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Community-based care for Chronic Disease Management in Navajo Nation Sonya Shin, MD MPH Gallup Indian Medical Center Brigham and Women’s Hospital Partners.

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Presentation on theme: "Community-based care for Chronic Disease Management in Navajo Nation Sonya Shin, MD MPH Gallup Indian Medical Center Brigham and Women’s Hospital Partners."— Presentation transcript:

1 Community-based care for Chronic Disease Management in Navajo Nation Sonya Shin, MD MPH Gallup Indian Medical Center Brigham and Women’s Hospital Partners In Health Harvard University

2  No disclosures

3 Health in the Four Corners Region: How are we doing?  Health Outcomes  Disease Prevalence  Cost of Care  Patient Experience

4 If things aren’t working, why not?  Geographic isolation  Workforce shortages, esp with professionals  Cultural gap (provider  patient)  Poverty, unemployment, basic services

5 Biomedical health model

6 Biomedical health model: Limitations

7 Community Health Workers: Addressing the barriers to quality care  Geographic isolation  Workforce shortages, esp with professionals  Cultural gap (provider  patient)  Poverty, unemployment, basic services

8 Community based-approach: Addressing Biosocial Determinants

9 Growing role of CHWs in health care National Academy of Sciences 2010; Smedley et al 2003; AHRQ ; CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009

10 Growing role of CHWs in health care National Academy of Sciences 2010; Smedley et al 2003; AHRQ ; CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009 “CHWs should be integrally included in diabetes management.” [CDC] “CHWs should be integrally included in diabetes management.” [CDC] “Addressing health disparities should include community health workers targeting minority populations” including cardiovascular diseases. [National Institutes of Health] “Addressing health disparities should include community health workers targeting minority populations” including cardiovascular diseases. [National Institutes of Health] “CHRs play an important role in promoting health in underserved populations.” [Obama’s Affordable Health Care for America Act] “CHRs play an important role in promoting health in underserved populations.” [Obama’s Affordable Health Care for America Act]

11 Community Outreach and Patient Empowerment (COPE) Community  Support Navajo CHRs with training, professional development, materials Outreach  Home-based care and services Health education Counseling & health promotion Social support Patient  Uncontrolled chronic diseases (DM, etc) Empowerment  Coach patients and families in disease self-management and prevention

12 LINKAGE WITH CARE TEAM TOOLS Equipment Teaching aides TOOLS Equipment Teaching aides CHR High risk clients At risk community COMMUNITY TRAINING Health Education Health Promotion

13 TOOLS Equipment Teaching aides TOOLS Equipment Teaching aides Patient Teaching Materials Flipcharts based on CHR request Culturally appropriate visual images Motivational interviewing techniques Other resources Finger stick certification and supplies Laptops, oximeters, etc

14 LINKAGE WITH CARE TEAM IPC (Improving Patient Care) Innovations: Provider referrals to COPE Coordinate COPE with related programs (pharmacy DM clinic, DM education, etc) Joint home visits (provider/CHR) Strengthen PHN-CHR collaboration Case management rounds Facilitate CHR access to Electronic Health Record (EHR)

15 Training for CHRs Standardized curriculum IHS Navajo-speaking trainers Health promotion skills (Motivational Interviewing, goal setting) Train the Trainer model Competency assessment CHR Supervisor training TRAINING Health Education Health Promotion

16 Preliminary Outcomes (5/12)

17 HIV: How well are we doing?

18 HIV: Dissecting the health care delivery chain Diagnosis Treatment Behavior change Favorable outcomes Reduced transmission

19 Where are we struggling as providers? Diagnosis Treatment Behavior change Favorable outcomes Reduced transmission

20 Pop quiz! Among people diagnosed with HIV in the U.S. since 2008:  What % established care in the first year? a. 45% b. 64% c. 88%  What % were retained in care? a. 45% b. 64% c. 88%  What % achieved virologic suppression? a. 53% b. 67% c. 77%

21 Follow-up study of 100,375 people diagnosed with HIV through 2008, U.S. Established care within a year of dx (n=5137): 64% Retention in care (n=100,375):45% Virologic suppression:77% (last viral load) 53% (all viral loads) Hall et al, JAIDS 2012

22 Pop quiz! Among people diagnosed with HIV in Navajo Area IHS, how do we compare to national figures?  Establishing care in the first year? a. Above average b. Average c. Below average  Retention in care? a. Above average b. Average c. Below average  Virologic suppression? a. Above average b. Average c. Below average

23 NAIHS Annual HIV Report, 2011 Established care within first year of diagnosis (n=39): 71% Retention in care, among those living (n=303): -Regular follow-up/seen elsewhere55% -Intermittent follow-up (<50% appointments)14% -No follow-up31% Virologic suppression:55% NAIHS Annual Report, 2011

24 Can we do better? At the national level: > one third do NOT establish care within a year of HIV dx > one half do NOT receive regular HIV care Almost half are not virologically suppressed

25 Partners In Health (PIH) Accompagnateur model

26 Community health workers Since 1985 Paid health workers Responsible for referrals, vaccines, hygiene, maternal and infant health Initial training plus ongoing training The “missing infrastructure” in many resource poor settings 100% directly-observed therapy (DOT) coverage for TB and HIV patients Accompagnateurs: The “Backbone” of PIH

27

28 EXPANSION TO OTHER RESOURCE-POOR SETTINGS

29 1041 people initiating ART , PIH-MOH HIV Program in Rwanda Established care within a year of dx: not reported Retention in care among those living (n=989):97% Virologic suppression (n=275): 98% Rich et al, JAIDS 2012

30  CHW accompanimentDirectly observed therapy (?) Psychosocial support Adherence coaching Screen for side effects Liaison with providers  Additional supportsNutrition Transportation costs Patient support groups Team-based care So, what’s the magic ingredient?

31 BUILDING AN ACCOMPANIMENT PROGRAM

32 Step 1: Create an outreach team  Identify the outreach worker  IHS, tribe, NGO, etc  Level of training  Cultural, organizational, geographic constraints  Create care coordination SYSTEM  Linkage is CRUCIAL  Case management  Documentation  Supervision

33  Establish the role of the outreach worker  Deliver medications?  Adherence coaching?  Counseling?  Directly observed therapy? Modified?  Case management? Referrals?  Always: Social support Communicator Patient advocate Step 2: Define the home-based intervention

34  Training  HIV content  Counseling skills, motivational interviewing  Materials  Teaching / coaching materials  Four-wheel drive?  Support  Access to care team  Clinical “back-up” for challenging cases  Support for their own wellbeing (burn-out, safety, trauma) Step 3: Equip the outreach worker with the necessary resources

35 Step 4: Match the intervention to your population  All patients?  High-risk only? (Clinical criteria? Psychosocial?)  Tiered interventions depending on needs?

36 HOPE in Navajo: HIV Outreach & Patient Empowerment  Hiring  Health technician, GIMC  Case manager, NAN  Training  Adherence Counseling  Motivational interviewing  Harm Reduction  Wellness & self-care o Materials o Patient flipcharts o Pill boxes and keychains o Transportation and food vouchers o Target population o New diagnoses o Not getting care o Not virologically suppressed o Team-based care o Case management rounds o Documentation o Multidisciplinary team

37 HOPE in Navajo  Flipcharts:  HIV basics  HIV and nutrition  HIV: Know my meds  Taking my meds  Harm reduction  Health maintenance  Exercise  Coping with stress  Caring for the caregiver  HIV and substance use  HIV and mental health  Hepatitis C  Tuberculosis  Other sexually transmitted infections  Communicating with my provider

38 Step 5: Get started!

39 ACKNOWLEDGEMENTS GIMC Bennie Yazzie, Paula Mora, Carla Baha-Alchesay Bruce Forman, Maricruz Merino, Jon Iralu, Bill Monroe, Watson Billie Navajo AIDS Network Brigham & Women’s Hospital / Partners In Health Chip Thomas (B&W photo) RX Foundation Contact information:


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