School Navigator Innovation Pilot KELLY VOLKMANN BENTON COUNTY HEALTH SERVICES DST PILOT CLOSEOUT PRESENTATION 1 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Pilot Summary • 2 years: July 1, 2015 – June 30, 2017 • Budget: • Year 1 – $215,000 IHN-CCO (DST pilot) • Year 2 - $110,000 IHN-CCO; plus $110,000 each from Benton County Health Services and Corvallis School District • Co-placed 3 bilingual, bicultural Community Health Workers (School Navigators or SNs) into 2 elementary schools and 1 middle school in Corvallis School District • SNs worked with the entire family to connect them to health care, social services, and community resources outside of the school system DST PILOT CLOSEOUT PRESENTATION 2 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Key Outcomes: Total Touches and Distinct Inc from Members Served: 4/1/2015 – 3/31/2017 Year 1 Year 2 Y-1 to Y-2 Total Distinct IHN-CCO Members Touched 466 569 103 783 Number of IHN-CCO Member Touches 2356 2546 190 4902 WCC and Preventive vision exam rates of Up to 1 visits before and after SN touch - for "N" year w/in 1 Follow up distinct IHN-CCO members touched: before year after percent 4/1/2015 - 3/31/2015 touch touch change Well-Child Check Visit (N = 134 members) 37 (28%) 69 (51%) + 23% Preventive Vision Visit (N = 167 members) 56 (34%) 95 (57%) + 23% DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK 3 COORDINATED CARE ORGANIZATION
Key Outcomes • Having CHW/SNs co-placed in schools increases the likelihood that children will be connected to their PCP, will get their well-child checks, and follow up with their vision exams • School Navigators increase access to care for students and families related to transportation, language, knowledge, food, clothing…this allows parents to focus their energy and attention on health • Helping these families overcome the social determinants of health barriers to accessing healthcare will ultimately lead to improved health and lowered health care costs DST PILOT CLOSEOUT PRESENTATION 4 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Successes – this story repeated over and over and over… “She [navigator] helped me with the doctor, she [navigator] helped me with the therapies [referring to counseling] that they are giving my daughter” Parent Survey 2016 DST PILOT CLOSEOUT PRESENTATION 5 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Learning Experiences • We had NO barriers to success – only challenges that we created strategies to overcome • In expanding the pilot from 2 schools to 3, we learned how to replicate the process of co-placing a CHW/SN into a school system • Having the SNs be county employees and attached to a large CHW team was beneficial, rather than having them be school employees • The few difficulties that arose were usually related to communication between two different systems (school and government entities) and were resolved immediately with proactive and personal communication DST PILOT CLOSEOUT PRESENTATION 6 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Partnerships & Collaboration • We increased the relationship and collaboration between IHN-CCO, the Corvallis School District and Benton County Health Services. We see each other as partners in the care of “our” students and their families… • We also deepened our relationships and connections with all of the mental health and social service agencies that serve students and families Our work can not be done without our community partners…it just isn’t possible! DST PILOT CLOSEOUT PRESENTATION 7 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Post Pilot Sustainability • Our pilot has been sustained for the 2017-2018 school year, and is going forward for the 2018-2019 school year with funding from the Corvallis School District and various grant funds from BCHS • This reliance on grant funding is stressful and potentially non- sustainable • This has been our only challenge to date… “The Health Navigator program has proven beneficial to our school community. Attendance, participation in the classroom, and readiness to learn have been affected positively as students' and families' basic needs have been better addressed through this program.” School Staff Survey, 2016 DST PILOT CLOSEOUT PRESENTATION 8 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Pre-Diabetes Boot Camp SAMARITAN NORTH LINCOLN HOSPITAL RUTH MORELAND, RN, CDE SUSAN RICHWINE, RN, OCN DST PILOT CLOSEOUT PRESENTATION 1 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Pilot Summary • July 1, 2016 to December 31, 2017 • $15,000 • Establish a pre-diabetes program in North Lincoln County to help reduce the transition of IHN-CCO members from pre-diabetes to diabetes. • Key pilot activities: • Identify IHN-CCO members with pre-diabetes • Establish referral workflows • Develop class materials • Conduct several different types of classes • Collect and analyze data DST PILOT CLOSEOUT PRESENTATION 2 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Key Outcomes • Specific key outcomes of the pilot, include: • Health Equity • People with pre-diabetes, estimated to be 1/3 of our adult population, are starting to receive more focused care • Metrics affected • Improved access to diabetes prevention services in a rural community • Identification and care of people with pre-diabetes is better integrated into primary care • Improved chronic disease prevention • Certified three people as CDC-approved diabetes prevention program Lifestyle Coaches DST PILOT CLOSEOUT PRESENTATION 3 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Successes • Pre-Diabetes Boot Camp was designed to attract attention in a noisy environment and succeeded at doing so • 51 participants - average weight loss 7.4 lbs, average A1C decrease 0.32 for the 23 participants with pre and post test results • Increased provider and patient awareness of pre-diabetes and treatment options • Samaritan Health Services received CDC recognition as an approved Diabetes Prevention Program, allowing Medicare billing for classes starting April 2018 • A rural community project is driving organizational change • Project poster presented at 2018 Oregon and SW Washington Health Literacy Conference DST PILOT CLOSEOUT PRESENTATION 4 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Learning Experiences • Relationships are the foundation for change, both personal and professional • The IHN-CCO pilot project structure and support was key in keeping the pilot on track during difficult periods • One significant adjustment during the pilot was to have one class follow the CDC diabetes prevention program guidelines, resulting in Samaritan Health Services becoming an approved site, allowing Medicare billing • Healthcare organizations are conservative • Form and function follows the Electronic Medical Record • Front line non-management staff can impact organizational change • Learnings gave us courage to spawn other improvement projects DST PILOT CLOSEOUT PRESENTATION 5 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Partnerships & Collaboration • Lincoln City Community Center • Lincoln City Cultural Center • Newport Recreation Center and 60+ Activity Center • Non-Samaritan local providers • OHSU Diabetes Prevention Program • Samaritan EPIC Health Information Services • Physician Champions • Samaritan Health Education Services DST PILOT CLOSEOUT PRESENTATION 6 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Remaining Challenges • Moving diabetes prevention program to south Lincoln County and beyond • Coding and billing support for CDC approved diabetes prevention program • Continuing to focus on people with pre-diabetes, which represents 1/3 of the adult population, as an important in-road to impact population health DST PILOT CLOSEOUT PRESENTATION 7 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
Post Pilot Sustainability • Pilot will be sustained and expanded with 2018 Lincoln County classes in Lincoln City and Newport. Additional classes being planned in Linn and Benton Counties starting 2019. • Reimbursement through Medicare for CDC approved programs starting April 2018 has been critical to sustainability. DST PILOT CLOSEOUT PRESENTATION 8 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
We had a great pilot project. Discussion Take me for a walk. DST PILOT CLOSEOUT PRESENTATION 9 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION
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