COMMUNITY HEALTH
WORKER:
HEALTH SERVICES & CARE
Earl Nupsius Benjamin, MHA
Introduction
Public Health
Disaster
Management
Community
Organizing/
Planning
Mental Health
Health System
Case
Management
Barriers to
Use/Access to
Health Care
Cultural
Competency
Health
Interventions:
The Health
Belief Model
Desired Outcomes
 Understand
the role of community health centers
 Be able to better understand health service
coordination
 Begin to understand the tools of community asset
mapping
 Identify community health resources and existing
health services
PRIMARY CARE
What is Primary Care?

1961: Institute of Medicine
Primary care is the activity of a health
care provider who acts as an entry
point into the health care system for all
patients.
Primary care is comprehensive,
collaborative, coordinated, continuous
and inclusive.
Challenges in Primary Care

Delivering all evidence-based guidelines for preventive and chronic disease care
has been estimated to take 18 hours a day for an average sized patient panel.
(Yarnall et al 2009; Alexander et al 2005)

Most physicians only deliver 55% of recommended care, 42% report not having
enough time with their patients.
(Center for Studying Health System Change 2008; Bodenheimer & Laing 2007)

Providers are spending 13% of their day in care coordination and only using their
medical knowledge 50% of the time.
(Gottschalk 2005; Margolis & Bodenheimer 2010)

Patient care is fragmented and patients are dissatisfied with the level of attention
they receive in primary care.
(Bodenheimer 2008)

More not less primary care is needed especially with more people becoming
insured under the Affordable Care Act (ACA)
The Primary Care Crisis



National shortage of Primary Care Providers
In 1998, half of internal medicine residents chose
primary care; currently, about 80 percent become
subspecialists or hospitalists
This is occurring at a time when more, not fewer
primary care providers (PCPs) are needed
Current State of Primary Care






Rushed practitioners who keep being asked to take
on more responsibility
Patients receiving inconsistent care
Lack of care coordination
Lack of active follow-up to ensure the best outcomes
Patients inadequately trained to manage their
condition
More patients obtaining access to primary care
under ACA
What’s Wrong with Primary Care?

Not enough time for providers to perform tasks

Too much to remember

Too many tasks not reimbursed

Too many non-provider tasks

Poor health outcomes

Providers and patients are left dissatisfied…
What can be done?

Redesign how Primary Care is delivered
 The Patient Centered Medical Home
 Enhancing knowledge and skills of all team
members
 Having the right mix of team members
 Highly organized and appropriately
standardized office workflows and processes
 Providing ongoing training support
 Using technology
 Engaging patients and families
10
HEALTH CENTERS
Do you know what community health
centers are?
No.
2. Yes.
3. I think I do.
1.
0%
1
0%
2
0%
3
Have you ever used a community
health center’s services?
No.
2. Yes.
3. I think I have.
1.
0%
1
0%
2
0%
3
Do you have a community health
center[s] in your community?
No.
2. Yes.
3. I think I do.
1.
0%
1
0%
2
0%
3
What is a Health Center?
Health centers are community-based and patientdirected organizations that serve populations with
limited access to health care.
Types of Health Centers



Grant-Supported Federally Qualified Health Centers (FQHC)
are public and private non-profit health care organizations
that meet certain criteria under the Medicare and Medicaid
Programs
Non-grant-supported Health Centers are health centers that
have been identified by HRSA and certified by the Centers for
Medicare and Medicaid Services as meeting the definition of
“health center”. They do not receive grant funding under
Section 330. They are referred to as "look-alikes."
Outpatient health programs/facilities operated by tribal
organizations (under the Indian Self-Determination Act, P.L.
96-638) or urban Indian organizations (under the Indian
Health Care Improvement Act, P.L. 94-437).
Health Center Program Fundamentals





Located in or serve a high need community (designated
Medically Underserved Area or Population).
Governed by a community board composed of a majority
(51% or more) of health center patients who represent the
population served.
Provide comprehensive primary health care services as well
as supportive services (education, translation and
transportation, etc.) that promote access to health care.
Provide services available to all with fees adjusted based on
ability to pay.
Meet other performance and accountability requirements
regarding administrative, clinical, and financial operations.
Community Health Centers:
Their Role & Reach


In 2009, they served over 20 million patients at
over 8,000 sites, including 941,000
migrant/seasonal farm worker patients and 1
million homeless patients.
Their patients typically are without access to
other health care settings: low-income people,
the uninsured, those with limited English
proficiency, migrant and seasonal farm workers,
individuals and families experiencing
homelessness, and those living in public housing.
…Their Role & Reach - Continued


Today, approximately 1,200 health centers operate
nearly 9,000 service delivery sites that provide
care to over 20 million patients
This network of health centers has created one of
the largest safety net systems of primary and
preventive care in the country with a true national
impact.
The Affordable Care Act: The Essential
Role of Community Health Centers
The Affordable Care Act established the Community
Health Center Fund that provides $11 billion over 5 a
year period for the operation, expansion, and
construction of health centers throughout the Nation.
 $9.5 billion is targeted to: support ongoing health
center operations, create new health center sites
and expand preventive and primary health care
services.
 Health centers will focus more on coordinating
primary and preventive services or a “medical
home”.
Community Health Resources (Activity)
PATIENT-CENTERED MEDICAL
HOME & COMMUNITYCENTERED HEALTH HOME
Coordinated Care
Patient-Center Medical Home (PCMH)
 Community-Centered Health Home
(CCHH)

Along Comes Patient Centered
Medical Home…



A model of care where each patient has an
ongoing relationship with a personal
physician/provider who leads a team that takes
collective responsibility for all aspects of the
patient’s care
Examples of best practices from successful physician
office practices combined with theory and vision of
how care ought to be delivered
Reinforces the importance of all team members
24
Core Concepts for the Patient
Centered Medical Home
• Each patient assigned a
personal physician/physician
extender
• Whole person orientation
• Coordinated , integrated
across settings
• Quality and safety emphasis
• Enhanced access to care
• Utilizing performance
measures; how well they are
fairing with quality measures
Team-based care:
MD/NP/PA
Medical Assistant/RN
Office Staff
Care Coordinator
Nutritionist/Educator
Pharmacist
Behavioral Health
Case Manager
Social Worker
Community resources
CHWs (and others)
25
Along Comes Patient Centered
YOUMedical Home…


Other Care

A model of care where each patient has an ongoing
relationship with a personal physician/provider who
leads a team that takes collective responsibility for all
aspects of the patient’s care
Examples of best practices from successful physician
office practices combined
theory and vision of how
YOU with
(CHW)
care ought to be delivered
Reinforces the importance of all team members and
supports the value of medical assistants (YAY!)
YOU
26
Value of PCMH
•
Demonstration Projects
– Reduced hospitalization rates 6-19%
– Reduced ER visits 0-29%
– Increased savings per patient $71-$640
Source: Fields, et al. 2010
•
Other Benefits
– Less staff burnout (10% in PCMH practices compared to 30% in
controls)
– Reduced cost of care (29% fewer ER visits, 6% fewer hospitalizations,
estimated saving of $10.30/patient/month
– Improved patient experience
– Improved patient outcomes
Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE,
Erikson M, Larson EB. The Group Health Medical Home At Year Two: Cost Savings,
Higher Patient Satisfaction, And Less Burnout For Provider. Health Affairs 29:5 (2010): 835-843
27
PCMH Essential Skills
Essential Skills enable people to perform tasks
required by their jobs as well as
adapt to change
Patient Centered/Whole person care
Practice-based learning
Communication & Professionalism
Teamwork
Chronic disease management
Practice & Population Management
Coordination & Transitions of Care
Integration of Care
Quality, Performance, & Practice
Improvement
Information Technology
Behavioral Health
28
What is distinctive about CHWs?
Community Health Workers:






Do not provide clinical care
Generally do not hold another professional license
Have expertise based on shared culture and life
experience with population served
Rely on relationships and trust more than on clinical
expertise
Relate to community members as peers rather than
purely as client
Can achieve certain results that other professionals
can't (or won't)
Community Health Workers - Continued

CHWs have shown promise in addressing many highpriority concerns in public health and health care for the
underserved. They have proven impact in important
areas such as:
Access to care
 Prenatal/perinatal care
 Chronic disease management
 Long term care (in support of home- and community-based
care)
 Utilization of services, especially reducing inappropriate use
of the ER

CHW roles in the PCMH

In partnership with medical professionals, a CHW can
serve as the team member with expertise in cultural
factors and social determinants.
Facilitate patient-provider communication
 Spend more time with patient and family, including home
visits
 Facilitate more complete patient-provider communication
(candor), potentially making diagnosis and treatment more
efficient and effective
 Communicate more frequently and continuously with patients
 Reduce numbers of patients “lost to follow-up”
 Improve care transitions and help reduce hospital
readmissions

Why Health Centers should care about
CHWs
Effective PCMHs will have to maintain a
higher level of patient-provider
communication in terms of
openness/candor and also continuity.
 CHWs are key to this happening.

Community-Centered Health Homes


The community-centered health home provides high
quality health care services while also applying
diagnostic and critical thinking skills to the
underlying factors that shape patterns of injury and
illness.
By strategically engaging in efforts to improve
community environments, CCHHs seek to improve the
health and safety of their patient population,
improve health equity, and reduce the need for
medical treatment.
Community-Centered Health Homes –
Continued
The Importance of Community
Prevention


Community prevention is integral to effective health
reform. It reduces the burden placed on the health
system by reducing rates of preventable injury and
illness and better aligning resources to address the
factors that shape health and safety outcomes.
Prevention can substantially diminish health
inequities by focusing attention on unhealthy policies
and inequitable resource distribution and improving
community environments.
Inquiry
Assessment
Action
Elements of the CCHH: Possible Roles
for the CHW
Inquiry elements – Collect data on social,
economic, and community conditions
 Analysis elements - Identify priorities and
strategies with community partners
 Action elements – 1.) Coordinate activity with
community partners 2.) Advocate for
community health 3.) Mobilize patient
populations

A HEALTH CARE FACILITY IN YOUR COMMUNITY SAW THAT MANY
OF ITS PATIENTS WERE DIABETIC. THE FACILITY IS NOW INVOLVED IN
COMMUNITY PLANNING PROCESSES THAT ARE FOCUSED ON
REDUCING THE NUMBER OF PEOPLE SUFFERING FROM DIABETES
AND OTHER CHRONIC ILLNESSES. IS THIS SCENARIO AN EXAMPLE
OF A COMMUNITY-CENTERED HEALTH HOME?
1.
2.
3.
No.
Yes.
I do not know
0%
1
0%
2
0%
3
YOU
COMMUNITY ASSET
MAPPING
Community Asset Mapping
Asset mapping is an inventory of the businesses,
organizations, and institutions that help create a
community.


A community asset is a quality, person, or thing that is an
advantage, a resource, or an item of value to an organization or
community.
There are three levels of assets:



Level 1 – Gifts, skills, and capacities of the individuals living in the
community.
Level 2 – Citizens’ organizations/networks through which local people pursue
common goals.
Level 3 – Institutions present in the community, such as local government,
hospitals, education, and human service agencies.
Community Asset Mapping – Continued
Community Asset Chart
Individual
Skills
Talents
Experiences
Professional
Personal
Resources
Leadership
Networks
Institutional
Churches
Colleges and universities
Elderly care facilities
Police/Fire department
Hospitals and clinics
Mental health facilities
Libraries
Schools
Transportation
Governmental
State/City/Local government
Federal government agencies
Bureau of Land Management
Economic development
Military facilities
Small Business Administration
State education agency
Telecommunications
Organizational
Small and large businesses
Citizen groups/Clubs
Community centers
Home-based enterprises
Radio/TV stations
Nonprofit organizations
Physical/Land
Utility companies
Parks and recreational
facilities
Real estate agencies
Waste management facilities
Chamber of Commerce
Culture
Historic/Arts council groups
Council for cultural affairs
Tourism
City council
Museums
Community Asset Mapping – Continued





The Asset Mapping Process
Phase One: Determining healthcare consumers’
needs and current resources
Phase Two: Searching the healthcare consumers’
community
Phase Three: Identifying potential resources
Phase Four: Verifying asset mapping results
Phase Five: Share asset mapping results with the
community
Community Asset Mapping (Activity)
Reflection
Summary