Integration of Behavioral and Medical Care by Using Traditional Health Workers (THW)

1. Integration of Behavioral and Medical Care by Using Traditional Health Workers (THW) MOMS and EDIT Veronica Sheffield MS BSN RN

2. Meeting Members Where They Are • One of the CCO mandates is the use of Traditional Health Workers. (THW) • THW are called navigators, community health workers, and peer wellness specialists here in Oregon. • AT WVCH we also call them mentors. • When we think of health care – we often think of doctors, nurses and social workers, those “experts” who tell us what is “wrong” and they often decide what’s “happen next”. • THW are not experts, they are not here to tell members what is wrong or what to do.

3. “Non”-Traditional Health Workers Their primary goal is to activate members so that: • Members feel empowered to express their needs and desires. • Members learn skills to advocate for themselves. • Members and providers have shared control and shared responsibility for what happens next.

4. THW- Mentors: • Role modela success story and enhance a member’s belief in self • Encourages members to develop and focus on reaching their personal health goals. • Navigates the member through the maze of community/health resources. • Advocate for the member .

5. MOMS PROGRAM Empowering pregnant women who struggle with drugs/alcohol to stay clean and sober while developing the tools they need for themselves and their families.

6. MOMS In 2005, the year before we started MOMS: • Methamphetamine abuse was a major problem. • The number of babies born with a positive drug screen was increasing. • The number of babies taken at birth for a positive drug screen in Marion county was 114.

7. Who is involved? The program consists of: • Mentors (THW) • Plan Level Nurse Case Managers- Public Health Nurses (CaCoon, Babies First) • Providers (OB, PCP, Behavioral Health) • Other Agencies (DHS, parole/probation, drug court, Early Childhood programs) • Members

8. HOW IT WORKS? Screening/Assessment: Alcohol/Drug assessment , mental health assessment, random drug screenings, and depression screening Services: Prenatal care, behavioral health, dental, and non-medical services (WIC, housing, vocational and educational services, parenting classes,and domestic violence interventions)

9. Results in Marion County The number of babies taken at birth for a positive drug screen in Marion county has dropped from: • 114 in 2005 • 11 in 2012 • 99.9% of MOMS participants test negative for illegal drugs and alcohol at the birth of their babies.

10. Emergency Department Intervention Team (EDIT) Empowering individuals to build healthy lives

11. Emergency Department Intervention Team (EDIT) • This team includes mentors, plan level nurse case managers, a psychiatrist, the member’s providers, and most importantly the MEMBER. • This team’s goal is to identify the healthcare needs and care barriers for members who use the Emergency Department frequently - • 3 times in a month, • 6 times in 6 months or • 10 or more times a year. • The team develops a plan together to help meet the complex health needs of these members. This plan includes Metric screening (Depression, SBIRT)

12. A Case Study… Clinical Picture • Diabetic type 2, Fibromyalgia, chronic lung disease (COPD), Bi-polar, Coronary Artery Disease, Hypertension and chronic nausea- gastro paresis. .. • Interventions • Member actively engaged in developing their own plan of care • PCP no longer prescribed psych meds- their newly engaged mental health provider does • Transportation, a major barrier to care, was addressed • Member was scheduled with needed specialists • Mentor supported member during a stressful court issue (non medical) .

13. Outcomes to Date: For this member: ED visits last year were 41, there has been only two visits since entering the EDIT program. Overall we have seen approximately a 70% reduction in ED use in our EDIT participants who also verbalize their experience of care as improved.