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- 1. BUILDING ACOMMUNITY HEALTH WORKER PROGRAM The Key to Better Care, Better Outcomes,& Lower Costs Presentation ID: 066
- 2. Disclosure Today’s presenters do not have any relevant financial interests presenting a conflict of interest to disclose. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non- ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives. Note: AONE will follow up directly with specific language for those speakers that disclosed a conflict of interest The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
- 3. Objectives 1) Describe the value of community health care workers as part of the mainstream health care system in a manner that will effectively communicate the importance of these programs to hospital executives and board members. 2) Describe how to integrate and implement a community health worker program into a hospital or healthcare system in a cost effective manner. 3) Apply tools and resources to aid in implementation of a Community Health Worker Program in any healthcare setting. Building a Community Health Worker Program 3
- 4. RWJF Executive Nurse Fellows • Loraine Frank-Lightfoot, DNP, MBA, RN, NEA-BC • Beth A. Brooks, PhD, RN, FACHE • Sheila Davis, DNP, ANP, FAAN • Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN • Shawanda Poree, MBA, BSN, RN • Lisa Sgarlata, MSN, MS, RN, FACHE . Building a Community Health Worker Program 4
- 5. THE CHW ROLE: Why Now?
- 6. History and Background “As the demand for care increases, so will the role of community health workers” 6Building a Community Health Worker Program
- 7. Twenty percent of the people in the U.S. have inadequate or no access to primary care. Building a Community Health Worker Program 7 The healthcare system in the United States is undergoing a monumental transformation. Escalating costs have limited the public’s ability to access affordable, high-quality health and medical care. With the implementation of the Patient Protection and Affordable Care Act (U.S. House of Representatives, 2010), commonly called the Affordable Care Act (ACA), healthcare insurance coverage will expand to an estimated 32 million people by 2014, with millions more to follow in the years to come. Obviously there is a need for novel approaches to provide access to primary care – approaches that will help hospitals and health systems to decrease readmissions and emergency department visits; increase patient adherence; improve health and wellness; reduce risk; prevent disease; and meet population needs identified by ACA-mandated Community Health Needs Assessments.
- 8. CHW Interventions Produce Cost Savings Building a Community Health Worker Program 8
- 9. FORMULATING THE CHW ROLE
- 10. CHW ROLE • History of the role – Global – USA • Definitions of the role – ACA, APHA, WHO,BOL, HRSA • Uni-modal vs. Polyvalent • CHW compared to other roles – CNA, MA, HHA 10Building a Community Health Worker Program
- 11. The ACA defines community health worker as “an individual who promotes health or nutrition within the community in which the individual resides.” Per the Act, a CHW promotes health in the following ways: •By serving as a liaison between communities and healthcare agencies •By providing guidance and social assistance to community residents •By enhancing community residents’ ability to effectively communicate with healthcare providers •By providing culturally and linguistically appropriate health or nutrition education •By advocating for individual and community health •By providing referral and follow-up services or otherwise coordinating care •By proactively identifying and enrolling eligible individuals in federal, state, local, private, or nonprofit health and human services programs
- 13. FORMULATING THE ROLE • Education – Type, setting • Performance Management • Tools, Job Aids • Workload – Catchment area • Outcomes – Triple Aim 13Building a Community Health Worker Program
- 15. STRATEGIC STAKEHOLDERS • External – Community agencies • Internal – Senior leadership – Medical staff – Care team members • Talking Points • Tailor the message 15Building a Community Health Worker Program
- 17. Implementation Best Practice • What drives developing a CHW program? • What size and scope does my community need? • Program management – Who is involved? – Who runs the program? – How to supervise? – What tools are needed? Building a Community Health Worker Program 17
- 18. Implementation Best Practices • Education of existing staff • Monitor effectiveness • Liability and safety issues • The business case Building a Community Health Worker Program 18
- 19. Implementation Best Practices • Elements of successful programs: – Recruitment – The CHW Role – Training – • Initial • Ongoing – Equipment and Supplies – Supervision – Evaluation 19Building a Community Health Worker Program
- 20. Implementation Best Practices • Elements of Successful Programs (cont.) – Incentives – Community Involvement – Referral System – Opportunity for Advancement – Documentation & Information Management – Linkages to Health Systems – Program Performance Evaluation Building a Community Health Worker Program 20
- 21. Implementation Best Practices – Patient Sources Building a Community Health Worker Program 21
- 22. CASE STUDIES WOOSTER COMMUNITY HOSPTIAL & PARKVIEW REGIONAL MEDICAL CENTER & AFFILIATES
- 25. Who we are . . . • 172 Open / Staffed Beds • 6,100 Admissions • 1,100 Births • 33,000 ED Visits • 1,000 Employees • Payroll - $38 million • Net Revenue: $107 million
- 26. Program Inception • Opportunity to address: – Readmission issues – Complex patients – Community Need – Physician (unrecognized) need • Opportunity for: – Partnership with local college – Increased positive community perception • “The right thing to do” Building a Community Health Worker Program 26
- 27. The Program – A Partnership Wooster Community Hospital & College of Wooster Building a Community Health Worker Program 27
- 28. Program Components: Students as Health Coaches • Student Selection • Student Preparation / Education – Semester long course – Shadowing – CPR – Clinical Competency Assessment Building a Community Health Worker Program 28
- 29. Program Components: Participants & Process • Patient Referrals & Enrollment • Detailed Assessment • Motivational Interviewing • Comprehensive Care Plan • Intervention • Evaluation *Primary Care Physician Building a Community Health Worker Program 29
- 30. Wooster Community Hospital CCN Screening and Patient Identification Identification Sources: •CCN – Date Review •Practitioner Identification •Community Referral Screening Site: •Hospital •Patient’s Home •Practitioner’s Office In-Patient Screening Identification Screening Data Review Chronic Diagnosis Screen (refer to diagram below) Other Diagnosis Review patient’s Healthcare Utilization Decline screening Program introduction and Overview Screened Program interest expressed Not Screened No Utilization No further actionRisk tool performed Needs identifiedNo needs No further action Obtained consent RefusedConsent signed Offer Follow-Up phone callComplete CCN Care Plan and notify PCP of enrollment in program Start If > 2 hospitalizations or ED visits in last 6 months OR If history of chronic medical problem yes n o END
- 31. Building a Community Health Worker Program 31
- 32. Building a Community Health Worker Program 32
- 33. Program Components: Tools Building a Community Health Worker Program 33
- 34. Program Components: Tools Building a Community Health Worker Program 34
- 35. Care Plan Building a Community Health Worker Program 35
- 36. Disease Specific Care Plan Building a Community Health Worker Program 36
- 37. Program Components: Staff • Program Director: 1 FTE • Physician Medical Directors: 0.1 – 0.2 • LPN: 1.5 FTE • Social Worker: 0.5 FTE • Dietician, Pharmacist, Therapist: PRN • Health Coaches Building a Community Health Worker Program 37
- 38. Program Components: Evaluation • Data collection • Results Building a Community Health Worker Program 38
- 39. Results • 54% Reduction in Admissions • 26% Decrease in use of the ED • 100% Compliance with correct medication use (med boxes) • Smoking cessation • HgA1C – goal achievement • BP goal achievement – 100% Building a Community Health Worker Program 39
- 40. CASE STUDIES WOOSTER COMMUNITY HOSPTIAL & PARKVIEW REGIONAL MEDICAL CENTER & AFFILIATES
- 41. Parkview Health Building a Community Health Worker Program 41
- 42. Parkview Regional Medical Center & Affiliates
- 43. Who we are . . . • Open / Staffed Beds: 807 • Discharges: 41,927 • Births: 4,444 • ED Visits: 168,093 • Employees: 9,002 • Payroll - $623 million • Net Revenue (Operations): $1.35 billion
- 44. Care Continuum • Community Nursing – School Nurses – Community Agencies • Aging & In-home Services • Discharge Clinics • Home Healthcare & Hospice • EMS House Calls • Tele Health • Nursing Homes – Extended Care – Mobile Care Building a Community Health Worker Program 44
- 45. Where Do CHWs Fit? • Care Advisors & Transitional Care Nurses • Physician Practice Based? • Hospital Based? • Home Health Based? • Paramedic? Qualifications? Students? • Elective College Course Building a Community Health Worker Program 45
- 46. Key Recommendations & Take-Aways Clear expectations & outcomes – Student vs. patient focus •Budget for equipment – Medication Boxes: $300 purchase & $20 / mo. software – Tele-health Units: $2,500 purchase & $60 / mo. software •Clear patient outcomes – “What do we want to accomplish?” •Feedback – patients and CHWs •Administrative support •Clear roles & job descriptions Building a Community Health Worker Program 46
- 47. Building a Community Health Worker Program 47
- 49. CHW GUIDEBOOK AONE Webpage: http:// www.aone.org/resources/building-a-community-h Building a Community Health Worker Program 49
- 50. Contact Us • Loraine Frank-Lightfoot loraine.frank-lightfoot@parkview.com or frank-lightfoot.1@osu.edu 260-266-1022 • Beth Brooks beth.brooks@resu.edu 773-252-5313 Building a Community Health Worker Program 50
- 51. Special Thanks • Alex Davis Wooster Community Hospital Manager, Community Care Network 330-263-8478 Building a Community Health Worker Program 51
Notas del editor
- Now that you have heard about the value, impact and importance of these programs, I’ll share with you the real world experience of initiating a program. Until the end of August – was CNO at WCH where we had successfully implemented a program – program is ongoing. WCH is a single, community hospital. Responsible for HH, private duty – full continuum of nursing care. In September, transitioned to Parkview Health – a complex system in NE Indiana. Describe the process of developing a CHW program in a new system - - one in which I do not have responsibilities for post acute / physician practices. Have been working with stakeholders there to implement a similar program. Will share both experiences.
- Wooster Community Hospital (WCH) is located in Wayne County, Ohio, with a population of around 114,600 people
- Point out Wooster AND Ft. Wayne
- Single entity in Ohio. Progressive – outward looking: how do we meet the needs of our community and the patients we serve? Had HH Implemented private duty care Inpatient Rehab Transitional (skilled level) NH care Recognition that current programs were not meeting the needs of patients / families.
- Had initiated disease specific HH visitsUncompensated Post DC visit: CHFStroke Recognition that there were unmet needs – Not addressed by WCH’s services nor community resources Hospital – felt strong commitment to community / responsibility to address community needs regardless of reimbursement Saw program in Meadville PA – Used concepts and grew from there Opportunity to use existing programs & leverage them for success: HH, College’s experience / volunteer program Partnership w college – inform their practice for the future “Patient-centered care includes active engagement of patients in shared decision making. This represents a marked cultural change for medical providers, who traditionally relate to patients as passive recipients of their care” (Berryman, Palmer, & Parham, 2013). WCN provides a different system of care coordination that improves a patient’s health by coaching them into managing their health risk factor. An interdisciplinary team develops a plan of care based on a patient’s goals and provides guidance and services that assists the patients in reaching their goals.
- CCN was born! a program that uses an interdisciplinary team approach to create an individualized care plan focused on a patient’s goals towards a healthier lifestyle. WCH and College of Wooster Liberal arts school – BS / BA only; most move on to graduate degrees Partnership – college & hospital Opportunity for both to extend reach beyond their traditional roles / boundaries Why students? Opportunity to inform their future practice Educational give back for hospital Opportunity for 2 large organizations in community to partner for well being of the community FREE LABOR! Hospital supplied: Education of students Coordination / oversight of students as HEALTH COACHES Access to patients Knowledge of how to provide post acute care / knowledge of systems of care College supplied – Established APEX program Students
- Semester long course (total: 22.5 hrs) Shadowing CPR (4 hrs) Clinical Competency Assessment (2 hrs) *if done as independent course, plan on 4 – 8 hour days Topics: chronic diseases and their management – COPD, HTN, DM (others covered in weekly team meetings) HIPPA regulations Literacy Communication Monitoring & adherence issues role of the Health Coach After 1st group – determined the need for more content on chronic disease
- Patient sources: Does not take the place of other svcs (HH) – is an adjunct Hospital ED MD offices Community agencies Our HH Detailed assessment – RN – will review contents in a minute MOTIVATIONAL INTERVIEWING!!! Goal of program – promote independence and self care Need to focus on what is important to the patient. Partnership – not us telling them what to do
- Screen patients within 48 hours of referral Patient met the inclusion / selection criteria and expressed a desire to improve their health. Inclusion criteria: Adm to hospital – last 6 mo ED visit – last 6 mo Use 5 or more meds Chronic disease Example of delaying seeking care that worsened symptoms Exclusion criteria: Hospice Severe dementia / unable to participate in care Mental health issue ONLY No chronic / co-morbid conditions
- Within 72 hours of discharge (if hospitalized) or of referral, Comprehensive assessment completed. Socio economic issues Housing situation Education level Self health rating Adherence potential # Health conditions / co-morbidities Used Elixhauser criteria plus expanded psychiatric Psychosocial stressors impacting medical outcomes – loss, finances, legal issues Social support needs: lack of support, medical issues, financial issues Medication compliance Mental health assessment Fall risk
- The MNA® is a validated nutrition screening and assessment tool that can identify geriatric patients age 65 and above who are malnourished or at risk of malnutrition. The MNA® was developed nearly 20 years ago and is the most well validated nutrition screening tool for the elderly. Find many patients are malnourished
- Timed up and Go Test – TUG Combine with fall assessment
- After assessment – Plan Care! Med Management Nutritional needs DME Smoking Coordination of ongoing care Behavioral Health Goals Depression / Anxiety Substance Abuse / Dependency Pain Housing Legal Financial support Financial Mgmt Transportation Communication (effective) with their providers
- DM HTN COPD / Asthma / Pneumonia Secondary stroke prevention
- Pharmacist reviews all meds, all patients Dietician: referral if patient screens as malnourished (MNA) or is DM. Most cases, can get reimbursed. DM education – hospital program if able to travel; in home if not Students / coaches – provide weekly visits to help the patient meet their goals (may be more often) Team meetings – weekly Review progress towards goals Coach reports on progress (eyes and ears in the home) – Patients tell coaches things they would not tell their nurse
- 35 patients Enrolled patients – all by Feb 2014 – followed 6 mo Comparison against their hospitalizations – prior 6 mo Results follow
- Pro’s: Great community initiative Unexpected volunteers! Informed student’s practice for the future Organic growth of the program Now up to 45 coaches Over 100 patients through the program Ongoing capacity approx 60
- Extensive care continuum Currently in place: Community health based nurses Case managers – prepare discharge / transition plan Transitional care nurses / Care advisors - in physician practices – coordinate care as patients transition Or hospital based to follow up after DC EMS house calls – in some areas Tuck in service Have new grant and are expanding services Nurse manned phone line Situation – my role is inpatient based; this is outpatient MANY people involved Can become territorial Promotion of individual ‘pet’ projects Need someone with big picture view Even then, multiple people may think that person is them. Spoke with many stakeholders to secure interest / opportunity to develop the role
- Closest alignment: Care advisors / Transitional care nurses --- home health Physicians wanted only one place to look for the care plan Developing elective course Implementation of paid / volunteer untrained students this summer Hopeful – class for next fall
- CHWs need to honor commitment to time / place for meetings Professionalism