Planning and Delivering a Better Health System: Community Health Workers In a New Environment

1. Center for Health Innovation Planning and Delivering a Better Health System: Community Health Workers In a New Environment

2. 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

3. Who is the Safety Net for? Those who fall through the cracks……….or?

4. Everyone!!! 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!!!!

5. Policy and Financing Expand Access – Increase Workforce Demand Before HMS After HMS . 96% of Population has 30 Minutes Access to Primary Care! Increases Demand For Comprehensive PC Services!

6. Serving Frontier AmericaGeographic Access to Specialty Care PC Capacity, Patient Management and Access to Specialty Services are Critical Issues in the Frontier

7. Disproportionate Representation of High Need Populations = Service Challenges • United States Census Bureau, 2010 Census • U.S. Census Bureau, 2005-2009 American Community Survey

8. Disproportionate Poverty =Health Disparities As Well 1. U.S. Census Bureau, Small Area Income and Poverty Estimates, 2010

9. Health Disparities Example73% Overweight / Obese

10. Almost 70% Pre-Hypertensive or Worse

11. Center for Health Innovation Reducing Cost Improving Care Improving Health Meaningful Use - EMR Potential Patient Centered Medical Home + (Not Medical Only) Innovations Application Payment Reform Work -General Rural Health Dilemma – Volume-Based Payments -CHW Innovations Dilemma – Volume Based Payments Service Focused Payments vs. Patient Focused Payments Responding to New Incentives and Directions

12. 4 Core Primary Care Services • Medical • Dental • Behavioral • Family Support Services • Community Health Workers • Care Coordination • Clinical Support Staff • Nutrition, Exercise, Supervision

13. 4 Core Primary • Care Services • Medical • Dental • Behavioral • Family Support • (CHW’s +) • Range of Care • Prevention • Diagnosis • Treatment • Management • Internal Systems • Vertical Services • Therapeutic Care • Subspecialty • In/Outpatient Hospital • Long Term Care • Horizontal / Social Context • Health Equity • Economic Opportunity • Education • Social Services Categorical Services, Payment Disincentives and Dis-integration

14. Shifting Goals in a New Health and Cost Focused System Chaos to OrderComplexity to SimplicityDisincentives to Incentives Scientific Advances to Social Determinants Over Treating to Improving Quality of LifeService Focus to Patient Self Management

15. PC System: Vertical and Horizontal Patient Support Center for Health Innovation V E R T I C A L C O O R D I N A T I O N • Prevention • Diagnosis • Management • Treatment Current Model Horizontal – Actual / Virtual Team Support

16. Education & Support CHW - Interventions Based on Spectrum of Health Services • Care Coordination • Community Organization and Advocacy • Enrollment & Prevention Management w/ Team Interventions Diagnosis & Treatment Cost/Complexity Prevention % Population

17. Dimensions of CHW Intervention Strategies Community Level Promotion V I R T U A L A C T U A L Patient Population Communication Categorical Patient Support High Need Patients

18. 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

19. Build Capacity for Integrated Clinical Primary Care Services 2011 Rural Rotations at HMS

20. New Types of Health Professional Skills Clinical Support Staff 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 • 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

21. Does it Work? We Believe!

22. HbA1c Lab Analysis – Clinical Interventions Diabetic 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

23. 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

24. Non-Clinical Approach – CDCBefore and After Visit to CHW CHW Intervention

25. Findings: UNM NIH Grant 2011 Corazon Por La Vida Control N= 400 Tx Group = 98

26. 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

27. More is Not Necessarily Better Benefits of Complexity Level of Complexity Complexity, Problem Solving and Sustainable Societies, Tainter 1996

28. 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.

29. HMS – Opportunities to Integrate Silver City Commons Nutrition Team – Training Exercise Team Education Team – Training

30. HMS-Integrated Services 2nd Floor Plan Silver City Team – Training Team Team Community Health Worker

31. HMS – Senior Wellness Center Lordsburg Team Nutrition PC and MH Exercise Education Education Team Community Health Worker

32. For More Information Charlie Alfero, Executive Director Hidalgo Medical Services Center for Health Innovation 610 N. Bullard Street Silver City, NM 88061 575-534-0101 x2101 Calfero@hmsnm.org