Welcome to the New England QIN-QIO Webinar! Slides may be downloaded at:

Transcription

1 Welcome to the New England QIN-QIO Webinar! Slides may be downloaded at: 1

2 The Role of Community Health Workers in Chronic Disease Management and Behavioral Health February 21, :30am 12:30pm This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINB

3 Today s Speakers Amber Culver Community Health Worker at the North Country Health Consortium James Pleischl Community Health Worker at Ammonoosuc Community Health Center, Inc. Chad Proulx Health Education Specialist at Ammonoosuc Community Health Services, Inc. 3

4 Building a Community Health Worker Network to A Address Chronic Disease in a Rural Community A Resource for your Practice and Community Presented by: Amber Culver Community Health Worker, North Country Health Consortium

5 Objectives Learn the process of building a Community Health Worker program in a rural and underserved area Gain a clear understanding of the role of a CHW in Diabetes management. Be introduced to options for program payment and funding sustainability

6 Overview What is a Community Health Worker (CHW) Building a CHW Program Funding a CHW Program North Country Culture Social Determinants of Health Chronic Disease Management The New Hampshire Community Health Worker (CHW) Coalition

7 Leading innovative collaboration to improve the health status of northern New Hampshire NCHC seeks to meet the unmet health needs of our region. Healthcare workforce shortage Gaps in the continuum of care High ED utilization Social determinants of health Rural health disparities

8 What is a Community Health Worker?

9 Are You A Community Health Worker? Wellness Coach Health Advocates Outreach Worker Home Visitors Lay Health Educator Case Manager

10 American Public Health Association Definition A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. Liaison Link Intermediary

11 CHW Qualities Membership in or shared experience with the community in which they work Friendly and outgoing Open-minded and non-judgmental Motivated and capable of self-directed work Caring and compassionate Respectful Flexible and adaptable Desire to help the community Resourceful A model for trying to live a healthy lifestyle

12 National Standard CHW Competencies and Complimenting Roles CORE COMPETENCIES Communication skills Interpersonal skills Organizational skills Knowledge base Teaching skills Capacity Building skills Advocacy skills Service Coordination skills CORE ROLES Health Education Cultural Mediation Advocating: Individuals and Communities Navigation/Access Providing Referrals/direct services Building Capacities: Individuals and Community Informal Counseling

13 Building a CHW Program in a rural area Funding: NCHC attained both state and federal funds to build and manage their CHW program. Models: Researched many models for CHW programs across the country. Models were from programs that served: Refugees Children Adults with chronic disease And much more NCHC used these models as a guide to create their own program to serve northern New Hampshire. Resource for you! Rural Health Information Hub

14 Care Coordination Model: At NCHC, this model was the foundation for the program. Using the care coordination model, the CHW acts as the liaison/link between the patient and needed services including: Health & behavioral health care Housing & heating Food related needs Transportation Etc. The CHW role is to assist patient in meeting goals to manage chronic disease; addressing needs regarding the social determinants of health, providing health education, and connecting them to needed services.

15 Sustainable Funding Options Provider funding based on: Return on Investment Cost/Benefit Analysis Medicaid Reimbursement State Funding Through Public Health Department

16 Barriers to Building a CHW Program Securing sustainable funding Providers understanding CHW role and value Implementing a credentialing program Broad role and scope

17 NCHC Ways 2 Wellness CONNECT CHW Program The current model is grant funded, supported by state and federal funds Partnered with hospitals, health centers, and human service organizations Specific Focus Women s Health and preventative Screenings Chronic Disease Self-Management for adults 65+

18 Education and Training North Country Health Consortium provides CHW Training 12 Week Hybrid Course 6 In-Person Sessions and 5 Online Units Opportunity for Further Training with Topic Specific Modules Focus on the North Country Culture

19 Supervision Implementation CHWs will need support and professional development after initial training. Home based work often gets messy, as it intentionally erases some boundaries, so CHWs will need support in boundary determination and setting. CHW will often face challenges of engagement and relationship, things of a less medical nature.

20 Infrastructure Checklist A home visiting policy that includes home visiting safety protocols. Cell phones enabled with text At least basic laptops with the ability to connect via wireless or hot spot in patient homes Support for mileage reimbursement Supervisors who have some training in and understanding of CHW history and roles, as well current functions and challenges Dedicated supervision time that is long enough to allow for reflective learning To be connected to other peer CHWs

21 North Country Culture Culture is defined as a congruent set of practices, attitudes and beliefs that shape people s way of surviving. A culture of poverty exists in northern NH. There is diversity among the socioeconomic classes. exists in the socioeconomic classes.

22 Rural Challenges The North Country Spirit Fierce independence, private, prideful, may be unwilling to ask for help Access Long distances between locations, none-very limited public transportation Very few health centers with affordable or free care for uninsured

23 The Importance of Utilizing Community Health Workers

24 The CHW is a member of the healthcare team that can address the whole person, outside of the provider s office.

25 Social Determinants of Health The social determinants of health are the economic and social conditions and their distribution among the population that influence individual and group differences in health status. Access to Healthcare Transportation Housing Social Support Financial Instability Health Literacy AND SO MUCH MORE

26 CHW s and Chronic Disease Management How can CHW s help patients better manage their chronic conditions?

27 Chronic Disease Management CHW s play a key role in helping patients meet goals around chronic disease management, and assist providers understand what patients are doing outside of the provider s office. Chronic Disease Educational Programs Healthy Eating Support Systems Community Outreach

28 The purpose is to bring together community health workers, health professionals, stakeholders and community leaders throughout NH, to inspire and educate about the value of the CHW in NH. Opportunities for organizations to collaborate Training opportunities A platform to let others know about programs, facilities, and activities that promote healthy living. Basecamp for communication Explore the creation of CHW logic models in NH NH CHW Coalition

29 NH CHW Coalition Registration To become a member of the NH CHW Coalition follow this registration link: -OR- Fill out the brochure and return it to the North Country Health Consortium For questions, Please contact Jennifer Goulet at jgoulet@nchcnh.org

30 Thank You! For Community Health Worker Questions, Please Contact Amber Culver at

31 CHW Utilization In the Changing Landscape of Rural Healthcare

32 FAST FACTS ABOUT ACHS One of 9 FQHC s in NH (~1400 nationwide) USDA designated Rural, Medically Underserved Area (MUA) Over 10,000 patients served annually in 26 towns, 2 counties Insurance breakdown Medicare % Medicaid 14.5% Private 47.2% Self Pay 10.5% - *$1.062 million in sliding fee discounts in 2016

33 ACHS Services Primary Preventative Medical Care Prenatal Family Planning Breast & Cervical Cancer Screening Program Behavioral Health Dental & Oral Health Nutrition Pharmacy

34 The CHW Role at ACHS New Beginnings in Familiar Territory CHW position is relatively new to NH First CHW hired at ACHS December 2017 Along with CHW role, various positions share CHW activities Health Educator WIC Nutritionist Patient Navigator Various Program Caseworkers

35 Developing the CHW Position A Few Small Hurdles Defining clear-cut activities Grant funding dictating activities Training and orientation can lag after hiring Job description: a work in progress Developing a face within in the community and rapport with patients

36 Reducing Health Disparities Chronic disease happens with greater frequency in areas where the money ain t CHW role is to reduce the manageable components of health disparities, and thereby helping to reduce chronic disease Resources Education Barriers to income BH Barriers

37 Round and Round We Go! High-Utilizers High-utilizer = a community member/patient who chronically re-enters a certain part of the system without addressing their long-term needs. Need for community interface and meet them where they are CHW role is perfect for addressing and preventing high utilization in a value-based medical model. warm hand-offs in primary care Developing systems of collaborations Being on-site at collaborating entities

38 CHW Role in Action Example 1 DSMP offered in Littleton area 10/5/17 to 11/9/17 Out of 10 participants completing the 6-week program, 5 were ACHS patients: Patient 1: Lost 7.2lbs. From August to January. A1C was 8.0 in May 2017, 7.5 in December 2017 Patient 2: Lost 35.8 pounds from 9/6/17 to 1/23/18, no A1C data Patient 3: lost 4 from Oct 2017 to January 2018 (pre-diabetic) Patient 4: gained 6 pounds from August to January, A1C from 8.1 on 8/14 to 6.9 on 12/6

39 CHW Role in Action (cont) Patient 5: No significant weight changes noted, A1C went from 8.7 on 10/18 to 7.0 on 12/4 5 Patients, 5 Successes!

40 CHW Role in Action Recent Collaboration with Grafton County Jail Viewing chronic offenders as high-utilizers Need recognized to disrupt the turnstile pattern Housing Employment Substance Misuse/Abuse BH Turning reaction (crisis management) into proaction (selfmanagement)

41 Questions/ Discussions We will open the phone lines so you can weigh in with comments and questions 41

42 Contact Us to Learn More Brenda Jenkins, RN, D.Ay., CDOE, CPEHR, PCMH CCE Michele Kelvey-Albert, MPH, CHES 42

43 Connect with the New England QIN-QIO on Social Media! 43