Community Health Worker Led Diabetes Coaching within the Medical Home

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1 Community Health Worker Led Diabetes Coaching within the Medical Home Christine Snead, RN Erin Kane, MD Baylor Scott & White Health

2 Objectives Identify tools, resources and tactics needed to effectively implement a low-cost diabetes selfmanagement training and advocacy program as part of the PCMH care coordination strategy Describe how Community Health Workers (CHWs) can be utilized to provide diabetes disease management programs to underserved populations Acknowledgement: This project is supported by a grant from the Merck Foundation as part of its Alliance to Reduce Disparities in Diabetes. 2

3 Presentation at a Glance Background Program Design Outcomes Lessons Learned Sustainability 3

4 Scope of the Problem 4

5 Projected Increase of Diabetes by Race/Ethnicity Reference: Texas Diabetes Council, Texas Department of State Health Services, The Burden of Diabetes in Texas, October

6 Scope of the Problem: Health Care Costs The national cost of diabetes in the U.S. in 2007 exceeds $174 billion. Approximately 1 in 10 health care dollars is attributed to diabetes. Adjusted for age and geography, the medical expenditures for people with diabetes are over twice the amount spent for people without diabetes. Reference: Texas Diabetes Council, Texas Department of State Health Services, The Burden of Diabetes in Texas, October

7 Background Diabetes Equity Project Designed with Baylor Health Care System & Dallas County Medical Society - Project Access Dallas Baylor Community Care Primary care service line for the uninsured (high utilizers) 6/7 practices are Patient Centered Medical Homes Challenges Patient volume outweighs capacity of PCPs Additional patient navigation, education and support needed for high-risk diabetic patients Limited budget 7

8 Diabetes Equity Project Locations 8

9 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

10 Diabetes Equity Project (DEP) Funding: Merck Foundation Grant $1.7 million over five years Alliance to Reduce Disparities in Diabetes To address the growing problem of health care disparities related to type 2 diabetes in the United States among low income and underserved adult populations Five grantees: University of Chicago, Camden Coalition of Health Providers, Wind River Reservation, Healthy Memphis Common Table, BHCS 10

11 Patient Demographics Data for participants enrolled in DEP Year One from September 2009 through March N =

12 Patient Demographics, 2 Data for participants enrolled in DEP Year One from September 2009 through March N =

13 Community Health Workers in Texas Community Health Worker: A new and emerging health care worker Trusted patient peer* Culturally competent Supports patient navigation and health education Certification: 160-hour program via DSHS approved entities, building competencies in: Communication skills - Interpersonal skills Service coordination - Capacity-building Advocacy - Teaching skills Organizational skills - Knowledge base Continuing education requirements: 20 hours/2 years 13

14 DEP s Community Health Workers Medical Assistant Background Bilingual Rigorous training: 3-4 week preceptorship Diabetes training (AADE Level 1 certification, complete Certified Diabetes Educator led classes) On the job training CHW certification Continuing education (20 hours/year): motivational interviewing basics, diabetes, depression, compassion fatigue 14

15 DEP Core Model: Augmenting the PCMH Strong PCP-DHP relationship Direct communication (EMR and in-person) Time Training and support Diabetes education Assess barriers Follow-up Basic patient care duties Cultural competence Time to build trust Team approach Motivation Open communication Have confidence in DHP Verbalize support Shadow DHP, review protocol Be available Comply with lifestyle modifications & med mgmt Participate in intervention Share info about health status 15

16 Shifting Tasks to the CHW 16

17 DEP Program Tool Development Standardized protocols clearly define CHW role Visit-by-visit instructions Red flags for handoffs to other team members Standardized, low health literacy, culturally relevant educational tools Hands-on models (food, sugar content, foot ulcer) Handouts Relevant community resources/process for referrals 17

18 DEP Visit One Protocol 18

19 Low Health Literacy Materials 19

20 Diabetes Registry Visit Summary used as patient activation tool Registry Design Provides longitudinal tracking (reduces patients falling through the cracks ) Workflow support Operational outcome reporting tool 20

21 CHW Panel Size unduplicated patients is average panel size for established program (increase of 2.5% in 3 months). Data source is the DEP registry, October 2011 September

22 Preliminary Outcomes: Mean Hemoglobin A1c Decreases 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,

23 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,

24 A Population View: Poor Glycemic Control Decreases 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, p<

25 Other Preliminary Outcomes BMI: Little change, not statistically significant Blood Pressure: Little change, good control throughout Systolic: Diastolic:

26 Self-Management Confidence Improves 26

27 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,

28 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,

29 Qualitative Interviews: CHWs Changing to this model is a process There hasn t been a model like the DEP. The CDEs thought we were taking their jobs. The director of the clinic had a big meeting about roles roles and processes were defined for everyone. CHW team support is important They are moral support. We vent and help each other out. They are like a support group. Patient relationships are fulfilling Before I worked with patients in a group setting. It was not personal. I did not have a relationship with the patients. Here you have a relationship with the patients. They want to tell you everything. I enjoy it. Stress/compassion fatigue can be a factor I love my job, but when they tell sad stories it breaks your heart. Sometimes it can be very stressful. * Five qualitative interviews conducted by BHCS Director of Health Sciences Research Funding,

30 Lessons Learned: An Operational Perspective Unique CHW/Patient relationship is the cornerstone of the intervention CHW competency is a must have EMR access facilitates model acceptance and effectiveness Communicate and track outcomes 30

31 Lessons Learned: A Physician s Perspective Improved provider acceptance with CHW embedded IN THE CLINIC, not off-site Quarterly clinical outcomes reporting Aided provider acceptance of CHW role VIP patient population collaboration between provider and CHW for patient interventions Centralized management, team structure Protects the role of CHW as a health coach Not pulled into other fill-in roles in the clinic 31

32 Challenges Financial No reimbursement for CHW visits YET Mainstream acceptance of CHW role Relatively unknown role Perception of infringing on other health care roles No national professional CHW organization YET 32

33 Expansion of CHWs: Baylor Scott & White Health Career path building blocks established CHW job code Promotional CHW position 50% of existing CHW team members enrolled in college courses Three additional CHW programs are now in place Elder House Calls Reduce Emergency Department use through navigation to primary care (Primary Care Connection) Reduce hospital utilization through navigation to primary care (Community Care Navigation) 33

34 Future and Sustainability Communicate performance internally Outcome data (triple aim: cost, quality, and satisfaction) One DEP site recently ranked in the top 10% among 60 Health Texas practices for Diabetes metrics Medicaid 1115 Waiver funding Expand CHW role to other chronic diseases Add RN to team to care-manage most complex patients Local nonprofit funding Toolkit website in development: 34

35 Conclusions CHW-led Care Coordination model demonstrates positive outcomes Improved glucose control Improved self-management confidence scores Potential for improved efficiencies by task shifting to CHW Requires reimbursement mechanism for long-term sustainability 35

36 Thank You! 36

37 Presenters Erin Kane, MD Principal Investigator, Diabetes Equity Project Christine Snead, RN Director, Care Coordination 37

Expanding PCMH Team Roles in Diabetes Care: Diabetes Equity Project

Expanding PCMH Team Roles in Diabetes Care: Diabetes Equity Project Christine Snead, RN Erin Kane, MD Baylor Health Care System www.alliancefordiabetes.org Objectives Identify tools, resources, and tactics