planning and delivering a better health system: community health workers in a new environment center...
TRANSCRIPT
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Planning and Delivering a Better Health System:
Community Health WorkersIn a New Environment
Center for Health Innovation
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The Center for Health Innovation
• Create the Environment that ensures the success of HMS and the Communities it serves through:– Policy – Planning – Resource Development– Capacity Building and Program Implementation– Partnering
• Management Services Organization• Professional Service Contracts• Topical Conferences, Training and Education• Collaborative and Organizational Resource Development
• No Direct Health Services Provided
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Who is the Safety Net for?
Those who fall through the cracks……….or?
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What Do We Want? Evidenced Based Change!!!!When Do We Want It? After Peer Review!!!!What Do We Want? Evidenced Based Change!!!!When Do We Want It? After Peer Review!!!!
Everyone!!!
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Before HMS After HMS
Increases Demand For Comprehensive PC Services!
.
Policy and FinancingExpand Access – Increase Workforce Demand
96% of Population has 30 Minutes Access to Primary Care!
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Serving Frontier AmericaGeographic Access to Specialty Care
PC Capacity, Patient Management and Access to Specialty Services are Critical Issues in the Frontier
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Disproportionate Representation of High Need Populations = Service Challenges
1.United States Census Bureau, 2010 Census2.U.S. Census Bureau, 2005-2009 American Community Survey
Demographic Data Grant Hidalgo NM U.S.
Total Population 1 29,514 4,894 2,059,179 308,745,538
Population under age 18 1 21.9% 25.8% 25.2% 24.0%
Population 65 and over 1 21.3% 16.7% 13.2% 13.0%
Hispanic 1 48.3% 56.6% 46.3% 16.3%
White, Non-Hispanic 1 48.6% 41.4% 40.5% 63.7%
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Disproportionate Poverty =Health Disparities As Well
Poverty and Income Grant Hidalgo NM U.S.
Population in poverty 1 18.9% 25.2% 19.8% 15.3%
Under age 18 in poverty 1 29.5% 38.9% 28.5% 21.6%
Median Household Income 1 $36,756 $30,280 $42,186 $50,046
1. U.S. Census Bureau, Small Area Income and Poverty Estimates, 2010
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Health Disparities Example73% Overweight / Obese
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Almost 70% Pre-Hypertensive or Worse
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RESPONDING TO NEW INCENTIVES AND DIRECTIONS
Reducing CostImproving CareImproving Health
Meaningful Use - EMR PotentialPatient Centered Medical Home + (Not Medical Only)Innovations Application Payment Reform Work-General Rural Health Dilemma – Volume-Based Payments
-CHW Innovations Dilemma – Volume Based PaymentsService Focused Payments vs. Patient Focused Payments
Center for Health Innovation
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4 Core Primary Care Services
• Medical• Dental• Behavioral• Family Support Services
• Community Health Workers• Care Coordination• Clinical Support Staff
• Nutrition, Exercise, Supervision
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Horizontal / Social Context
• Health Equity• Economic Opportunity• Education• Social Services
Vertical Services• Therapeutic Care• Subspecialty• In/Outpatient
Hospital• Long Term Care
4 Core Primary Care Services
• Medical• Dental• Behavioral• Family Support (CHW’s +)
Range of Care• Prevention• Diagnosis• Treatment• ManagementInternal Systems
Categorical Services, Payment Disincentives and Dis-integration
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Shifting Goals in a New Health and Cost Focused System
Chaos to OrderComplexity to Simplicity
Disincentives to IncentivesScientific Advances to Social DeterminantsOver Treating to Improving Quality of LifeService Focus to Patient Self Management
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Prevention
Diagnosis
Treatm
entManagement
Horizontal – Actual / Virtual Team Support
VERTICAL COORDINATION
CurrentModel
Center for Health Innovation
PC System: Vertical and Horizontal Patient Support
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Community
Organization
and Advocacy
Education &
Support
Care
Coordination
Cost/Complexity% Population
Management w/Team Interventions
CHW - Interventions Based on Spectrum of Health Services
Diagnosis & Treatment
Prevention
Enrollment &
Prevention
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Dimensions of CHW Intervention Strategies
Community Level Promotion
Patient Population Communication
Categorical Patient Support
High Need Patients
VIRTUAL
ACTUAL
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What Can a Health System do?• Develop New and Viable Models
– Invest in Workforce Development / Partnerships• FORWARD NM – Student / Resident Rotations• 1+2 Residency Development• Incorporate New Types of PC Providers and Integrate Training
– Rethink CHC/FQHC Service Requirements – PC System• Minimum Requirements or Best Practices and Evidenced Based Modeling?
Enabling vs Family Support Services• Core PC Services Articulation (CHC+ Model)
– Rethink the Health Care System• Focus on People, Families and Community – Not Services• Active vs Passive / Reactive Systems• Integrated Health Services and Collaborative Systems• Service Centric Payments or Patient Centric Payments?• Global PC Core Service Payments• Contracted Services Based on – Participation Agreements
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2011 Rural Rotations at HMS
Medical Providers Dental Providers Nurse Practitioners/Midwifery
5 Pediatric Residents5 Family Medicine Residents3 Family Medicine Residents2 Physician Assistants1 Physician Assistant
Other Disciplines1 Anthropology Intern3 MA Counseling1 MA Counseling
11 Dental Residents4 Dental Students
2 Family Nurse Prac./Cert. Nurse Midwife1 Family Nurse Prac./Cert. Nurse Midwife
1 Family Nurse Practitioner
Medical Students5 BA/MD Students
2 Practical Immersion Medical Students
Nursing Students22 WNMU students
Total for the Year
69 Trainees
LEGEND: University of the Southwest
University of New Mexico Arizona School of Dentistry & Oral Health
University of Texas at El Paso
Frontier School of Midwifery & Nursing
Memorial Medical Center Western New Mexico University
Vanderbilt University School of Nursing
Wageningen University (Holland)
As of 12/31/11
Build Capacity for IntegratedClinical Primary Care Services
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New Types of Health Professional SkillsClinical Support Staff
• Community Health Workers– Outreach – Community Health– Prevention Campaigns
• CHW Navigators– Patient Support / Eligibility– Education– Social Determinants
• CHW Care Coordinators • Patient Communication Specialists –
Clinical Preventive Services – Scheduling / Reminders
• TEAM WORK!!! Training, Coaching and Facilitation
Technical Support Staff
• Researchers and Evaluators– EMR Utilization to Support Patient
Care Priorities and Program Development
– Geographic Analyses– Move from Process Problems to
Outcomes Improvements– Health Status Focus
• Virtual Patient Systems Communicators / Journalists– Community / Patient Population Levels– EMR Infrastructure Support
• UNM HEROs– Resource / Expertise Linking
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Does it Work?
We Believe!
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HbA1c Lab Analysis – Clinical InterventionsDiabetic Patient were given the option of CHW support. In 2011 :- 1,089 unduplicated patients were given a primary
assessment of Diabetes (ICD-9 250.xx)- Of these patients, 988 had at least 1 reportable HbA1c lab value from
October 2010 – December 2011- 717 had at least 2 lab values- 363 had at least 3 lab values- 157 had at least 4 lab values- 41 had at least 5 lab values- 4 had at least 6 lab values
- The following chart plots the progress of the 157 patients and their 4 most recent lab values
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HbA1c Lab Analysis
Of the 157 patients we saw an increase in pts. under control and a decrease in those not in control:-43 saw a decrease in HbA1c over the year-26 maintained an HbA1c under 7 throughout the year-19 had an increase in HbA1c over the year-The remaining 69 either maintained a level between 7.0 – 8.9 or a level over 9 throughout the year
Finally, the median lab value of the 1st lab was 7.9 and the median value of the 4th lab was 7.4
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Non-Clinical Approach – CDCBefore and After Visit to CHW
CHWIntervention
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Findings: UNM NIH Grant 2011
Control
TreatmentControl
TreatmentControl
TreatmentControl
Treatment0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
16.23% 14.14% 13.96% 15.15% 14.61% 15.15% 13.64% 15.15%
32.79%
48.48%38.96%
50.51%41.23%
50.51%
38.64%
52.53%
39.29%
25.25%
31.82%
24.24%
30.52%
27.27%
33.12%
28.28%
11.69% 12.12% 15.26%10.10% 13.64%
7.07%14.61%
4.04%
Changes in Hypertension Rates(unadjusted)
Stage 2Stage 1PrehypertensiveNormal
.Post-intervention 6-month follow-upBaseline 3-month follow-up
CorazonPorLaVidaControl N= 400Tx Group = 98
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When Is It Too Much?
• Virtual Interventions• Actual Interventions• Info Overload• Scientific / Technical Models • CBPR and Evidenced Based Change• Process Evaluation(PDSAs)• Endless Committees• Accreditation
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More is Not Necessarily Better
Complexity, Problem Solving and Sustainable Societies, Tainter 1996Level of Complexity
Bene
fits
of C
ompl
exity
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Molina / UNM / HMS Care CoordinationNon-Clinical Interventions
• During a 25-month period, HMS/UNM provided Care Coordination Services to the most expensive Medicaid Patients regardless of Condition.
• Substantial reduction in ER, in-patient, prescription, and narcotic drug utilization and cost among the CHW-intervention group compared to the non-intervention group.
• Total cost savings was over $2 million post intervention, compared to an estimated total program cost of $521,343.
• Molina is now expanding the program in half the counties in NM and will implement the program in all states in which they operate.
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HMS – Opportunities to Integrate
Nutrition
Exercise
Education
Team
Team –
Training
Team –
Training
Silver CityCommons
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HMS-Integrated Services 2nd Floor Plan
Team
Community Health Worker
Team
Team –
Training
Silver City
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HMS – Senior Wellness CenterLordsburg
Nutrition
Education
Exercise
Community Health Worker
Education
PC and MH
Team
Team
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For More Information
Charlie Alfero, Executive DirectorHidalgo Medical ServicesCenter for Health Innovation610 N. Bullard StreetSilver City, NM 88061575-534-0101 [email protected]