Community Health Workers: Enhancing Readiness for Value Based Care - - PDF document

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Community Health Workers:

Enhancing Readiness for Value Based Care

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Presenter: Lisa Ladendorff, LCSW

Northeast Oregon Network Executive Director Community Health Worker Community Health Worker Trainer

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Learning objectives

• Review of Community Health Worker (CHW) definitions, roles

and functions;

• Enhance understanding of CHW alignment with specific

Patient Centered Primary Care Home standards and goals;

• Explore how CHW implementation can further readiness for

Value Based Care Reimbursement for clinics and hospitals;

• Learn about specific CHW program return on investment

examples;

• Orient to and learn how to use a tool to help support

implementation of CHWs for individual sites and programs.

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Community Health Worker Definitions and Roles

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American Public Health Association Definition

“A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.”

• Liaison
• Link
• Intermediary

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Oregon’s Definition of CHWs (ORS 414.025)

• Has expertise or experience in public health;
• Works in an urban or rural community, either for pay or

as a volunteer in association with a local health care system.

• To the extent practicable, shares ethnicity, language,

socioeconomic status and life experiences with the residents of the community where the worker serves;

• Provides health education and information that is

culturally appropriate to the individuals being served;

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Oregon’s Definition of CHWs (ORS 414.025)

• Assists members of the community to improve their

health and increases the capacity of the community to meet the health care needs of its residents and achieve wellness;

• Assists community residents in receiving the care they

need;

• May give peer counseling and guidance on health

behaviors; and

• May provide direct services(e.g. first aid; blood pressure

screening)

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Promoting Health Equity

• There are distinctive differences in the CHW role in relation to other

health occupations.

• CHWs apply a broad range of skills to provide holistic or wrap

around services to community members.

• CHWs provide assistance to community members in a variety of

settings with a focus on where the community member is

• comfortable. It might be a home visit, in the library or a coffee shop.
• CHWs focus on working with the community member and

empowering the community member to prioritize their own concerns regarding their health and well being.

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• CHWs are involved in work

providing equitable and culturally responsive access to information and services for historically disenfranchised populations and individuals.

• Recruitment and training of CHW

has historically been driven by culturally responsive practices that identify the need to find, empower, and support individuals whom already work, live and function within disenfranchised communities.

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Traditional Health Worker Resource Links

• Traditional Health Worker Registry:

https://traditionalhealthworkerregist ry.oregon.gov/

• Traditional Health Worker OHA

Rules and Policies: https://www.oregon.gov/oha/health plan/Pages/thw-policy.aspx

• State Approved Training Programs:

https://www.oregon.gov/oha/oei/Pa ges/thw-approved.aspx

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ALIGNMENT WITH PCPCH STANDARDS

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PCPCH Core Attributes

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Core Attribute: Access to Care

Standard Description Example In-Person Access PCPCH surveys a sample

• f its population….and

meets a benchmark on patient satisfaction with access to care CHWs increase access satisfaction by being more readily available, and by being able to meet for longer periods

• f time, and in patient homes.

Prescription Refills PCPCH tracks and shows improvement for time to completion for prescription CHWs can assist with advocacy and problem solving for issues arising around refills, especially with insurers. They also serve a linking function with pharmacists.

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Core Attribute: Accountability

Standard Description Example Performance and Clinical Quality PCPCH tracks, reports and meets benchmarks on two measures from core set and one from menu set CHWs can assist with meeting any screening and care benchmarks, whether immunization, cancer screening or post partum care by engaging and persuading those patients with high no-schedule or no- show rates to engage. Patient and Family Involvement in Quality Improvement Patient, caregiver and patient –defined family advisors are integrated into the PCPCH and function in peer support/training roles CHWs are hired as natural leaders from the populations they are serving, and thus are natural patient advisors and peers.

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Core Attribute: Accountability

Standard Description Example Ambulatory Sensitive Utilization PCPCH tracks selected utilization measure and shows improvement on selected utilization measures. CHWs have the strongest documented ROI evidence in the area of reducing costly ER and inpatient utilization, and increasing outpatient utilization. Many health plans and hospitals assign CHWs to engage with high utilizers or those at risk of high utilization to engage in care that can stabilize and manage health conditions.

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Core Attribute: Comprehensive Whole Person Care

Standard Description Example Preventive Services and Preventive Services Reminders PCPCH routinely offers or coordinates 90% of all recommended age and gender appropriate preventive services. CHWs are especially useful at engaging those patients that refuse to schedule or routinely no show regular preventive care visits. Medical Services PCPCH reports that it routinely offers all of the categories of care: ….coordination of care, preventive services, patient education and self management support CHWs can serve as excellent patient educators and provide self health management support, either formally via curriculums, or informally according to the patient's care plan.

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Core Attribute: Continuity

Standard Description Example Personal Clinician Assigned PCPCH meets a benchmark in the percentage of active patients assigned to a personal clinician or team Many CCOs have patients assigned who receive no medical care. CHWs can be assigned to make contact, develop relationships and work with the patient to choose a personal clinician and set up appointments for preventive care. Medication Reconciliation PCPCH provides comprehensive medication management for appropriate patients and families. CHWs can be a pat of the reconciliation process by working with patients in their home to understand and document their understanding of how to take their

• medications. This can be provided to

physicians for use in the reconciliation process.

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Core Attribute: Coordination/Integration

Standard Description Example Complex Care Coordination PCPCH develops an individualized care plan for patients/families with complex medical or social

• concerns. Plan includes self

management goals; goals of preventive and chronic illness care…… CHWS are ideal members of the treatment team to work at goal setting and implementation for some of the highest medical and social risk patients. They are able to take the time in home based settings to develop a relationship that can lead to effective goal setting and change. Referral and Specialty Care Coordination PCPCH tracks referrals and cooperates with community service providers such as dental, educational, social service, foster care, public health, etc. A core role of CHWs is to provide navigation and linkage services to multiple community entities on behalf of an in conjunction with patients.

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Core Attribute: Person-and Family- Centered Care

Standard Description Example Language and Cultural Interpretation PCPCH offers and uses providers who speak a patient’s/family’s language of choice or uses interpreters. CHWs, if hired from the populations they serve, will often speak the same language, and can be cross trained as interpreters. Education and Self- Management Support More than 10% of unique patients are provided patient- specific education resources and self-management services. A key CHW role is to provide patient education using standardized sources and self health management support.

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ENHANCING READINESS FOR VALUE BASED CARE

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Rural Health Value

• Based at the University of Iowa
• Staffed by RUPRI and Stratis Health
• Tools and Resources to help support rural health care

transformation

• http://cph.uiowa.edu/ruralhealthvalue/
• Value-Based Care Assessment Tool
• http://cph.uiowa.edu/ruralhealthvalue/TnR/vbc/vbctool.php
• 121 value based capacities within eight value based care

categories

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Value Based Care Categories

Care Management Clinical Care Community Health Patient and Family Engagement Performance Improvement

• Health Information

Technology

• Financial Risk

Management

• Governance and

Leadership

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CHWS Assist to Meet the Following Care Management Capacities:

• HCO assesses and

identifies patients at high risk for poor outcomes or high resources utilization, and assigns care managers to them.

• HCO offers chronic

disease management services.

• HCO utilizes a broad

community resource network in care management.

• HCO engages a non-

traditional health care workforce in care management.

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CHWS Assist to Meet the Following Clinical Care Capacities:

• Primary Care Practices

are accredited health homes (PCPCH)

• HCO generates action

lists for providers of patients who are due/overdue for services.

• Medication reconciliation
• ccurs during each

patient encounter.

• For non-urgent clinic

visits, pre visit planning

• ccurs for complex

patients.

• Clinical practices offer

group visits, e-visits and

• ther alternative patient

encounters.

• Primary care practices

encourage advanced care planning.

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CHWS Assist to Meet the Following Community Health Capacities:

• HCO has implemented

programs in response to needs identified in a Community Health Needs Assessment survey.

• HCO has implemented

community preventive health programs .

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CHWS Assist to Meet the Following Patient and Family Engagement Capacities:

• Specific strategic

programs with measureable objectives focus on improving patient and family engagement.

• Prior to each admission,

HCO staff provides and discusses a planning checklist.

• HCO generates reminder

for patients who are due/overdue for services.

• HCO collects data

regarding patient and family cultural/language preferences.

• HCO modifies care based
• n patient and family

cultural/language preferences.

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CHWS Assist to Meet the Following Performance Improvement Capacities:

• HCO actively works to

reduce potentially avoidable readmissions.

• HCO actively works to

reduce inappropriate emergency department utilization.

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SUSTAINABILITY AND ROI MODELS

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Models for Sustainability (ROI)

SUMMARY ROI FIND OUT MORE

Molina Healthcare

• f New Mexico

(Medicaid Managed Care)

Uses CHWs to intervene with plan’s highest resource- consuming patients, including those with high ED usage and low treatment adherence Approximately $4 of savings for every $1 of cost.

http://www.ncbi.nlm.nih.gov /pmc/articles/PMC3343233/

Denver Health

Community Voices

• utreach program

works with underserved populations on issues including appropriate

• utpatient service

utilization. $2.28 savings for every $1.00 invested in the program.

http://communityvoices.org/ assets/wp- content/uploads/2014/02/R OI-of-Community-Health- Workers.pdf

CHRISTUS Community Health Care

Management for the Uninsured Quality Management Committee Annual Report Average annual cost for care among program participants decreased by $10,000 or 58%. Over a three year period, the ROI was 3.84:1

http://www.christushealth.or g/CHRISTUSHealthComm unityDedication

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SUMMARY ROI FIND OUT MORE

Social Return on Investment: CHWs in Cancer Research

Wilder Research Center’s 2012 cost-benefit analysis of CHW services in cancer outreach. $2.30 in return in benefits fro every $1 invested

http://www.wilder.org/Wilder- Research/Publications/Studies/C

• mmunity%20Health%20Worker

s%20in%20the%20Midwest/Soci al%20Return%20on%20Investm ent%20- %20Community%20Health%20 Work

A Community-Based Asthma Management Program: Effects on Resource Utilization and Quality of Life

A CHW asthma intervention in Hawaii shows a decline in emergency room visits and increased quality

• f life.

Asthma related per capita charges decrease d from $735 to $181

See accompanying research grid. The Effectiveness of CHWs on Healthcare Utilization of West Baltimore City Medicaid Patient with Diabetes

A CHW intervention

• utreach program

created savings and improved quality of life Per patient savings of $2,245 for 117 patients

See accompanying research grid.

CHW Reimbursement

Fee for Service

• Direct reimbursement in a

fee for service model from payers who have included it as a covered services. Value Based

• NEON Pathways

Community Hub

• Transformation Grants
• FQHC/Migrant Health

Centers

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Indirect Reimbursement

Fee for Service

• Twinned with RN Care

Manager Value Based

• Patient Centered Primary

Care Home Value Added PMPM

• Medicare Chronic Care

Management

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CHW IMPLEMENTATION TOOL

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Tool Categories

• General Population

Demographics

• Population Health and

Social Needs

• CCO Metrics
• CHW Volume and

Workload

• CHW Cost
• CHW Revenue

Generation

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CHW Analysis Tool: Needs Assessment Community Assessment

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CHW Analysis Tool: CCO Metrics

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CHW Analysis Tool: Workload

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CHW Analysis Tool: Budget

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CHW Analysis Tool: Revenue

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THANK YOU!

Please send any further questions to: lladendorff@neonoregon.org

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Additional Resources

Rural Assistance Center The CHW Toolkit is made up of several modules concentrating

• n different aspect of

CHW programs https://www.raconline.org /communityhealth/chw US Dept of Health and Human Services Health resource and Service Admin (HRSA), Office

• f Rural Health Policy

(ORHP) The CHWs Evidenced Based Models toolkit includes several successful strategies with rural communities. https://www.hrsa.gov/rur alhealth/pdf/chwtoolkit.p df Northeast Oregon Network The NEON website includes information about local health

• utreach efforts and a

training schedule for CHW trainings. www.neonoregon.org

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References

• Agency for Healthcare Research and Quality. (2013) Clinical-

Community Relationships Evaluation Roadmap and Clinical-Community relationships Measures Atlas. Retrieved from AHRQ at: http://www.ahrq.gov/professionals/prevention-chronic- care/resources/clinical-community-relationships-measures- atlas/index.html

• American Public Health Association (APHA). (2016). Community Health
• Workers. Retrieved from the APAH Community Health Workers

webpage at: https://www.apha.org/apha-communities/member- sections/community-health-workers

• Bovbjerg, R.R.; Eyster, L.; Ormond, B.A.; Anderson, T.; Richardson, E.

(2013). Integrating Community Health Workers into a Reformed Health Care System. Retrieved from The Urban Institute online at: http://www.urban.org/sites/default/files/alfresco/publication- pdfs/413070-Integrating-Community-Health-Workers-into-a-Reformed- Health-Care-System.PDF

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References

• Mueller, K. J.; Alfero, C.; Coburn, A. F.; Lundblad, J. P.; MacKinney,

A.C.; McBride, T.D.; Weigel, P. (2015) Medicare Value-based Payment Reform: Priorities for Transforming Rural Health Systems. Retrieved from Rural Policy Research Institute at: http://www.rupri.org/wp-content/uploads/FORHP-comments-km- DSR-PANEL-DOCUMENT_PRD_Review_112315.clean-4_sn-3.pdf

• National Quality Forum. (2015). Performance Measurement for

Rural Low-Volume Providers. Retrieved from National Quality Forum at: http://www.qualityforum.org/Publications/2015/09/Rural_Health_Fina l_Report.aspx

• Oregon Health Authority. (2016) 2017 Recognition Criteria for

Patient Centered Primary Care Homes. Retried from Oregon Health Authority at: http://www.oregon.gov/oha/pcpch/Documents/2017- PCPCH-Standards-Measures.pdf

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References

• Panning, A. (2015). Community Health Worker Financing. Retrieved

from Northwest Regional Primary Care Association website at: http://www.nwrpca.org/news/211392/Community-Health-Worker- Financing.htm

• Rural Health Innovations. (2015). Rural Hospital Toolkit for

Transitioning to Value-Based Systems. Retrieved from National Rural Health Resource Center at: https://www.ruralcenter.org/rhi/resources/rural-hospital-toolkit- transitioning-value-based-systems

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