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 x2101Calfero@hmsnm.org