Transcript Montana AHEC and Office of Rural Health Montana Community Health Worker Dialogue May 28, 2015 Community Health Workers: National Perspectives and Trends Carl H.

Montana AHEC and Office of Rural Health
Montana Community Health Worker Dialogue
May 28, 2015
Community Health Workers:
National Perspectives and Trends
Carl H. Rush, MRP
Community
Resources LLC
5/28/15
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What’s your definition of CHW?
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Community Health Worker Definition
American Public Health Association (1)
• The CHW is a frontline public health worker
who is a trusted member of and/or has an
unusually close understanding of the
community served.
• This trusting relationship enables the CHW to
serve as a liaison/link/intermediary between
health/social services and the community to
facilitate access to services and improve the
quality and cultural competence of service
delivery.
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Community Health Worker Definition (2)
• The CHW also builds individual and
community capacity by increasing health
knowledge and self-sufficiency through a range
of activities such as
• outreach, community education, informal
counseling, social support and advocacy.
APHA Policy Statement 2009-1, November 2009
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CHWs are unlike other health-related
professions

Do not provide clinical care

Generally do not hold another
professional license

Expertise is based on shared life experience and
(usually) culture with the population served
(cont’d)
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CHWs are unlike other health-related
professions (2)

Rely on relationships and trust more than on clinical
expertise

Relate to community members as peers rather than
purely as client

Can achieve certain results more effectively than
other professionals
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Why CHWs now?

Growing diversity of U.S. population

Growing prevalence of chronic diseases

Growing complexity of health care

Cost pressures on health care system

Shortages of clinical personnel

Commitment to reducing health inequities

Recognition of social/behavioral determinants of health

Growing experience/evidence base with CHWs
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Why CHWs now?


The “Triple Aim”

Improving patient experience of care (quality and satisfaction);

Improving the health of populations; and

Reducing the per capita cost of health care
Health care reform: changing accountability for outcomes:
CHW as members of care teams

Accountable care organizations (ACOs)

Patient-centered medical homes (PCMHs)

Incentives to reduce costs, improve care
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Why CHWs now?

Why are we spending more than other industrialized
countries and getting worse outcomes?

We have the best trained clinicians, advanced
pharmaceuticals, expensive technology

What missing (or broken) in our system? My theory:
…relationships and communication
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CHWs are uniquely able to
“work both sides of the street:”
Skilled at techniques for both
community-level and patient-level
strategies
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CHWs address social determinants by:

Acting as SDOH expert on care team

Assisting patient with specific non-medical needs that affect
health and access to care

Mobilizing at the community level to enhance provider
understanding of community needs and preferences

Engaging the community to improve underlying social and
economic conditions that impact health
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CHWs can be the integrators!
Social determinants
have not been
integrated in clinic
practice or health
care systems
Leads
to lower value,
substandard care
Public
Health
SDOH
research &
intervention
Health Care
Individual Level
Disease Research &
Intervention
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The
National Academies Press.
11/7/2015
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Important National Trends
 Pace
of state experimentation with CHWs continues
to grow: ID, UT, ND, MO, KS starting recently
 Other
active states holding “kickoff” or other
statewide meetings in 2015: ID,VA, OR, UT
 More
national organizations getting on board:
ASTHO, NASHP, NIIOH, PCORI, AAFP, Sanofi
 Health
plan receptiveness to apprenticeships
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Example – National Academy for State Health Policy
(NASHP):
 State
 SIM
Health Refor(u)m blog on CHWs
Learning System for CMMI
 State
Health Refor(u)m webinar on CHWs:
highest ever attendance – 900+
 Potential
featured presentation at Fall conference
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Example: Sanofi US CHW initiative
 Create
a National CHW Organization
 Advance
State-level Policy Development
 Expand Awareness
 Pursue
of CHW Roles
a Focused Research Agenda
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= policy process driven/
sponsored by state health dept.
or Medicaid Office
Updated 2/26/15
© 2014-5 Community Resources LLC
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On the fast track
 Massachusetts
Credentialing Commission
 CHW
bills passed very quickly in first half of 2014:
IL, MD, NM
 Oregon
CCO legislation and
Traditional Health Workers Commission
 Wisconsin
Medicaid preventive services SPA
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National trends in
CHW training
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Successful CHW training systems must
consider key dynamics
 Unique
nature of the CHW workforce
 Dynamics
of the CHW labor market
 Emerging
consensus on definitions and standards
 Other
necessary aspects of policy infrastructure
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In addition to training standards, workforce
development strategy for CHWs must
consider:
 Who
will pay for training?
 Are
alternative models like apprenticeship
appropriate for CHWs?
 Long-term
career development and career
pathways
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High-performing CHW training programs
show key characteristics (1)

Strong emphasis on core competencies/skills

Instructional methods: adult learning,
participatory/experiential

“Popular education” model is favored

Build on life experience and prior learning

Courses offered in familiar community settings
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High-performing CHW training programs
show key characteristics (2)

Central importance of practicum/internship

Use performance-based assessment

Apprenticeship models gaining in popularity

Most students require financial aid or employer subsidy

CHW National Education Collaborative 2004-8
(www.chw-nec.org)

Focus on college based programs – funded by FIPSE
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Module 17 H09
Evaluation for Oral Presentation
Student ________________________
Date ______________________
Instructor ______________________
Recommended
indicators
Organization:
Main points distinct
1
2
3
Lack of
structure. Ideas
are not
coherent.
General structure
and organization
seems adequate,
main points and
details are blurred.
Content
Knowledge of subject
matter
Clearly did not
do homework,
inadequate
Demonstrated
minimum
preparation
Exercise thinking skills in
understanding
instructions
Did not
indicate
awareness of
the assignment
Actively interprets
directions but
needed
prompting toward
implementation
Good
presentation
however often
times needed
response from
peers to allow
the presentation
to flow.
Voice
rate, pitch, volume
Fails to
maintain
audience
interest due to
excessive
monotone rate
Not present on
day scheduled
for
presentation.
Inconsistent use of
voice to present
message
Tone fits verbal
message,
changing for
emphasis at
appropriate
moments
Good
presentation,
demonstrated
completion of
assignment
Overall oral
presentation
Present but not
ready.
Presentation was
unorganized,
directions not
followed.
Clear
organizational
pattern. Main
points are
distinct from
supporting
details.
Demonstrated a
good grasp of
the material,
Adequate
4
Effective
organization well
suited to purpose.
Main points are
clearly defined.
Excellent
presentation,
obviously
demonstrated
preparation of
content, Thorough
. Demonstrates
thorough
understanding of
instructions, well
organized
presentation and
informative
responses to
audience
Tone is authentic
and appropriate
to topic. Rate,
pitch and volume
vary at key points
Excellent
presentation,
organized, able to
entertain questions
from peers
Total Score _____/20 = ____ %
85% minimum required to successfully complete Performance Evaluation.
VERIFICATION OF SKILL PERFORMED:
N OTES/COMMENTS:
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Other parties need training too!

Upper management

Direct Supervisors

Instructors

Need is based on:


Unique nature of the CHWs work (and work style)

Characteristics of people who become CHWs

Fit of the CHW into organizational culture, especially in health care!
Supervisors and instructors will need to role model the relationship
they expect CHWs to have with community members (patients)
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Consensus is emerging on CHW skills

Based on full range of diverse CHW roles

Strong sense of state level self-determination

Wariness toward standards “imposed” from national level

Ongoing dialog about knowledge base requirements and
pre-hire vs. in-service learning

Interest in nationally standardized specialization training
as continuing education
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CHW roles and skills are better understood

National Community Health Advisor Study (U. of Arizona,
1998) was first systematic study of CHW roles and skills

CHW Scope of Practice is evolving, with greater emphasis
on roles within health care and in research

Growing demand has led to nationwide quest for “a good
curriculum”

…but existing curricula not often available to share/buy

National AHEC Organization began research in 2012…

…leading to the “CHW Core Consensus” (C3) Project
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C3 Benchmark Documents
STATE
Roles /Scope of Practice
(SOP)
Training Standards
(Curricula)
California
California Health
Workforce AllianceState Conf./Study
Community Health Works/
City College of San
Francisco
Massachusetts
Official State SOP
Official State Board of
Cert. Core Competencies
New York
New York State CHW
Initiative
New York State CHW
Initiative
Oregon
Scope of Practice
Committee, State Traditional
Health Worker Commission
Scope of Practice Comm., State
Traditional Health Worker
Comm.
(Comm. Capacitation Center Multnomah
County)
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Minnesota
MN Community Health
Worker Alliance
Official State Curriculum
CHR/IHS
Formal SOP
NA/Revisit –date tbn
Texas
State Definition of CHWs
State Curriculum
Standards 5/28/15
(Coastal AHEC certified curriculum )
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Crosswalk Sample Entry:
Skill: Communication Skills
Sub-Skill: Listening skills
Running Log: all skills standards /curricula address Listening
Benchmark Documents: (1-7)
• 1: Reflective listening skills
• 2: Practice careful listening, repeating back important information as necessary
to confirm mutual understanding, continually working to improve
communication and revisit past topics as trust develops with client
• 3: Identify and use active listening skills
• 4: Use active listening techniques
• 5: linked to other skill, see row 89
• 6: underlying skills, see Running Log
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• 7: see stated Roles
Proposed CHW Roles
 Maintained 7 roles from Nat’l CHW Study (1998)
 Identified 3 new roles:
 Implementing Individual and Community
Assessments (was a sub role)
 Conducting Outreach (was a sub role)
 Participating in Evaluation and Research
 (was an emerging role in 1998)
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NSub
Role
C3 Project CHW Roles - NOT FOR DISTRIBUTION 5-2015
-roles
1. Cultural Mediation
among Individuals,
Communities, and
Health and Social
Service Systems
a. Educating individuals and communities about how to use health and social service
systems (including understanding how systems operate)
b. Educating systems about community perspectives and cultural norms (including
supporting implementation of Culturally and Linguistically Appropriate Services
[CLAS] standards)
c. Building health literacy and cross-cultural communication
2. Providing Culturally a. Conducting health promotion and disease prevention education in a manner that
Appropriate Health
matches linguistic and cultural needs of participants or community
Education and
b. Providing necessary information to understand and prevent diseases and to help
Information
people manage health conditions (including chronic disease)
3. Care Coordination, a. Participating in care coordination and/or case management
Case Management,
b. Making referrals and providing follow-up
and System
c. Facilitating transportation to services and helping to address other barriers to
Navigation
services
d. Documenting and tracking individual and population level data
e. Informing people and systems about community assets and challenges
4. Providing Coaching a.
Providing individual support and informal counseling
and Social Support
b. Motivating and encouraging people to obtain care and other services
c.
Supporting self-management of disease prevention and management of health
conditions (including chronic disease)
d.
Planning and/or leading support groups
5. Advocating for
a. Acting as an advocate for individuals
Individuals and
b. Advocating for the needs and perspectives of communities
Communities
c. Connecting to and advocating for basic needs (e.g. food and housing)
d. Conducting policy advocacy
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6. Building Individual a.
and Community
b.
Capacity
c.
Building individual capacity
Building community capacity
Training and building individual capacity with CHW peers and among groups of CHWs
7. Providing Direct
Service
a. Providing basic screening tests (e.g. heights & weights, blood pressure)
b. Providing basic services (e.g. first aid, diabetic foot checks)
c. Meeting basic needs (e.g. direct provision of food and personal health-related items)
8. Implementing
Individual and
Community
Assessments
a. Participating in design, implementation, and interpretation of individual-level
assessments (e.g. home environmental assessment)
b. Participating in design, implementation, and interpretation of community-level
assessments (e.g. windshield survey of community assets and challenges)
9. Conducting
Outreach
10. Participating in
Evaluation and
Research
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a. Case-finding/recruitment of individuals, families, and community groups to
services and systems
b. Follow-up on health and social service encounters with individuals, families, and
community groups
c. Home visiting to provide education, assessment, and social support
d. Presenting at local agencies and community events
a.
b.
c.
i)
ii)
iii)
iv)
v)
Engaging in evaluating CHW services and programs
Identifying and engaging research partners, including community consent processes
Participating in evaluation and research:
Identification of priority issues and evaluation/research questions
Development of evaluation/research design and methods
Data collection and interpretation
Sharing results and findings
Engaging stakeholders to take action on findings
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Early Release Review &
Feedback Exchange
Memorandum of Understanding
C3 is working with select states/organizations offering limited
early release in exchange for feedback
 Wisconsin: active collaboration– integrating into




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Apprenticeship Program design
Illinois: coordination - response to state leg
Florida: coordination -new state association
Washington: local level training /pending
Oregon: state /pending
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Activity 1
Case study: Overview
p
of an initial assessment
l
This is a imulti-ar t cl ien t case study activtyi tha t asks learners to apply key concepts related
to client assessment. This activty w orks well as a review of the informatio
n
fr om
n Chapter
9 of Foundatios . This case study is in three parts, corresponding to the way that Chapter 9
describes the beginning, the middle and the end of an initia
t asses sme n t.
We recommend facilitatin
g
thi s as a cl os ed book activi y , or one in which the learnersl do not
consult the textbook. This helps them to internalize key concepts and to express them in their
own way.
Learning outcomes
Learners will be able to
•
•
T
F
Discuss and apply key concepts and skills sfor client-assessment to a case study scenario
Identify and explain key responsibilitie f or the beginning, middle and
i end of an
assessment
Time
A
R
This activty t akes 60-80 minutes. It can also be facilitated as three 20-25
i minute
. activties
Materials needed
•
•
Client case study. We have provided a case study about Arnold Winters, the client
introduced at the beginning of Chapter 9 of Foundatio
n
s (Appendix 1). As an alternative,
you may wish to develop your own 3-part case study.
Small and large groupndiscussion questios (pr ovided with each step below)
D
Trainer preparation
n
•
•
•
•
•
Review Chapter 9 from Foundatios
Assign learners to carefully read the chapter
Select or develop a case study scenario and make copies
Revise as necessary small groupndiscussion questios and m
a k e copies or post in the
training space
Review your own responses to
i the case study activties (inpr eparatio
n
of lar ge group
discussion)
Activity
STEP 1: Introduce the assignment
Tell learners that they will be discussing a client case study in small groups. They will be asked
to discuss
n
a series of questios , and t o describe how they would work with the client during
the beginning, middle and end
i of an initia in terview.
Assign learners to small groups of 3-5 particpan ts, and distribute Part 1 of the case study.
4 - Conducting initial client assessments
Foundations for Commuity Health W orkers - Guide for Teachers and Trainers
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National trends in
CHW employment
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An historic shift is taking place

CHWs’ roots are in economic opportunity and social justice

Their “outreach” role has been marginal to the health care system

Paid CHW positions have been “siloed” and financed by short
term grants and contracts

… but now they have been “discovered” by the health care
establishment
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www.spectrumhealth.org/healthiercommunities
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Overview of Core Health
Overview:
Core Health is a continuum-based free 12 month program for
adult clients with Heart Failure and/or Diabetes that:
■ Live in Kent County
■ Have economic, demographic, or cultural barriers to
healthcare
■ Are able to participate in a self-management program
Address barriers to achieve Self Management!
5
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Case Manager RN/CHW Model
Community
Health Worker
6
Case Manager
RN
Medical
Home/Specialist
Core Health Program Team
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Case Manager RN/CHW Model
Patient Experience - CHW
Weekly to Monthly visits
■ Data collection – VS, foot check, self
report
■ Goals using Motivational Interviewing
■ Education
■ Referrals – community connections
■ Self-Efficacy
Patient Centered - Address barriers
of equity and access
8
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Cost Efficiencies – Right Place Care
Emergency Department Visits
35.0%
Hospital Admissions
45.0%
40.0%
30.0%
35.0%
25.0%
30.0%
20.0%
25.0%
15.0%
20.0%
15.0%
10.0%
10.0%
5.0%
5.0%
0.0%
0.0%
Diabetes
Only
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Usage Rate
BEFORE Core
Health
Usage Rate for
Core Health
Experience
Heart
Failure
Only
Heart
Failure
AND
Diabetes
16.4%
31.1%
31.1%
12.0%
11.0%
11.0%
Usage Rate
BEFORE Core
Health
Usage Rate for
Core Health
Experience
Diabetes
Only
Heart
Failure
Only
Heart
Failure
AND
Diabetes
8.5%
38.2%
38.2%
3.1%
10.2%
9.3%
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Community Health Worker Led
Diabetes Coaching within the
Medical Home
Christine Snead, RN
Erin Kane, MD
Baylor Scott & White Health
www.alliancefordiabetes.org
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Diabetes Equity Project
•
•
Goal: To optimize primary care for “at-risk”
patients with diabetes
Tactics:
–
–
–
–
Embed community health workers within PCMH
Train and manage CHWs
Leverage software for data capture and
communication
Scale to five sites
9
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Shifting Tasks to the CHW
16
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A Population View:
Glycemic Control Improves
DEP patients with at least two measures within specified period were included in the analysis. Visits
listed are quarterly. The most recent measure was used. Data source is the registry used for the DEP.
Data extracted January 6, 2014.
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Patient Feedback: Qualitative Interviews
•
•
•
Relaxed, safe environment
Frequent contact
Relatable and accessible when there are issues
“With the (CHW), you can be part of the conversation
in deciding your health.”
“She tells me the truth. I believe she’s honest about things. I feel
I can get open with her because she’s the kind of person who will
listen to what you’re going to say.”
* Twelve qualitative interviews conducted by BHCS Director of Health Sciences Research Funding, 2012.
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Provider Feedback: Qualitative Interviews, 2
•
CHWs improve efficiency and quality of care
–
–
Build rapport with patients quickly  identify
barriers  providers refine medical management
Spends more time with patients than providers
are able
•
•
•
–
Navigate needed services
Hold patients accountable as the driver of improved outcomes
Follow up with CHW occurs between provider visits
Providers recognized CHW knowledge base
which increased professional trust
* Twelve qualitative interviews conducted by BHCS Director of Health Sciences
Research Funding, 2012.
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CHW Labor Market has unusual dynamics (1)
 History
of marginalization and isolation
 Dominant
pattern of “siloed” financing thru
short term grants and contracts
 Most
training done by employers – focused on
knowledge base and specific job duties
 Unique
presence of volunteers
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CHW Labor Market has unusual dynamics (2)
 Diversity

of roles
…but specific jobs often narrowly defined
 Central
importance of “community membership”
or shared life experience as a qualification

…not everyone can be a CHW

…and employers will hire the “right person” first and
then train them – no conventional pipeline
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Healthcare payers are interested in CHWs
 “Hot-spotters”
 Chronic
disease management
 Improving
 Cancer
 Care
– better care for “super-utilizers”
birth outcomes
screening and navigation
transitions
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The “evidence base” exists
 If
CHWs achieve such striking results in so many
different settings, roles and health issue areas…
…there must be something going on here!
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National trends in
CHW policy and financing
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4 interrelated policy areas affect CHWs
 Occupational
definition (agreement on scope of
practice and skill requirements)
 Sustainable
financing models
 Workforce
development (training capacity/resources)
 Documentation, research
and data standards
(records, evidence of effectiveness and “ROI”)
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Certification

Declaration by issuing authority that an individual has
necessary skills

NOT the same as an educational “certificate of completion”

Issuing authority: government, educational, association or
employer-based; does NOT have to be the State govt.
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Is the professionalization of CHWs
a good thing?

Will CHWs lose touch?

Will employers “kill the goose?”

Can CHWs balance accountability to community and
employer institutions?

Emulating existing professions?

What about volunteers?

“Community membership” as a qualification: who is a CHW?
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Basic components of a
CHW credentialing program

Scope of practice: boundaries with other professions

Eligibility and application process

Procedure for assessing applicant's skills

Administrative home: $

Continuing education requirement

Procedures to renew, revoke/expire
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A responsive CHW certification system
has:

Multiple paths to entry, including based on experience
(“grandfathering”)

User friendly application process without unnecessary barriers of
education, language, citizenship status

Required education available in familiar, accessible settings

Skills taught using appropriate methods (adult/popular education)

Easy access to CEUs, distance learning

Respect for volunteer CHWs – “first, do no harm!”
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Live poll, NASHP webinar, 2/23/15
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Employer Awareness Stages
Clueless
• “What’s a CHW?”
Unclear
• “Nice, but how does it fit my
business?”
Wellintended
• “Great – if we can
just get a grant…”
True
Believer
• “CHWs are
essential to
what we
do”
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Key principles in policy change
 Minimize
barriers of language, education level,
citizenship status, and life experience
 Encourage
contracting with community-based
organizations for CHWs’ services
 Remember
 Respect
not all CHWs work in health care!
volunteers: first, do no harm!
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States are pursuing various strategic paths in
CHW policy innovation
 Legislative: TX, OH, MA, NM, IL, MD, ND
 Medicaid rules: KY?, MN, WI, DC
 Policy driven by specific health reform initiatives:
NY, OR, SC + SIM states
 Broad-based coalition process: AZ, FL, MI, WV
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Federal agencies are increasing support
for CHW strategies
 CDC, HRSA
 CMMI
 HHS
support for state policy change
grantee learning collaboratives
CHW Interagency Work Group
 CMS-CDC
discussions
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[CDC 2014]
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Medicaid Preventive Services rules have changed!
 78 FR 135 p. 42306: 7/15/13– (effective Jan. 2014)
§ 440.130 Diagnostic, screening, preventive, and rehabilitative
service
 “Preventive services means services recommended by a physician or other
licensed practitioner…” (previously read “provided by”)
 Brings rules into conformance with ACA
 Commentary clearly reflects interest in funding services by CHWs and
other “nonlicensed” providers
 Payment for CHW services will no longer need to be treated as admin
costs
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Taking Advantage of Medicaid Rule Change
Medicaid State Plan Amendment – must specify:
 What non-licensed occupations are covered, and
qualifications (skill requirements)
– not necessarily certification
 What services will be paid for (CPT codes), and what
categories of Medicaid recipients may receive them
 Rates and mechanisms of payment (FFS, MCO, bundled
payment etc.)
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National trends in
Documentation and evaluation
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Documentation of CHW activity has not
been a high priority

Historically separate from medical records

Lack of common metrics has hampered pooling and
comparison of data

No coherent research strategy exists

Example: CMMI Innovation Grants
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Documentation of CHW activity has not
been a high priority (2)

Increasing recognition of beneficial CHW roles in research
(CBPR)

Value of CHW observations for clinicians is being recognized

Adapting to the CHW workforce:

Equipping CHWs to document and report appropriately

User-friendly documentation tools for field work
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Pathways Mobile
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Other initiatives on CHW research

Institute for Clinical and
Economic Research 2013
report
The New England Comparative Effectiveness Public Advisory Council

PCORI planning national
conference to fill evidence
gaps
Public Meeting – June 28, 2013
Community Health Workers:
A Review of Program Evolution, Evidence on
Effectiveness and Value, and Status of Workforce
Development in New England
Final Report – July 2013
Developed by:
The Institute for Clinical and Economic Review
©Institute for Clinical & Economic Review, 2013
Page 1
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Contact Info
Carl H. Rush, MRP
Community Resources LLC
(210) 775-2709
[email protected]
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