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Community Health Worker Outreach Among Frequent Utilizers of the Emergency Department (ED) : What Is the Impact on Primary Care Follow-Up? Erica Shelton, MD, MPH, MHS Assistant Professor Department of Emergency Medicine Johns Hopkins

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Community Health Worker Outreach Among Frequent Utilizers of the Emergency Department (ED) : What Is the Impact on Primary Care Follow-Up?

Erica Shelton, MD, MPH, MHS Assistant Professor Department of Emergency Medicine Johns Hopkins University @EricaSheltonMD

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Rise of CHW Programs

CHW concept gained prominence in the 1960s with emergence of CHW programs in many LMIC

Limitations of Western medical model to reach needs of large rural and impoverished populations WHO publication Health by the People (1975) Significant impact in areas of communicable diseases (TB, HIV), nutrition, and maternal & child health

_________________________________________________________________________________ Perry HB, et al. Annu Review Publ Health 2014. 35:399-421. Newell KW, ed. World Health Orgn.(WHO) Health by the People 1975.

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Rise of CHW Programs…cont’d

Later in 1980s & 1990s, CHW programs gained attention in US for achieving positive health outcomes

Limited health literacy and socioeconomically disadvantaged populations in urban and rural settings Self-care for chronic diseases (DM, HTN) and

  • vercoming barriers to health care

experienced in underserved communities

________________________________________________________

Perry HB, et al. Annu Review Publ Health 2014. 35:399-421. Newell KW, ed. World Health Orgn.(WHO) Health by the People 1975.

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Background

 From 1997 to 2007, annual number of U.S. ED visits increased by 23% from 96 million to 117 million visits  From 2006 to 2014, this number increased by 14.8%

  • 4.5–8% of patients visiting the ED are frequent

utilizers

  • Yet frequent ED utilizers account for 21–28% of

all ED visits  ED utilization by this group is often perceived as nonemergent and contributing toward ED

  • vercrowding

________________________________________________

Jencks SF, et al. N Engl J Med. 2009 Apr 2;360(14):1418-28 Moore BJ, et al. HCUP Statistical Brief #227, AHRQ. Sept 2017 Shulan M, et al. Health Care Manag Sci.2013 Jun;16(2):167-75. Epub 2013 Jan 27 Kansagara D, et al. JAMA 2011 Oct 19: 306(15):1688–1698

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The Perception…

Insert ‘boo boo’ cartoon

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The Reality…

 Research of frequent ED users in the US has found these patients to have

  • higher overall mortality
  • to be admitted to the hospital more

frequently

  • to incur larger heath care costs when

compared to occasional ED users

___________________________

LaCalle E, Rabin E. Ann Emerg Med. 2010 Jul;56(1):42-8 Mandelberg JH, et al. Acad Emerg Med, 2000, July: 637-646 Ruger JP, et al. Acad Emerg Med. 2004 Dec;11(12):1311-7

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ED Resource Utilization & Costs

 Care for this group of patients within the emergency department represents approximately 50% of the Medicaid dollars utilized for ED care  Given finite resources to address ED healthcare, interventions directed towards these patients may

  • reduce ED utilization rates
  • improve provider-to-patient ratios for the critically ill

___________________________

LaCalle E, Rabin E. Ann Emerg Med. 2010 Jul;56(1):42-8 Ruger JP, et al. Acad Emerg Med. 2004 Dec;11(12):1311-7

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CHW Impact in the US Inpatient Setting

 Community health worker (CHW) models within the inpatient setting have demonstrated

Decreased 30-day hospital readmissions Increased adherence to primary care follow-up after hospital discharge Increased patient activation and medication adherence

_______________________________________________ Kangovi S, et al. JAMA Intern Med. 2014 Apr;174(4):535-43 Gaskin DJ, et al. Health Affairs. 2018; 37(10): 1546-1554

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Hypothesis

 CHW intervention for frequent utilizers

  • f the ED increases adherence to

recommended follow-up primary care and may potentially reduce repeat ED encounters for non-urgent presentations.

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Patient Activation Measure (PAM)

…Selected Excerpts

1) ‘When all is said and done, I am the person who is responsible for managing my health condition.’ Do you

 Strongly agree Agree Disagree Strongly disagree

2) ‘Taking an active role in my own health care is the most important factor in determining my health and ability to function.’ Do you

 Strongly agree Agree Disagree Strongly disagree

3) ‘I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition.’ Do you

 Strongly agree Agree Disagree Strongly disagree

4) ‘I know what each of my prescribed medications does.’ Do you

 Strongly agree Agree Disagree Strongly disagree

5) ‘I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself.’ Do you

 Strongly agree Agree Disagree Strongly disagree

______________________________________________________________________________________ Hibbard JH, et al. Development of the Patient Activation Measure (PAM). Health Serv Res. 2004;39(4, pt 1):1005-1026

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Methods

 Performed a block randomization of 191 patients presenting to an urban ED in Baltimore, MD from July 2016-August 2017  Patients were followed over time through June 2018  All participants had >4 ED visits in the past year, described in the literature as indicative of frequent ED utilization.  Enrolled low acuity (Emergency Severity Index Level 3-5) medical and trauma patients discharged from the ED to home within 24 hours  Demographic information collected (age, race, gender); patient intrinsic factors of medication adherence & patient activation measured  ITT analysis completed using Poisson regression

____________________________________________ Morisky DE, et al. Med Care. 1986 Jan;24(1):67-74. Ware JE, et al. New England Medical Center, Health Institute; 1995.

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Characteristics Number (%)

Enhanced Standard

  • f Care (n=113)

CHW Intervention (n=82) Age Group 18-36 32 (28.3) 28 (34.1) 37-60 65 (57.5) 47 (57.3) 60+ 16 (14.2) 3(2.7) Gender Male 55 (48.7) 39 (47.6) Female 58 (51.3) 43 (52.4) Race White 14 (12.4) 15 (18.3) Black 99 (87.6) 67 (81.7) Morisky Medication Adherence Score 7 (6.19) 8 (9.76) 1 17 (15.0) 10 (12.2) 2 20 (17.7) 23 (28.0) 3 34 (30.1) 8 (9.76) 4 33 (29.2) 20 (24.4) Baseline PAM Level 1 12 (10.6) 4 (4.88) 2 27 (23.9) 27 (32.9) 3 36 (31.9) 29 (35.4) 4 38 (33.6) 22 (26.8)

Baseline Study Participant Characteristics

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Participant Characteristics

Poisson Regression of Primary Care Visits IRR (95% CI)

CHW Group

1.12 (0.94-1.33) 1.17 (0.98-1.40) 1.10 (0.92-1.30) 1.16 (0.98-1.38) 1.36 (1.14-1.64) 1.12 (0.95-1.34) 1.56 (1.29-1.88)

Age Group 18-36

Reference Reference

37-60

2.14 (1.71-2.68) 2.36 (1.87-2.97)

>60

2.42 (1.81-3.24) 2.13 (1.57-2.89)

Female

1.72 (1.44-2.05) 1.76 (1.46-2.12)

African-American or African Descent

3.12 (2.10-4.62) 2.75 (1.84-4.10)

Morisky Medication Adherence Score

Reference Reference

1

0.82 (0.55-1.21) 0.67 (0.45-1.00)

2

0.98 (0.70-1.38) 0.89 (0.63-1.27)

3

1.42 (1.02-1.99) 1.18 (0.84-1.68)

4

1.02 (0.73-1.42) 0.85 (0.60-1.19)

Baseline PAM Level 1

Reference

2

0.49 (0.37-0.64) 0.42 (0.32-0.56)

3

0.46 (0.35-0.60) 0.36 (0.27-0.48)

4

0.55 (0.42-0.71) 0.36 (0.28-0.48)

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Study Implications

CHW Intervention

 Associated with increased adherence to primary care follow-up post ED encounter  May have a potential role for decreasing frequent ED utilization for non-emergent conditions  Larger sample size and longer follow-up duration can help better characterize impact

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….But What do Our Patients Think?

 “She followed up with me, over the entire thing—about 3 months. She met with me at some of my appointments. She was really great.”  “…thoughtful for the medical profession to follow up behind the patients and see how they’re doing after their visit. Very helpful.”

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….But What do Our Patients Think?

 “Really wonderful. She came with us to different appointments and when the doctor said something we didn’t understand, she was able to ask the question in a way so that the doctor could clarify for us and say things in a way where we could understand.”

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Acknowledgements

Tynetta (Tye) Lane, CHW Eili Klein, PhD Yu-Hsiang Hsieh, PhD Scott Levin, PhD Felicia Hill-Briggs, PhD Richard Rothman, MD, PhD

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References

  • 1. Perry HB, Zulliger R, Rogers MM. “Community health workers in low-, middle-, and high-income countries: An overview of

their history, recent evolution, and current effectiveness.” Annu Review Publ Health 2014 Jan; 35:399-421.

  • 2. Newell KW, ed. 1975. Health by the People. Geneva: World Health Orgn.(WHO)
  • 3. Jencks SF, Williams MV, Coleman EA. “Rehospitalizations among patients in the Medicare fee-for-service program.” N Engl

J Med. 2009 Apr 2;360(14):1418-28.

  • 4. Shulan M, Gao K, Moore CD. “Predicting 30-day all-cause hospital readmissions“ Health Care Manag Sci. 2013

Jun;16(2):167-75. Epub 2013 Jan 27.

  • 5. Moore BJ (IBM Watson Health), Stocks C (AHRQ), Owens PL (AHRQ). Trends in Emergency Department Visits, 2006–2014.

HCUP Statistical Brief #227. September 2017. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup- us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-VisitTrends.pdf

  • 6. LaCalle E, Rabin E. “Frequent users of emergency departments: the myths, the data, and the policy implications.” Ann

Emerg Med. 2010 Jul;56(1):42-8.

  • 7. Ruger JP, Richter CJ, Spitznagel EL, Lewis LM. “Analysis of costs, length of stay, and utilization of emergency department

services by frequent users: implications for health policy.” Acad Emerg Med. 2004 Dec;11(12):1311-7.

  • 8. Lehmann U, Sanders D. “Community health workers: What do we know about them? The state of the evidence on

programmes, activities, costs and impact on health outcomes of using community health workers.” January 2007. Evidence and Information for Policy, Department of Human Resources for Health. World Health Organization, Geneva, CH.

  • 9. Ogunniyi A, et al. “Analysis of trauma care education in the South Sudan community health worker training curriculum.”

Prehosp Disaster Med. 2015 Apr;30(2):167-74.

  • 10. Khan, et al. “Study Protocol: Validation and Adaptation of community-worker-administered stroke symptom

questionnaire in a periurban Pakistani community to determine disease burden.” J Vasc Interv Neurol. 2015 Feb;8(1):1-10.

  • 11. Charanthimath U, et al. “The feasibility of task-sharing the identification, emergency treatment, and referral for women

with pre-eclampsia by community health workers in India.” Reprod Health. 2018 Jun 22;15(Suppl 1):101.

  • 12. Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, Shannon RP, Long JA. Patient

centered community healthworker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern

  • Med. 2014 Apr;174(4):535-43.
  • 13. Gaskin DJ, Vazin R, McCleary R, Thorpe RJ. The Maryland Health Enterprise Zones Initiative reduced hospital cost and

utilization in underserved communities. Health Affairs. 2018 Oct;37(10):1546-1554.

  • 14. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing

and measuring activation inpatients and consumers. Health Serv Res. 2004;39(4, pt 1):1005-1026.

  • 15. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication
  • adherence. Med Care. 1986 Jan;24(1):67-74.
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Thank You

Erica Shelton, MD, MPH, MHS eshelto1@jhmi.edu @EricaSheltonMD