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Community Health Worker: Health Services & Care

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1 Community Health Worker: Health Services & Care
Earl Nupsius Benjamin, MHA

2 Introduction Health System Public Health Mental Health Case Management Barriers to Use/Access to Health Care Health Interventions: The Health Belief Model Cultural Competency Community Organizing/ Planning Disaster Management Brief overview connecting these elements to Health Systems.

3 Desired Outcomes Understand the role of community health centers
Be able to better understand health service coordination Begin to understand the tools of community asset mapping Identify community health resources and existing health services The role of CHWs should focus on empowering and developing individuals, families and communities. Thus, the content in this CHW workbook seeks to support CHWs to enable citizens to assume responsibility for their own and their community's health through understanding their community's health problems and the societal influences that act upon them. Topic areas inside this workbook are the following: Community Healthy Center Health Service Coordination Community Health Resources community asset mapping

4 Primary Care

5 What is Primary Care? 1961: Institute of Medicine
Primary care is the activity of a health care provider who acts as an entry point into the health care system for all patients. Primary care is comprehensive, collaborative, coordinated, continuous and inclusive. Primary Care Physicians are trained in a variety of specialties: General Internal Medicine Family Medicine Osteopathic Medicine (osteopaths make up < 10% of PCP’s but 49% of osteopaths are PCP’s) Pediatrics Geriatrics Other Primary Care Providers include: Nurse Practitioners Physician Assistants Other (e.g. T. Bodenheimer’s health care coaches) Work in collaborative teams to provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). It, preventive health care, works at the level of population health rather than individual health. Preventive health care, also know as preventive medicine, consists of measures taken to prevent diseases, (or injuries) rather than curing them or treating their symptoms. One of the major tasks of preventive health care is to give people a positive sense of health. This is not only a matter of improving lifestyles and reducing premature deaths but also the concern for wellbeing and better quality of life.

6 Challenges in Primary Care
Delivering all evidence-based guidelines for preventive and chronic disease care has been estimated to take 18 hours a day for an average sized patient panel (Yarnall et al 2009; Alexander et al 2005) Most physicians only deliver 55% of recommended care, 42% report not having enough time with their patients. (Center for Studying Health System Change 2008; Bodenheimer & Laing 2007) Providers are spending 13% of their day in care coordination and only using their medical knowledge 50% of the time (Gottschalk 2005; Margolis & Bodenheimer 2010) Patient care is fragmented and patients are dissatisfied with the level of attention they receive in primary care (Bodenheimer 2008) More not less primary care is needed especially with more people becoming insured under the Affordable Care Act (ACA)

7 The Primary Care Crisis
National shortage of Primary Care Providers In 1998, half of internal medicine residents chose primary care; currently, about 80 percent become subspecialists or hospitalists This is occurring at a time when more, not fewer primary care providers (PCPs) are needed Poor access to care, especially for the uninsured Rising costs and gaps/variation in quality of services Increase in chronic conditions Need for better care coordination Dysfunctional payment system; rewards volume, face-to-face services Impending “collapse” of primary care

8 Current State of Primary Care
Rushed practitioners who keep being asked to take on more responsibility Patients receiving inconsistent care Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their condition More patients obtaining access to primary care under ACA

9 What’s Wrong with Primary Care?
Not enough time for providers to perform tasks Too much to remember Too many tasks not reimbursed Too many non-provider tasks Poor health outcomes Providers and patients are left dissatisfied… How many of you have come from a setting where the providers seemed pressed for time with patients? Delivering all evidence-based guidelines for preventive and chronic disease care has been estimated to take 18 hours a day for an average sized patient panel. (Yarnall et al 2009; Alexander et al 2005) Most physicians only deliver 55% of recommended care, 42% report not having enough time with their patients. (Center for Studying Health System Change 2008; Bodenheimer & Laing 2007) Providers are spending more than an hour a day in care coordination and only using their medical knowledge 50% of the time (Gottschalk 2005; Margolis & Bodenheimer 2010) Patient care is fragmented and patients are dissatisfied with the level of attention they receive. (Bodenheimer 2008)

10 What can be done? Redesign how Primary Care is delivered
The Patient Centered Medical Home Enhancing knowledge and skills of all team members Having the right mix of team members Highly organized and appropriately standardized office workflows and processes Providing ongoing training support Using technology Engaging patients and families

11 Health centers

12 Do you know what community health centers are?
Yes. I think I do.

13 Have you ever used a community health center’s services?
No. Yes. I think I have.

14 Do you have a community health center[s] in your community?
No. Yes. I think I do.

15 What is a Health Center? Health centers are community-based and patient- directed organizations that serve populations with limited access to health care.  For more than 45 years, HRSA-supported health centers have provided comprehensive, culturally competent, quality primary health care services to medically underserved communities and vulnerable populations.

16 Types of Health Centers
Grant-Supported Federally Qualified Health Centers (FQHC) are public and private non-profit health care organizations that meet certain criteria under the Medicare and Medicaid Programs Non-grant-supported Health Centers are health centers that have been identified by HRSA and certified by the Centers for Medicare and Medicaid Services as meeting the definition of “health center”. They do not receive grant funding under Section 330. They are referred to as "look-alikes." Outpatient health programs/facilities operated by tribal organizations (under the Indian Self-Determination Act, P.L ) or urban Indian organizations (under the Indian Health Care Improvement Act, P.L ). But CHW it is also important to know a variety of health care facilities like: not-for-profit primary care clinics; 2) community health centers; 3) FQHC and FQHC look-alikes (2nd bullet); 4) outpatient clinics of hospitals and universities established specifically for the purpose of providing primary care in the context of PCMH; 5) National Health Service Corps sites in Federally-designated Health Professional Shortage Areas (“HPSAs”); 6) primary care clinics operated by charitable organizations, including faith-based organizations; 7) other clinic entities (faith-based or otherwise) and primary care providers whose specific mission is to provide primary care, but that do not formally fall within the more discrete and identifiable categories mentioned above. In such case where no viable not-for-profit candidate is available, then a for-profit primary care provider may be considered for funding, upon agreement of the terms of the Outreach Program.

17 Health Center Program Fundamentals
Located in or serve a high need community (designated Medically Underserved Area or Population). Governed by a community board composed of a majority (51% or more) of health center patients who represent the population served. Provide comprehensive primary health care services as well as supportive services (education, translation and transportation, etc.) that promote access to health care. Provide services available to all with fees adjusted based on ability to pay. Meet other performance and accountability requirements regarding administrative, clinical, and financial operations. Added these documents to appendix: Bullet 1 – Develop activity with this link (divide them into 2 groups), This involves application of the Index of Medical Underservice (IMU) to data on a service area to obtain a score for the area. The IMU scale is from 0 to 100, where 0 represents completely underserved and 100 represents best served or least underserved. Under the established criteria, each service area found to have an IMU of 62.0 or less qualifies for designation as an MUA. The IMU involves four variables - ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. The value of each of these variables for the service area is converted to a weighted value, according to established criteria. The four values are summed to obtain the area's IMU score. Bullet 2 – At least 51 percent of the board's members must be patients or “consumers” of the health center. These consumer board members must reasonably represent the individuals served by the health center in terms of demographic factors: ethnicity race sex Where possible, it is encouraged that socioeconomic status be considered as well. The remaining non-consumer members of the board (49 percent or less) must be representatives of the area served by the center and have expertise in community affairs; Federal, State, and local government; accounting; health administration; health professions; business; finance; banking; legal affairs; trade unions; insurance; and personnel management as well as social services such as religion, education, and welfare. No more than half of these remaining, non-consumer members of the board (49 percent or less) can not earn more than 10 percent of their income from the health care industry.  (Example: if the board has 10 members, then no more than 4 members may be “non-consumers” of the center's services. Of those four, only two members may earn more than 10 percent of their income from the health care industry.)

18 Community Health Centers: Their Role & Reach
In 2009, they served over 20 million patients at over 8,000 sites, including 941,000 migrant/seasonal farm worker patients and 1 million homeless patients. Their patients typically are without access to other health care settings: low-income people, the uninsured, those with limited English proficiency, migrant and seasonal farm workers, individuals and families experiencing homelessness, and those living in public housing. Community Health Centers (CHCs) are a major component of America's health care safety net, providing high quality primary health care to low-income citizens, the uninsured, and other vulnerable populations. Over two-thirds of the patients who receive care at community health centers are members of racial and ethnic minorities these centers are so successful at reducing racial and ethnic health disparities in our country

19 …Their Role & Reach - Continued
Today, approximately 1,200 health centers operate nearly 9,000 service delivery sites that provide care to over 20 million patients This network of health centers has created one of the largest safety net systems of primary and preventive care in the country with a true national impact. For more than 45 years, health centers have delivered comprehensive, high‐quality preventive and primary health care to patients regardless of their ability to pay. During that time, health centers have become the essential primary care medical home for millions of Americans including some of the nation’s most vulnerable populations. With a proven track record of success, health centers will play a key role in implementation of the Affordable Care Act. Health centers, supported by the Health Resources and Services Administration (HRSA), treated approximately 20.2 million people in 2011, One out of every 15 people living in the U.S. now relies on a HRSA‐funded clinic During this time, health centers have also added more than 25,300 new full‐time positions, increasing their employment from 113,000 to more than 138,000 staff nationwide. Overall, since the beginning of 2009, health centers have increased the total number of patients served on an annual basis by 3.1 million people, increasing the number of patients served from 17.1 million to 20.2 million annually.

20 The Affordable Care Act: The Essential Role of Community Health Centers
The Affordable Care Act established the Community Health Center Fund that provides $11 billion over 5 a year period for the operation, expansion, and construction of health centers throughout the Nation. $9.5 billion is targeted to: support ongoing health center operations, create new health center sites and expand preventive and primary health care services. Health centers will focus more on coordinating primary and preventive services or a “medical home”.

21 Community Health Resources (Activity)

22 Patient-Centered medical Home & Community-Centered Health Home

23 Coordinated Care Patient-Center Medical Home (PCMH)
Community-Centered Health Home (CCHH)

24 Along Comes Patient Centered Medical Home…
A model of care where each patient has an ongoing relationship with a personal physician/provider who leads a team that takes collective responsibility for all aspects of the patient’s care Examples of best practices from successful physician office practices combined with theory and vision of how care ought to be delivered Reinforces the importance of all team members

25 Core Concepts for the Patient Centered Medical Home
Each patient assigned a personal physician/physician extender Whole person orientation Coordinated , integrated across settings Quality and safety emphasis Enhanced access to care Utilizing performance measures; how well they are fairing with quality measures Team-based care: MD/NP/PA Medical Assistant/RN Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources CHWs (and others) Framework is comprised of 6 medical home domains, which you see listed here. The Patient Centered Medical Home Enhancing knowledge and skills of all team members Having the right mix of team members Highly organized and appropriately standardized office workflows and processes Providing ongoing training support Using technology Engaging patients and families

26 Along Comes Patient Centered Medical Home…
YOU A model of care where each patient has an ongoing relationship with a personal physician/provider who leads a team that takes collective responsibility for all aspects of the patient’s care Examples of best practices from successful physician office practices combined with theory and vision of how care ought to be delivered Reinforces the importance of all team members and supports the value of medical assistants (YAY!) Other Care YOU (CHW) The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery. There is no single definition that has been universally accepted, but in general, the PCMH model: 1. Emphasizes the relationship between patients and their primary care physicians 2. Employs a team-based approach 3. Integrates evidence-based practices, clinical decision-support tools, disease registries, and health information technology CHW are an integral part to the PCMH dynamic. (where else do you possibly see yourself in this dynamic?) YOU

27 Value of PCMH Demonstration Projects
Reduced hospitalization rates 6-19% Reduced ER visits 0-29% Increased savings per patient $71-$640 Source: Fields, et al. 2010 Other Benefits Less staff burnout (10% in PCMH practices compared to 30% in controls) Reduced cost of care (29% fewer ER visits, 6% fewer hospitalizations, estimated saving of $10.30/patient/month Improved patient experience Improved patient outcomes Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Provider. Health Affairs 29:5 (2010):

28 PCMH Essential Skills Essential Skills enable people to perform tasks required by their jobs as well as adapt to change Patient Centered/Whole person care  Practice-based learning  Communication & Professionalism  Teamwork  Chronic disease management  Practice & Population Management  Coordination & Transitions of Care  Integration of Care  Quality, Performance, & Practice Improvement  Information Technology  Behavioral Health

29 What is distinctive about CHWs? Community Health Workers:
Do not provide clinical care Generally do not hold another professional license Have expertise based on shared culture and life experience with population served Rely on relationships and trust more than on clinical expertise Relate to community members as peers rather than purely as client Can achieve certain results that other professionals can't (or won't) Carl Rush, MRP, University of Texas Institute for Health Policy Project on Community Health Worker Policy and Practice - The American Public Health Association (APHA) has defined the CHW as “…a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. “This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. “The CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”

30 Community Health Workers - Continued
CHWs have shown promise in addressing many high- priority concerns in public health and health care for the underserved. They have proven impact in important areas such as: Access to care Prenatal/perinatal care Chronic disease management Long term care (in support of home- and community-based care) Utilization of services, especially reducing inappropriate use of the ER REFERENCES Johnson D, Saavedra P, Sun E et al.  (2011) Community Health Workers and Medicaid Managed Care in New Mexico.  J Community Health, Sept Robert Wood Johnson Foundation (2011).  Health Care’s Blind Side: The Overlooked Connection between Social Needs and Good Health.  Princeton, NJ: RWJF, December 2011.  Accessed 12/10/11 at Rosenthal EL, Brownstein JN, Rush CH et al. “CHWs: Part of the Solution.”  Health Affairs, July 2010.  Download from Volkmann, K.; Castañares, T. (2011)  Clinical Community Health Workers: Linchpin of the Medical Home. J Ambulatory Care Manage 34(3) 221–233

31 CHW roles in the PCMH In partnership with medical professionals, a CHW can serve as the team member with expertise in cultural factors and social determinants. Facilitate patient-provider communication Spend more time with patient and family, including home visits Facilitate more complete patient-provider communication (candor), potentially making diagnosis and treatment more efficient and effective Communicate more frequently and continuously with patients Reduce numbers of patients “lost to follow-up” Improve care transitions and help reduce hospital readmissions



34 Why Health Centers should care about CHWs
Effective PCMHs will have to maintain a higher level of patient-provider communication in terms of openness/candor and also continuity. CHWs are key to this happening. Who better than CHWs to perform this role, with their ability to create trust and interact with the patient and family in home and community settings.

35 Community-Centered Health Homes
The community-centered health home provides high quality health care services while also applying diagnostic and critical thinking skills to the underlying factors that shape patterns of injury and illness. By strategically engaging in efforts to improve community environments, CCHHs seek to improve the health and safety of their patient population, improve health equity, and reduce the need for medical treatment. “Bridging the gap between health services and community prevention” - The CCHH model advances a number of existing health care delivery models and practices, including the patient-centered medical home, as defined by the Patient-Centered Primary Care Collaborative, and the health home, as defined in the ACA. These models aren’t necessarily linear or sequential, as all are being advanced simultaneously and the concepts are evolving and expanding to include additional, complementary elements. - This approach builds upon pioneering work on community-oriented primary care (COPC). COPCs developed over a generation ago, made strong links between clinical practice and community action; the community-centered health home adds the sophistication and accumulated wisdom of prevention practice into a consistent approach that focuses efforts on policy and environmental change.


37 Community-Centered Health Homes – Continued
“Bridging the gap between health services and community prevention” The passage of Affordable Care Act has brought about an important time of innovation in the health system. One key opportunity is to integrate clinical service delivery with community prevention in order to reduce demand for resources and services; improve health, safety, and equity outcomes; and provide medical providers with skills and strategies to change the social circumstances that shape the health of their patients. In Community Centered Health Homes: Bridging the gap between health services and community prevention.

38 The Importance of Community Prevention
Community prevention is integral to effective health reform. It reduces the burden placed on the health system by reducing rates of preventable injury and illness and better aligning resources to address the factors that shape health and safety outcomes. Prevention can substantially diminish health inequities by focusing attention on unhealthy policies and inequitable resource distribution and improving community environments. - “America’s health care system is in crisis precisely because we systematically neglect wellness and prevention.” —Senator Tom Harkin Researchers have consistently concluded that the factors that have the greatest impact on health—the environments in which we live, work, and play and our behaviors (in part affected by those environments)—are outside of health care. 1.) “Prevention has a proven track record of saving lives.” 2.) “Prevention also saves money” People intuitively understand the value of prevention. Our health systems and institutions typically focus prevention efforts primarily on education and screenings. While these services are important, they have limited capacity to effect broad-based change on their own. Transforming health at the population level comes from shifting social norms and creating policies that anchor other efforts. Health promotion is defined by the World Health Organization as "the process of enabling people to increase control over their health and its determinants, and thereby improve their health". The primary means of health promotion occur through developing healthy public policy that addresses the basics of health such as income, housing, food security, employment, and quality working conditions. Primary prevention includes: General Health Promotion. The focus is on promoting individual and group well-being since a healthy host or population is one that is generally less susceptible to illness. For example, provision of condition at home, health education, good standard of nutrition adjusted to developmental phases of life, marriage counseling and sex education, genetics, are based on general health promotion as a part of primary prevention. Specific Protection. Examples include immunization, environmental sanitation, protection against occupational hazards, protection from accidents, use of specific nutrients, protection from carcinogens, avoidance of allergens, genetic counseling, stimulation of proper personal hygiene and control of disease vectors lice mosquitoes, and even the use of suppressive drugs. The whole idea behind primary prevention strategies is to alter the host, the agent or environment in such a way that disease is averted. Secondary prevention takes place early in the disease process. It is aimed at early diagnosis and treatment to prevent death or limit disability. For example: early identification of breast cancer, early identification of hypertension, prevention of rheumatic fever and other complications from streptococcal infections. From epidemiological point of view the secondary prevention should reduce the morbidity rate too. Tertiary prevention usually occurs when the disease process is clearly present. It is not so much an effort to slow the disease process as it is an attempt to prevent complete or unnecessary disability after anatomic and physiologic changes have more or less stabilized. The therapeutic and rehabilitation measures (social, psychological and physical rehabilitation) applied in the management of chronic diseases help the patient to achieve longer periods of remission and to adapt to a new style of life. With the help of tertiary prevention more years are added to the life expectancy for the patient. The provision of hospital and social facilities for the training and education of the disabled patients will help to achieve optimal usage of the remaining capacities, as well as the work therapy in the hospitals or communities. Each intervention which might stop the progression of the disease to handicap and might improve the remaining functions in the face of already present disability is determined as tertiary prevention.

39 Inquiry Assessment Action
Taking Two Steps to Prevention - Traces a pathway from the medical condition to the behaviors and exposures that led to it and then to the environmental conditions that are at the root of the behaviors and exposures. For example, a man has chest pains, and his doctor diagnoses severe heart disease. Treatment may be expensive and may come too late to prevent impaired quality of life. While developing an appropriate treatment plan, a CCHH clinician will also reflect on how the man developed heart disease in the first place -he ate poorly, didn’t exercise. Earlier intervention might have led to healthier choices. The CCHH provider recognizes that significant, long-term health benefits could result from community level interventions, so she helps to launch coordinated efforts that support the patient’s need for healthy food and physical activity. These changes benefit her patient as well as patients with other health concerns with related risk


41 Elements of the CCHH: Possible Roles for the CHW
Inquiry elements – Collect data on social, economic, and community conditions Analysis elements - Identify priorities and strategies with community partners Action elements – 1.) Coordinate activity with community partners 2.) Advocate for community health 3.) Mobilize patient populations The skills needed to engage in community change efforts are closely aligned with the problem solving skills providers currently employ to address individual health needs. It is a matter of applying these skills to communities The evidence argues for a new approach to health care: one that integrates quality health care services with strategies to support people in living healthier lives. This shift necessitates engaging in efforts to reshape communities.

42 A health care facility in your community saw that many of its patients were diabetic. The facility is now involved in community planning processes that are focused on reducing the Number of people suffering from Diabetes and other Chronic Illnesses. Is this Scenario an example of a Community-centered Health Home? No. Yes. I do not know Then ask why….

43 YOU

44 Community Asset Mapping

45 Community Asset Mapping
Asset mapping is an inventory of the businesses, organizations, and institutions that help create a community. A community asset is a quality, person, or thing that is an advantage, a resource, or an item of value to an organization or community. There are three levels of assets: Level 1 – Gifts, skills, and capacities of the individuals living in the community. Level 2 – Citizens’ organizations/networks through which local people pursue common goals. Level 3 – Institutions present in the community, such as local government, hospitals, education, and human service agencies. Asset mapping is a collaborative exercise that helps you create a “map” of the resources available in your community. It focuses on creating a complete picture of a community’s strengths and needs when it comes services. There are three major arenas that serve as focal point for uncovering community assets: residents, formal institutions, and informal organizations located within the community. The asset mapping process identifies local resources that have the potential to provide programs, services, funds, or in-kind gifts to a center. By strategically locating the social, material, and financial assets in a community, a center discovers a local network of resources to target when seeking a broader base of support and partnership.

46 Community Asset Mapping – Continued
Community Asset Chart Individual Institutional Governmental Skills Talents Experiences Professional Personal Resources Leadership Networks Churches Colleges and universities Elderly care facilities Police/Fire department Hospitals and clinics Mental health facilities Libraries Schools Transportation State/City/Local government Federal government agencies Bureau of Land Management Economic development Military facilities Small Business Administration State education agency Telecommunications Organizational Physical/Land Culture Small and large businesses Citizen groups/Clubs Community centers Home-based enterprises Radio/TV stations Nonprofit organizations Utility companies Parks and recreational facilities Real estate agencies Waste management facilities Chamber of Commerce Historic/Arts council groups Council for cultural affairs Tourism City council Museums Why Is Asset Mapping Important? Creating an asset map with your community partners and a broader stakeholder group will help you achieve several important goals, including: • identifying community assets that can benefit healthcare consumers; • identifying resource issues, including overlaps, gaps, bottlenecks, “hidden” resources and barriers that can impact the implementation of healthcare services; • identifying potential areas where coordination and collaboration would benefit healthcare services; • getting to know your community partners and organizations and setting the stage for lasting working relationships; and • getting to know the local healthcare services and supports that are available for healthcare consumers. Asset mapping effectively helps an organization discover the value of and build upon the strengths of its community’s assets. Understanding that community value constantly changes, asset mapping is an ongoing process. Healthcare consumers should be invited to participate in the asset mapping process. Healthcare consumers are the “first line” of community assets.

47 Community Asset Mapping – Continued
The Asset Mapping Process Phase One: Determining healthcare consumers’ needs and current resources Phase Two: Searching the healthcare consumers’ community Phase Three: Identifying potential resources Phase Four: Verifying asset mapping results Phase Five: Share asset mapping results with the community Asset mapping effectively helps an organization discover the value of and build upon the strengths of its community’s assets. Understanding that community value constantly changes, asset mapping is an ongoing process. ***walk through the CHW Community Asset Mapping Fact Sheet

48 Community Asset Mapping (Activity)

49 Reflection What do you think know about your Role as a CHW and where do you see yourself 3 years from as a Community Health Worker?

50 Summary

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