Community)Health)Navigator) Intervention)for)Patients)with) - - PowerPoint PPT Presentation

Community)Health)Navigator) Intervention)for)Patients)with) Multiple)Chronic)Diseases:) Results)from)the)ENCOMPASS) Pilot)Study

March)6,)2020 Jennifer)Malkin,)Dailys)Garcia)Jorda,)Natalie)C.)Ludlow,) David)Campbell,)Gabriel)Fabreau,)Kerry)A.)McBrien

Pr Presenter:(Jennifer(Ma Malkin

• Speakers(Bureau/Honoraria:(N/A
• Consulting(Fees:(N/A
• Grants/Research(Support:(N/A
• Patents:(N/A
• Other:(N/A

Mosaic'Primary'Care'Network' (MPCN)

• Located'in'Calgary’s'Northeast
• 91'clinics
• 296'physicians
• Serve'over'300,000'patients
• SocioEeconomically'disadvantaged'neighbourhoods
• High'proportion'of'new'immigrants,'ethnic'minorities
• High'burden'of'chronic'diseases
• Patients'face'challenges'accessing'health'care

Co Community)H y)Health)N )Navigators)(CHNs)

• While)not)a)health)care)professional,)a)CHN)

is)a)patient;centered)care)provider)with) strong)roots)in)the)community.

• A)trusted)member)of)the)primary)care)team,)

a)CHN)can)accompany)patients)through)their) health)care)journey.

• CHNs)can)support)patients)in)three)areas)

that)contribute)to)better)management)of) chronic)health)conditions:

• 1. System)navigation
• 2. Patient)self;management
• 3. Social)connection

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Ev Evidence(ba base sed, d,pr progr gram,the theory

Provide(information(to(health( care(provider Translation,(interpretation Provide(education( (written/verbal) Advocate(for(patient Connect(patient(with( resources((social,(financial) Motivational(interviewing,( goal(setting Verify(adherence(to(care(plan Facilitate(health(care(referrals Schedule(and(monitor( appointments Facilitate(transportation Provide(information(to(health( care(provider Translation,(interpretation Provide(education( (written/verbal) Advocate(for(patient Connect(patient(with(resources( (social,(financial) Motivational(interviewing,(goal( setting Verify(adherence(to(care(plan Facilitate(health(care(referrals Schedule(and(monitor( appointments Improve(patient(communication( with(health(care(provider Enable(patient(understanding Provide(social(support Support(selfEmanagement Coordination,(navigation Patient(experience Patient(activation Provider(experience Appropriate(medication(use Weight Blood(pressure A1C Illness(exacerbations Smoking(cessation Optimize(use(of(primary(care Reduce(duplication(of(care Provider(attachment Improve(health(status/health( related(quality(of(life Decrease(adverse(outcomes Decrease(emergency(room(and( hospital(use Facilitate(transportation

Community(Health( Navigator(Activity: How(It(Works: Intermediate(Outcomes: Long(Term(Outcomes:

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EN ENCOM OMPASS)* EN

ENhancing CO COMmunity health) through)Patient)navigation,)Advocacy)and)Social) Support

A)one*year)pilot)study)exploring)the)feasibility)and)effectiveness)of)a)community) health)navigation)program)for)adults)with)multiple)chronic)conditions)began)in)June) 2017 ENCOMPASS) Pilot)Study

2)Primary)Care)Clinics 2017<2019 Single)arm)observational) study)

ENCOMPASS)Trial

20)Primary)Care)Clinics 2018<2021 Cluster<randomized)to) immediate)vs.)delayed) implementation

ENCOMPASS)Expansion

3)Additional)PCNs 2019<2022

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Quantitative)Methods

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Pa Patient)health)surveys)(baseline,)67 and)127months)

• Sociodemographic)characteristics
• Health)questions
• Patient7reported)outcomes)(health)status;)experience)of)care;)patient)

activation;)social)support) Ad Administr trati tive)data)(17year)pre7 and)post7enrollment)

• ED)visits
• Hospitalization)admissions)

An Analysis

• Pre7post)outcomes)tested)in)patient)health)survey)and)administrative)data
• Wilcoxon)signed7rank)test
• Mcnemar test)

An Analysis

• Interviews.and.observation.field.notes.were.transcribed,.coded,.and.organized.into.

themes.using.thematic.analysis.

• Consensus.in.coding,.theming,.and.definitions.achieved.as.part.of.an.iterative.process.

among.the.complete.research.team..

Qualitative.Methods

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16. 16.se semiAst structured. in intervie iews

2. Managers 2. Nurses 3. Physicians 4. CHNs 5. Patients

4. 4.fie field ld.obse servatio ions 4.CHNs.were.observed.for.3.hours.each

Patient'Demographic'Characteristics'(n=21)

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62%'of'patients'self;identified'as'female 52%'of'patients'had'an'average'household' income'less'than'$30,000/year 48%'of'patients'had'less'than'a'high'school' diploma'as'their'highest'education'level Mean'age'of'patients'was'60 Median'number'of'chronic' conditions/patient'was'6'(range=' 1;11)

Patient'Reported'Outcomes'

Variable Baseline+ Median+ (IQR)+ (n=21) Baseline+– 68months+(N=14) Baseline+– 12+months+(N=16) Baseline Median*(IQR)* 61months Median (IQR) p1value (BL1 61 months) Baseline* Median*(IQR)* 121months Median (IQR)* p1value* (BL1121 months) EQ85D8 5L 0.7*(0.4) 0.68*(0.6) 0.8*(0.4) 0.29 0.67*(0.6) 0.7*(0.4) 0.25 EQ+VAS 50.0*(30.0) 50.0*(27.5) 50.0*(25.0) 0.64 50.0*(28.75) 50.0*(20.0) 0.47 mMOS8 SS 37.5*(75.1) 56.3*(67.2) 75.0*(40.6) 0.19 37.5*(74.2) 81.3*(43.8) 0.0042* PACIC 1.8*(0.5)* 1.9*(0.7) 2.5*(1.2) 0.22 1.9*(0.6) 1.9*(0.7) 0.30

ED#Visits#and#Hospital#Admissions#(N=21)

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Variable 12*months1pre Proportion/Median1(IQR) 12*months1post Proportion/Median1(IQR) p*value ED1visit1(Y/N)1 47.6&% 38.1&%

0.48

#1ED1visits 0.0&(2.0) 0.0&(1.0) 0.81 Hospital1admission1(Y/N) 19.0&% 14.3&%

0.56

#1Hospital1admissions 0.0&(0.0) 0.0&(0.0) 0.81 Total1#1ED1&1Hospital 0.0&(3.0) 0.0&(2.0) 0.92

At At#the#patient#level:#Poverty;#lack#

• f#social#support;#cultural#barriers#

(health#literacy;#language#issues;# lack#of#knowledge#of#the#health# care#system)

Qualitative#data#revealed#Ba Barri rriers#to#

• #Ca

Care

That’s'the'biggest'barrier'that'I’ve'seen'with'people,'like'healthy'eating' and'fitness,'is'the'money'involvedA CHN# Even'if'the'family'doctor'explains'to'me'the'process,'I'do'not'know'how' to'go'there'and'deal'with'the'medical'staff'on'my'own= Patient#

At At#the#provider#level:#Poor# communication#(short# consultation#times) At At#the#system#level:#Fragmented# healthcare#system#(lack#of# knowledge#of#the#health#care# system)

Our'visits'are'structured'to'kind'of'communicate'what'we'want'to' communicate'but'sometimes'we'don’t'have'the'time'to'listen'to'what' the'patient'really'wants= RN# We'have'six'and'seven'physicians'even'more'they'have'up'to'like'30=40' patients'so'they'only'get'to'spend'15'minutes'with'each'patient,'so'we' focus'entirely'on'the'biomedical,'but'sometime'we'do'forget'that'you' know,'there'are'also'barriers'that’s'preventing'them'from'doing'this= RN So,'when'I'did'my'complex'care'plan'and'I'found'that'they' needed'a'number'of'referrals'to'specialists,'they'were'very' hesitant'in'attending'those'appointments= Physician

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CHN$Program$was$Ac Acceptable

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CHNs$found$their$role$to$ be$rewarding$and$ impactful$for$both$patients$ and$clinicians Patients$identified$benefits$ and$positive$experiences Physicians$noted$positive$ impacts$and$were$ welcoming$of$CHNs$in$ their$practices

I"feel"my"patients"are"happy,"they"feel"they"are"getting"the,"a"wide"range"of" care"from"uh"different"places,"yeah. […]"I"am"very"happy"and"I’m"thankful"for" you"for"providing"this"service"for"us"and"even"my"patients"I’ve"found"they" were"very"thankful,"yeah."[…]"I"appreciate"the"program." They"[CHNs]"are"very"professional,"very"helpful,"very"uh"astute,"you"know" theyBthey"take"it"very"seriously"and"I"like"how"meticulous"they"are." the"doctors"I’ve"dealt"with"a"few"times"directly,"where"I"attend"the"patient"visits" with"the"patient,"um"and"they"are"always"really"supportive,"and"excited"to"see" the"CH[N]"there I"think"[…]"there’s"support"in"that"way"because"he"[doctor]"knows"who"I"am," and"when"I'm"in"the"room,"[…]"he’ll"ask"me,"like"[CHN"name]"do"you"have"any" questions"for"me?"Do"you"have"questions"for"the"patient?”" I"think"this"project"is"very"good"and"useful"as"I"follow"up"with"them,"they" continue"to"care"about"me."The"services"were"great. The"benefits"for"me"were" more"follow"up"for"my"health,"my"treatment"and"better"communication" between"me"and"my"doctor."

How$It$Works:$Causal$pathways

Goal setting and Goal setting and identifying social identifying social barriers barriers CHNs working alongside CHNs working alongside the patient on their goals the patient on their goals Outcomes for Outcomes for patients and patients and providers providers

She$went$to$doctor’s$appointments$with$me$and$we$discussed$afterwards$what$had$been$said,$so$I$was$more$familiar$ and$could$get$everything$straight; CHN […]$it$might$be$going,$like,$to$a$fitness$centre$with$them$to$help$them$get$a$membership$or$help$acquaint$them$with$the$ gym$and$gym$equipment,$um$just$to$make$that$a$little$less$daunting$for$them; CHN$ So,$one$of$those$things$was$traveling$with$him$on$transit,$to$the$really$economical$um$fruit$and$vegetable$places$that$are$ in$the$northeast$part$of$the$city$close$to$him$[…]$I$believe$that$has$helped$the$patient$take$kind$of$more$control$over$his$

• wn$food$security$because$he$knows$there$are$options$other$than$just$like$getting$people$to$do$a$food$bank$referral;

Manager Pr Providing$support$< sp spending$time,$building$ ra rapport,$listening “F “Following ng<up”$ up”$and$ and$ac accoun untabilit ability Ed Educating$and$advising

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Conclusions

We+successfully+implemented+a+CHN+intervention+within+the+context+of+a+Primary+ Care+Network. Qualitative+data+highlights+the+barriers+to+patient+care+and+how+a+CHN+intervention+ works to+improve+patient+outcomes.+ Due+to+a+small+sample+size,+there+was+little+statistical+power+to+detect+significant+ differences+in+patient+outcomes.+Overall,+use+of+acute+care+was+low+in+our+pilot+ sample. The+ENCOMPASS+trial+was+informed+by+the+results+of+the+pilot.+In+particular,+the+ referral+process+was+refined.+The+trial+is+currently+in+the+recruitment+and+data+ collection+phase.+

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Acknowledgements