Integrating Community Health Workers across the Healthcare Continuum
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1 Integrating Community Health Workers across the Healthcare Continuum SUSANNE CAMPBELL, MSN SENIOR PROJECT DIRECTOR LIZ FORTIN, LICSW CTC-RI PROGRAM DIRECTOR MARIE PADILLA, BA COMMUNITY HEALTH TEAM LEAD MAY 11,
2 OBJECTIVES Identify successful components for funding a community health team Solicit and engage key stakeholders and payers to build support Develop program criteria Design a model that support s the needs of patients with complex care needs Create systems that build on existing relationships to coordinate care Develop Agreements and Compacts that define mutual communication and coordination responsibilities Design methods to identify, refer and share information in real time Build innovative solutions for engaging patients/families and measuring success/results Develop patient registry, patient care documents and data collection tools Define key metrics, establish baselines and implement performance improvement processes Identify barriers, and solutions to improve care and achieve patient and program outcomes
3 CTC-RI MULTI-PAYER PRIMARY CARE INITIATIVE
4 Care Transformation Collaborative-RI (CTC-RI) Multi-Payer PCMH Model 5 PCMH Pilots (2008) 8 in Expansion 1 (2010) 3 in Expansion 2 (2012) 32 in Expansion 3 (2013) 25 in Expansion 4 (2014) 9 PCMH-Kids Pilots (2016)
5
6 What else works? CHT Model Use care management processes to address patients : Physical health needs Help accessing PCP, specialists, tests, treatments, medications Behavioral health needs Short term counseling by CHT and referral to external counseling Health education Medication management, nutrition, use of the health care system, appointment preparation Social determinants of health needs Help accessing: safe, affordable housing; home medical equipment; food and food banks; transportation; and completing paperwork for entitlements applications Sources: See references at end of slide set
7 Learning from Others Vermont Maine
8 Pre-req: Soliciting RI Multi-Payer and CTC-RI Board Support Charter Work plan and budget Community Health Team Committee Meeting schedule Metrics Contracts with CHT entities Evaluation Plan Enthusiasm to get started
9 CTC-RI COMMUNITY HEALTH TEAM PILOT
10 CTC-RI CHTs Phase 1 Program Model CTC-RI CHT program: started in 8/2014 Community Health Needs Assessments by HARI identified BH care as an unmet need in Pawtucket/Central Falls and South County 2 teams: North - hosted by Blackstone Valley Community Health Care; South - hosted by South County Health Funding: Multi-payer (NHP, United HealthCare, BCBS RI, Tufts) through CTC-RI RI Foundation grant to support behavioral health clinicians in year 1 Host agency contributions (BVCHC, South County Health)
11 CTC-RI CHTs Phase 1 Program Model CHTs serve as an extension of primary care practices, work with practice based nurse care managers CHT staff: CHWs, BHCM, administrative and management support Targeted patients: Adult patients of participating PCMHs, HP HR Lists In top 5% high risk/high cost/ high utilizers Impactable by CHT services Goal: Improve patient care, heath, and satisfaction with care, reduce cost/unnecessary utilization Program Evaluation Mixed-Methods Goal: Develop recommendations and lessons learned See CTC-RI Community Health Team Pilot Program Final Evaluation Report, February 2016
12 Recommendations Phase 2 Standardize Operations across Regional Teams Standardize policies and procedures Allowed teams to establish change control process for the shared database Facilitated the development of performance metrics and improvement process Memorandum of Understanding (MOU) was replaced with Memorandum of Agreement (MOA) Strengthen the Agreements MOA/BAA executed between CHT and primary care practices within defined geographic areas MOA more explicitly states responsibilities of practices, CHT, and CHT host entity; Health Plans added to agreements 7/1/16 MOA provides more prescriptive framework for how CHT and practices must work together to manage high risk patients Explicitly encourages warm handoffs
13 CTC New CHT Model Phase 2 Reorganized per Recommendations CTC-RI CHT Centralized Management Data Management Services database and core analytic services for all teams Local CHT South County Local CHT Pawtucket Central Falls TBD Additional Local CHTs 13
14 Community Health Program Primary Care Practices Dr. Cunniff Dr. DelSesto Dr. Demirs SC Internal Medicine SCMG EG, Wakefield, Westerly SC Walk-In and Primary Care Thundermist Wakefield Wood River Health Services Centralized Management Liz Fortin, LICSW Program Director Gail Meisner, Database Manager Community Health Team Marie Padilla, BA, CHW Team Lead Cassandra Stukus, LCSW BHCM Tonya Pete, CHW Stephanie Nacci, CHW Savanna Bebe, MSW Intern Nicole Faison, MSW Intern Office Set Up Woodruff Ave in Narragansett Co-located with SC Community Health & Wellness/HEZ Grant Washington County Coalition for Children
15 Primary Care Practices Affinity Family Medicine Blackstone Valley Community Health Care Pawtucket & Central Falls Memorial Hospital RI-Family Care Memorial Hospital RI-Internal Medicine Nardone Medical Associates Community Health Team Scott Hewitt, MA Program Manager Adrian Restrepo, CHW Doroteia Andrade, CHW Shannan Victorino, RN BH NCM Hosted by BVCHC Located in BVCHC Admin Office in Pawtucket Integrated with the Central Falls Neighborhood Health Station
16 CHT Model Who are we focused on? Drivers of Cost RN Acute Illness Complex Care Mgmt Team CHW Rising Risk Cohort 5% 5 > 50% TME top 5% LICSW 10% $ Chronic Disease Under-use of PCP Over/Misuse of ED/Inpatient Social disconnection Chronic Disease Management < 50% TME $ Substance Abuse Mental Health Disabilities Planned Care Team Poverty Routine Care and Prevention Care Management Staff Model Top 5-10% Source: Adapted from Carr, E. (2015). Building a Complex Care Management Program to Support Primary Care [PowerPoint slides]. Retrieved from
17 Phase 2 Who is High Risk? Of what? Health Plan Predictive Modeling Generate lists of patients Send high risk/high cost lists to PCMH Practices PCMH Practice Identify patients from payer lists, provider referrals, and practice based knowledge Complete CHT Triage tool, ask patient, and refer to CHT Healthcare Continuum Hospital, home health & SNF s identify patients with disposition issues, potential recidivists Complete CHT Triage tool, ask patient, and refer to CHT
18 CTC-RI CHT Referral Triage Tool Risk Drivers Higher total cost, super utilizers Moderate medically complex Fundamental rising risk Source: Adapted from Cambridge Health Alliance
19 South CHT Referrals with Triage Tool 4/1/16 3/31/17 n=266 Patients Served with at least 1 high risk utilization driver
20 South CHT Self Reported Barriers # of Barriers 4/1/16 3/31/17 n= 266
21 South County Health CARE CONTINUUM
22 SOUTH COUNTY HEALTH VISION: TO FORGE EXTRAORDINARY CONNECTIONS WITH OUR COMMUNITY THAT SUPPORT HEALTH AT EVERY STAGE OF LIFE
23 South County Health Care Continuum Integrated Care Management Home Health Community Health Team Community Agencies PCMH Nurse Care Managers Medication Therapy Management Palliative Care Respiratory Therapy Health Plans Wound Care Oncology Navigator State & Local Community PCP Inpatient & ED Case Managers Skilled Nursing Facilities Behavioral Health RN PT OT CNA
24 Vulnerable Populations Conference High risk individuals cycling in and out of levels of care related to medical issues, deplorable living situations, lack of adequate supports, potential self-neglect or abuse PARTICIPANTS Collaborative Team Members Invited community representatives with a role in taking care of vulnerable individuals Panelists provided overview of his/her role and experiences in supporting the community and/or vulnerable patient populations. Case studies presented by CHT Robust discussion OUTCOME Rich list of ideas to pursue for existing cases Networking/sharing contacts Suggestion to form SWAT team follow-up Group interest in future conferences Recommendations to expand participants
25 Statewide Synergies Power of Integration
26 CHT Program
27 Evidence Based Practice CHW TRAINING RIDOH CHW Certification Program Training /Education to 9 Domains Competencies 70 hours Experience Six months or 1000 hours of paid/volunteer work Supervision hours Recertification every 2 years 20 hours of education Mental Health First Aid (MHFA) Question Persuade Refer (QPR) TOOLS BH Screens and Referrals PHQ;GAD;CAGE-AID BH Assessment Psychosocial & Mental Status Exam Health Coaching using ProChangeTrans-theoretical Model Preventing unnecessary Hospitalization Transitions of Care Fall Prevention Caregiver supports Environmental modifications Long Term Services & Supports
28 Measuring Consistency & Efficiency
29 CHT Care Plan Outcomes
30 CHT WORKFLOW
31 CTC-RI CHT Referral Triage Tool Risk Drivers Higher total cost, super utilizers Moderate medically complex Fundamental rising risk Source: Adapted from Cambridge Health Alliance
32 CHT Intervention Outreach Engagement Releases Assessment Standardized Screens Referral Reason Care Plan Outcomes Summary of Success Assessments Care Plan Discharge Summary Activities Barriers problems Interventions Follow up Outcomes Advocacy Health Coaching Case Management Care Coordination Crisis Intervention
33 Extension of PCMH Team Roles and Responsibilities Behavioral Health Care Manager Assess substance use, mental health needs and assess patient readiness for change Address anxiety, depression and substance use needs Coach behavior change Address systemic barriers to care Integrated care among various providers especially BH providers Care plan development Community Health Worker Nurse Care Manager Meet with patient during hospitalization Care plan development Arrange post-acute home visit and other home visits as needed Appointment reminders and accompaniment Arrange transportation Arrange entitlements Link to community resources Teach patients self-monitoring strategies Care Plan development Integrate care among various providers Assess degree of support required : diabetes, COPD, etc. Arrange consults for nutrition, pulmonary, etc. Arrange and coordinate care with VNA, assisted living, post-acute care Coach patient re: med adherence and self-care strategies
34 Local Hope Valley resident brought back on his feet with South County Health I wouldn t be living here at this point if it wasn t for her. That s Paul Wilms, a 65 year old resident of Hope Valley and patient of Marie Padilla of the Community Health Team. Paul has been a patient with the CHT for 3 years. He had been down and out when it came to his health. After having issues getting appointments, being dropped from insurance more than 10 times, and suffering two strokes, Paul was ready to give up; until he started working with the CHT and Marie. Marie has helped me sort through all of the paperwork and politics of insurance which has been very helpful, said Paul This team was receptive enough to when I should and shouldn t do things for myself or when I would need advice and counsel. They weren t trying to control everything They encouraged me to be more productive and self aware and solve problems for myself, said Paul. A grateful patient, Paul wanted to help others facing similar hardship, donating $100 to the CHT. I suspect a lot of people are shutting down and giving up out there. I hope they get to use this opportunity locally with South County Hospital.
35 Housing to 3RD FLOOR 1 ROOM Home SUBSIDIZED APARTMENT
36 What s next? SUSTAINABILITY Total Cost of Care Analysis Value Proposition or Business Model for stakeholder groups Health plans CHT Entity PCP Patients & families Community State Expansion CMS State Innovation Model SAMHSA SBIRT Models of Reimbursement ACO Other Value Based options
37 Acknowledgements Blue Cross and Blue Shield of RI Neighborhood Health Plan of RI Tufts Health Plan UnitedHealthcare CTC-RI North Team staff and Blackstone Valley Community Health Care Inc. CTC-RI South County Team staff and South County Health CTC Community Health Team Committee and Board of Directors Rhode Island Department of Health, Rhode Island Office of Health & Human Services Warren Alpert School of Medicine of Brown University, RI Foundation CTC-RI Co-Directors: Debra Hurwitz, RN, MBA and Pano Yeracaris, MD, MPH Evaluation Team: Roberta Goldman, PhD; Mardia Coleman, MS; Marisa Sklar, PhD
38 Link to CTC-RI CHT Resources OOLS/COMMUNITY-HEALTH-TEAMS
39 Questions? THANK YOU
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