HEALTH CARE HOME SPOTLIGHT:
EARLY LESSONS AND RESULTS FROM CHW
INTEGRATION PROMOTING PATIENT CENTERED
CARE AND COMMUNITY HEALTH
Tara M. Nelson
Intercultural Mutual Assistance Association
Community Health Worker
Jean M. Gunderson
Mayo Clinic Employee Community Health
Community Engagement Coordinator
Minnesota Community Health Worker
Alliance Statewide Meeting
June 5, 2014
OBJECTIVES
Illustrate the impact of CHW home visits on the
understanding of the patient experience through
descriptions of goal setting, self-management,
and acts of resiliency
 Review the collaborative infrastructure and
funding aligning CHW capacities promoting
community health
 Describe the building of teams integrating CHWs
in a certified Health Care Home
 Examine the community based co-supervisory
CHW model integrating patient centered team
based care
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PATIENT STORY …
CHALLENGE AS OPPORTUNITY
1990’s influx of immigrant and refugee
populations
 Public program and funding transitions
 Unmet and uncoordinated patient/consumer
needs across a continuum of care
 Recognition of the social determinants of health
and community oriented primary care
 Navigation, communication and engagement

History
LOCAL COLLABORATIVE RESPONSE
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The Multicultural Health Care Alliance (1997)
The Olmsted County Health Care Access Taskforce in
2005 (access; context)
The Olmsted County Community Health Care Access
Collaborative in 2007 (community priorities;
workgroups)
The Coalition of Community Health Integration in
2012 (formalization of systems, policy and funding)
The United Way of Olmsted County (alignment of
early intervention: behavioral health, oral health,
medical home)
History
LOCAL CHW WORKFORCE DEVELOPMENT
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Standardized, competency-based CHW curriculum
offered at Rochester Technical & Community College
(2006 and 2012)
CHW Workgroup (2008); small study (2009)
90 hour CHW internships at lead partner sites (2006
and 2012)
MN CHW Employer Forum in Rochester (2009)
CHW Employer Consortium (2011)
Community Based Co-Supervisory CHW Pilot (2013)
History
CHW CURRICULUM
Standardized, competency based 11 credit
curriculum (2003-2005)
 Revised to 14 credits (2010)
 Core competencies (9 credit hours)
 Health promotion competencies (3 credit hours)
 Internship (2 credit hours)
 CHW certificate upon graduation
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Curriculum
COMPETENCIES
CHW Role, Advocacy and Outreach, Organization
and Resources, Teaching and Capacity Building,
Legal and Ethical Responsibilities, Coordination
and Documentation, Communication and
Cultural Competency
 Healthy Lifestyles, Heart Disease and Stroke,
Maternal and Child/Teen Health, Diabetes,
Cancer, Oral Health, and Mental Health
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Curriculum
FUNDING
The United Way of Olmsted County
 The Mayo Clinic Office of Population Health
Management
 Potential: Team based care in the Accountable
Care Organization Model
 Potential: Care Coordination/HCH
 Testing: Minnesota Health Care Program
(MHCP) Medicaid fee-for-service option
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Funding
CHW PILOT:
CO-CREATING TRANSDISCIPLINARY TEAM BASED CARE
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Internship and Pilot aligned and co-created with lead Care
Coordinators and leaders in Mayo Clinic Employee and
Community Health (ECH) Health Care Home
Specific service areas: Primary Care Internal Medicine
(PCIM), Integrated Behavioral Health (IBH) and
Community Pediatric & Adolescent Medicine (CPAM)
Referral Criteria: complex care needs, eligible for or
enrolled in care coordination (recognizing health
determinants)
Expanded programming: DIAMOND, EMERALD,
COMPASS, and EPSDT (C&TC) complex care needs
utilizing two lead Care Team RNs
Infrastructure
CHW ROLE
Navigator
 Advocate
 Liaison
 Knowledge- Bearer: community relationships,
local lived experiences, cultural, linguistic and
language needs
 Connector to community resources
 Educator: reinforcement and support
 Walker of the Margins
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Role
CHW STORY…
QUALITY DIMENSIONS:
ASSET BASED AND HOLISTIC TEAM BASED CARE
Community based co-supervisory CHW model
 Order by Proxy options (Primary Care
orientation)
 Team huddles, patient conferences and consults
 Telephonic support
 Patient home visits and at other community
based sites
 Non Visit Care coordination supports
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QUALITY DIMENSIONS:
ASSET BASED AND HOLISTIC TEAM BASED CARE
Social Determinants data identified in
partnership and reported utilizing patient
language
 Patient centered visit schedule (service,
frequency & number)
 Referral, patient goals, and self-management
skills tracking
 Transdisciplinary teaming (relational practice)
 Secondary partner sites reporting every 3 months
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CHW PILOT
CURRENT
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STATUS
Total patients served: 181
Total Visits: 452 (since July 1, 2013)
Active patients: 103; Average CHW caseloads: 50
patients
Average number of visits per patient: 2.5
CHWs working with ECH teams: 2-3 FTE
Care Coordinators in the Pilot: 24
Lead Care Team RNs: 2 (EPSDT)
Weekly reporting 5-19-2014
WHO ARE WE SERVING?
Age Group
Gender
1
1
17
39
0--9
5
5
10--14
15-17
Male
18-64
NR
65+
56
Female
39
NR
83
WHO ARE WE SERVING ?
WORKING ACROSS CULTURES, LANGUAGE AND
LITERACY
Languages
11 1 1
English
14
Somali
7
Spanish
Laotian
Khmer
99
Arabic
ASL
WHO ARE WE SERVING ?
Insurance Type
17
Goverment
59
47
Commercial
Not
documented
* Documentation and tracking are challenging due to insurance enrollment status,
patient and internal reporting, and when multiple payers per patient exist
WHO ARE WE SERVING?
Primary Diagnosis
Depression
33
45
COPD
Diabetes
Asthma
4
4
Hypertension
13
6
20
CHF
Other
• Often multiple comorbid conditions exist
WHO ARE WE SERVING ?
Social Determinates Score
26
30
Tier One (18-24)
Tier Two (25-29)
Tier Three (30+)
NR
24
35
Multiple reasons for (NR) not reporting including,
patient refusal of assessment, limited visits
number and attention to urgent needs
Minnesota Department of Human Services and the Hennepin County Ryan White Program
HIV/AIDS Medical Case Management Standards (Appendix C, HIV/Aids Acuity Assessment,
pages 24-26)
WHAT ARE WE DOING?
TOP DIRECT CARE THEMES-PATIENT
DIRECTED GOALS
Daily Living
 Healthy Living
 Independence
 Care of Chronic Conditions
 Social Support
 Public Programs
 Safety
 Spiritual Needs
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NON VISIT CARE THEMES: AREAS OF
IMPACT
Basic Human Needs
 Patient Engagement/Communication
 Insurance/Coverage of Services
 Referrals to Direct Health-Related Services
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SELF-MANAGEMENT THEMES
o
Budgeting: figure out expenses, find bills, set-up a
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Social Activity: get outside more, call churches,
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Goal setting and Planning: use a journal, calendar,
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Advocating for Self: communicate with teams, home
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Gaining Independence: organize paper work, find a
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Managing health: check BP, journal, relaxation
financial consult, track bank account
volunteer, get involved in an activity, obtain a computer, find
a buddy system for the Laundromat
or a list
care agencies, and PCAs, being assertive and setting rules
home, schedule transportation, go to work regularly,
understand care plan
breathing
LEAD PATIENT EDUCATION TOOLS
 PHQ-9
 Asthma
Control Test
 Asthma Control Assessment
 Asthma Action Plan
 Peds Quality of Life Form
 Goal Setting
 Goal Map
 Journaling
 Log books (BP, Diabetes, Activity)
CARE COORDINATOR STORY…
SATISFACTION AND ASSURANCE DATA
Patients , Care Coordinators and CHW
satisfaction data collected using surveys (mail
and on-line, interview option with CHW team)
 Integration of human stories/cultural narratives
 Review of lead reporting tool: CHW Visit Form
 Monthly case consultation with CHWs & ECH
teams
 Bi-monthly co-supervisory meetings at IMAA site
 MN CHW Alliance & MN CHW Alliance
Supervisor Roundtable
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PATIENT EXPERIENCE
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Cultural narrative
LESSONS LEARNED:
THE ART FORM OF HOLISTIC CARE WITHIN
RELATIONSHIP
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A fillable PDF CHW Reporting Form would create
improved outputs in reporting and in-direct time.
Home visits are critical in understanding
patient/family experiences, assets, needs, and health
determinants
Use of one’s language, literacy, and culture remain
significant factors within care, healing, and health
outcomes
Mixed methods analysis is important when reviewing
and reporting patient data
Community based CHW services are essential in the
integration of community contexts within team based
care.
REFLECTION ON THE “A-HA” MOMENTS
Market community based non-profits
 Integrate collaborative funding
 Recognize the impact of team champions
 Living the mantra: systems, tools, teams,
processes (process outputs/the collective flow)
 Model how specialized training impacts
observation, interviewing, documentation,
reporting and referral (the transdiciplinary
practice lens)
 Align resources to envision and deliver
 Recognize transformation as both challenge and
opportunity
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NEXT STEPS
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Continue to develop CHW billing processes,
integrating both fee-for-service and shared revenue
cost saving options
Maintain the evaluation of CHW programming
addressing complex care needs and the social
determinants of health
Expand the CHW reporting and referral pathways to
include additional Care Team RN leads and Social
Workers.
Build the SE MN CHW Regional Pipeline with
collaborative partners and expand local CHW
programming
Maintain CHW specialized training and crosstraining across the care continuum
QUESTIONS
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Thank you!
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Tara.nelson@imaa.net
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Gunderson.jean@mayo.edu
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507-289-5960, ext.102
507-538-8458
QuirindongoCedeno.Onelis@mayo.edu