Download - Planning and Delivering a Better Health System: Community Health Workers In a New Environment
Planning and Delivering a Better Health System:
Community Health WorkersIn a New Environment
Center for Health Innovation
The Center for Health Innovation
• Create the Environment that ensures the success of HMS and the Communities it serves through:– Policy – Planning – Resource Development– Capacity Building and Program Implementation– Partnering
• Management Services Organization• Professional Service Contracts• Topical Conferences, Training and Education• Collaborative and Organizational Resource Development
• No Direct Health Services Provided
Who is the Safety Net for?
Those who fall through the cracks……….or?
What Do We Want? Evidenced Based Change!!!!When Do We Want It? After Peer Review!!!!What Do We Want? Evidenced Based Change!!!!When Do We Want It? After Peer Review!!!!
Everyone!!!
Before HMS After HMS
Increases Demand For Comprehensive PC Services!
.
Policy and FinancingExpand Access – Increase Workforce Demand
96% of Population has 30 Minutes Access to Primary Care!
Serving Frontier AmericaGeographic Access to Specialty Care
PC Capacity, Patient Management and Access to Specialty Services are Critical Issues in the Frontier
Disproportionate Representation of High Need Populations = Service Challenges
1.United States Census Bureau, 2010 Census2.U.S. Census Bureau, 2005-2009 American Community Survey
Demographic Data Grant Hidalgo NM U.S.
Total Population 1 29,514 4,894 2,059,179 308,745,538
Population under age 18 1 21.9% 25.8% 25.2% 24.0%
Population 65 and over 1 21.3% 16.7% 13.2% 13.0%
Hispanic 1 48.3% 56.6% 46.3% 16.3%
White, Non-Hispanic 1 48.6% 41.4% 40.5% 63.7%
Disproportionate Poverty =Health Disparities As Well
Poverty and Income Grant Hidalgo NM U.S.
Population in poverty 1 18.9% 25.2% 19.8% 15.3%
Under age 18 in poverty 1 29.5% 38.9% 28.5% 21.6%
Median Household Income 1 $36,756 $30,280 $42,186 $50,046
1. U.S. Census Bureau, Small Area Income and Poverty Estimates, 2010
Health Disparities Example73% Overweight / Obese
Almost 70% Pre-Hypertensive or Worse
RESPONDING TO NEW INCENTIVES AND DIRECTIONS
Reducing CostImproving CareImproving Health
Meaningful Use - EMR PotentialPatient Centered Medical Home + (Not Medical Only)Innovations Application Payment Reform Work-General Rural Health Dilemma – Volume-Based Payments
-CHW Innovations Dilemma – Volume Based PaymentsService Focused Payments vs. Patient Focused Payments
Center for Health Innovation
4 Core Primary Care Services
• Medical• Dental• Behavioral• Family Support Services
• Community Health Workers• Care Coordination• Clinical Support Staff
• Nutrition, Exercise, Supervision
Horizontal / Social Context
• Health Equity• Economic Opportunity• Education• Social Services
Vertical Services• Therapeutic Care• Subspecialty• In/Outpatient
Hospital• Long Term Care
4 Core Primary Care Services
• Medical• Dental• Behavioral• Family Support (CHW’s +)
Range of Care• Prevention• Diagnosis• Treatment• ManagementInternal Systems
Categorical Services, Payment Disincentives and Dis-integration
Shifting Goals in a New Health and Cost Focused System
Chaos to OrderComplexity to Simplicity
Disincentives to IncentivesScientific Advances to Social DeterminantsOver Treating to Improving Quality of LifeService Focus to Patient Self Management
Prevention
Diagnosis
Treatm
entManagement
Horizontal – Actual / Virtual Team Support
VERTICAL COORDINATION
CurrentModel
Center for Health Innovation
PC System: Vertical and Horizontal Patient Support
Community
Organization
and Advocacy
Education &
Support
Care
Coordination
Cost/Complexity% Population
Management w/Team Interventions
CHW - Interventions Based on Spectrum of Health Services
Diagnosis & Treatment
Prevention
Enrollment &
Prevention
Dimensions of CHW Intervention Strategies
Community Level Promotion
Patient Population Communication
Categorical Patient Support
High Need Patients
VIRTUAL
ACTUAL
What Can a Health System do?• Develop New and Viable Models
– Invest in Workforce Development / Partnerships• FORWARD NM – Student / Resident Rotations• 1+2 Residency Development• Incorporate New Types of PC Providers and Integrate Training
– Rethink CHC/FQHC Service Requirements – PC System• Minimum Requirements or Best Practices and Evidenced Based Modeling?
Enabling vs Family Support Services• Core PC Services Articulation (CHC+ Model)
– Rethink the Health Care System• Focus on People, Families and Community – Not Services• Active vs Passive / Reactive Systems• Integrated Health Services and Collaborative Systems• Service Centric Payments or Patient Centric Payments?• Global PC Core Service Payments• Contracted Services Based on – Participation Agreements
2011 Rural Rotations at HMS
Medical Providers Dental Providers Nurse Practitioners/Midwifery5 Pediatric Residents5 Family Medicine Residents3 Family Medicine Residents2 Physician Assistants1 Physician Assistant
Other Disciplines1 Anthropology Intern3 MA Counseling1 MA Counseling
11 Dental Residents4 Dental Students
2 Family Nurse Prac./Cert. Nurse Midwife1 Family Nurse Prac./Cert. Nurse Midwife
1 Family Nurse Practitioner
Medical Students5 BA/MD Students
2 Practical Immersion Medical Students
Nursing Students22 WNMU students
Total for the Year
69 Trainees
LEGEND: University of the Southwest
University of New Mexico Arizona School of Dentistry & Oral Health
University of Texas at El Paso
Frontier School of Midwifery & Nursing
Memorial Medical Center Western New Mexico University
Vanderbilt University School of Nursing
Wageningen University (Holland)
As of 12/31/11
Build Capacity for IntegratedClinical Primary Care Services
New Types of Health Professional SkillsClinical Support Staff
• Community Health Workers– Outreach – Community Health– Prevention Campaigns
• CHW Navigators– Patient Support / Eligibility– Education– Social Determinants
• CHW Care Coordinators • Patient Communication Specialists –
Clinical Preventive Services – Scheduling / Reminders
• TEAM WORK!!! Training, Coaching and Facilitation
Technical Support Staff
• Researchers and Evaluators– EMR Utilization to Support Patient Care
Priorities and Program Development– Geographic Analyses– Move from Process Problems to
Outcomes Improvements– Health Status Focus
• Virtual Patient Systems Communicators / Journalists– Community / Patient Population Levels– EMR Infrastructure Support
• UNM HEROs– Resource / Expertise Linking
Does it Work?
We Believe!
HbA1c Lab Analysis – Clinical InterventionsDiabetic Patient were given the option of CHW support. In 2011 :- 1,089 unduplicated patients were given a primary
assessment of Diabetes (ICD-9 250.xx)- Of these patients, 988 had at least 1 reportable HbA1c lab value from
October 2010 – December 2011- 717 had at least 2 lab values- 363 had at least 3 lab values- 157 had at least 4 lab values- 41 had at least 5 lab values- 4 had at least 6 lab values
- The following chart plots the progress of the 157 patients and their 4 most recent lab values
HbA1c Lab Analysis
Of the 157 patients we saw an increase in pts. under control and a decrease in those not in control:-43 saw a decrease in HbA1c over the year-26 maintained an HbA1c under 7 throughout the year-19 had an increase in HbA1c over the year-The remaining 69 either maintained a level between 7.0 – 8.9 or a level over 9 throughout the year
Finally, the median lab value of the 1st lab was 7.9 and the median value of the 4th lab was 7.4
Non-Clinical Approach – CDCBefore and After Visit to CHW
CHWIntervention
Findings: UNM NIH Grant 2011
Control
TreatmentControl
TreatmentControl
TreatmentControl
Treatment0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
16.23% 14.14% 13.96% 15.15% 14.61% 15.15% 13.64% 15.15%
32.79%
48.48%38.96%
50.51%41.23%
50.51%
38.64%
52.53%
39.29%
25.25%
31.82%
24.24%
30.52%
27.27%
33.12%
28.28%
11.69% 12.12% 15.26%10.10% 13.64%
7.07%14.61%
4.04%
Changes in Hypertension Rates(unadjusted)
Stage 2Stage 1PrehypertensiveNormal
.Post-intervention 6-month follow-upBaseline 3-month follow-up
CorazonPorLaVidaControl N= 400Tx Group = 98
When Is It Too Much?
• Virtual Interventions• Actual Interventions• Info Overload• Scientific / Technical Models • CBPR and Evidenced Based Change• Process Evaluation(PDSAs)• Endless Committees• Accreditation
More is Not Necessarily Better
Complexity, Problem Solving and Sustainable Societies, Tainter 1996Level of Complexity
Bene
fits o
f Com
plex
ity
Molina / UNM / HMS Care CoordinationNon-Clinical Interventions
• During a 25-month period, HMS/UNM provided Care Coordination Services to the most expensive Medicaid Patients regardless of Condition.
• Substantial reduction in ER, in-patient, prescription, and narcotic drug utilization and cost among the CHW-intervention group compared to the non-intervention group.
• Total cost savings was over $2 million post intervention, compared to an estimated total program cost of $521,343.
• Molina is now expanding the program in half the counties in NM and will implement the program in all states in which they operate.
HMS – Opportunities to Integrate
Nutrition
Exercise
Education
Team
Team –
Training
Team –
Training
Silver CityCommons
HMS-Integrated Services 2nd Floor Plan
Team
Community Health Worker
Team
Team –
Training
Silver City
HMS – Senior Wellness CenterLordsburg
Nutrition
Education
Exercise
Community Health Worker
Education
PC and MH
Team
Team
For More Information
Charlie Alfero, Executive DirectorHidalgo Medical ServicesCenter for Health Innovation610 N. Bullard StreetSilver City, NM 88061575-534-0101 [email protected]