Cara Castleberry, RN/BSN, BS, LDE, CLC CHM Program Nurse Manager - - PowerPoint PPT Presentation

Cara Castleberry, RN/BSN, BS, LDE, CLC CHM Program Nurse Manager 12/07/18

 A program to teach patients self-

management of their chronic disease(s)

 Overall Goal = Reduce hospital admissions

and Emergency Department utilization related to diabetes, COPD, and/or heart failure

 A team approach, with a Community Health

Worker and a Registered Nurse

 Community Health Workers (CHWs) provide

home visits and phone follow up to help clients better manage their disease(s) and associated complications

▪ CHWs are medically trained (RMA, CMA, LPN)  Funding by local tax dollars primarily

 Resident of the 10-county BRADD area  Non-pregnant adults, 18 or older  Diagnosis of diabetes, COPD, and/or heart

failure

 Referrals received in a variety of ways (PCP,

specialists, hospital, self referral, etc)

 Length of program 6-9 months

Social Medical

Provide social support to

• vercome barriers

Link to needed resources Reinforce health education Enhance communication between patient and healthcare team Encourage positive behavior changes

 Community Health Worker services:

▪ Monthly home visit

▪ Check weight, blood pressure, and SpO2 per protocols ▪ Observe client perform self-monitoring

 Phone contact– Community Health Worker

services:

▪ Follow up by phone on non-clinical plans or

concerns at least once weekly, and bi-weekly later in the program

 Community Health Worker services: ▪ At monthly home visits, follow an

individualized lesson plan of the client’s choice

▪ Topics include: following your healthy eating plan, physical activity, smoking cessation, preventive care, etc.

▪ Follow up on goal progress and help patient

problem solve to reach goals

 CHW’s DO NOT: ▪ Provide Diabetes/Chronic Disease

Self-Management Education

▪ Provide Medical Nutrition Therapy ▪ Give medical advice or treatment ▪ Diagnose medical conditions

 The Institute for Healthcare Improvement

created a framework known as the Triple Aim, to describe an optimized approach to healthcare reform

The IHI Triple Aim. Institute for Healthcare Improvement,2016.

Three components of the “Triple Aim” 1. Improve patient experience of care (quality and satisfaction) 2. Improve the health of populations 3. Reduce the per capita cost of health care

 Improve patient experience of care (quality and

satisfaction)

▪ Facilitates enhanced communication within the

healthcare team and promotes a trusting relationship

▪ Encourages the pt to follow HCP orders for disease

exacerbations and Plan of Care

▪ Advocates for quality healthcare delivery

 Result: The patient feels like they are heard and

cared about, leading to greater satisfaction

Social Medical

Provide social support to

• vercome barriers

Link to needed resources Reinforce health education Enhance communication between patient and healthcare team Encourage positive behavior changes Improve patient experience

 Improve the health of populations ▪ The CHW directly encourages positive behavior

changes by identifying and removing barriers

▪ The CHM program team addresses goal setting

and progress, and providing lots of encouragement

 Improvements in healthcare compliance,

such as keeping appts, taking medications as prescribed, risk reduction, blood pressure control, and associated mortality

 An analysis of 18 studies involving CHW

integration showed improved patient knowledge, lifestyle, and self-management behavior amongst patients with diabetes, as well as decreases in ED usage.

Brownstein J, Chowdhury F, Norris S, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007:32(5):435-447. Norris SL, Chowdhury FM, Van Le K, et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med. 2006;23(5):544-556.

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 ED Visits Hospitalization

Average Decrease in Healthcare Visits for Patients Active during Oct 2015-Oct 2017

n=69; avg # of home visits 5.94

Before Program After Program

• “Before” program

and “After” program defined as 6 months prior, and 6 months post program completion

• In order to be

included in the subset, each participants had a minimum of 3 face- to-face home visits.

• Data includes all

eligible diseases (DM, HF, COPD).

• All cause

hospitalization/ED visits

Social Medical

Provide social support to

• vercome barriers

Link to needed resources Reinforce health education Enhance communication between patient and healthcare team Encourage positive behavior changes Reduce health care costs Improve patient experience

 Reduce the per capita cost of healthcare ▪ “Using their unique position, skills, and an

expanded knowledge base, CHWs can help reduce system costs for healthcare by linking patients to community resources and helping patients avoid unnecessary hospitalization and other forms of more expensive care as they help improve

• utcomes for community members.” (CDC, April

2015)

National Centers for Chronic Disease, Prevention and Health Promotion, in conjunction with the Department of Health and Human Services and Centers for Disease Control and Prevention. Addressing chronic disease through community health workers; A policy and systems-level

• approach. 2nd ed. April 2015.

 CHW integration has been shown to reduce

healthcare costs in management of cardiovascular disease

▪ A decrease of $157 per every 1% drop of systolic

blood pressure

▪ A decrease of $190 per every 1% drop of diastolic

blood pressure

Allen J, Dennison C, Himmelfarb D, Szanton S, Frick K. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. J Cardiovasc Nurs. 2013:29(4):1-7.

 Changes in Blood Pressure (10/2016 to 11/2017) ▪ On average, 77% of patients were meeting the

target for controlled blood pressure, compared to the national average of 60.42% (2015)

▪ Average decrease in Systolic BP of 11.12 mmHg ▪ Average decrease in Diastolic BP of 3.45 mmHg

Social Medical

Provide social support to

• vercome barriers

Link to needed resources Reinforce health education Enhance communication between patient and healthcare team Encourage positive behavior changes Reduce health care costs Improve population health Improve patient experience

 Cara Castleberry, RN/BSN, BS, LDE, CLC

▪ Community Health Management Program, Nurse Program Manager

▪ T:270-781-8039 x 186 ▪ F:270-796-8946 ▪ E: carisa.castleberry@barrenriverhealth.org