Performance Measurement: The What & Why.2. PM Definitions: Categories & Their Service Activities...3. PM Data Collection: Direct Service Reporting 10

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1 Founded in 1995 by the National Association of Community Health Centers, Community HealthCorps is the largest health-focused national AmeriCorps program that promotes health care for America s underserved, while developing tomorrow s health care workforce. This toolkit was created to: Provide Community HealthCorps Program Coordinators with the information they need to understand national programmatic data collection and measurement processes and build a data-driven program at the local level. Give Community HealthCorps AmeriCorps members a step-by-step guide for utilizing specific educational content and data collection processes to interact with clients in an effective and impactful way and ensure improved health care access. Performance Measurement: The What & Why.2 PM Definitions: Categories & Their Service Activities...3 PM Data Collection: Direct Service Reporting 10 Engaging Site Supervisors: Best Practices 13 Training Members: What They Need to Know 14 PM Knowledge Modules: Independent Living...16 Reporting PM Data: The Process & Timeline.40 PM Data Feedback: Utilizing Progress Reports 41 Additional Tools: FAQs & Resources..42 Page 1 of 42

2 Performance Measurement (PM) is defined as the process of regularly measuring what Members do, how much of that they do, and the impact of what they do on the beneficiaries of service. It is about gathering and reporting data to prove Community HealthCorps is helping communities. You might think, My Members can provide several personal accounts about how they ve helped someone! And that is great, crucial qualitative data. But we need quantitative data to back up those stories. Stories and numbers work together as a one-two punch with the stories capturing the emotional interest and numbers describing that the story is not a one-time occurrence and is a result of our program. There are so many reasons why we measure performance: Community HealthCorps is held accountable by our funder, Corporation for National and Community Service (CNCS), for providing PM data. It helps everyone involved with Community HealthCorps work together to make course corrections and program improvements. Community HealthCorps Members are a piece of the puzzle, so knowing what types of tasks they are performing and the impact they are making is critical. It helps tell our story to the public, funders, partners, and other stakeholders. Community HealthCorps Member service includes ensuring patients have everything they need to have better health outcomes. The last point is one of the most important. PM is not a separate or extra component to service. It is an integrated part of the service. Page 2 of 42

3 CNCS develops standardized National Performance Measures aligned with their current strategic plan, which allows them to assess the individual and collective results of programs and tell the national story of service. CNCS develops outputs & outcomes for each measure. These are based on the AmeriCorps Logic Model, which is the diagram that demonstrates the relationship between resources, service activities, and the desired results of an AmeriCorps program. Community HealthCorps, as an AmeriCorps program, must select from these measures with some limited freedom to customize them. The following categories provide more information about the 5 National Performance Measures selected for the program grant cycle. Definition The set of skills and knowledge that allow an individual to make informed and effective health-related decisions about utilizing preventive and primary health care services. Overarching Goal Improved knowledge about the effective utilization of preventive and primary health care services in achieving the best health outcomes. Why is Access to Care Important? 1 in 5 Americans have little or no access to primary health care and are considered medically underserved. 1 Page 3 of 42

4 Access to health care encompasses a lack of sufficient insurance, inadequate knowledge about health care locations & services, inability to find a health care provider with whom the patient can communicate, and social & cultural barriers. 2,3 43% of the medically underserved are also members of low-income households affected by social issues, such as lack of transportation and food insecurity. 4 Outputs Enrollment subcategory: Number of unduplicated individuals enrolled in health insurance, health services, or health benefits programs. Information subcategory: Number of unduplicated individuals to whom information on health insurance, health care access, or health benefits programs is provided. Outcome Enrollment subcategory: Number of unduplicated enrolled in a health insurance, health services, or health benefits programs who indicate increased knowledge about the effective utilization of preventive and primary health care services in achieving the best health outcomes. Related Community HealthCorps Service Activities Community HealthCorps aims to be part of the solution by meeting with individuals at least once for a minimum of 15 minutes to assist those who previously lacked access in enrolling in primary health services, insurance, and benefits; to help them understand the health benefits of seeking preventive and primary care and the risks of waiting until a health emergency arises before seeking care; and to assist them with navigating the health care system: Insurance Submission*: Assistance that results in the submission of a health insurance/marketplace application for new or continued coverage on behalf of themselves and/or family members. Registration*: Assistance that results in an individual newly or re-applying/signing up for health services (e.g. disease management classes, nutrition classes, transitions of care programs) and/or non-insurance benefits (e.g. WIC, prescription assistance). Insurance Outreach: Information sharing out in the community to educate individuals about new affordable insurance options and provide enrollment assistance. Primary Care Outreach: Information sharing out in the community to direct individuals to early intervention services and/or primary care with the ultimate goal of providing them with ongoing primary care. Page 4 of 42

5 Health Education: Provision of information and/or support in a designed and planned format which focuses on promoting wellness, disease prevention and/or management, or other improved health outcomes. Interpretation Services: Provision of written and/or verbal language translations intended to help individuals not fluent in English better communicate their health needs and understand their medical instructions. Non-Financial Case Management Assessment: Non medical evaluation measuring wellness and/or other health needs. Facilitation: Provision of a follow-up encounter (e.g. appointment reminder calls or follow-ups, referral follow-ups) or a referral to a health and/or social services provider (e.g. transportation assistance, housing assistance). *Insurance Submission and Registration are subcategorized into Access to Care Enrollment, while all Access to Care service activities fall under the subcategory Access to Care Information. Definition The set of skills and knowledge that allow an adult to make informed and effective health-related decisions and understand the impacts of those decisions on their personal financial resources. Overarching Goal Improved financial-health knowledge to ensure the most cost-effective use of preventive and primary health care services. Why is Financial-Health Literacy Important? 9 in 10 people in America lack proficiency in health literacy, which includes understanding how to use health insurance benefits. 5 40% of Americans cannot define health insurance terminology, like deductible. 6 Uninsured and low-income individuals have the least awareness of health insurance costs million Americans have overdue medical debt on their credit reports, which constitutes half of all overdue debt on credit reports. 8 For every uninsured person, over $900 of unpaid medical bills per year is shifted to higher premiums for the insured. 9 Page 5 of 42

6 People with a household income under $40,000 are 29% more likely to forgo medical care due to cost than people with a household income of over $100, Output Number of unduplicated individuals who receive financial-health literacy services. Outcome Number of unduplicated individuals receiving financial-health literacy services who indicate improved financial-health knowledge. Related Community HealthCorps Service Activities Community HealthCorps aims to be part of the solution by meeting with adults at least once for minimum of 15 minutes to help them understand how to reduce personal medical costs and credit impacts by identifying savings on prescription drugs, preventing and self-managing chronic conditions, determining when best to seek primary versus emergency room care, and enrolling in eligible health insurance and benefits programs: Eligibility Assistance: Assistance that results in the development of a payment plan and/or the submission of a completed application to a sliding fee scale, health insurance program (e.g. Medicaid, Medicare), or pharmaceutical benefits program. Insurance Outreach: Information sharing out in the community to educate individuals about new affordable insurance options and provide enrollment assistance. Financial Education: Provision of information and/or support to improve the understanding of health insurance terminology, disease prevention and/or management, appropriate utilization of emergency departments, and medical debt management. Financial Case Management Assessment: Non medical evaluation measuring financial needs. Facilitation: Provision of a follow-up encounter (e.g. appointment reminder calls or follow-ups, referral follow-ups) or a referral to a social services provider (e.g. financial counseling, utility expense relief, medical bill assistance) which focuses on providing financial assistance. Definition The set of skills and knowledge that allow an individual considered an older adult Page 6 of 42

7 and/or person with a disability to access supportive resources and services that help them live in their own home (i.e., a private residence rather than an assisted living facility, nursing home, or group home). Overarching Goal Improved knowledge about community support services and/or programs to achieve the best health, function, and quality of life of older adults and persons with disabilities. Why is Independent Living Important? By 2030, an unprecedented 72 million Americans or 20% of the population will be over Almost 6,500 New York seniors currently living in nursing homes could live in their own home and save $73 million per year for taxpayers. 12 Older adults and individuals with disabilities face barriers to living in their own home, including lack of transportation, isolation, and limited mobility. 13 Individuals with a stronger social network have a lower risk of institutionalization. 14 Output Number of unduplicated older adults and individuals with disabilities who receive services helping them to live independently. Outcome Number of unduplicated older adults and individuals with disabilities receiving independent living services who indicate increased knowledge about community support services and/or programs. Related Community HealthCorps Service Activities Community HealthCorps aims to be part of the solution by meeting with older adults and persons with disabilities at least once for a minimum of 15 minutes to deliver health literacy education related to self-management of chronic conditions and connecting them to supportive resources, programs, and services in the community: All Access to Care and Financial-Health Literacy service activities relate to this category when delivered to someone identifying under one of the following special populations & live in their own home. Older Adults: Individuals age 65 or older. Persons with Disabilities: An individual who has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. NOTE: It is only expected of Members to report serving this population if the individual being served either has a disability noted in their medical file or self discloses a disability to the Member who is Page 7 of 42

8 providing services. For further clarification about impairments that are considered disabilities, refer to the definition of disability in the Americans with Disabilities Act Title III Regulations. Definition The set of skills and knowledge that allow a child and/or their family to make informed and effective decisions related to nutrition and physical activity. Overarching Goal Improved knowledge about healthy eating and exercise at an early age to reduce instances of childhood obesity. Why is Reducing Childhood Obesity Important? Since 1980, obesity rates for U.S. children have tripled. 15 In 2012, more than 1/3 of children and adolescents were overweight or obese. 16 Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. 17 Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, and social & psychological problems such as stigmatization and poor self-esteem. 18,19,20 Outputs Physical Education subcategory: Number of unduplicated children and youth engaged through in-school or afterschool activities with the purpose of reducing childhood obesity. Nutrition Education subcategory: Number of unduplicated children and youth receiving nutrition education with the purpose of reducing childhood obesity. Outcome This Performance Measure currently has no associated outcome that is measured. Related Community HealthCorps Service Activities Community HealthCorps aims to be part of the solution by meeting with overweight, obese, or related at-risk children & youth under 18 years of age at least once for a minimum of 15 minutes to provide health education related to nutrition and/or physical activity: Physical Education: Provision of knowledge and ways to counteract obesity and other risk factors that negatively affect the individual s ability to live a healthier life. Page 8 of 42

9 Exercise comprehension skills should be given to support the necessity of ongoing mind and body wellness. Nutrition Education: Provision of knowledge which focuses on nutrition that is in addition to what the individual would have regularly received as part of planned school curriculum or afterschool activity. Definition The set of skills and knowledge that allow an individual considered a veteran and/or veteran s family member to access supportive resources and services that enhance their quality of life. Overarching Goal Improved knowledge about community support services and/or programs to achieve the best health, function, and quality of life of veterans and their families. Why is Serving Veterans & Their Families Important? Unemployment rates among veterans of all ages are greater than those for civilians. 21 Veterans returning from combat face significant socioeconomic challenges that can also impact their families. 22 Veterans and their families face unique barriers to feelings of support and good health, particularly when transitioning into civilian life. 23 Output Number of unduplicated veterans and veterans family members receiving CNCSsupported assistance. Outcome This Performance Measure currently has no associated outcome that is measured. Related Community HealthCorps Service Activities Community HealthCorps aims to be part of the solution by meeting with veterans and/or their family members at least once for a minimum of 15 minutes to deliver health literacy education related to mental health and substance abuse and connect them to supportive resources, programs, and services throughout the community focused on serving veterans and military personnel: All Access to Care and Financial-Health Literacy service activities relate to this category when done with someone identifying under one of the following special populations. Page 9 of 42

10 Veterans: An individual who served in the active military, naval, or air service and who was discharged or released therefrom under conditions other than dishonorable. (section 101 of title 38, 23 United States Code) Veterans Family Members: Immediate family members related by blood, marriage, or adoption to a veteran of the U.S. armed forces, including one who is deceased. Access to Care Enrollments, Financial-Health Literacy, & Independent Living. We are required to report the number of unique people served and the number of people who show a positive change in knowledge in each of the three categories for which CNCS holds us accountable. This information is collected using the direct service reporting tool and outcome questionnaires. Additional information that we collect is used internally for program development and externally for communications other than reporting to CNCS. Direct Service Reporting (DSR) is the process of tracking and submitting data related to the Member activities which aligned with our PMs. Direct service occurs directly with or for a client. Other types of service include volunteer mobilization and capacity building, which are reported in different ways as is illustrated by our Member Service Reporting Flow Chart. Page 10 of 42

11 PM data collection occurs in the Community HealthCorps Direct Service Tracking Excel Spreadsheet. Members use this spreadsheet to report their interactions and each person served. In the spreadsheet, Members track: Their name, A unique ID number for each patient, The length of their interaction with each patient, The defined service activities performed during each interaction, The social determinants of health addressed during each interaction, The special population to which each patient belongs, and The scores each patient reports on their pre & post outcome questionnaire. Detailed step-by-step instructions for completing the spreadsheet & FAQs can be found on the Community HealthCorps website. The Direct Service Tracking Excel Spreadsheet is similar to an Electronic Health Record in that Members use the tool to track each interaction (i.e. appointment) with each individual client (i.e. patient) who has an ID number for recordkeeping and identification. A positive change in knowledge also known the outcome is measured using a pre and post-interaction questionnaire with patients and is defined as a 20% increase from pre to post score. In order for patients to increase in their pre to post score, Members must act as educators and provide information to each patient they serve. NACHC has identified 6 topics relevant to improving patients knowledge about their health: Health insurance, Medications and prescription assistance, Managing their health, Wellness and prevention, Understanding their health care, and Finding services and resources. Each of the 3 sets of outcome questionnaires contains one questionnaire per topic. To implement this questionnaire, Program Sites were randomly assigned to one of the three PM categories. Because assignments were random, your Program Site is Page 11 of 42

12 representing those Program Sites not assigned to your PM category. This means that it is ok if your Members do not provide many people with service activities categorized in your assigned PM category because you are representing other Program Sites with similar Member activities. Your Program Site is assigned to measure changes within the Independent Living category. Each time a Member meets an adult who is older than 65 years of age and/or has a disability for the first time, the Member will utilize the outcome questionnaire from the topic that most directly applies to the service they are providing. The outcome questionnaire should not be used with children. Your Community HealthCorps Members should be providing services in all of the PM categories; however, they are measuring the impact of only the Independent Living services. The purpose of this questionnaire is to measure the impact of your Community HealthCorps Members every day service. It should not be provided to patients at the end of a patient interaction, as an addition to what the Member normally does. It should not be provided only with a certain subset of patients, such as only those that meet in groups. When encouraging data collection by Community HealthCorps Members, keep in mind some of the following best practices shared by Program Coordinators: Divide Program Site PM targets among Members to set expectations around data collection from the beginning and promote accountability. Meet with Members one-on-one to review their data collection processes and how their roles tie in with our defined service activities. Send Members periodic reminders about the DSRs via or a newsletter. Utilize back-up data collection systems, such as having Members track patients in the health center EHR or tallying those seen in a special notebook, which can then be transferred into the DSR. Put in place a policy whereby Site Supervisors review and approve Direct Service Reports for their Members on a regular basis to ensure completeness and accuracy. Collect Direct Service Reports from Members on a periodic basis, such as biweekly or monthly to ensure data is being tracked regularly. Provide time at every team meeting to review data, practice scenarios, and discuss roses and thorns of data collection. Pair Members who are successful in data collection with those who experience challenges to provide some mentorship opportunities. Page 12 of 42

13 Perform service location site visits with time for shadowing Members to review data collection processes. Develop creative incentives to encourage data collection from Members. Example incentives include free food at the next team meeting if a benchmark is met or additional leadership opportunities for Members who meet goals. Work with your organization s IT department to set up an Excel Tips & Tricks training focused on completing the Direct Service Reporting Excel Spreadsheet. After you understand the background behind our PMs and how Members collect data to show we are meeting our mission, the next step in building a culture of data collection and use is to engage Community HealthCorps Site Supervisors and obtain their buy-in. You should: 1. Provide Site Supervisors with background on Community HealthCorps Performance Measures before Members begin service. 2. Be sure to give them a heads up in early trainings that things may change throughout the year. They should be prepared for and open to new processes. 3. Develop a Member Assignment Description (MAD) with the PMs in mind, including data collection and patient education as integral parts of service. It may be helpful to map out how Member s roles and responsibilities align with the defined Community HealthCorps service activities using a table similar to our Member Roles & Related Service Activities Worksheet. 4. Coordinate with Site Supervisors to develop any tools, visual aids, and resources Members will use for patient education purposes. Page 13 of 42

14 5. Site Supervisors should train Members in-service, including data collection processes. 6. Determine a timeline for Site Supervisors collecting and reviewing direct service reporting data to ensure completeness and accuracy. 7. Throughout the year, include Site Supervisors in trainings and communications about direct service data collection, report due dates, PM progress, and other PM-related reminders. It is important when training Members not to overwhelm them and focus only on what they need to know: The categories of service & the associated goals, The defined service activities within each category, Examples of their step-by-step interaction with patients (i.e. knowledge modules), and How to track & report their direct service activities. It is recommended that you, as the Program Coordinator, train Members on the categories, service activities, and goals of their service during PSO. Site Supervisors should provide training on the specific knowledge modules that the Members will use and the direct service reporting process during the on-site/in-service training. You and Site Supervisors should then provide check-ins and refresher trainings periodically throughout the program year. NACHC provides a number of tools & guides for training every Community HealthCorps Member on the required PM-related information: Page 14 of 42

15 An Introduction to Your Community HealthCorps Direct Service includes definitions & goals for each PM category & the related service activities. CMS From Coverage to Care Roadmap provides Members with a background on various patient education topics. Consumer Financial Protection Bureau s Your Money, Your Goals Toolkit provides Members with a background on basic financial literacy content. Member Roles & Related Service Activities Worksheet to help align Member s roles with the Community HealthCorps-defined service activities. Overview of the Community HealthCorps Independent Living patient education content with English & Spanish outcome questionnaires. Remember that not every Member learns in the same way, so you may need to create your own tools or edit ours to translate the information into language that resonates with your Community HealthCorps team. When training Members, try to incorporate some of the following best practices that other Program Coordinators have found useful: Have Members role play their interactions with patients using the knowledge modules. You can record their role play scenarios and send them to NACHC to share with other Program Sites. Incorporate knowledge modules into motivational interviewing training. Assign Members as topic leads and have them research one of the 6 topics. Then, they can train the rest of the team on that topic. Afterwards, have them shadow peers during service to offer suggestions for improvement. Have each Member create a legacy binder with all of the content, resources, tools, and visual aids they use with patients. This binder can be passed to new Members each Program Year. The knowledge modules provide step-by-step patient interactions and incorporate some of the following tips & tricks for integrating the outcome questionnaires into the interaction: Frame the pre questions as a way for the Member to ensure they are providing the patient with everything they need. Expand on the questions to provide context for patients. Page 15 of 42

16 Ask follow-up questions after a patient provides an answer. This will help Members determine what type of specific information patients are interested in learning related to the topic being covered. This will also validate that the score provided is an accurate representation of the patient s familiarity with that topic. Frame the post-interaction questions as a review of the patient s experience with the Member to help patients feel more comfortable and less like they are being tested. Ask patients after the interaction if they would like to change their pre scores to validate those responses. Sometimes patients may overestimate how familiar they are with a topic during the pre-interaction questionnaire. A knowledge module is an example of a step-by-step patient interaction for Community HealthCorps Members. The module is based on service activity and interaction topics. For example, a Member who provides health education on diabetes self-management practices would have a knowledge module focused on the outcome topic Managing Your Health as it relates to diabetes. While the rest of this toolkit is to help you as the Program Coordinator better understand the Community HealthCorps Performance Measures, the knowledge modules are to be given to Members as worksheets for their patient interactions. Each knowledge module includes the pre & post questions, education content, and scripts in the format of 5 steps: Needs Assessment, Patient Education, Patient Resources, Interaction Summary, and Reporting. We strongly encourage you to work with Members to tailor knowledge modules to their specific roles. Page 16 of 42

17 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: I would like to sign up for health insurance through the Marketplace. I would be happy to help! May I ask you a few questions first so that I can better know how to help you? There are only 3 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Where you can go to sign up for health insurance, score: How to determine the health insurance you are eligible for, score: How to determine the services covered by your health plan, score: Page 17 of 42

18 After providing the needs assessment, you should help the patient complete health insurance applications. While doing so, you will need to provide education about terminology definitions and other pertinent health insurance information. **use visual aid** In-network refers to the facilities, providers, and supplies that your health insurer or plan has contracted with to provide health care services. Although Medicaid/Medicare doesn t have in-network providers, there are certain providers that will and will not accept Medicaid/Medicare patients. Out-of-network refers to a provider that doesn t have a contract with your health insurer or plan to provide services to you. HMO stands for health maintenance organization and means that you can only go to health providers on the plan s list except in an emergency. You will need to have a primary care provider selected and will need referrals to visit a specialist. PPO stands for preferred provider organization and means that you should go to providers on the plan s preferred list. If you visit a different provider, it will likely cost more. To find out what services are covered by your plan, you can go to your insurance company s website or give them a call. **review sample health insurance card** A specialist is a provider that focuses on a specific area of medicine to diagnose, manage, prevent, or treat certain types of symptoms and conditions. Sometimes, you need to get a referral from your primary care provider before seeing a specialist. A premium is the amount that must be paid for your health insurance or plan, and it may be covered by you or your employer. A copay is an amount you may be required to pay as your share of the cost for a medical service or supply. A deductible is the amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. Co-insurance is your share of the costs of a covered health service, calculated as a percent of the allowed amount for the service. For more information on this topic, check out CMS From Coverage to Care Enrollment Toolkit kff.org/understanding-health-insurance Health Insurance Literacy webinar AssetPlatform.org Page 18 of 42

19 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: After providing education, patients may have additional questions that you cannot answer. Providing them with resources will help empower them to learn more about using their health insurance. Here are some resource ideas: CMS' "From Coverage to Care" Enrollment Toolkit The name and phone number for a certified application/eligibility counselor The Marketplace, Medicaid, or Medicare website An example health insurance care with the health insurance company's phone number circled Local resource: Local resource: Local resource: When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've finished your application for health insurance and talked a little bit where you can go for more information about using your health insurance, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper pre/post questionnaire** For each of these words, please let me know how familiar you are with their definitions. Where you can go to sign up for health insurance, score: How to determine the health insurance you are eligible for, score: How to determine the services covered by your health plan, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with how to determine your eligibility for health insurance before our conversation. Now Page 19 of 42

20 that you know more about that topic, was that really how familiar you were beforehand? You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Insurance Submission 2. Eligibility Assistance The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 3. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 3. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 20 of 42

21 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: I split the pills that I take for my high blood pressure in half to make them last longer. My doctor told me that I shouldn t do that, but I just can t pay for all of my medications every month. I would be happy to help you find ways to save money on your medicines! First, may I ask you a few questions so that I can better know how to help you? There are only 2 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Ways to save money on prescription medications, score: Where you can learn more about your medications, score: Page 21 of 42

22 After providing the needs assessment, you should help the patient complete Prescription Assistance Program applications and/or find resources for paying for medications. While doing so, you will need to provide education about ways to save money on prescriptions. **use visual aid** At each visit, your doctor will often ask which medications you are taking, so you should be keeping track of them. You can use a pill container, write reminder on your calendar, and keep a wallet card with you at all times. Before you leave the provider s office, you should be able to answer the following questions about your prescribed medications: o How do I take my medications? o How much do I take? o Are there side effects? o When should I stop taking this medication? o Is there a generic available? Many large chain stores offer common generic drugs for cheaper than the brand name. Generic drugs are required to meet the same standards and can be taken the same way and for the same reasons as brand-name drugs. Prescription Assistance Programs help you receive free or low-cost prescription drugs. The programs are through the pharmaceutical companies and have differing eligibility requirements. Talk with your doctor about getting prescriptions for 90 days instead of 30 days, as that can save you money in the long term. Our health center has a pharmacy (or contracts with a pharmacy) that provides prescription drugs at a cheaper price than other pharmacies in the community. For more information on this topic, check out AHRQ s Your Medicine: Be Smart. Be Safe. After providing education, patients may have additional questions that you cannot answer. Providing them with resources will help empower them to learn more about their prescribed medications. Here are some resource ideas: AHRQ s Sample Prescription Wallet Card Partnership for Prescription Assistance website GoodRx website for prescription coupons The name and phone number for a prescription assistance counselor Page 22 of 42

23 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: The name and phone number for the health center s pharmacist Local resource: Local resource: Local resource: When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've finished your application for Prescription Assistance and talked a little bit about who you can talk to about your medications, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper pre/post questionnaire** For each question, please let me know how familiar you are with the topic: Ways to save money on prescription medications, score: Where you can learn more about your medications, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with ways to save money on prescription medications before our conversation. Now that you know more about that topic, was that really how familiar you were beforehand? You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: Page 23 of 42

24 There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Registration 2. Eligibility Assistance The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 24 of 42

25 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: I was referred to you by my doctor. She said you could help me with my diabetes. I need to lower my blood glucose level or something. I would be happy to help! May I ask you a few questions first so that I can better know how to help you? There are only 2 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Where you can learn more about taking care of your health, score: Ways to save money on prescription medications, score: Page 25 of 42

26 After providing the needs assessment, you should provide education about diabetes and help the patient set healthy goals related to lowering their blood glucose level. **use visual aid** Managing your diabetes can help you decrease medical costs by 130%. That s like spending only $100 per month on your health care, instead of $230! Taking your medications as prescribed to help you manage your diabetes can save you an additional 23% on health care costs. At each visit you should be reviewing medications with your provider, so keep track of them with a pill container, calendar reminders, and a wallet card. Provide patient with recommended monitoring steps for their diabetes. For example, they should be getting an HbA1c test every 6 months and monitoring blood glucose levels at home. **use a goal-setting worksheet like the example to the left** Prescription assistance programs help you receive free or low-cost prescription drugs. The programs are through the pharmaceutical companies and have differing eligibility requirements. Many large chain stores offer common generic drugs for cheaper than the brand name. Generic drugs are required to meet the same standards and can be taken the same way and for the same reasons as brand-name drugs. For more information on this topic, check out American Diabetes Association National Institute of Diabetes and Digestive and Kidney Diseases AHRQ s Your Medicine: Be Smart. Be Safe. After providing education, patients may have additional questions that you cannot answer. Providing them with resources will help empower them to learn more about managing their diabetes and taking their prescribed medications. Here are some resource ideas: A nutrition or physical education class/diabetes support group The name and phone number for a local diabetes educator AHRQ s Sample Prescription Wallet Card Page 26 of 42

27 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: GoodRx website for prescription coupons The name and phone number for a prescription assistance counselor Local resource: Local resource: Local resource: When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've set some healthy goals, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper questionnaire** For each question, please let me know how familiar you are with the topic: Where you can learn more about taking care of your health, score: Ways to save money on prescription medications, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with your prescribed medications before our conversation. Now that you know more about that topic, was that really how familiar you were beforehand? You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: Page 27 of 42

28 There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Health Education 2. Financial Education 3. Registration, if you helped patient sign up for a health education class The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 28 of 42

29 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: I was referred to you by my doctor because I told him that I wanted to quit smoking. I would be happy to help! May I ask you a few questions first so that I can better know how to help you? There are only 2 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Where to learn more about staying healthy, score: Where to learn more about preventive health services, score: Page 29 of 42

30 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: After providing the needs assessment, you should help the patient set smoking cessation goals, while providing some additional education about preventive health care behaviors. **use visual aid** You should be receiving recommended preventive services, like a flu vaccination, a visit with your primary care provider at least once per year, a screening for depression, and a screening for colon cancer. Many of these services are covered by health insurance/medicaid/medicare. Talk with your provider about any medications you can take in order to prevent some diseases, like breast cancer and heart attacks. Now, let s set some goals to help you stop smoking and stay healthy. Your goals should follow the SMART standard, which stands for specific, measureable, attainable, realistic, and timely. **use goal-setting worksheet** For more information on this topic, check out AHRQ s Living a Healthy Lifestyle Understanding Your Preventive Care Health Coverage National Council on Aging Smokefree.gov The Guide to Community Preventive Services After providing education, patients may have additional questions that you cannot answer. Providing them with resources will help empower them to learn more about preventive health care. Here are some resource ideas: A class focused on preventive health care, such as nutrition, exercise, diabetes management, intergenerational programs, etc. The name and phone number for a case manager Healthfinder.gov to find out more about specific recommended preventive services for your patient Local resource: Local resource: Local resource: Page 30 of 42

31 When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've set some goals and talked a little bit about the importance of preventive health care services, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper questionnaire** For each question, please let me know how familiar you are with the topic: Where to learn more about staying healthy, score: Where to learn more about preventive health services, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with where to learn more about preventive health care services before our conversation. Now that you know more about that topic, was that really how familiar you were beforehand? You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: Page 31 of 42

32 There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Health Education 2. Registration The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 32 of 42

33 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: My doctor told me to come see you because I went to the ER recently. I had the flu. I would be happy to help! May I ask you a few questions first so that I can better know how to help you? There are only 3 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Where to go for specialty health services that fit your needs, score: Who can help support you and your health needs, score: Where to go for services that can help you be independent, score: Page 33 of 42

34 After providing the needs assessment, you should provide education to help empower the patient to take charge of their health care. **use visual aid** Choosing where to go for health care is an important decision. Depending on your health coverage plan, the Emergency Room may cost more money to visit than a health center, especially if the visit is not for an emergency. You should go to the emergency room only when you are injured or very sick. You will likely have to wait several hours to be seen if you are there for a non-emergency, and you will see whatever provider is working that day. If you visit a health center for your health care needs, you will likely not have to wait a very long time, and you will see the same provider each time. **use handout like the example to the left** Choosing who to go to for health care is also an important decision. If you visit a provider that is not on your health plan s list of preferred providers, it may cost you more money. Review the patient s health coverage and discuss ways to find out if a provider is covered by their plan. There are important financial documents that you need to bring to your visits, including a health insurance card and a copay, if you have it. Be sure to talk to the front desk staff about updating your health insurance information. Before you leave the provider s office, you should be able to answer these questions: o How is my health? What can I do to stay healthy? o What do I do next? o What is my diagnoses and treatment options? o How do I take my medications? After your health care visit, you should determine if the provider was a good fit for your health care needs. Think about whether you trust the provider, if they listened to your needs, and if they answered all of your questions. Talk with your insurance company to make sure you are able to change your primary care provider. An explanation of benefits is a summary of health care charges that your insurance company sends you after you see a provider or get a service. For more information on this topic, check out Universal Health Care Action Network Talking with Your Doctor Presentation Toolkit CMS From Coverage to Care Roadmap Page 34 of 42

35 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: After providing education, patients may have additional questions that you cannot answer. Providing them with resources will help empower them to learn more about their health care decisions. Here are some resource ideas: The health center locations that have geriatric providers, behavioral/mental health providers, etc. The health center s patient portal The name and phone number for a case manager The name and phone number for organizations that provide special assistance, such as home health, sign language, braille, wheelchair accessibility, etc. Local resource: Local resource: Local resource: When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've talked a little bit about where and who you can go to for health questions, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper questionnaire** For each question, please let me know how familiar you are with the topic: Where to go for specialty health services that fit your needs, score: Who can help support you and your health needs, score: Where to go for services that can help you be independent, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with where to go for specialty health services before our conversation. Now that you know more about that topic, was that really how familiar you were beforehand? Page 35 of 42

36 You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Health Education 2. Financial Education 3. Registration, if you helped patient sign up for patient portal The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 3. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 3. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 36 of 42

37 When you first meet your patient, begin the conversation by figuring out what their needs are and how you can help them: Hello, my name is. What can I help you with today? Patient: Well, my case manager said that you could help me find some housing assistance. I would be happy to help! May I ask you a few questions first so that I can better know how to help you? There are only 2 questions, so it shouldn't take long. I just want to make sure that I'm giving you all the information you need and am doing the best that I can to help you with your health care goals. Patient: I guess that would be okay... Great, thank you! For each question, you can use a 1 to let me know that you aren't at all familiar, a 5 to let me know you are very familiar, or any number in between. Here's a chart to show you the numbers and what they mean. **show laminated scale and/or paper questionnaire** Can you let me know how familiar you are with each of the following: Where to go for help with {housing}, score: Who can help you sign up for health with {housing}, score: Page 37 of 42

38 After providing education, patients may have additional questions that you ca nnot answer. Providi ng them with re sour ces will help empower the m to learn more about usi ng their health insurance. Here are some resource idea s: After providing the needs assessment, you should help the patient find resources by using a community asset map. Provide patient with housing assistance programs and resources. Be sure to tell the patient the organization name, information for a contact person, and which documents (if any) the patient needs to bring with them to get the help. Call your contact person at the organization with the patient to help make the connection. You may even be able to escort the patient to the organization and help them apply for assistance. For more information on this topic, check out Benefits.gov When your patient interaction is ready to come to an end, provide a summary of your conversation: I'm so glad that you came in to talk to me today. Now that we've got some places for you to go and get help with housing, can I ask you the same questions I had asked when you first came in? I want to make sure I gave you all the information you need and your experience with me was a positive one. Is that okay? Patient: My experience was great, but if you need to ask me the questions again, then that is fine. Thank you. Just as a reminder, a 1 means you are not at all familiar and a 5 means you are very familiar. **show laminated scale and/or paper questionnaire** For each question, please let me know how familiar you are with the topic: Where to go for help with {housing}, score: Who can help you sign up for health with {housing}, score: At this point, you can ask the patient if they would like to change any answers to the pre-interaction questions: You answered that you were familiar with where to go for help with housing before our conversation. Now that you know more about that topic, was that really how familiar you were beforehand? Page 38 of 42

39 You should now ask the patient what they thought were the most interesting and/or helpful things that you discussed today: There's a saying that goes "if it isn't reported, it didn't happen!" Report the details of this interaction on your Direct Service Report Tracking Excel Spreadsheet. The service activities for this interaction would include: 1. Non-Financial Case Management-Facilitation The special populations for this interaction would include: 1. Older Adults (65 or Older) 2. Persons with Disabilities The pre & post outcome scores should be reported as an average. Add the numbers from the pre-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Add the numbers from the post-interaction questionnaire together:. Divide that number by 2. This is the pre outcome score:. Don't forget to include the patient's unique ID number and the length of the interaction (in minutes). Page 39 of 42

40 You will periodically submit one report representing all of your Program Site s data year-to-date. To do so, Community HealthCorps Members submit their Excel tracking spreadsheets to you. You compile all of the spreadsheets into a single spreadsheet by copying & pasting each Member s data. When you submit your Program Site s data, you are certifying its accuracy and completeness. Therefore, you should put in place a system of checks prior to submission: Site Supervisors should be the first to review a Member s data on a periodic basis. After the Site Supervisor signs off on the data, you should review it using this list of common errors. The following timeline depicts the Community HealthCorps Direct Service Reporting Periods for the Program Year: Period Data Represents Data Due to NACHC Report Sent to Program Period One (P1) 8/1 9/30/ /16/ /13/2015 Period Two (P2) 10/1-12/31/2015 1/15/2016 2/12/2016 Period Three (P3) 1/1-3/31/2016 4/15/2016 5/13/2016 Period Four (P4) 4/1-7/31/2016 8/12/2016 9/16/2016 Period Five (P5) 8/1-9/30/ /14/ /11/2016 Page 40 of 42

41 The Research/Data Associate analyzes your Program Site s report to determine: The number of unique individuals who received a service within each of the PM categories, The number of unique individuals who report that they improved their knowledge about supportive services and programs by at least 20%, and Your Program Site s progress towards previously agreed upon targets for each PM category. This information is sent back to you in a Progress Reporting Feedback Memorandum to keep you informed of your Program Site s progress. After each reporting period, this data is compiled for the entire national program and displayed on our Data Dashboard. You should review your Program Site s progress in comparison to our national progress. At the end of a Program Year, the Research/Data Associate also determines: The total overall number of unique individuals that received services, The total number of interactions Members have with patients, and The number of unique individuals that received each type of service. This information is presented in annual national & state reports on our website. Our ultimate goal is to have timely and actionable data that can be used for program development and improvement. Click on the image to the right to view a sample data use flow chart, which should be used after every reporting period. Page 41 of 42