1. Greater Kansas City Health Care Economy Forum March 11, 2014 Joan Cleary, Executive Director - Interim Minnesota Community Health Worker Alliance Community Health Worker Strategies: Overview and Economic Impacts Workforce innovation for advancing health equity and achieving the Triple Aim

2. Presentation Outline  CHW Role  Introduction to Minnesota CHW Alliance and building blocks  Economic Impacts of CHW Strategies  Selected resources

3. What’s keeping you up at night?

4. Kansas City area health and demographic trends Greater than 25% of the population uninsured or on Medicaid Growing poverty rate with correlation between poverty, adverse health outcomes and ability to access care Uninsured rate growing among working adults Growth in senior population Obesity and diabetes rates on the rise Kansas City Regional Health Assessment Report Mid-America Regional Council, 6/2013

5. Sleepless in the Twin Cities Integrated Health Systems Impact of the Affordable Care Act and becoming an ACO Achieving the Triple Aim Dealing with the social determinants of health Getting more out of fewer resources East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

6. Sleepless in the Twin Cities Payers Cost of care while improving health outcomes for more people Addressing the needs of an increasingly disparate membership Counteracting and/or addressing the social determinants of health East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

7. Sleepless in the Twin Cities Policymakers Reducing costs associated with health care and burden on society Understanding and addressing the social determinants of health Addressing health disparities in culturally-appropriate ways Taking a less siloed approach to health care East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

8. Sleepless in the Twin Cities State Agencies Implementing MNsure (the state’s health insurance exchange) Best addressing health disparities while reducing costs Successful implementation of Patient-Centered Medical Homes (“Health Care Homes” in Minnesota) East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

9. Team-based CHW Strategies: Health Reform Trifecta! Advance health equity Help achieve the Triple Aim*…improving patient experience (including quality and satisfaction), improving population health, reducing per capita health care costs Grow and diversify our health care and public health workforce *Institute for Healthcare Improvement

10. CHW Role

11. An emerging workforce Adapted from NM Dept of Public Health presentation Community Health Advocates Lay Health Advisors Outreach Workers Care Guides CHWs Promotoras Tribal CHRs Community Educators Patient Navigators

12. CHWs are uniquely equipped They typically reside in the communities they serve, and share the same language, ethnic, cultural and educational background Adapted from NM Dept of Public Health presentation Health & Social Service Systems CHWsCommunity

13. Focus on social aspect of care Adapted from NM Dept of Public Health presentation Providing culturally- responsive, cost effective health information Teaching and supporting families to learn the knowledge/skills needed to manage treatment and prevent disease Linking communities to health/social service systems of care and helping them to navigate the systems Advocating for services to meet community needs Empowering individuals and communities to advocate for their health

14. Working “upstream” & “downstream” Educate and connect underserved communities to care, coverage and support Provide outreach, advocacy, patient education, care coordination, navigation, social support and informal counseling Trusted and knowledgeable members of the communities they serve, with shared culture and/or life experience Address social determinants of health

15. CHW strategies: Evidenced-based best practices Effectively address barriers related to culture, language, literacy, ability, place, socioeconomic and other factors Increase access and improve quality, cost-effectiveness and cultural competence of care Organize and advocate for healthier communities Well-documented outcomes: asthma, diabetes, HIV/AIDS, hypertension, maternal and child health as well as cancer outreach and immunizations

16. CHWs benefit patients & communities CHWs help patients of all ages: Prevent costly health conditions, diseases and injuries Access needed care, coverage and services Avoid unnecessary ER and hospital visits Navigate our complicated health care system Manage chronic illness and maintain quality of life Improve individual and family capacity Foster healthy homes and communities

17. CHWs benefit the health care system CHWs help health providers, health plans and public health: Produce better outcomes Coordinate care and reduce costs Find coverage options for the uninsured Educate, empower and activate patients for better health Improve provider cultural competence Reach those who are vulnerable, underserved or isolated Effectively tackle health disparities Link to community services and organizations

18. Recognized by leading public & private authorities American Public Health Association (APHA) Centers for Disease Control (CDC) Centers for Medicare and Medicaid Services (CMS) Health Affairs Health Resources and Services Administration (HRSA) Institute of Medicine U.S. Dept. of Labor Standard Occupational Classification (DOL)

19. Introduction to Alliance and Our CHW Building Blocks

20. About the Alliance We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a 14-member nonprofit board. OUR VISION Equitable and optimal health outcomes for all communities OUR MISSION Build community and systems’ capacity for better health through the integration of community health worker strategies http://www.mnchwalliance.org/

21. CHW employer types in Minnesota Community-based Nonprofits Clinics and Hospitals Federally Qualified Health Centers Public Health Departments Dental Services Community Mental Health Faith-based Networks

22. What are we trying to accomplish? Full integration of CHWs in MN systems of care Reduce health inequities Advance Triple Aim Adapted from NM Dept of Public Health presentation

23. Workforce Development Workforce Development Education Objective: Advance CHW knowledge & skillset and inter- professional education to better serve Minnesota communities Objective: Raise awareness of CHW impacts through research & evaluation Objective: Foster policies that promote healthy people and healthy communities Objective: Improve access to coverage and care Research MN CHW Alliance Help achieve the Triple Aim, address health disparities, expand & diversify the health care workforce and foster healthier communities through CHW strategies Policy

24. MN CHW Building Blocks Recognized by the Agency for Healthcare Research and Quality Recognized by the Agency for Healthcare Research and Quality CHW scope of practice developed (2004) Standardized, competency-based 11 credit curriculum created by Healthcare Education Industry Partnership, leading to certificate (2003– 2005); revised to 14 credit program (2010) Minnesota CHW Peer Network formed (2005) for cont ed & peer support CHW payment legislation successfully introduced (2007) in follow-up to commissioned research on sustainable funding strategies (2006) Minnesota CHW Alliance formed as outgrowth of CHW Policy Council (2010) and incorporated as nonprofit (2011)

25. Minnesota CHW Scope of Practice Role 1: Bridge the gap between communities and the health and social service systems. Role 2: Promote wellness by providing culturally appropriate health information to clients and providers. Role 3: Assist in navigating the health and human services system. Role 4: Advocate for individual and community needs. Role 5: Provide direct services. Role 6: Build individual and community capacity.

26. MN Standardized CHW curriculum Model statewide curriculum based in higher education Offered at no charge to post-secondary schools in Minnesota Sold to over 30 organizations outside of Minnesota; online version now available Credits provide educational pathway for CHWs interested in other health careers Leads to certificate recognized by MN Dept of Human Services (state Medicaid agency)

27. Curriculum is competency-based Core Competencies: 9 credits Role, Advocacy and Outreach – 2 Organization and Resources – 1 Teaching and Capacity Building – 2 Legal and Ethical Responsibilities – 1 Coordination and Documentation - 1 Communication and Cultural Competency - 2 Health Promotion Competencies: 3 credits Practice Competencies – Internship: 2 credits

28. MN CHW Certificate Program Currently six schools offer the certificate program: Minneapolis Community and Technical College, Minneapolis Northwest Technical College, Bemidji Rochester Community and Technical College, Rochester St. Catherine University, St. Paul South Central College, Mankato (online version) Summit Academy OIC, Minneapolis Normandale Community College to introduce the program in 2014–2015 Over 500 graduates to date

29. MN CHW Payment Legislation Timeline 2007 Legislation 12/19/07: Federal approval received Minnesota Health Care Program (MHCP) enrollment criteria: CHW certificate from school offering MnSCU-approved curriculum Supervised by a physician or advanced practice registered nurse Grandfathering provision 2008 Amendment 3/18/09: Federal approval of expansion of CHW supervision to the following provider types: Certified public health nurses within a unit of government and dentists 2009 Amendment Federal approval of supervision by Mental Health Professionals

30. MHCP CHW payment legislation Minnesota Statute (MS 256B.0625, Subd. 49)

31. CHW covered service: Diagnostic-related patient education Signed diagnosis-related order for patient education in patient record Face-to-face services, individual and group Standardized education curriculum consistent with established or recognized health or dental care standards Document all services provided

32. Provider types authorized to bill for CHW services Advanced Practice Nurses Hospitals Clinics Indian Health Services Facilities Critical Access Hospitals Mental Health Professionals Dentists Physicians Family Planning Agencies Public Health Clinic Nurses Tribal Health Facilities To learn more, contact: Susan.Kurysh@state.mn.us

33. What’s Next?

34. Looking ahead Fully integrate the CHW role into state-funded health and human services programs, local public health and human services, and health care systems redesign efforts Incorporate CHW workforce into: Health care home program Health Insurance Exchange (as assistors and navigators) ACO models Build greater awareness of the role and its impacts

35. Challenges and opportunities Increasingly diverse and rapidly aging population ACA will increase access to thousands of uninsured Focus on Triple Aim and team-based care Payment shift from fee-for-service to value-based purchasing and total cost of care Health equity growing in priority

36. Economic Impact of CHW Strategies

37. Spotlight on evidence-based CHW models Molina Health, New Mexico Reduced ER utilization Community Health Access Program (Pathways) Ohio Improved birth outcomes Sinai Pediatric Asthma Intervention, Illinois Improved child asthma management, reduction in asthma symptoms and ER use GRACE Model, Indiana and IMPaCT, University of Pennsylvania Reduction in hospital readmission rates and improve post-hospital outcomes Arkansas Community Connectors Program Averted nursing home placement

38. What are we learning from recent CHW studies on Return on Investment?

39. New England Comparative Effectiveness Advisory Council: Final Report & Action Guides, July 2013 BEST PRACTICE RECOMMENDATIONS INCLUDE: Getting started States and organizations can choose comprehensive or incremental approach to CHW implementation Program Funding Payors and providers need to work together on stable funding mechanisms, including CHW strategies in new payment models as well as existing case management and home visiting funding streams CHWs: A Review of Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England

40. Implementing CHW Strategies City-wide and regional partnerships Example: Super Utilizers Local public health agencies Example: Family home visiting Hospitals & integrated health systems Example: Patient-centered medical homes, ER Community clinics Example: Outreach and education to improve screening rates Social service agencies, housing providers, schools Example: Address unmet health and social needs, link to coverage and care Companies Example: Occupational Health Dept

41. Conclusion

42. Call to action CHW strategies are an integral part of the solution to the challenges facing our nation’s health and your region! It’s time to take this workforce innovation to scale to fully realize its contributions. Join efforts to address your region’s health care and economic issues through the strategic implementation of team-based CHW models.

43. Selected resources Brownstein JN et al. Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach. CDC. 2011. Cleary J, Lee J and Itzkowitz V. CHWs in Minnesota: Bridging Barriers, Expanding Access, Improving Health. 2010. www.bcbsmnfoundation.orgwww.bcbsmnfoundation.org Johnson, D, Saavedra, P, Sun, E, Stageman, A, Grovet, D, Alfero, C, Kaufman, A. 2011. Community Health Workers and Medicaid Managed Care in New Mexico. Journal of Community Health. doi: 10.1007/s10900- 011-9484-1 Pathways Model www.innovations.ahrq.govwww.innovations.ahrq.gov Wilder Research Center CHW Assessment and ROI http://reg.miph.org/2012CancerSummit/presentationpdfs/Diaz.pdf

44. For more information: Joan Cleary, Executive Director-Interim Minnesota Community Health Worker Alliance 612-250-0902 joanlcleary@gmail.com Thank you!