COMMUNITY HEALTH WORKER: HEALTH SERVICES & CARE

Earl Nupsius Benjamin, MHA

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

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

PRIMARY CARE

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.

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)

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

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

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…

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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

HEALTH CENTERS

Do you know what community health centers are?

1 2 3

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1. No.2. Yes.3. I think I

do.

Have you ever used a community health center’s services?

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1. No.2. Yes.3. I think I

have.

Do you have a community health center[s] in your community?

1 2 3

0%0%0%

1. No.2. Yes.3. I think I

do.

What is a Health Center?

Health centers are community-based and patient-directed organizations that serve populations with limited access to health care. 

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. 96-638) or urban Indian organizations (under the Indian Health Care Improvement Act, P.L. 94-437).

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.

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.

…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.

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”.

Community Health Resources (Activity)

PATIENT-CENTERED MEDICAL HOME & COMMUNITY-CENTERED HEALTH HOME

Coordinated Care

Patient-Center Medical Home (PCMH)

Community-Centered Health Home (CCHH)

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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

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• 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/PAMedical Assistant/RN

Office StaffCare CoordinatorNutritionist/EducatorPharmacistBehavioral HealthCase ManagerSocial WorkerCommunity resourcesCHWs (and others)

Core Concepts for the Patient Centered Medical Home

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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 and supports the value of medical assistants (YAY!)

Oth

er C

are

YOU (CHW)

YOU

YOU

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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): 835-843

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PCMH Essential Skills

Essential Skills enable people to perform tasks required by their jobs as well asadapt 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, & PracticeImprovement Information Technology Behavioral Health

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)

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

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

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.

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.

Community-Centered Health Homes – Continued

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.

Inquiry Assessment

Action

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

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?

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1. No.2. Yes.3. I do not know

YOU

COMMUNITY ASSET MAPPING

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.

Community Asset Mapping – Continued

Community Asset ChartIndividual 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

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

Community Asset Mapping (Activity)

Reflection

Summary