Community Health Educator Referral Liaison (CHERL): A Potential New Role for Primary Care Practice

1. Community Health Educator Referral Liaison (CHERL): A Potential New Role for Primary Care Practice Jodi Summers Holtrop PhD Michigan State University Department of Family Medicine Great Lakes Research Into Practice Network (GRIN)

2. Our Story… Of how CHERL was born

3. 5 A’s Clinical Practice Guidelines for Health Behaviors1 • Assess • Advise • Agree • Assist • Arrange

4. Practices were having trouble getting past the first two A’s (assess/ask and advise) • Assess, Advise • Tobacco – pretty good; diet/physical activity – some; alcohol - poor • Agree, Assist, Arrange • Mostly not happening • Some studies MADE it happen – not sustainable2,3

5. At the same time… Holtrop, et al., qualitative study of clinician referral to a smoking cessation quit line – why do they NOT refer? • Overwhelmed and gave up • Black hole phenomenon 4 “…I have a lot going on with the patients … other than smoking. If there’s a program in place that can actually track whether or not the patient is successful in quitting really is what I’m most interested in…” - clinician

6. Their Idea “…it’s wonderful to have a single referral source that I can simply refer people to, and it make the job infinitely simpler. And it actually makes it possible in my mind. It’s almost impossible if within the context of our office we have to look up and see what the health plan is, and then try to match that against the appropriate referral capabilities.” - Clinician

7. We Need a Bridge! Health behavior change resources Patients in primary care “CHERL”

8. What is a CHERL? Community Health Educator Referral Liaison • Pronounced like CHERYL or SHARYL

9. CHERL – What we Proposed Problem: Patients in primary care with poor health behaviors don’t get effectively connected with services • Behaviors not identified • Patients not referred to services • When referred, patients don’t follow through Solution: CHERL coordinates the referral • Practice identifies behaviors, refers to CHERL • CHERL contacts patients, coordinates referral, provides feedback to practice

10. Intervention - Practice 15 Practices in Three Communities: • Identify health risks (diet, physical activity, tobacco, alcohol) • Refer to CHERL (fax) • Review feedback letters Perspective of Practices… • Research project • Totally NEW role • NO money • Don’t send us too many (only one 70-80% CHERL per community)

11. Intervention – CHERL CHERL: • Develop relationship with community resources and maintain resource guide • Develop, together with the practice, a plan for identification and referral of eligible patients • Accept patient referrals from practices • Contact patients (all telephone) and refer them to resources. Provide behavior change counseling if needed • Reassess patients at 3 and 6 months • Send clinician patient-specific feedback letter (initial, 3, 6 months)

12. Our Results

13. Diversity of Patients Mean age 48 (SD=13) Female 70% African American 18%; White 78% High school education or less 39% Less than $15,000 income 25% Positive depression screen 42% One or more chronic diseases 88% No health insurance, Medicaid or local health plan 28%

14. Most Practices Referred Patients to CHERL • Most practices found at least some patients with health risks and referred to the CHERL • One liked the idea so well, they hired their own “CHERL” type person (nurse practitioner)

15. Practice Referral to CHERL 589 797 Referrals* 517 267 19 *Raw numbers of referrals for each behavior and total

16. Patients Reported Improved Health Behaviors • Once engaged, able to change regardless of age, race, gender or SES

17. Patients Health Behaviors Pre-Post5 N=446; intention to treat analysis

18. What we Really Learned

19. We Need a Bridge! Health behavior change resources Patients in primary care “CHERL”

20. What the Bridge was Really Like6 Health behavior change resources Patients in primary care “CHERL”

21. Patient Referrals 446 Community Referrals

22. So Why Don’t We Just Have Practices Refer to Resources? Why do we need a CHERL?

23. Practices Need Support • Demands to see more patients in less time • Focus on doctor visit for payment • Lack of personnel to support prevention • Change can be difficult

24. CHERYL Offered “One Stop Shopping” Health Behavior Referral Easy for the practices to refer patients to the CHERL

25. Patients Needed to be Supported Not Just “Connected” • Patients needed more just a pass-off to another resource. Follow-through important. “If it weren’t for you, I would not have done this (quit smoking).” – Patient

26. CHERL Facilitated Use of Unused Existing Resources “The diabetic educator comes to the clinic 1 day a week for 4 hours every Wednesday. Did you (the clinical staff) forget that she’s there? Did you forget that [diabetes] is their overall major problem, and you/no one referred the patient to this wonderful community resource we have that’s covered by insurance for the most part?” - CHERL

27. CHERL Facilitated Relationships with Community Resources to Get Patients Engaged in Using Them “I knew the person over at the YMCA so I got a couple people on the scholarship program. Referring them over to Patty at the YMCA, and they were able to apply for the scholarship and now they’re going to the YMCA.” - CHERL

28. “Then somebody has to reinforce [behavior change] long-term. So follow-up is real important until people ingrain those behavioral changes into them and it’s just something that they do.” - Clinician CHERL Filled in Gaps where There Was a Lack of Resources Offering Behavior Change Support

29. CHERL Facilitated Motivation Not Just Dispensed Information • CHERL used motivational focus rather than education focus • Need for understanding on how to make change “I needed someone to be held accountable to other than myself.” - Patient

30. CHERL Addressed Other Patient Issues • Majority had chronic disease • Almost half screened positive for depression; co-morbid mental health an issue • Low-income and lack of money to pay for services

31. As a Result…the Resource Guide Changed FROM – Alcohol, Diet Physical Activity, Tobacco TO - Diabetes education, Mental Health, Food Pantry Referral helpline (211), Financial Assistance

32. CHERL Supported Practices by Assisting with Difficult/Complex Patients • “… it would actually help the entire staff because you would be taking patients that are frequently frustrating to the nursing staff and the physician …” - CHERL

33. CHERL Supported the Patient-Physician Relationship • “Working with the patients, I did a lot of educating them to advocate for their health. How did they ask their doctor questions? I gave them a lot of tips like write things down before you go in to your doctor…”-CHERL

34. CHERLs had Different Training, but all Were Successful • Deb (Nurse) • Amy • (Dietitian/HE) MSU • Laurie (Health Educator)

35. What is Unique about the CHERL Role?

36. CHERL is Many Roles… • Health care team member • QI facilitator • Health behavior change counselor/coach • Referral coordinator/resource guide manager • Relationship-builder (practice/patient/community) • Data collector (C-base)

37. CHERL Implementation Challenges and Questions • Difficult to reach people via telephone • Is it better to combine in-person and telephone counseling? • Limited scope of CHERL’s role • Does CHERL only do health behavior or chronic disease self-management (or other) also? • Managing the patient contacts and data • What systems support patient identification and referral? • What systems assist CHERLs in counseling and referral to resources? • What data gets reported to clinicians/practices? • Overwhelmed by patient load • What is a reasonable/cost effective patient load? • Lack of follow-through - both patients and practices • How to improve reach to patients?

38. CHERL Sustainability Funding at the practice level is key. Opportunities include: • Insured patients – • Pay for performance/PCMH initiatives • Direct billing for care management for patients with chronic disease • Group visits • Documentation improvement/billing for more comprehensive care • Care management “delegation” • Other ideas – • Employer/community resource contracting • Out of pocket payment

39. Further Information http://www.aboutcherl.org Jodi Summers Holtrop, PhD Department Family Medicine Michigan State University B105 Clinical Center East Lansing MI 48824 (517) 884-0432 Jodi.holtrop@hc.msu.edu

40. References 1Whitlock E, Olreans C, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-283. 2Woolf SH, Glasgow RE, Krist A, Bartz C, Flocke SA, Holtrop JS, Rothemich SF, Wald ER. Putting it together: finding success in behavior change through integration of services. Annals of Family Medicine. 2005;3(S2):S20-27. 3Dosh S, Holtrop J Summers , Torres T, White L, Baumann J, Arnold A. Changing organizational constructs into functional tools: an assessment of the five A’s in primary care practices. Annals of Family Medicine. 2005;3(S2):S50-52. 4Holtrop J Summers, Malouin R, Weismantel D, Wadland W. Clinician perceptions of factors influencing referrals to a smoking cessation program. Biomed Central Family Practice. 2008;9:18. 5Holtrop J Summers, Dosh SA, Torres T, Thum YM. The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors. American Journal of Preventive Medicine. 2008;35(5S):S365-72. 6Etz R, Cohen D, Stange K, Holtrop J Summers, Olson A, Donahue K, Woolf S, Ferrer R, Hickner J. Linking primary care practices and communities. American Journal of Preventive Medicine. 2008;35(5S):S390-7.