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

Questions? Comments?