Community Health Workers: Making it Real

Community Health Workers:
Making it Real
Marc Pierson, M.D.
[email protected]
June Robinson, MPH
[email protected]
Kathy Burgoyne, Ph.D.
[email protected]
• frontline workers who help individuals and communities to improve their
health
• trusted member of and/or has an unusually close understanding of the
community serve
• a unique position to engage individuals and populations that professionals
have difficulty reaching.
• founded on natural helping systems within communities and is based on
peer-to-peer relationships rather than provider-client relationships
The trusting relationship enables the CHW to serve as a
link between systems and the community to facilitate
access to services and improve the quality and cultural
competence of service delivery systems.
(Amy Cuddy, social psychologist)
• Outreach
• Cultural mediation
• Navigation: help people get the services they need
• Create more effective linkages between communities and care
systems
• Provide culturally appropriate health education and self-management
support
• Advocate for underserved individuals and community needs
• Informal counseling and social support
• Build individual and community capacity in addressing health issues
• Some direct services (e.g. screening)
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social service organizations
outpatient care centers
education programs
public health departments
hospitals
physicians’ offices
behavioral health programs
• Population Health: CHWs are effective in preventing and
controlling chronic conditions
• Patient Care: CHWs improve the patient experience
• Cost Effective. ROI average is 3:1
THREE QUESTIONS
Who is “We”?
Where is “Home”?
How long will we care?
• For for our wellbeing?
• Partners?
• Competition among the parts?
• Collaborate?
OUR CHILDREN’S
FUTURE
How to get
upstream of
illness?
Dynamics = Relationships over Time
19+ Levers—4 Categories
1. FINANCE A NEW SYSTEM
2. PERSON-CENTRIC VALUE CREATION
3. COMMUNITY OPPORTUNITIES
4. REDESIGN THE PROFESSIONAL WORKPLACE
From ReThink Health, Fannie E. Rippel Foundation
13
FINANCE THE NEW SYSTEM
1. Establish innovation fund
2. Capture savings
3. Pay providers for performance (out of captured
savings)
From ReThink Health, Fannie E. Rippel Foundation
14
PERSON-CENTRIC
REORIENTATION FOR BEHAVIORAL OUTCOMES
1. Improve post-discharge care to reduce hospital
readmissions
2. Coach and coordinate health care
3. Provide adherence support for routine care
4. Improve routine preventive and chronic physical illness
care
5. Improve care for chronic mental illness
6. Enable healthier behaviors
7. Extend the use of hospice care (end of life choice)
From ReThink Health, Fannie E. Rippel Foundation
15
COMMUNITY OPPORTUNITIES
1. Create pathways to advantage
2. Reduce environmental hazards
3. Reduce crime
From ReThink Health, Fannie E. Rippel Foundation
16
REDESIGN THE PROFESSIONAL WORKPLACE
1. Create medical homes
2. Recruit primary care providers for safety net clinics
3. Recruit primary care providers in private practice
4. Redesign primary care practices for efficiency
5. Prevent hospital-acquired infections
6. Improve hospital efficiency
From ReThink Health, Fannie E. Rippel Foundation
17
A COMMUNITY NETWORK
• Navigating a Complex System
• Connection People To Resources
• Supporting individual choices & behaviors
• Integrating medical and social systems with
• Community-based health navigator-coaches
• Informed of patient capability
• (Patient Activation Measure)
• Connected electronically around each patient
• HIE and Care Manager Dashboard
Finanical
Services
Jobs /
Employment
Neighborhood
Support (CHW)
[Hundreds Thousands]
Volunteer
Parish Nurse
(Health
Ministries
Network)
[Hundreds]
Education
Patient
[Thousands]
PEER
Supporters
Thousands]
Persnonal Care
Workers
[Hundreds]
NEIGHBORHOOD
Legal Aid /
Criminal Justice
FAMILY Care
Givers
[Thousands]
HOME
Crisis
Intervention
Community
Based
NAVIGATOR
COACH
([Tens]
Family Support
Transportation
COMMUNITY
Food
Care
COORDINATOR
[Hundreds]
Physician
[Hundreds]
Practice Nurse
(Triage)
[Hundreds]
Housing
MEDICAL INSTITUTIONS
SOCIAL SERVICES
Practice
Scheduler
[Hundreds]
June Robinson
[email protected]
Kathy Burgoyne
[email protected]
Marc Pierson
[email protected]
.