Role of Community Health Workers in Preventing Avoidable Readmissions

Role of Community Health Workers in Preventing Avoidable Readmissions

Minnesota Community Health Worker Alliance Joan Cleary, MM Executive Director Interim

&Spectrum Health System

Patricia A. Duthie, RN, BSNFebruary 26, 2013

Today’s Agenda

Objectives:•Define the role and scope of practice of community health workers•Identify work settings and target populations for community health workers•Describe how community health workers could be used to help reduce avoidable readmissions

The Role of Community Health Workers in Preventing Hospital Readmissions

Overview of the field and promising opportunities

RARE Campaign Webinar February 26, 2013Joan Cleary, Executive Director - InterimMinnesota Community Health Worker Alliance

Presentation Outline

• Introduction to the Minnesota CHW Alliance

• Overview of the CHW Role & Building Blocks of Minnesota’s CHW Field

• Contributions to Preventing Hospital Readmission

• Considerations and Outlook• Selected resources

Minnesota CHW Alliance

We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a 16-member nonprofit board, who work together to address health disparities, help achieve the triple aim and foster healthier communities

http://www.mnchwalliance.org/

Workforce Development

Education Objective: Advance CHW knowledge & skillset and interprofessional education to better serve Minnesota communities

Objective: Raise awareness of CHW impacts through research & evaluation

Objective: Foster policies that promote healthy people and healthy communities

Objective: Improve access to coverage and care

Research

Policy

MN CHW Alliance

Help achieve the Triple Aim, address health disparities, expand & diversify

the health care workforce and foster

healthier communities through

CHW strategies

CHWs: An Emerging Profession

• Educate and connect underserved communities to care, coverage and support

• Work under different titles & in many settings

• Provide outreach, advocacy, patient education, care coordination, navigation, social support and informal counseling

• Trusted members of the communities they serve, with shared culture and life experiences

CHW Strategies:Evidenced-based best practices

• Effectively address barriers related to culture, language, literacy, ability, place, socioeconomic and other factors

• Increase access and improve quality, cost- effectiveness and cultural competence of care

• Expand and diversify our health care workforce• Organize and advocate for healthier communities• Well-documented outcomes: asthma, diabetes, HIV/AIDs,

hypertension, maternal and child health as well as cancer outreach and immunizations

CHW Roles CHWs help patients of all ages:

•Prevent costly health conditions, diseases and injuries

•Access needed care, coverage & services

•Avoid unnecessary ER and hospital visits

•Navigate our complicated health care system

•Manage chronic illness and maintain quality of life

•Improve individual and family capacity

•Foster healthy homes and communities

CHW Roles, continued

CHWs help health providers, health plans & public health:

• Produce better outcomes • Coordinate care and reduce costs• Find coverage options for the uninsured• Educate, empower and activate patients for better health• Deliver culturally-sensitive services• Reach those who are vulnerable, underserved or isolated • Effectively tackle health disparities• Link to community services and organizations

CHW employer types in Minnesota

• Community-based Nonprofits• Clinics and Hospitals • Federally Qualified Health

Centers • Public Health Departments• Dental Services• Mental Health Centers• Faith-based Networks

CHW Profession & Benefits: Recognized by Leading Public & Private Authorities

• American Public Health Association (APHA)

• Centers for Disease Control (CDC)• Health Affairs• Health Resources and Services

Administration (HRSA)• Institute of Medicine (IOM)• U.S. Dept. of Labor Standard

Occupational Classification (DOL)

CHWs & Healthcare Reform • Centers for Medicare and Medicaid Services Workforce Innovation Grants

• Patient-Centered Medical Homes

• Health Insurance Exchanges

• Three sections of the Affordable Care Act

–CDC grant (section 5313) to promote positive health behaviors and outcomes in medically underserved communities through Community Health Workers.

–National Health Care Workforce Commission (Sec 5101) includes CHWs as primary care professionals

–Area Health Education Centers (sec. 5403 Sec.751) add CHWs to mandate for interdisciplinary training of health professionals

MN CHW Building BlocksRecently recognized by the Agency for Healthcare Research & Qualityhttp://innovations.ahrq.gov/content.aspx?id=3700

• CHW scope of practice developed (2004)

• Standardized, competency-based 11 credit curriculum created by Healthcare Education Industry Partnership, leading to certificate (2003-2005); revised to 14 credit program (2010)

• Minnesota CHW Peer Network formed (2005)

• CHW payment legislation successfully introduced (2007) in follow-up to commissioned research on sustainable funding strategies (2006)

• Minnesota CHW Alliance formed as outgrowth of CHW Policy Council (2010) and incorporated as nonprofit (2011)

Minnesota CHW Scope of Practice

• Role 1: Bridge the gap between communities and the health and social service systems.

• Role 2: Promote wellness by providing culturally appropriate health information to clients and providers.

• Role 3: Assist in navigating the health and human services system.

• Role 4: Advocate for individual and community needs.

• Role 5: Provide direct services.

• Role 6: Build individual and community capacity.

MN CHW Curriculum• Model curriculum was updated in 2010 to a

required 14 credit certificate program

• MnSCU curriculum offered at no charge to post-secondary schools in Minnesota

• Sold to over 30 organizations outside of Minnesota; now available in online format

• Credits provide educational pathway for CHWs interested in other health careers

MN CHW Curriculum• Role of the CHW – Core Competencies (9 credit hours)

– Role, Advocacy and Outreach - 2– Organization and Resources - 1– Teaching and Capacity Building - 2– Legal and Ethical Responsibilities - 1– Coordination and Documentation - 1– Communication and Cultural Competency - 2

• Role of the CHW – Health Promotion Competencies (3 credit hours)

• Role of CHW – Practice Competencies – Internship (2 credit hours)

CHW Certificate Program

• Currently five schools offer the certificate program:– Minneapolis Community and Technical College– Rochester Community and Technical College– St. Catherine University, St. Paul– South Central College, Mankato (online version)– Summit Academy OIC, Minneapolis

• Normandale Community College and Northwest Technical College, Bemidji to introduce the program in 2013-2014

• Over 500 graduates to date

CHW Peer NetworkCo-chaired by CHWs & sponsored by Wellshare International

Established in 2005 in follow-up to CHW focus group research commissioned by the Blue Cross Foundation identified peer support and professional growth as priorities of practicing CHWs

Goals:• Improve resource sharing and

information exchange among CHWs• Create opportunities for peer

mentoring and support• Offer continuing education and

professional developmenthttp://www.wellshareinternational.org/chwpeernetwork

Overview: MN CHW Payment Legislation

• 2007 Legislation– 12/19/07: Federal approval received– Minnesota Health Care Program (MHCP) enrollment criteria:

• CHW certificate from school offering MnSCU-approved curriculum• Supervised by a physician/advanced practice registered nurse • Grandfathering provision

• 2008 Legislation– 3/18/09: Federal approval of expansion of CHW supervision to the following

provider types:• Certified public health nurses operating under the direct authority of an

enrolled unit of government• Dentists

• 2009 Legislation– Federal approval of supervision by Mental Health Professionals

MHCP CHW Payment Legislation

Minnesota Statute (MS 256B.0625, Subd. 49)

Covered Services

• Signed diagnosis-related order for patient education in patient record

• Face-to-face services, individual and group

• Standardized education curriculum consistent with established or recognized health or dental care standards

• Document all services provided

Provider Types Authorized to Bill for CHW Services

Advanced Practice Nurses HospitalsClinics Indian Health Services FacilitiesCritical Access Hospitals Mental Health ProfessionalsDentists PhysiciansFamily Planning Agencies Public Health Clinic NursesTribal Health Facilities

To learn more about MN CHW coverage policy, contact:[email protected]

Looking Ahead

• Fully integrate the CHW role into state-funded health and human services programs, local public health and human services, and health care systems redesign efforts

• Incorporate CHW workforce into: - Health care home program - Health Insurance Exchange (as assistors and navigators) - ACO models

• Build greater awareness of the role and its impacts

Models that integrate CHW strategies to reduce avoidable hospital utilization

• Pathways Model, Community Health Access Project, • Duke University Health System, Division of Community

Health, Durham, NC• Camden Coalition of Health Care Providers, Camden, NJ • Spectrum Health System, Grand Rapids, MI• Montana Frontier Community Health Coordination

Network, Helena, MT

Minnesota Examples

• Mayo Clinic: We’re closely investigating the opportunity of aligning CHWs with our healthcare teams as an 18 month pilot to promote holistic patient-centered care, address complex care needs, invest in modifiable health determinants, and divert ED and hospitalization utilization to primary care.

• HCMC Health Care Home: Patients who are enrolled in health care home have a designated CHW. It is an expectation that they call the patient within 48 hours and go through a four question work flow. CHWs are also very involved with hospitalized patients that are high risk for readmission. An order referral is sent to the CHW by the Clinical Care Coordinator to make an appointment with the PCP within 2-3 days post discharge. The CHW then will attempt to enroll them into the health care home when they come in for a visit.

Integrating CHW Services for Improved Transitions Patient and Caregiver Factors to Consider

• Language differences• Cultural barriers• Low SES • Low literacy; lack of HS diploma• New to locale/socially isolated• Unstable housing /homeless• Generational poverty/ACEs• Urban or domestic violence/war

trauma • Lives alone or caregiver issues

• 2+ chronic illnesses

• Behavioral health issues

• Disability

• History of repeat ED visits and/or admissions

• Lack of trust and “low activation”

• No transportation

Upstream Issues, Downstream Consequences Readmission sensitive to social conditions

• Recent BMJ study finds strong link between income inequality and readmission risk

• Patients exposed to greater levels of income inequality were at increased risk for readmission for within 30 days of discharge for heart attack, heart failure and pneumonia

• Implications for care coordination and CHW strategies

Team-based CHW approaches help hospitals reach outside their walls to make a difference

• Data-driven approaches target high risk cases• No one fix but non-medical challenges often top the

list• Outreach and post-discharge care coordination begin

at bedside • CHWs provide warm connection, coaching,

navigation and follow-up• Cross continuum hand-offs & communication key • Designing sustainable delivery models that work

Trends that Impact the Future of the CHW Field

• Move from volume-oriented payment to pay for performance/outcomes and total cost of care

• Workforce needs related to expanded coverage and primary care shortages

• Demographic shifts with aging baby boomers and growth in populations of color

• New care delivery and financing models such as health care homes and accountable care organizations

• Focus on team-based, patient-centered care with everyone “working at the top of their license”

Trends, cont.

• Greater recognition of social, environmental and economic determinants of health and use of tools such as community assessments and HIA

• Need for proven, integrated, lower cost models • Increased accountability for reporting and outcomes,

leading to wider adoption of best practices to address health disparities

• Growing body of outcome-based studies that point to effectiveness of CHW strategies to reduce health disparities and improve cultural competence

Conclusion

CHW strategies are an integral part of the response to the

challenges facing our nation’s health.

They contribute to cost-effective team-based interventions for

effectively reducing avoidable hospital readmissions.

Let’s work together to integrate and implement CHW approaches to

reduce health disparities and help achieve the Triple Aim!

Selected Resources

• Brownstein JN et al. Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach. CDC. 2011.

• Cleary J, Lee J and Itzkowitz V. CHWs in Minnesota: Bridging Barriers, Expanding Access, Improving Health. 2010. www.bcbsmnfoundation.org

• Johnson, D, Saavedra, P, Sun, E, Stageman, A, Grovet, D, Alfero, C, Kaufman, A. 2011. Community Health Workers and Medicaid Managed Care in New Mexico. Journal of Community Health. doi: 10.1007/s10900-011-9484-1

• Fisher et al.A Randomized Controlled Evaluation of the Effect of CHWs on Hospitalization for Asthma: The Asthma Coach. Archives of Pediatrics & Adolescent Medicine. Jan 2009. 163, 3

• Lindenauer P et al. Income Inequality and 30 day outcomes after acute myocardial infarction, heart failure and pneumonia. BMJ 2013; 346:f521. doi: http://dx.doi.org/10.1136/bmj.f521

• Pathways Model http://www.innovations.ahrq.gov/content.aspx?id=2040• Wilder Research Center CHW Assessment and ROI

http://reg.miph.org/2012CancerSummit/presentationpdfs/Diaz.pdf

For more information:

Joan Cleary, Executive Director-InterimMinnesota Community Health Worker Alliance612-250-0902 [email protected]

Thank you!

Pat Duthie, RN, BSNFebruary 26, 2013

Optimizing Your Investment in Community Health

Spectrum Health System

Health systemHospitalsMedical

groupHealth plan

Quality care Community partner

Spectrum Health Healthier Communities

Overview Philosophy Community

outreach Outcomes driven Community health

worker model

Successful Programs

School Health Advocacy Program Core Health Programa Puente Mothers Offering Mothers Support

(MOMS)

Speaking the language

“Cost avoidance” “Population health” “Triple Aim” “Affordable Care Act” “Return on

investment"

The First Step: Most important

What are you trying to achieve?Decreased emergency department

visitsDecreased hospitalizationsDecreased premature birthsDecreased absenteeism rates in

schools

Second Step: What do you know?

Where can you find data? Information systemsED visits & hospital admissionsSelf reported versus claims data

Third Step: Can you compare?

Before and after Is this program is successful?Pre-program vs. program enrollmentCompare to other programs

Fourth Step: Analysis

Cost avoidance per patient total estimated program savings

Divide by the cost of the program to determine the ROI

The First Step: Core Health

What are we trying to achieve? Diabetes and Congestive Heart Failure

Decreased ED visitsDecreased hospitalizations

Emergency department visits

# of patients Hospital cost Hospital cost

(per patient)

Diabetes only 482 $223,486 $464Heart failure w/wo diabetes 107 $61,606 $576

Hospital admissions

Diabetes only 545 $5,232,316 $9,601Heart failure w/wo diabetes 1114 $13,212,146 $11,860

Second Step: What do you know?


•Emergency department visits

47

Core HealthParticipants

Enrolled

Usage Rate Before Core

Health

Usage Rate for Core Health Experience

Diabetes 458 16.4% 7.4%

Heart Failure 196 35.9% 11.4%


48


Enrolled

Usage Rate Before Core

Health

Usage Rate for Core Health Experience

Diabetes 458 8.5% 2.8%

Heart Failure 196 43.5% 9.1%

• Inpatient admissions


•Emergency department

49


Enrolled

EstimatedEmergency

Visits “Saved”

Cost Avoidance

Diabetes 458 248.1 $115,118

Heart Failure 196 206 $118,656


50


Enrolled

Hospitalization “Saved”

Cost Avoidance

Diabetes 458 158.6 $1,522,719

Heart Failure 196 272.4 $3,230,664

• Inpatient admissions

Fourth Step: Analysis

Cost savings for diabetes of $1.64M Cost savings for heart failure of $3.35 M Total estimated program savings $5MCore Health returned $2.53 in savings for every $1.00 of cost

Lessons learned

Time in the program

Patient selection Patient

engagement Efficiency and

effectiveness

Framework for the future

Creativity Innovation Collaboration Integration of care

Contact information

Pat Duthie, BSN, RN [email protected]

Questions ?

Upcoming RARE Events….

•RARE Webinar, Health Care Homes – Improving Care Transitions, Friday March 15, 2013,

12 noon -1p.m.

•RARE Rapid Action Learning Day, April 23, 2013, (8:30 a.m. – 3:30 p.m.)Mpls. Marriot Northwest, Brooklyn Park, MN

Future webinars…

•To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, [email protected]

Resource Contacts For Community Health Workers

DeAnn Rice, RN, PHNManager, Care CoordinationAmbulatory AdministrationHennepin County Medical CenterDirect: 612-873-2350Fax: [email protected]

Jean M. Gunderson, DNPCommunity Engagement CoordinatorPrimary Care Internal Medicine-ECH~BA 1BMayo ClinicPhone: 507.538.8458Pager:(53) 8- 8758Fax: 507.266.0036E-mail: [email protected]

Resource Contacts For Community Health Workers

Jason Turi, RN, MPHClinical Manager, Care ManagementCamden Coalition of Healthcare Providers808 Cooper Street, 7th FloorCamden, NJ 08102856.261.0699 mobile856.365.9510 ext. 2017856.365.9520 faxwww.camdenhealth.org/programs/care-management-program/"Jason Turi" <[email protected]>,

Heidi Blossom MSN RNCare Transition CoordinatorMHA…An Association of Montana Health Care Providers406 [email protected]

Sarah Redding, [email protected] Health Access ProjectMansfield, OHPathways Modelhttp://www.innovations.ahrq.gov/content.aspx?id=2953419-525-2555

Documents

Role of Community Health Workers in Preventing Avoidable Readmissions