Julie Ribardo, PhD
Director of Health Education & Prevention
February 2008

 BVCAA, Inc. is a private not for profit agency
 Serving the 7 counties of the Brazos Valley since 1972
 Providing health and social services to the underserved
 Mission Statement
 To assist in the empowerment of individuals, families and communities to reach their full potential economically, educationally, health-wise, culturally and socially

Brazos Valley Community Action Agency, Inc.
 Health Services
 Brazos Valley Community Health Centers (5 locations)
 Bryan-College Station CHC
 Grimes County CHC (Navasota)
 Robertson County CHC (Hearne)
 Madison County CHC (Madisonville)
 Leon County CHC (Centerville)
 College Station Community Health Center
 Women, Infant, and Children (WIC) nutrition program
 Family Planning Clinic in Washington County
 Community Services
 Elder Aid
 Head Start and Early Head Start
 Food Services – Senior Nutrition
 Energy and Housing Services
 Child Care Management Services

 Federally Qualified Health Center
 Over 3000 FQHCs nationwide
 Over 49 FQHCs in Texas
 All focus on medically underserved populations
 Rural and urban
 Migrant
 Homeless
 Affordable health care
 Sliding fee scale
 Benefiting those at 200% or below of the Federal Poverty
Income Limits
 Comprehensive package of services

 Mission Statement
 We strive to eliminate health disparities by offering quality primary and preventive health care to the medically underserved of the Brazos Valley
 Bryan-College Station Community Health Center became fully operational as an FQHC in
December 2002
 Expansion of satellite CHC’s
 Robertson County CHC in February 2004
 Grimes County CHC in July 2004
 Madison County CHC in August 2005
 Leon County CHC in December 2006
 College Station CHC in October 2007

 Services include
 Medical care (adults and pediatrics)
 Dental care
 Pharmacy
 Pfizer Sharing the Care program
 Client Services
 Registration and eligibility determination
 Medical Case management
 Medication Assistance Program (MAP)
 Health education
 HIV Prevention
 WIC nutrition program

 Co-located agencies provide comprehensive package of services
 TAMU Counseling and Assessment Clinic
 Prenatal Clinic
 Project Unity – Medical Case Management
 TDHS – Medicaid Screening and Enrollment
 Brazos Transit System

Adult Medicine
 4 Family Practice Physicians
 1 Family Nurse Practitioner
 1 Women’s Health Nurse
Practitioner
 2 Physician Assistants
 1 Dir. of Adult Health, RN
 1 RN

1 Dir. of Quality Management, RN
 2 LVNs
 14 nursing staff (CNAs/CMAs/MAs)
Dental Services
 2 Dentists
 4 Dental Assistants
 2 Dental Students
(periodically)
Pediatric Medicine
 Medical
Director/Pediatrician
 1 full-time Pediatrician
 1 part-time Pediatrician
 1 Pediatric Nurse
Practitioner
 1 Director of Pediatrics,
LVN
 2 LVNs
 4 nursing staff
(CNAs/CMAs/MAs)

 Over 16,918 unduplicated clients in 2007
 Over 40,000 encounters in 2006 (dental & medical)
 Gender
 66% Female
 34% Male
 Race/Ethnicity
 57% Hispanic
 19% African American
 20% White
 1% Asian/Pacific Islander
 1% Other
 Language
 40% identify English as primary language

 Poverty Level
 66% 100% and below
 29% 200 and below
 3% Over 200%
 2% Unknown
 Health Insurance Status
 61% of clients are uninsured
 31% of clients have Medicaid
 2% of clients have Medicare
 2% have CHIP (public insurance)
 3% have private insurance

 Mission
 We strive to provide quality health education services to clients of the Brazos Valley Community Health
Centers and individuals in the Brazos Valley in an effort to increase the practice of healthy behaviors
 Services
 Patient Education
 Community Education
 HIV Prevention
 Breast and Cervical Cancer case management
 Staff Development

 Staff
 Director of Health Education
 Full-time Staff
 Health Educator, Desiree Flores
 Health Educator, Carolina Diaz-Puentes
 HIV Prevention Specialist, Derek Gentry
 HIV Prevention Specialist, John Phelps
 BCCS, open
 Health education interns/students
 Volunteers
 Varies each semester

 Community Health Education Center (CHEC)
 Health Education resource center at the CHC
 Open Monday through Friday from 8:00 am – 5:00 pm
 Services available by walk-in or appointment
 Services include
 Public access computers for online health information
 Individual sessions with a health educator
 Brochures and health education written materials
 Education and information provided on any health topic

 Diabetes and heart disease self-management
 Individual educational sessions, coordinated visits, group sessions, and follow-up phone calls
 Health education services include: assessment of educational needs, collaborative goal setting with patients, problem solving, action planning and follow-up
 Diabetes and heart disease prevention
 Individual sessions for children and their caregivers
 Tobacco Use Cessation
 Individual sessions to assist in quitting tobacco
 Group series of 4 classes
 Family planning/reproductive health
 Group classes twice a week in each language

 Partnering with Texas Cooperative Extension on two community education programs
 Do Well, Be Well with diabetes (5 week program)
 Diabetes Cooking School (4 week program)
 Partnering with Area Agency on Aging to offer Stanford
Chronic Disease Self-Management Program
 Living Well Brazos County (6 week program)

 Promotores (Lay Health Advisor) Program
 Implementing first promotores program in the Brazos
Valley
 Trained 9 volunteers to date
 Training includes: logistics of being a promotora, safety, professionalism, confidentiality, resources in the community, facilitating access to affordable health and social services, evaluation and the health topic of their choice (nutrition and family planning)

Quarterly trainings and monthly meetings also provided to continue to increase skills and provide support to the volunteers
 Volunteers conduct health education within their community and facilitate access to affordable health and social services
 Volunteers began conducting outreach in their communities June 2005 on nutrition education

 Educational Outreach
 Programs on a variety of topics including
 Reproductive health, healthy relationships, communication skills, motivation for change, stress management, preventing diabetes and heart disease and much more!
 Information dissemination through health fairs
 Program advertisement through flyers at clinic, PSAs, press releases, and flyer distribution through network of local social and health service providers
 Tobacco use cessation program
 Teen pregnancy/STI prevention program
 Partnerships with community organizations
 Do Well, Be Well with Diabetes
 Cooking School

 HIV Prevention services
 HIV counseling, testing and referral (CTR)
 Free anonymous/confidential CTR is provided at the community health center, local health and social service agencies, correctional facilities, and
TAMU
 Community Education and Outreach
 Includes street outreach, condom distribution, and education/presentations on HIV prevention

 The Breast and Cervical Cancer Services program
(BCCS) offers clinical breast examinations, mammograms, pelvic examinations, and Pap tests throughout Texas at no or low-cost to eligible women

 Staff development
 Train 50-60 staff once per month on a variety of topics including
 Stress management
 Cultural competency
 Communication skills
 Work styles
 Diabetes and heart disease basics
 Health education staff provide training or coordinate guest speakers
 Provide additional training as needed
 Departmental trainings
 Agency wide trainings and health services wide trainings

 FQHCs are invited to participate in National Health
Disparities Collaboratives
 BPHC began Collaboratives in 1997 with focus on Diabetes
 Currently implementing Collaboratives on
 Diabetes
 Cardiovascular Disease
 Depression
 Cancer
 Asthma
 Redesign system to improve chronic illness care for patients with a specific condition
 Chronic Care Model
 Improvement Model
 Learning Model
 Refer to http://www.healthdisparities.net/ for more information

Know, apply, and monitor evidence based guidelines and standards of care
Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Act Plan
Study Do
Know and apply the Care Model
Conduct PDSAs

Community
Resources and
Policies
Self-
Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Act Plan
Study Do

 Questions to ask yourself
 What changes can we make that will improve our environment?
 What changes can we make to better serve our patients?
 What changes can we make to improve patients’ clinical measures?

 Diabetes Guidelines
 < 7.0% HbA1c
 > 90% of patients with 2 HbA1c in last year
 >70% of patients with self management goal
 > 75% of patients with ACE/ARB
 > 60% of patients on statin
 > 40% of patients with blood pressure < 130/80
 > 90% of patients with foot exam in last year

 Cardiovascular Disease Outcomes
 > 50% of hypertensive patients with blood pressure
<140/90
 > 90% of patients with 2 blood pressures in last year
 > 80% of patients with fasting lipid profile documented
 > 60% of patients with LDL cholesterol < 100 mg/dl
 > 70% of patients with documented self management goal
 > 90% of patients on aspirin or anti-thrombotic agent use

Benefits
 Better patient care
 Better disease management
 More patient participation
 Higher level of patient satisfaction
 Documented improvement of health status

 Provider buy-in
 Data entry
 Resistance to change
 Reinforcement of implemented changes

“
Barlow et al, Patient Educ Couns 2002;48:177

 Emphasize the patient’s active and central role in managing their illness
 Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
 Organize internal and community resources to provide ongoing self-management support to patients

 Information and skills are taught
 Skills to solve patient identified problems are taught
 Usually disease-specific  Skills are generalizable
 Assumes that knowledge creates behavior change
 Assumes that confidence yields better outcomes
 Goal is compliance
 Health care professionals are the teachers
 Goal is increased self-efficacy
 Teachers can be professionals or peers

ASSESS :
Beliefs, Behavior & Knowledge
ARRANGE :
Specify plan for follow-up (e.g., visits, phone calls, mailed reminders Personal Action Plan
1. List specific goals in behavioral terms
ADVISE :
Provide specific
Information about health risks and benefits of change
2. List barriers and strategies to address barriers
3. Specify Follow-up Plan
4. Share plan with practice team and patient’s social support
ASSIST :
Identify personal barriers, strategies, problem-solving techniques and social/environmental support
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
AGREE:
Collaboratively set goals based on patient’s interest and confidence in their ability to change the behavior

 Partnership with Center for the Study of Health
Disparities at TAMU
 Diabetes Prevention and Management Project funded by National Institutes of Health (NIH) for 3 years
 Staffed by Dir of Health Education and students from
HLKN

 Intervention is informed by evidence-based practices guidelines, and standards, specifically,
 National Health Disparities Collaboratives
 Including implementation of the Chronic Care Model and
Improvement Model
 <http://www.healthdisparities.net/>
 National Standards for Diabetes Self-Management
Education (2000)
 Developed by task force, including representatives AADE,
American Diabetes Association, American Dietetic Association,
Centers for Disease Control and Prevention
 American Association of Diabetes Educators
 A Core Curriculum for Diabetes Education, 5 th edition (2003)
 Chronic Disease Self-Management Education Program
 Developed by Lorig, K. et al at Stanford University

 Adult providers refer patients to health education
 Health education staff provide three specific services for patients with diabetes
 Individual diabetes self-management education
 Group self-management education and goal setting
 Coordinated visits
 Group nutrition education classes

 Self-Management Goal Sheet
 Patient selects one of 11 goals
 10 are preset goals, one is individual
 Personal Action Plan
 Specific plan
 Barriers to changing behavior
 Plans to overcome barriers
 Confidence in ability to change behavior
 Social support
 Health Education Notes Page
 Topics covered
 Materials distributed
 Concerns expressed by the patient
 Goal setting notes
 Follow-up plan

Please choose goals you are willing to work on to better manage your diabetes.
Goal 1:
I will work hard to keep my HbA1c below 7%. My last HbA1c was ________.
Goal 2:
I will exercise ______ minutes ______ days per week as recommended by my doctor. If I notice chest pain, leg pain or shortness of breath, I will call my doctor immediately. Type of exercise:____________________
Goal 3:
I will check my feet daily and never go barefoot. If I notice a sore that does not heal, I will call my doctor immediately. I will see my foot doctor for a comprehensive foot exam every year or as instructed.
My last appointment was ___________. My foot doctor is _____________.
Goal 4:
I will eat a healthy, low fat, diabetic diet to reduce my blood sugar and cholesterol.
I will see a registered dietician by _____________ (date).
Goal 5:
I will try to obtain my goal body weight of _______, which has been discussed with my doctor.
I will lose _____ pounds by _______________ (date).
Goal 6:
I will stop smoking by _______________ (date).
I will attend the smoking cessation classes at the Bryan-College Station
Community Health Clinic by _______________ (date) as recommended by my doctor.
Goal 7:
I will have an eye exam every year or as needed.
My last appointment was ____________. My eye doctor is ____________.
Yes
Goal 8:
I will have a dental exam twice a year or as needed.
My last dental appointment was ___________. My dentist is _____________.
Goal 9:
I will check my blood sugar as instructed and will call my doctor if the results are consistently below 70 or above 180.
Goal 10:
I will talk about how I feel about having diabetes with my family, friends and/or chaplain. I will attend a diabetes support group.
Goal 11:
Doctor
Clearance
Needed
Yes
Yes
Yes

Personal Action Plan
1. Goal: something the patient WANTS to do
2. Describe the specific plan
How Where
What Frequency
When
3. Barriers to changing behavior
4. Plans to overcome barriers
5. Confidence rating (1-9)
6. Social support
7. Follow-Up plan

 Health education staff call patients in 1-2 weeks
 Check on self-management goal(s)
 Answer questions
 Provide support
 Health education staff schedule follow-up appointments in 3-5 weeks
 Total number of visits is individualized
 Likely 3 visits

 85% met their goal
 Decrease in HbA1c

 Partnership
 Decision making
 Financial management of grant
 Sustainability
 Research and benefiting the community
 Students
 Holiday coverage
 Supervision and management

 Fresh Start Smoking Cessation Program
 American Cancer’ Society’s smoking cessation program
 Complete online facilitator training
 http://www.acsworkplacesolutions.com/index.asp
 Four one hour sessions
 Review of tobacco cessation programs
 http://www.thecommunityguide.org/tobacco/default.htm

 Safer Choices
 http://www.etr.org/recapp/programs/saferchoices.htm
 School-based program
 High risk youth from all racial and ethnic backgrounds
 Grades 9 through 12

 Safer Choices
 The curriculum is skill-based and interactive.
 Curriculum focuses on knowledge, social norms, attitudes, and skills to avoid sex or use condoms
 Includes practical activities to build skills in communication, delay the initiation of sex, and promote condom use by sexually active participants

 Safer Choices
 Effective in
 increasing condom use and use of other contraceptive methods
 decreasing the frequency of sex without condoms
 decreasing the number of sexual partners without condoms

 School/Community Program for Sexual
Risk Reduction Among Teens
 http://www.advocatesforyouth.org/programsthatwork/
8riskreduction.htm
 School-based intervention
 Overall goal of reducing unintended pregnancy
 K-12, multiethnic, and rural youth

 School/Community Program for Sexual
Risk Reduction Among Teens
 Instruction is designed to increase knowledge, decision-making skills, communication skills, self-esteem, and to align values with those of the community
 Effective in delaying
 initiation of sexual intercourse
 assisting males in increasing condom use
 reducing teen pregnancy rates

 Stanford Patient Education
 http://patienteducation.stanford.edu/
 Living Well ______ County
 6 weekly sessions for 2 ½ hours
 Skill based course
 Teaches skills needed in the day-to-day management and treatment of chronic disease and to maintain and/or increase life’s activities

 Protocol based counseling
 http://www.dshs.state.tx.us/hivstd/default.shtm
 Evidence based intervention
 Focuses on plan-based counseling
 Framework provided for risk reduction specialists

 Protocol based counseling
 Essential elements
 Introducing and orienting client to the session
 Enhancing client's self-perceived risk
 Exploring client's most recent risk
 Reviewing client's previous risk reduction experiences
 Summarizing patterns of risks and triggers (putting risk in context)
 Negotiating a realistic and acceptable risk reduction step
 Identifying sources of support and providing referrals
 Summarizing and closing the session
 Supporting test decision counseling (when appropriate)
 Providing results simply and supportively
 Providing partner elicitation (when appropriate)

 Tobacco Cessation as an example
 Determine needs of patients (target population)
 Research evidence-based programming
 Develop program objectives and plan
 Train providers on program
 Advertise program
 Implement program
 Evaluate program

 Focus groups
 Surveys
 Government websites
 Interview
 Community leaders
 Patients
 Program participants

 Funding
 Recruitment & retention
 Services are not billable
 Justifying existence
 Change (adaptation and resistance)
 Referrals from providers
 Patients recognizing value of health education

 Motivational interviewing
 http://www.pec.stedwards.edu/counselingSeri es/index.asp
 Introductory counseling course
 Cultural competency
 thinkculturalhealth.org
 Learn second language

 University/junior college
 Health department
 Local health educators
 Hospitals, health department, doctor’s offices

 Local organizations
 March of Dimes, American Heart Association, ACS
 Texas AgriLife Extension office
 Domestic Violence Shelter
 Juvenile Justice Program
 Adult Probation programs
 Faith based organizations (churches)

 Local organizations
 Alternative Education Program
 Drug treatment facilities (BVCASA)
 School districts
 Boys & girls clubs
 4-H clubs
 Homeless shelter
 Local employers

 Business of health education
 Vision & mission
 Strategic plan
 Goals & objectives
 Funding sources
 Quality assurance
 Managing employees (hiring, evaluating, disciplining)

 Staying current in field
 Conferences
 Serving as a resource
 Leading trainings
 Patient education materials
 Serving as the marketing department
 Change, politics, and administration

 Materials
 Translation
 Content
 Literacy level
 Rapport building with community

 It’s fun! 
 It’s hard work
 You will be under appreciated at times
 You can significantly impact the lives of people

 Public speaking
 Teaching and training
 Partnering and diplomacy
 Public relations, marketing and advertising
 Evaluating program goals and objectives
 Researching
 Grant writing
 Reporting
 Counseling and communication skills
 Organizing and program coordination
 Visioning
 Working with a team and independently
 Ability to analyze data
 Ability to assess needs
 Like people genuinely

 Assess Individual and Community Needs for
Health Education
 Plan Effective Health Education Programs
 Implement Health Education Programs
 Evaluating Effectiveness of Health Education
Programs
 Coordinating Provision of Health Education
Services
 Act as a Resource Person in Health Education

 Responsibilities include, but are not limited to:

Assist with the design, organization, implementation and evaluation of health education presentations, classes, programs, and campaigns
 Identify, order and organize educational materials for the clinic
 Staff health fairs as needed
 Assist with staff development and training of volunteers
 Assist in completing various obligations and objectives of current grants

Attend bi-monthly meetings and trainings
 Assist with other activities/projects as needed
 Required:
 Bachelor’s degree in community health, health education, or related discipline
 Working knowledge of health education principles and techniques, including use of behavior change theories
 Desire to work with medically underserved population
 Excellent written and verbal communication skills, strong organizational skills, and keen attention to detail
 Preferred:
 Fully bilingual (English/Spanish)
 1-2 years of experience in health education or public health