Community-based care for Chronic Disease Management in Navajo Nation Sonya Shin, MD MPH Gallup Indian Medical Center Brigham and Women’s Hospital Partners In Health Harvard University No disclosures Health in the Four Corners Region: How are we doing? Health Outcomes Disease Prevalence Cost of Care Patient Experience If things aren’t working, why not? Geographic isolation Workforce shortages, esp with professionals Cultural gap (provider patient) Poverty, unemployment, basic services Biomedical health model Biomedical health model: Limitations Community Health Workers: Addressing the barriers to quality care Geographic isolation Workforce shortages, esp with professionals Cultural gap (provider patient) Poverty, unemployment, basic services Community based-approach: Addressing Biosocial Determinants Growing role of CHWs in health care “CHWs should be integrated into as an approach to eliminating ,” including a focus on hypertension [Institute of Medicine] “CHWs can , particularly when caring for underserved populations where are essential.” [Agency for Healthcare Research and Quality] National Academy of Sciences 2010; Smedley et al 2003; AHRQ 2009 290-2007-10056; CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009 Growing role of CHWs in health care “Addressing health disparities should include community health workers targeting minority populations” including cardiovascular diseases. [National Institutes of Health] “CHWs should be integrally included in diabetes management.” [CDC] “CHRs play an important role in promoting health in underserved populations.” [Obama’s Affordable Health Care for America Act] National Academy of Sciences 2010; Smedley et al 2003; AHRQ 2009 290-2007-10056; CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009 Community Outreach and Patient Empowerment (COPE) Community Support Navajo CHRs with training, professional development, materials Outreach Home-based care and services Health education Counseling & health promotion Social support Patient Uncontrolled chronic diseases (DM, etc) Empowerment Coach patients and families in disease self-management and prevention TRAINING Health Education Health Promotion LINKAGE WITH CARE TEAM COMMUNITY CHR TOOLS Equipment Teaching aides High risk clients At risk community Patient Teaching Materials • Flipcharts based on CHR request • Culturally appropriate visual images • Motivational interviewing techniques Other resources • Finger stick certification and supplies • Laptops, oximeters, etc TOOLS Equipment Teaching aides IPC (Improving Patient Care) Innovations: • Provider referrals to COPE • Coordinate COPE with related programs (pharmacy DM clinic, DM education, etc) • Joint home visits (provider/CHR) • Strengthen PHN-CHR collaboration • Case management rounds • Facilitate CHR access to Electronic Health Record (EHR) LINKAGE WITH CARE TEAM TRAINING Health Education Health Promotion Training for CHRs • Standardized curriculum • IHS Navajo-speaking trainers • Health promotion skills (Motivational Interviewing, goal setting) • Train the Trainer model • Competency assessment • CHR Supervisor training Preliminary Outcomes (5/12) HIV: How well are we doing? HIV: Dissecting the health care delivery chain Diagnosis Reduced transmission Treatment Behavior change Favorable outcomes Where are we struggling as providers? Diagnosis Reduced transmission Treatment Behavior change Favorable outcomes Pop quiz! Among people diagnosed with HIV in the U.S. since 2008: What % established care in the first year? a. b. c. What % were retained in care? a. b. c. 45% 64% 88% 45% 64% 88% What % achieved virologic suppression? a. b. c. 53% 67% 77% Follow-up study of 100,375 people diagnosed with HIV through 2008, U.S. Established care within a year of dx (n=5137): 64% Retention in care (n=100,375): 45% Virologic suppression: Hall et al, JAIDS 2012 77% (last viral load) 53% (all viral loads) Pop quiz! Among people diagnosed with HIV in Navajo Area IHS, how do we compare to national figures? Establishing care in the first year? a. b. c. Retention in care? a. b. c. Above average Average Below average Above average Average Below average Virologic suppression? a. b. c. Above average Average Below average NAIHS Annual HIV Report, 2011 Established care within first year of diagnosis (n=39): 71% Retention in care, among those living (n=303): - Regular follow-up/seen elsewhere - Intermittent follow-up (<50% appointments) - No follow-up Virologic suppression: NAIHS Annual Report, 2011 55% 14% 31% 55% Can we do better? • At the national level: • > one third do NOT establish care within a year of HIV dx • > one half do NOT receive regular HIV care • Almost half are not virologically suppressed Partners In Health (PIH) Accompagnateur model Accompagnateurs: The “Backbone” of PIH • • • • • • • Community health workers Since 1985 Paid health workers Responsible for referrals, vaccines, hygiene, maternal and infant health Initial training plus ongoing training The “missing infrastructure” in many resource poor settings 100% directly-observed therapy (DOT) coverage for TB and HIV patients EXPANSION TO OTHER RESOURCE-POOR SETTINGS 1041 people initiating ART 2005-2006, PIH-MOH HIV Program in Rwanda Established care within a year of dx: not reported Retention in care among those living (n=989):97% Virologic suppression (n=275): Rich et al, JAIDS 2012 98% So, what’s the magic ingredient? CHW accompaniment Directly observed therapy (?) Psychosocial support Adherence coaching Screen for side effects Liaison with providers Additional supports Nutrition Transportation costs Patient support groups Team-based care BUILDING AN ACCOMPANIMENT PROGRAM Step 1: Create an outreach team Identify the outreach worker IHS, tribe, NGO, etc Level of training Cultural, organizational, geographic constraints Create care coordination SYSTEM Linkage is CRUCIAL Case management Documentation Supervision Step 2: Define the home-based intervention Establish the role of the outreach worker Deliver medications? Adherence coaching? Counseling? Directly observed therapy? Modified? Case management? Referrals? Always: Social support Communicator Patient advocate Step 3: Equip the outreach worker with the necessary resources Training HIV content Counseling skills, motivational interviewing Materials Teaching / coaching materials Four-wheel drive? Support Access to care team Clinical “back-up” for challenging cases Support for their own wellbeing (burn-out, safety, trauma) Step 4: Match the intervention to your population All patients? High-risk only? (Clinical criteria? Psychosocial?) Tiered interventions depending on needs? HOPE in Navajo: HIV Outreach & Patient Empowerment Hiring Health technician, GIMC Case manager, NAN Training Adherence Counseling Motivational interviewing Harm Reduction Wellness & self-care o Materials o Patient flipcharts o Pill boxes and keychains o Transportation and food vouchers o Target population o New diagnoses o Not getting care o Not virologically suppressed o Team-based care o Case management rounds o Documentation o Multidisciplinary team HOPE in Navajo Flipcharts: HIV basics HIV and nutrition HIV: Know my meds Taking my meds Harm reduction Health maintenance Exercise Coping with stress Caring for the caregiver HIV and substance use HIV and mental health Hepatitis C Tuberculosis Other sexually transmitted infections Communicating with my provider Step 5: Get started! ACKNOWLEDGEMENTS GIMC Bennie Yazzie, Paula Mora, Carla Baha-Alchesay Bruce Forman, Maricruz Merino, Jon Iralu, Bill Monroe, Watson Billie Navajo AIDS Network Brigham & Women’s Hospital / Partners In Health Chip Thomas (B&W photo) RX Foundation Contact information: sonya.shin@ihs.gov