1. H EALTH C ARE H OME S POTLIGHT : E ARLY L ESSONS AND R ESULTS FROM CHW I NTEGRATION P ROMOTING P ATIENT C ENTERED C ARE AND C OMMUNITY H EALTH Tara M. Nelson Intercultural Mutual Assistance Association Community Health Worker Jean M. Gunderson Mayo Clinic Employee Community Health Community Engagement Coordinator Minnesota Community Health Worker Alliance Statewide Meeting June 5, 2014

2. O BJECTIVES Illustrate the impact of CHW home visits on the understanding of the patient experience through descriptions of goal setting, self-management, and acts of resiliency Review the collaborative infrastructure and funding aligning CHW capacities promoting community health Describe the building of teams integrating CHWs in a certified Health Care Home Examine the community based co-supervisory CHW model integrating patient centered team based care

3. P ATIENT S TORY …

4. C HALLENGE AS O PPORTUNITY 1990’s influx of immigrant and refugee populations Public program and funding transitions Unmet and uncoordinated patient/consumer needs across a continuum of care Recognition of the social determinants of health and community oriented primary care Navigation, communication and engagement History

5. L OCAL C OLLABORATIVE R ESPONSE The Multicultural Health Care Alliance (1997) The Olmsted County Health Care Access Taskforce in 2005 (access; context) The Olmsted County Community Health Care Access Collaborative in 2007 (community priorities; workgroups) The Coalition of Community Health Integration in 2012 (formalization of systems, policy and funding) The United Way of Olmsted County (alignment of early intervention: behavioral health, oral health, medical home ) History

6. L OCAL CHW W ORKFORCE D EVELOPMENT Standardized, competency-based CHW curriculum offered at Rochester Technical & Community College (2006 and 2012) CHW Workgroup (2008); small study (2009) 90 hour CHW internships at lead partner sites (2006 and 2012) MN CHW Employer Forum in Rochester (2009) CHW Employer Consortium (2011) Community Based Co-Supervisory CHW Pilot (2013) History

7. CHW C URRICULUM Standardized, competency based 11 credit curriculum (2003-2005) Revised to 14 credits (2010) Core competencies (9 credit hours) Health promotion competencies (3 credit hours) Internship (2 credit hours) CHW certificate upon graduation Curriculum

8. C OMPETENCIES CHW Role, Advocacy and Outreach, Organization and Resources, Teaching and Capacity Building, Legal and Ethical Responsibilities, Coordination and Documentation, Communication and Cultural Competency Healthy Lifestyles, Heart Disease and Stroke, Maternal and Child/Teen Health, Diabetes, Cancer, Oral Health, and Mental Health Curriculum

9. F UNDING The United Way of Olmsted County The Mayo Clinic Office of Population Health Management Potential: Team based care in the Accountable Care Organization Model Potential: Care Coordination/HCH Testing: Minnesota Health Care Program (MHCP) Medicaid fee-for-service option Funding

10. CHW P ILOT : C O -C REATING T RANSDISCIPLINARY T EAM B ASED C ARE Internship and Pilot aligned and co-created with lead Care Coordinators and leaders in Mayo Clinic Employee and Community Health (ECH) Health Care Home Specific service areas: Primary Care Internal Medicine (PCIM), Integrated Behavioral Health (IBH) and Community Pediatric & Adolescent Medicine (CPAM) Referral Criteria: complex care needs, eligible for or enrolled in care coordination (recognizing health determinants) Expanded programming: DIAMOND, EMERALD, COMPASS, and EPSDT (C&TC) complex care needs utilizing two lead Care Team RNs Infrastructure

11. CHW R OLE Navigator Advocate Liaison Knowledge- Bearer: community relationships, local lived experiences, cultural, linguistic and language needs Connector to community resources Educator: reinforcement and support Walker of the Margins Role

12. CHW STORY …

13. Q UALITY D IMENSIONS : A SSET B ASED AND H OLISTIC T EAM B ASED C ARE Community based co-supervisory CHW model Order by Proxy options (Primary Care orientation) Team huddles, patient conferences and consults Telephonic support Patient home visits and at other community based sites Non Visit Care coordination supports

14. Q UALITY D IMENSIONS : A SSET B ASED AND H OLISTIC T EAM B ASED C ARE Social Determinants data identified in partnership and reported utilizing patient language Patient centered visit schedule (service, frequency & number) Referral, patient goals, and self-management skills tracking Transdisciplinary teaming (relational practice) Secondary partner sites reporting every 3 months

15. CHW P ILOT CURRENT S TATUS Total patients served: 181 Total Visits: 452 (since July 1, 2013) Active patients: 103; Average CHW caseloads: 50 patients Average number of visits per patient: 2.5 CHWs working with ECH teams: 2-3 FTE Care Coordinators in the Pilot: 24 Lead Care Team RNs: 2 (EPSDT) Weekly reporting 5-19-2014

16. W HO ARE WE SERVING ?

17. W HO ARE WE SERVING ? W ORKING A CROSS C ULTURES, L ANGUAGE AND L ITERACY

18. W HO ARE WE SERVING ? * Documentation and tracking are challenging due to insurance enrollment status, patient and internal reporting, and when multiple payers per patient exist

19. W HO ARE WE SERVING ? Often multiple comorbid conditions exist

20. W HO ARE WE SERVING ? Minnesota Department of Human Services and the Hennepin County Ryan White Program HIV/AIDS Medical Case Management Standards (Appendix C, HIV/Aids Acuity Assessment, pages 24-26)

21. W HAT A RE W E D OING ? T OP D IRECT C ARE T HEMES -P ATIENT D IRECTED G OALS Daily Living Healthy Living Independence Care of Chronic Conditions Social Support Public Programs Safety Spiritual Needs

22. N ON V ISIT C ARE T HEMES : A REAS OF I MPACT Basic Human Needs Patient Engagement/Communication Insurance/Coverage of Services Referrals to Direct Health-Related Services

23. S ELF -M ANAGEMENT T HEMES o Budgeting: figure out expenses, find bills, set-up a financial consult, track bank account o Social Activity: get outside more, call churches, volunteer, get involved in an activity, obtain a computer, find a buddy system for the Laundromat o Goal setting and Planning: use a journal, calendar, or a list o Advocating for Self: communicate with teams, home care agencies, and PCAs, being assertive and setting rules o Gaining Independence: organize paper work, find a home, schedule transportation, go to work regularly, understand care plan o Managing health: check BP, journal, relaxation breathing

24. L EAD P ATIENT E DUCATION T OOLS PHQ-9 Asthma Control Test Asthma Control Assessment Asthma Action Plan Peds Quality of Life Form Goal Setting Goal Map Journaling Log books (BP, Diabetes, Activity)

25. C ARE C OORDINATOR S TORY …

26. S ATISFACTION AND A SSURANCE D ATA  Patients, Care Coordinators and CHW satisfaction data collected using surveys (mail and on-line, interview option with CHW team)  Integration of human stories/cultural narratives  Review of lead reporting tool: CHW Visit Form  Monthly case consultation with CHWs & ECH teams  Bi-monthly co-supervisory meetings at IMAA site  MN CHW Alliance & MN CHW Alliance Supervisor Roundtable

27. P ATIENT E XPERIENCE Cultural narrative

28. L ESSONS L EARNED : T HE A RT F ORM OF H OLISTIC C ARE W ITHIN R ELATIONSHIP o A fillable PDF CHW Reporting Form would create improved outputs in reporting and in-direct time. o Home visits are critical in understanding patient/family experiences, assets, needs, and health determinants o Use of one’s language, literacy, and culture remain significant factors within care, healing, and health outcomes o Mixed methods analysis is important when reviewing and reporting patient data o Community based CHW services are essential in the integration of community contexts within team based care.

29. R EFLECTION ON THE “A-HA” M OMENTS Market community based non-profits Integrate collaborative funding Recognize the impact of team champions Living the mantra: systems, tools, teams, processes (process outputs/the collective flow) Model how specialized training impacts observation, interviewing, documentation, reporting and referral (the transdiciplinary practice lens) Align resources to envision and deliver Recognize transformation as both challenge and opportunity

30. N EXT S TEPS o Continue to develop CHW billing processes, integrating both fee-for-service and shared revenue cost saving options o Maintain the evaluation of CHW programming addressing complex care needs and the social determinants of health o Expand the CHW reporting and referral pathways to include additional Care Team RN leads and Social Workers. o Build the SE MN CHW Regional Pipeline with collaborative partners and expand local CHW programming o Maintain CHW specialized training and cross- training across the care continuum

31. Q UESTIONS Thank you! Tara.nelson@imaa.net 507-289-5960, ext.102 Gunderson.jean@mayo.edu 507-538-8458 QuirindongoCedeno.Onelis@mayo.edu