7/27/2016 Community Health Workers: Enhancing Readiness for Value Based Care Presenter: Lisa Ladendorff, LCSW Northeast Oregon Network Executive Director Community Health Worker Community Health Worker Trainer 2 1
7/27/2016 Learning objectives • Review of Community Health Worker (CHW) definitions, roles and functions; • Enhance understanding of CHW alignment with specific Patient Centered Primary Care Home standards and goals; • Explore how CHW implementation can further readiness for Value Based Care Reimbursement for clinics and hospitals; • Learn about specific CHW program return on investment examples; • Orient to and learn how to use a tool to help support implementation of CHWs for individual sites and programs. 3 Community Health Worker Definitions and Roles 4 2
7/27/2016 American Public Health Association Definition “A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served .” • Liaison • Link • Intermediary 5 Oregon’s Definition of CHWs (ORS 414.025) • Has expertise or experience in public health ; • Works in an urban or rural community , either for pay or as a volunteer in association with a local health care system. • To the extent practicable, shares ethnicity, language, socioeconomic status and life experiences with the residents of the community where the worker serves; • Provides health education and information that is culturally appropriate to the individuals being served; 6 3
7/27/2016 Oregon’s Definition of CHWs (ORS 414.025) • Assists members of the community to improve their health and increases the capacity of the community to meet the health care needs of its residents and achieve wellness; • Assists community residents in receiving the care they need; • May give peer counseling and guidance on health behaviors; and • May provide direct services(e.g. first aid; blood pressure screening) 7 8 4
7/27/2016 Promoting Health Equity • There are distinctive differences in the CHW role in relation to other health occupations. • CHWs apply a broad range of skills to provide holistic or wrap around services to community members. • CHWs provide assistance to community members in a variety of settings with a focus on where the community member is comfortable. It might be a home visit, in the library or a coffee shop. CHWs focus on working with the community member and • empowering the community member to prioritize their own concerns regarding their health and well being. 9 • CHWs are involved in work providing equitable and culturally responsive access to information and services for historically disenfranchised populations and individuals. • Recruitment and training of CHW has historically been driven by culturally responsive practices that identify the need to find, empower, and support individuals whom already work, live and function within disenfranchised communities. 10 5
7/27/2016 Traditional Health Worker Resource Links • Traditional Health Worker Registry: https://traditionalhealthworkerregist ry.oregon.gov/ • Traditional Health Worker OHA Rules and Policies: https://www.oregon.gov/oha/health plan/Pages/thw-policy.aspx • State Approved Training Programs: https://www.oregon.gov/oha/oei/Pa ges/thw-approved.aspx 11 ALIGNMENT WITH PCPCH STANDARDS 12 6
7/27/2016 PCPCH Core Attributes 13 Core Attribute: Access to Care Standard Description Example In-Person PCPCH surveys a sample CHWs increase access Access of its population….and satisfaction by being more meets a benchmark on readily available, and by being patient satisfaction with able to meet for longer periods access to care of time, and in patient homes. Prescription PCPCH tracks and shows CHWs can assist with Refills improvement for time to advocacy and problem solving completion for prescription for issues arising around refills, especially with insurers. They also serve a linking function with pharmacists. 14 7
7/27/2016 Core Attribute: Accountability Standard Description Example Performance PCPCH tracks, CHWs can assist with meeting any and Clinical reports and meets screening and care benchmarks, Quality benchmarks on two whether immunization, cancer measures from core screening or post partum care by set and one from engaging and persuading those menu set patients with high no-schedule or no- show rates to engage. Patient and Patient, caregiver and CHWs are hired as natural leaders Family patient –defined from the populations they are serving, Involvement in family advisors are and thus are natural patient advisors Quality integrated into the and peers. Improvement PCPCH and function in peer support/training roles 15 Core Attribute: Accountability Standard Description Example Ambulatory PCPCH tracks selected CHWs have the strongest Sensitive utilization measure and documented ROI evidence in the Utilization shows improvement on area of reducing costly ER and selected utilization inpatient utilization, and measures. increasing outpatient utilization. Many health plans and hospitals assign CHWs to engage with high utilizers or those at risk of high utilization to engage in care that can stabilize and manage health conditions. 16 8
7/27/2016 Core Attribute: Comprehensive Whole Person Care Standard Description Example Preventive PCPCH routinely offers or CHWs are especially useful Services and coordinates 90% of all at engaging those patients Preventive recommended age and that refuse to schedule or Services gender appropriate routinely no show regular Reminders preventive services. preventive care visits. Medical PCPCH reports that it CHWs can serve as excellent Services routinely offers all of the patient educators and provide categories of care: self health management ….coordination of care, support, either formally via preventive services, patient curriculums, or informally education and self according to the patient's management support care plan. 17 Core Attribute: Continuity Standard Description Example Personal PCPCH meets a Many CCOs have patients assigned Clinician benchmark in the who receive no medical care. CHWs Assigned percentage of can be assigned to make contact, active patients develop relationships and work with the assigned to a patient to choose a personal clinician personal clinician or and set up appointments for preventive team care. Medication PCPCH provides CHWs can be a pat of the reconciliation Reconciliation comprehensive process by working with patients in their medication home to understand and document their management for understanding of how to take their appropriate patients medications. This can be provided to and families. physicians for use in the reconciliation process. 18 9
7/27/2016 Core Attribute: Coordination/Integration Standard Description Example Complex PCPCH develops an CHWS are ideal members of the Care individualized care plan for treatment team to work at goal Coordination patients/families with setting and implementation for complex medical or social some of the highest medical and concerns. Plan includes self social risk patients. They are management goals; goals of able to take the time in home preventive and chronic based settings to develop a illness care…… relationship that can lead to effective goal setting and change. Referral and PCPCH tracks referrals and A core role of CHWs is to provide Specialty cooperates with community navigation and linkage services Care service providers such as to multiple community entities on Coordination dental, educational, social behalf of an in conjunction with service, foster care, public patients. health, etc. 19 Core Attribute: Person-and Family- Centered Care Standard Description Example Language and PCPCH offers and uses CHWs, if hired from the Cultural providers who speak a populations they serve, Interpretation patient’s/family’s language of will often speak the choice or uses interpreters. same language, and can be cross trained as interpreters. Education and Self- More than 10% of unique A key CHW role is to Management patients are provided patient- provide patient education Support specific education resources using standardized and self-management sources and self health services. management support. 20 10
7/27/2016 ENHANCING READINESS FOR VALUE BASED CARE 21 Rural Health Value • Based at the University of Iowa • Staffed by RUPRI and Stratis Health • Tools and Resources to help support rural health care transformation • http://cph.uiowa.edu/ruralhealthvalue/ • Value-Based Care Assessment Tool • http://cph.uiowa.edu/ruralhealthvalue/TnR/vbc/vbctool.php • 121 value based capacities within eight value based care categories 22 11
7/27/2016 Value Based Care Categories � Care Management • Health Information � Clinical Care Technology � Community Health • Financial Risk Management � Patient and Family Engagement • Governance and Leadership � Performance Improvement 23 CHWS Assist to Meet the Following Care Management Capacities: • HCO assesses and • HCO utilizes a broad identifies patients at high community resource risk for poor outcomes or network in care high resources utilization, management. and assigns care • HCO engages a non- managers to them. traditional health care • HCO offers chronic workforce in care disease management management. services. 24 12
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