michigan pathways to better health
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MICHIGAN PATHWAYS TO BETTER HEALTH
MACMHB May 21, 2014
PRESENTERS
Barb Glassheim – Project Manager, Saginaw
Judy Kell – HUB Director, Muskegon Linda Tilot – MIECHV HUB Project,
Saginaw Lori Noyer – Project Coordinator,
Ingham
OVERVIEW OF PRESENTATION
Objectives Describe an effective model for integrating health
care and social services for high-risk populations Describe the role of a Community Health Worker Describe the role and benefits of a Community HUB
Topics Community HUBs Integrated service delivery Community Health Workers Working with high-risk clients Using technology to enhance service delivery
MICHIGAN PATHWAYS TO BETTER HEALTH Funded by 3-yr CMS Innovations Grant awarded to MPHI to
demonstrate cost savings over usual care (7/1/12 - 6/30/15)
CMS Acknowledgement The project described was supported by Grant Number
1C1CMS331025 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
Implementation Ingham County HUB Muskegon County HUB Saginaw County HUB
MICHIGAN PATHWAYS TO BETTER HEALTH Supports Institute of Healthcare
Innovation’s Triple Aim by delivering better health and access to quality care at lower cost Improve individual’s experience of care Improve health of populations Reduce per capita cost of care
PROJECT GOALS
primary care-sensitive ED visits & inpatient admissions
utilization of primary care Connect clients to needed primary &
specialty care (mental health, substance abuse services, dental, etc.)
Connect clients to social services Social determinants of health
SOCIAL DETERMINANTS OF HEALTH
Health Status
Environmental
FactorsLifestyle,
etc.
TARGET POPULATION
Adult (age 18+) Enrolled in/eligible for Medicare &/or
Medicaid 2 or more chronic health conditions Live in Ingham, Muskegon, Saginaw &
selected adjacent counties High-risk (5 or more ED visits, 3 or
more hospitalizations in last 12 months)
CHRONIC CONDITIONS
Addictions/Substance abuse
Alcohol abuse Alzheimer’s disease Anxiety disorder Arthritis Asthma Osteoporosis Parkinson’s disease ADHD
Bipolar disorder COPD Diabetes Eating disorder Personality disorder Emphysema Congestive heart failure Dementia Depression Hypertension
CHRONIC CONDITIONS
Autism Hearing impairment Hyperlipidemia Aphasia Ischemic heart
disease Kidney disease Bipolar disorder Obesity Schizophrenia
Cancer Panic disorder Stroke/Transient
ischemic attack Tobacco abuse Vision impairment Atrial fibrillation Amputation Others
COMPONENTS
Community HUB Care Coordination Agencies (CCAs) Community Health Workers (CHWs) Pathways Technology
COMMUNITY HUB MODEL
Developed by Dr. Mark Redding & Dr. Sarah Redding
AHRQ http://
www.innovations.ahrq.gov/guide/HUBManual/CommunityHUBManual.pdf
MEASURE OUTCOMES
1. Find
2. Treat
3. Measure
Confirm connection to evidence-based care
Measure the results
Target Population - Find those at greatest risk
CHWS
Meet with clients (at home) to conduct an intake to determine unmet needs
Conduct monthly home visits Establish goals and help clients meet
those goals through Pathways Help clients understand their chronic
diseases and how to manage them Supervised by nurses and social workers
CHWS
Help clients make positive lifestyle choices to promote health and well-being
Help clients navigate the health and human services systems to get them connected to resources to improve their health and wellbeing
CHWS
CHWs work with each client according to specific structured checklists and Pathways (protocols) to facilitate access to needed human services agencies and/or healthcare services
CHWs track client progress to complete Pathways sequences and reach milestones
CHW TRAINING
Initial one week training session that includes: Communication & Relationship Building Chronic Conditions Healthy Lifestyles Client Education Client Motivation
Additional training: Cultural Competence/Social Justice 5 As – Tobacco Cessation Motivational Interviewing PATH (Personal Action Toward Health) Home Visiting Safety Healthy Homes for CHWs Mental Health First Aid
PATHWAYS
Pathways document steps toward an outcome: Primary care appointment kept Utilities turned back on Housing obtained Health education received
PATHWAYS
Medical Referral Medical Home Medication
Assessment & Management
Social Services Referral
Health Insurance Smoking
Cessation Pregnancy Post Partum Family Planning Education
MEDICAL SERVICES PATHWAYS
Primary care Specialty care Dental care Vision care Audiology Pharmacy Nutrition/Dietician
Family Planning Mental Health Tx SUD Tx COD Tx Speech & Language
Services DME (with script)
SOCIAL SERVICES PATHWAYS
Family Food/WIC/SNAP Housing Insurance Finances Medication Transportation Job/employment
Child care Medical debt Legal issues Parenting Domestic violence Clothing Utilities Translation services
COMMUNITY HUB
Serves as data and information clearinghouse Provides centralized client registry – avoid
duplication of services Receives referrals, screens clients, makes
assignments to CCAs; assures bi-directional communication with referral entities
Monitors project activity for quality, targeting, safety, and productivity; submits monitoring information to MPHI
Reports outcomes to the community
Regional organization and tracking of care
coordination
Community HUB
Care Coordination
Agencies
HUB – Client Coordination
• Demographic Intake• Initial Checklist assign Pathways• Regular home visits – checklists and
Pathways completed• Discharge when Pathways complete
(no issues)
A CONNECTED COMMUNITY OF SUPPORTS & SERVICES
HUB
CCAs Social &
Human Service
s
Health Care
Services
CHWs
Clients
CARE COORDINATION AGENCIES
Recruit, hire, supervise, deploy CHWs Accept referrals from HUB & assign
CHWs to clients Document care coordination
provided by CHWs using Pathways templates
Transmit data from CHWs and Clinical Supervisors to the HUB
TECHNOLOGY
At the HUB/CCA In the field
MiPATHWAYS DATABASE
Records client needs and readiness to adopt healthy behaviors
Documents services provided
Documents clinical outcomes
Suggests Pathways Prevents
Duplication
TAILORED TO EACH COMMUNITY
INGHAM
Lead Agency/Fiduciary – Ingham County Health Department
Community HUB – Ingham Health Plan Convener – Power of We
INGHAM CCAs
Allen Neighborhood Center Capital Area Community Services Ingham County Health Department National Council on Alcoholism North West Initiative South Side Community Center Tri County Office on Aging Volunteers of America
MUSKEGON
Lead Agency/Fiduciary – Muskegon Community Health Project/Mercy Health Partners
Community HUB – Muskegon County Government Administrative Services
Convener – Muskegon Community Health Project/Mercy Health Partners
MUSKEGON CCAs
Access Health Lakeshore Health Network Community enCompass Disability Connection of West Michigan District Health Department #10 Every Woman’s Place Hackley Community Center Mission for Area People Muskegon Community Health Project/Mercy Health Partners Public Health – Muskegon County Senior Resources West Michigan Therapy
MUSKEGON REFERRAL PARTNERS
Pro-Med Ambulance Call 211
Lead Agency/Fiduciary – SCCMHA Community HUB – SCCMHA Co-Conveners – Alignment Saginaw & MiHIA CCAs
Covenant/VNSS SMM/Center of HOPE Health Delivery, Inc. (FQHC) Saginaw County Department of Public Health
HUB CERTIFICATION
National Demonstration Pilot Project funded by Kresge Foundation grant HUB standards CCA standards Policies QA Manual
MATERNAL, INFANT & EARLY CHILDHOOD HOME VISITING (MIECHV) PROGRAMS
MIECHV HUB
Target population: pregnant women, children 0 – 5 & their families
Provide referrals to HV agencies Eliminate duplication of services,
capacity of HV providers Data system Collect & share info; communication
& coordination across agencies
PROJECT DATASource: MPHI 3/14
CHRONIC CONDITIONS
Self report through 3/7/2014
MOST COMMON PATHWAYS
Medical Referral
Social Services
Med. As-sessment
Education Med. Home
Tobacco Cessation
0
1,000
2,000
3,000
4,000
5,000
4,044
3,393
1,196
440 326 289
MOST COMMON MEDICAL REFERRAL PATHWAYS
Primary Care
Specialty Care
Dental Mental Health
Vision0
500
1,000
1,500
2,000
1,421
1,071
511
288147
606 OTHER MEDICAL REFERRAL PATHWAYS
Dietitian DME (requiring script) Family Planning Hearing Pharmacy Speech & Language Services Substance Abuse tx
MOST COMMON SOCIAL SERVICE PATHWAYS
1460 OTHER SOCIAL SERVICE PATHWAYS
Child & family assistance Education Financial Healthy homes Household items Insurance Job/employment Medication Social support
Successes & Challenges
VOICES FROM THE FIELD
SUCCESSES & ACCOMPLISHMENTS
Job creation + Impact on wellbeing of clients CHW Job satisfaction Community Support for program
CLIENT FEEDBACK
“My CHW has been readily available to me whenever I needed anything. They have worked with me to help access services and saw me through the processes until I got the help I needed.”
“[CHW] is a gem. She always made me feel like I was the only client she had and I know that is not true but she made me feel that way. She helped me with my insurance paperwork and prescription coverage and I am forever grateful. She has helped me regain confidence in myself.“
“The [Pathways] program has really been helpful in identifying programs and services that I otherwise would not have found on my own.”
CHW FEEDBACK
"I think my short time as a community health worker has benefitted me as much or maybe more so than my clients. This experience has enlightened me not only to the problems we face as a community but also the great things we have to offer; that to really be a "community" we have to work together for - and with - one another. I am excited about the possibilities".
“The [MPBH] program allows me to connect personally with my patients to help them identify and access programs and services they truly need in order to live healthier lives. It makes me feel good to see the positive changes in patient’s lives after helping them overcome the different barriers in their way to staying healthy.”
PROVIDER FEEDBACK
“I just want you to know what a privilege it has been to work with you in the Pathways Program. First of all my hope is this program will continue for a long time.
When I think about the Community Health Workers involved with this program, they perhaps have no idea how valuable they are. I am thinking of two patients we referred from [hospital] and what an impact they have made in their lives.
They have provided transportation, reminded of appointments, helped self manage medications for those that live alone. Those three things alone can prevent an unnecessary readmission to the hospital.
Secondly, many of this population that is served by your program, have fallen in the cracks of health care. They may not know what social services are available to them or what their "insurance" may or may not cover. If the services are not covered they are directed to an agency that may be able to assist. Thank you seems insignificant, but I am thankful for this service and plan to continue to make referrals.”
CHALLENGES
Meeting grant enrollment targets Engaging reluctant patients Ongoing funding/sustainability Scarce community resources
Universal – e.g., transportation Unique to each community – e.g.,
psychiatric services
CMS ACKNOWLEDGEMENT
The project described was supported by Grant Number 1C1CMS331025 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
THANK YOU
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