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, BSN
February 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, 2013
Joan Cleary, Executive Director - Interim
Minnesota 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/
Education
Objective:
Improve access to
coverage and care
Workforce
Development
Objective:
Foster policies that promote
healthy people and healthy
communities
MN CHW
Alliance
Help achieve the Triple
Aim, address health
disparities, expand &
diversify the health care
workforce and foster
healthier communities
through CHW strategies
Policy
Objective:
Advance CHW
knowledge & skillset
and interprofessional
education to better
serve Minnesota
communities
Research
Objective:
Raise awareness of
CHW impacts through
research & evaluation
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 Blocks
Recently recognized by the Agency for Healthcare Research & Quality
http://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 followup 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 postsecondary 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 Network
Co-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 development
http://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
Hospitals
Clinics
Indian Health Services Facilities
Critical Access Hospitals
Mental Health Professionals
Dentists
Physicians
Family Planning Agencies
Public Health Clinic Nurses
Tribal Health Facilities
To learn more about MN CHW
coverage policy, contact:
Susan.Kurysh@state.mn.us
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
•
2+ chronic illnesses
•
Behavioral health issues
•
Disability
•
History of repeat ED visits and/or
admissions
Generational poverty/ACEs
•
Lack of trust and “low activation”
•
Urban or domestic violence/war
trauma
•
No transportation
•
Lives alone or caregiver issues
•
Language differences
•
Cultural barriers
•
Low SES
•
Low literacy; lack of HS diploma
•
New to locale/socially isolated
•
Unstable housing /homeless
•
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
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•
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•
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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-Interim
Minnesota Community Health Worker Alliance
612-250-0902
joanlcleary@gmail.com
Thank you!
Optimizing Your Investment in
Community Health
Pat Duthie, RN, BSN
February 26, 2013
Spectrum Health System
 Health system
 Hospitals
 Medical
group
 Health 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
visits
 Decreased hospitalizations
 Decreased premature births
 Decreased absenteeism rates in
schools
Second Step: What do you know?
 Where can you find data?
 Information systems
 ED visits & hospital admissions
 Self reported versus claims data
Third Step: Can you compare?
 Before and after
 Is this program is successful?
 Pre-program vs. program enrollment
 Compare 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 visits
 Decreased hospitalizations
Second Step: What do you know?
Emergency
department visits
# of
patients
Hospital cost
Hospital cost
(per patient)
Diabetes only
Heart failure w/wo
diabetes
482
$223,486
$464
107
$61,606
$576
545
$5,232,316
$9,601
1114
$13,212,146
$11,860
Hospital admissions
Diabetes only
Heart failure w/wo
diabetes
Third Step: Can you compare?
•Emergency department visits
Core Health
Participants
Enrolled
Usage Rate Usage Rate for
Before Core Core Health
Health
Experience
Diabetes
458
16.4%
7.4%
Heart Failure
196
35.9%
11.4%
47
Third Step: Can you compare?
• Inpatient admissions
Core Health
Participants
Enrolled
Usage Rate Usage Rate for
Before Core
Core Health
Health
Experience
Diabetes
458
8.5%
2.8%
Heart Failure
196
43.5%
9.1%
48
Third Step: Can you compare?
•Emergency department
Core Health
Participants
Enrolled
Estimated
Emergency
Visits “Saved”
Cost
Avoidance
Diabetes
458
248.1
$115,118
Heart Failure
196
206
$118,656
49
Third Step: Can you compare?
• Inpatient admissions
Core Health
Participants
Enrolled
Hospitalization
“Saved”
Cost
Avoidance
Diabetes
458
158.6
$1,522,719
Heart Failure
196
272.4
$3,230,664
50
Fourth Step: Analysis
 Cost savings for diabetes of $1.64M
 Cost savings for heart failure of $3.35 M
 Total estimated program savings $5M
 Core 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
 Pat.duthie@spectrumhealth.org
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, kcummings@icsi.org
Resource Contacts For Community
Health Workers
DeAnn Rice, RN, PHN
Manager, Care Coordination
Ambulatory Administration
Hennepin County Medical Center
Direct: 612-873-2350
Fax: 612-904-4484
deann.rice@hcmed.org
Jean M. Gunderson, DNP
Community Engagement Coordinator
Primary Care Internal Medicine-ECH~BA
1B
Mayo Clinic
Phone: 507.538.8458
Pager:(53) 8- 8758
Fax: 507.266.0036
E-mail: gunderson.jean@mayo.edu
Resource Contacts For Community
Health Workers
Jason Turi, RN, MPH
Clinical Manager, Care Management
Camden Coalition of Healthcare
Providers
808 Cooper Street, 7th Floor
Camden, NJ 08102
856.261.0699 mobile
856.365.9510 ext. 2017
856.365.9520 fax
www.camdenhealth.org/programs/caremanagement-program/
"Jason Turi"
<jason@camdenhealth.org>,
Heidi Blossom MSN RN
Care Transition Coordinator
MHA…An Association of Montana
Health Care Providers
406 457-8025
heidi@mtha.org
Sarah Redding, MD
sarah.redding@me.com
Community Health Access Project
Mansfield, OH
Pathways Model
http://www.innovations.ahrq.gov/conte
nt.aspx?id=2953
419-525-2555