BC, RN Healthcare Initiatives Coordinator PartnerSHIP 4 Health kerickso@co.ottertail.mn.us Jody Lien, BSN, RN, PHN Assistant Public Health Director Otter Tail County Public Health jlien@co.ottertail.mn.us Megan Nieto, Certificate-Holding CHW Consultant President, CHW Services CHW Solutions megannieto@chwsolutions.com

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