Michigan Pathways to Better Health

1. MACMHB May 21, 2014 Michigan Pathways to Better Health

2. Barb Glassheim – Project Manager, Saginaw Judy Kell – HUB Director, Muskegon Linda Tilot – MIECHV HUB Project, Saginaw Lori Noyer – Project Coordinator, Ingham Presenters

3. Objectives • Describe an effective model for integrating health care and social services for high-risk populations • Describe the role of a Community Health Worker • Describe the role and benefits of a Community HUB • Topics • Community HUBs • Integrated service delivery • Community Health Workers • Working with high-risk clients • Using technology to enhance service delivery Overview of Presentation

4. Funded by 3-yr CMS Innovations Grant awarded to MPHI to demonstrate cost savings over usual care (7/1/12 - 6/30/15) • CMS Acknowledgement • The project described was supported by Grant Number 1C1CMS331025 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. • Implementation • Ingham County HUB • Muskegon County HUB • Saginaw County HUB Michigan Pathways to better Health

5. Supports Institute of Healthcare Innovation’s Triple Aim by delivering better health and access to quality care at lower cost • Improve individual’s experience of care • Improve health of populations • Reduce per capita cost of care Michigan Pathways to Better Health

6.  primary care-sensitive ED visits & inpatient admissions •  utilization of primary care • Connect clients to needed primary & specialty care (mental health, substance abuse services, dental, etc.) • Connect clients to social services • Social determinants of health Project Goals

7. Social determinants of health

8. Adult (age 18+) Enrolled in/eligible for Medicare &/or Medicaid 2 or more chronic health conditions Live in Ingham, Muskegon, Saginaw & selected adjacent counties High-risk (5 or more ED visits, 3 or more hospitalizations in last 12 months) Target Population

9. Chronic Conditions • Addictions/Substance abuse • Alcohol abuse • Alzheimer’s disease • Anxiety disorder • Arthritis • Asthma • Osteoporosis • Parkinson’s disease • ADHD • Bipolar disorder • COPD • Diabetes • Eating disorder • Personality disorder • Emphysema • Congestive heart failure • Dementia • Depression • Hypertension

10. Chronic Conditions • Autism • Hearing impairment • Hyperlipidemia • Aphasia • Ischemic heart disease • Kidney disease • Bipolar disorder • Obesity • Schizophrenia • Cancer • Panic disorder • Stroke/Transient ischemic attack • Tobacco abuse • Vision impairment • Atrial fibrillation • Amputation • Others

11. Community HUB Care Coordination Agencies (CCAs) Community Health Workers (CHWs) Pathways Technology Components

12. Developed by Dr. Mark Redding & Dr. Sarah Redding • AHRQ • http://www.innovations.ahrq.gov/guide/HUBManual/CommunityHUBManual.pdf Community HUB Model

13. Measure Outcomes • Find • Treat • Measure Target Population - Find those at greatest risk Confirm connection to evidence-based care Measure the results

14. Meet with clients (at home) to conduct an intake to determine unmet needs Conduct monthly home visits Establish goals and help clients meet those goals through Pathways Help clients understand their chronic diseases and how to manage them Supervised by nurses and social workers CHWs

15. Help clients make positive lifestyle choices to promote health and well-being Help clients navigate the health and human services systems to get them connected to resources to improve their health and wellbeing CHWs

16. CHWs work with each client according to specific structured checklists and Pathways (protocols) to facilitate access to needed human services agencies and/or healthcare services CHWs track client progress to complete Pathways sequences and reach milestones CHWs

17. Initial one week training session that includes: • Communication & Relationship Building • Chronic Conditions • Healthy Lifestyles • Client Education • Client Motivation • Additional training: • Cultural Competence/Social Justice • 5 As – Tobacco Cessation • Motivational Interviewing • PATH (Personal Action Toward Health) • Home Visiting Safety • Healthy Homes for CHWs • Mental Health First Aid CHW Training

18. Pathways document steps toward an outcome: • Primary care appointment kept • Utilities turned back on • Housing obtained • Health education received Pathways

19. Pathways • Medical Referral • Medical Home • Medication Assessment & Management • Social Services Referral • Health Insurance • Smoking Cessation • Pregnancy • Post Partum • Family Planning • Education

20. Medical Services pathways • Primary care • Specialty care • Dental care • Vision care • Audiology • Pharmacy • Nutrition/Dietician • Family Planning • Mental Health Tx • SUD Tx • COD Tx • Speech & Language Services • DME (with script)

21. Social Services Pathways • Family • Food/WIC/SNAP • Housing • Insurance • Finances • Medication • Transportation • Job/employment • Child care • Medical debt • Legal issues • Parenting • Domestic violence • Clothing • Utilities • Translation services

22. Serves as data and information clearinghouse Provides centralized client registry – avoid duplication of services Receives referrals, screens clients, makes assignments to CCAs; assures bi-directional communication with referral entities Monitors project activity for quality, targeting, safety, and productivity; submits monitoring information to MPHI Reports outcomes to the community Community HUB

23. Regional organization and tracking of care coordination Community HUB Care Coordination Agencies HUB – Client Coordination • Demographic Intake • Initial Checklist  assign Pathways • Regular home visits – checklists and Pathways completed • Discharge when Pathways complete (no issues)

24. A Connected Community of Supports & Services

25. Recruit, hire, supervise, deploy CHWs Accept referrals from HUB & assign CHWs to clients Document care coordination provided by CHWs using Pathways templates Transmit data from CHWs and Clinical Supervisors to the HUB Care Coordination Agencies

26. Technology At the HUB/CCA In the field

27. Mipathways database • Records client needs and readiness to adopt healthy behaviors • Documents services provided • Documents clinical outcomes • Suggests Pathways • Prevents Duplication

28. Tailored to Each Community

29. Lead Agency/Fiduciary – Ingham County Health Department • Community HUB – Ingham Health Plan • Convener – Power of We Ingham

30. Allen Neighborhood Center Capital Area Community Services Ingham County Health Department National Council on Alcoholism North West Initiative South Side Community Center Tri County Office on Aging Volunteers of America Ingham CCAs

31. Lead Agency/Fiduciary – Muskegon Community Health Project/Mercy Health Partners Community HUB – Muskegon County Government Administrative Services Convener – Muskegon Community Health Project/Mercy Health Partners Muskegon

32. Access Health • Lakeshore Health Network • Community enCompass • Disability Connection of West Michigan • District Health Department #10 • Every Woman’s Place • Hackley Community Center • Mission for Area People • Muskegon Community Health Project/Mercy Health Partners • Public Health – Muskegon County • Senior Resources • West Michigan Therapy Muskegon CCAs

33. Pro-Med Ambulance Call 211 Muskegon Referral Partners

34. Lead Agency/Fiduciary – SCCMHA • Community HUB – SCCMHA • Co-Conveners – Alignment Saginaw & MiHIA • CCAs • Covenant/VNSS • SMM/Center of HOPE • Health Delivery, Inc. (FQHC) • Saginaw County Department of Public Health

35. National Demonstration Pilot Project funded by Kresge Foundation grant • HUB standards • CCA standards • Policies • QA Manual HUB Certification

36. Maternal, Infant & Early childhood Home Visiting (MIECHV) Programs

37. Target population: pregnant women, children 0 – 5 & their families Provide referrals to HV agencies Eliminate duplication of services,  capacity of HV providers Data system Collect & share info;  communication & coordination across agencies MIECHV HUB

38. Source: MPHI 3/14 Project Data

39. Chronic Conditions Self report through 3/7/2014

40. Most Common Pathways

41. Most Common Medical referral pathways

42. Dietitian DME (requiring script) Family Planning Hearing Pharmacy Speech & Language Services Substance Abuse tx 606 Other Medical Referral Pathways

43. Most common social service pathways

44. Child & family assistance Education Financial Healthy homes Household items Insurance Job/employment Medication Social support 1460 Other Social Service Pathways

45. Successes & Challenges Voices from the Field

46. Job creation + Impact on wellbeing of clients CHW Job satisfaction Community Support for program Successes & Accomplishments

47. “My CHW has been readily available to me whenever I needed anything. They have worked with me to help access services and saw me through the processes until I got the help I needed.” “[CHW] is a gem. She always made me feel like I was the only client she had and I know that is not true but she made me feel that way. She helped me with my insurance paperwork and prescription coverage and I am forever grateful. She has helped me regain confidence in myself.“ “The [Pathways] program has really been helpful in identifying programs and services that I otherwise would not have found on my own.” Client feedback

48. "I think my short time as a community health worker has benefitted me as much or maybe more so than my clients. This experience has enlightened me not only to the problems we face as a community but also the great things we have to offer; that to really be a "community"  we have to work together for - and with - one another. I am excited about the possibilities". “The [MPBH] program allows me to connect personally with my patients to help them identify and access programs and services they truly need in order to live healthier lives. It makes me feel good to see the positive changes in patient’s lives after helping them overcome the different barriers in their way to staying healthy.” CHW Feedback

49. “I just want you to know what a privilege it has been to work with you in the Pathways Program. First of all my hope is this program will continue for a long time. When I think about the Community Health Workers involved with this program, they perhaps have no idea how valuable they are. I am thinking of two patients we referred from [hospital] and what an impact they have made in their lives. They have provided transportation, reminded of appointments, helped self manage medications for those that live alone. Those three things alone can preventan unnecessary readmission to the hospital. Secondly, many of this population that is served by your program, have fallen in the cracks of health care. They may not know what social services are available to them or what their "insurance" may or may not cover. If the services are not covered they are directed to an agency that may be able to assist. Thank you seems insignificant, but I am thankful for this service and plan to continue to make referrals.” Provider Feedback

50. Meeting grant enrollment targets • Engaging reluctant patients • Ongoing funding/sustainability • Scarce community resources • Universal – e.g., transportation • Unique to each community – e.g., psychiatric services Challenges