Cara Castleberry, RN/BSN, BS, LDE, CLC CHM Program Nurse Manager 12/07/18
A program to teach patients self- management of their chronic disease(s) Overall Goal = Reduce hospital admissions and Emergency Department utilization related to diabetes, COPD, and/or heart failure
A team approach, with a Community Health Worker and a Registered Nurse Community Health Workers (CHWs) provide home visits and phone follow up to help clients better manage their disease(s) and associated complications ▪ CHWs are medically trained (RMA, CMA, LPN) Funding by local tax dollars primarily
Resident of the 10-county BRADD area Non-pregnant adults, 18 or older Diagnosis of diabetes, COPD, and/or heart failure Referrals received in a variety of ways (PCP, specialists, hospital, self referral, etc) Length of program 6-9 months
Reinforce Provide social health support to education overcome barriers Encourage positive Social Medical behavior changes Enhance Link to communication needed between patient resources and healthcare team
Community Health Worker services: ▪ Monthly home visit ▪ Check weight, blood pressure, and SpO2 per protocols ▪ Observe client perform self-monitoring Phone contact – Community Health Worker services: ▪ Follow up by phone on non-clinical plans or concerns at least once weekly, and bi-weekly later in the program
Community Health Worker services: ▪ At monthly home visits, follow an individualized lesson plan of the client’s choice ▪ Topics include: following your healthy eating plan, physical activity, smoking cessation, preventive care, etc. ▪ Follow up on goal progress and help patient problem solve to reach goals
CHW’s DO NOT : ▪ Provide Diabetes/Chronic Disease Self-Management Education ▪ Provide Medical Nutrition Therapy ▪ Give medical advice or treatment ▪ Diagnose medical conditions
The Institute for Healthcare Improvement created a framework known as the Triple Aim, to describe an optimized approach to healthcare reform Three components of the “Triple Aim” 1. Improve patient experience of care (quality and satisfaction) 2. Improve the health of populations 3. Reduce the per capita cost of health care The IHI Triple Aim. Institute for Healthcare Improvement,2016 .
Improve patient experience of care (quality and satisfaction) ▪ Facilitates enhanced communication within the healthcare team and promotes a trusting relationship ▪ Encourages the pt to follow HCP orders for disease exacerbations and Plan of Care ▪ Advocates for quality healthcare delivery Result: The patient feels like they are heard and cared about, leading to greater satisfaction
Reinforce Provide social health support to education overcome barriers Encourage positive Social Medical behavior changes Enhance Link to communication Improve needed between patient patient resources and healthcare experience team
Improve the health of populations ▪ The CHW directly encourages positive behavior changes by identifying and removing barriers ▪ The CHM program team addresses goal setting and progress, and providing lots of encouragement
Improvements in healthcare compliance, such as keeping appts, taking medications as prescribed, risk reduction, blood pressure control, and associated mortality An analysis of 18 studies involving CHW integration showed improved patient knowledge, lifestyle, and self-management behavior amongst patients with diabetes, as well as decreases in ED usage. Brownstein J, Chowdhury F, Norris S, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med . 2007:32(5):435-447. Norris SL, Chowdhury FM, Van Le K, et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med . 2006;23(5):544-556.
Average Decrease in Healthcare Visits for Patients Active during Oct 2015-Oct 2017 n=69; avg # of home visits 5.94 • “Before” program 2 and “After” program defined as 6 months 1.8 prior, and 6 months post program 1.6 completion • In order to be 1.4 included in the 1.2 subset, each participants had a 1 minimum of 3 face- to-face home visits. 0.8 • Data includes all eligible diseases (DM, 0.6 HF, COPD). • All cause 0.4 hospitalization/ED 0.2 visits 0 ED Visits Hospitalization Before Program After Program
Reinforce Provide social health support to education overcome barriers Encourage positive Social Medical behavior changes Enhance Link to communication Improve needed between patient Reduce patient resources and healthcare health care experience team costs
Reduce the per capita cost of healthcare ▪ “Using their unique position, skills, and an expanded knowledge base, CHWs can help reduce system costs for healthcare by linking patients to community resources and helping patients avoid unnecessary hospitalization and other forms of more expensive care as they help improve outcomes for community members.” (CDC, April 2015) National Centers for Chronic Disease, Prevention and Health Promotion, in conjunction with the Department of Health and Human Services and Centers for Disease Control and Prevention. Addressing chronic disease through community health workers; A policy and systems-level approach. 2 nd ed. April 2015.
CHW integration has been shown to reduce healthcare costs in management of cardiovascular disease ▪ A decrease of $157 per every 1% drop of systolic blood pressure ▪ A decrease of $190 per every 1% drop of diastolic blood pressure Allen J, Dennison C, Himmelfarb D, Szanton S, Frick K. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. J Cardiovasc Nurs. 2013:29(4):1-7.
Changes in Blood Pressure (10/2016 to 11/2017) ▪ On average, 77% of patients were meeting the target for controlled blood pressure, compared to the national average of 60.42% (2015) ▪ Average decrease in Systolic BP of 11.12 mmHg ▪ Average decrease in Diastolic BP of 3.45 mmHg
Improve population health Reinforce Provide social health support to education overcome barriers Encourage positive Social Medical behavior changes Enhance Link to communication Improve needed between patient Reduce patient resources and healthcare health care experience team costs
Cara Castleberry, RN/BSN, BS, LDE, CLC ▪ Community Health Management Program, Nurse Program Manager ▪ T:270-781-8039 x 186 ▪ F:270-796-8946 ▪ E: carisa.castleberry@barrenriverhealth.org
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