Transcript Community-based Care for Chronic Disease Management in Navajo

Community-based care for
Chronic Disease Management
in Navajo Nation
Sonya Shin, MD MPH
Gallup Indian Medical Center
Brigham and Women’s Hospital
Partners In Health
Harvard University

No disclosures
Health in the Four Corners Region:
How are we doing?
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
Health Outcomes
Disease Prevalence
Cost of Care
Patient Experience
If things aren’t working, why not?
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Geographic isolation
Workforce shortages, esp with professionals
Cultural gap (provider  patient)
Poverty, unemployment, basic services
Biomedical health model
Biomedical health model:
Limitations
Community Health Workers:
Addressing the barriers to quality care
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Geographic isolation
Workforce shortages, esp with professionals
Cultural gap (provider  patient)
Poverty, unemployment, basic services
Community based-approach:
Addressing Biosocial Determinants
Growing role of CHWs in health care
“CHWs should be integrated
into
as
an approach to eliminating
,” including a
focus on hypertension [Institute
of Medicine]
“CHWs can
, particularly when caring
for underserved populations where
are
essential.” [Agency for Healthcare
Research and Quality]
National Academy of Sciences 2010; Smedley et al 2003; AHRQ 2009 290-2007-10056;
CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009
Growing role of CHWs in health care
“Addressing health disparities should
include community health workers targeting
minority populations” including
cardiovascular diseases.
[National Institutes of Health]
“CHWs should be integrally included
in diabetes management.”
[CDC]
“CHRs play an important role in promoting health
in underserved populations.”
[Obama’s Affordable Health Care for America Act]
National Academy of Sciences 2010; Smedley et al 2003; AHRQ 2009 290-2007-10056;
CDC 2011; NHLBI 2010; Affordable Health Care for America Act 2009
Community Outreach and Patient
Empowerment (COPE)
Community
 Support Navajo CHRs with training, professional
development, materials
Outreach
 Home-based care and services
 Health education
 Counseling & health promotion
 Social support
Patient
 Uncontrolled chronic diseases (DM, etc)
Empowerment
 Coach patients and families in disease
self-management and prevention
TRAINING
Health Education
Health Promotion
LINKAGE WITH
CARE TEAM
COMMUNITY
CHR
TOOLS
Equipment
Teaching aides
High risk
clients
At risk
community
Patient Teaching Materials
• Flipcharts based on CHR request
• Culturally appropriate visual images
• Motivational interviewing techniques
Other resources
• Finger stick certification and supplies
• Laptops, oximeters, etc
TOOLS
Equipment
Teaching aides
IPC (Improving Patient Care)
Innovations:
• Provider referrals to COPE
• Coordinate COPE with related
programs (pharmacy DM clinic,
DM education, etc)
• Joint home visits (provider/CHR)
• Strengthen PHN-CHR
collaboration
• Case management rounds
• Facilitate CHR access to
Electronic Health Record (EHR)
LINKAGE WITH
CARE TEAM
TRAINING
Health Education
Health Promotion
Training for CHRs
• Standardized curriculum
• IHS Navajo-speaking trainers
• Health promotion skills
(Motivational Interviewing,
goal setting)
• Train the Trainer model
• Competency assessment
• CHR Supervisor training
Preliminary Outcomes (5/12)
HIV: How well are we doing?
HIV: Dissecting the health care
delivery chain
Diagnosis
Reduced
transmission
Treatment
Behavior
change
Favorable
outcomes
Where are we struggling as providers?
Diagnosis
Reduced
transmission
Treatment
Behavior
change
Favorable
outcomes
Pop quiz!
Among people diagnosed with HIV in the U.S. since 2008:
 What % established care in the first year?
a.
b.
c.

What % were retained in care?
a.
b.
c.

45%
64%
88%
45%
64%
88%
What % achieved virologic suppression?
a.
b.
c.
53%
67%
77%
Follow-up study of 100,375 people
diagnosed with HIV through 2008, U.S.
Established care within a year of dx (n=5137): 64%
Retention in care (n=100,375):
45%
Virologic suppression:
Hall et al, JAIDS 2012
77% (last viral load)
53% (all viral loads)
Pop quiz!
Among people diagnosed with HIV in Navajo Area IHS, how do we
compare to national figures?
 Establishing care in the first year?
a.
b.
c.

Retention in care?
a.
b.
c.

Above average
Average
Below average
Above average
Average
Below average
Virologic suppression?
a.
b.
c.
Above average
Average
Below average
NAIHS Annual HIV Report, 2011
Established care within first year of diagnosis (n=39):
71%
Retention in care, among those living (n=303):
- Regular follow-up/seen elsewhere
- Intermittent follow-up (<50% appointments)
- No follow-up
Virologic suppression:
NAIHS Annual Report, 2011
55%
14%
31%
55%
Can we do better?
•
At the national level:
• > one third do NOT establish care within a year of HIV dx
• > one half do NOT receive regular HIV care
• Almost half are not virologically suppressed
Partners In Health (PIH)
Accompagnateur model
Accompagnateurs:
The “Backbone” of PIH
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•
•
•
•
•
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Community health workers
Since 1985
Paid health workers
Responsible for referrals,
vaccines, hygiene, maternal
and infant health
Initial training plus ongoing
training
The “missing infrastructure”
in many resource poor
settings
100% directly-observed
therapy (DOT) coverage for
TB and HIV patients
EXPANSION TO OTHER
RESOURCE-POOR SETTINGS
1041 people initiating ART 2005-2006,
PIH-MOH HIV Program in Rwanda
Established care within a year of dx: not reported
Retention in care among those living (n=989):97%
Virologic suppression (n=275):
Rich et al, JAIDS 2012
98%
So, what’s the magic ingredient?

CHW accompaniment
Directly observed therapy (?)
Psychosocial support
Adherence coaching
Screen for side effects
Liaison with providers

Additional supports
Nutrition
Transportation costs
Patient support groups
Team-based care
BUILDING AN
ACCOMPANIMENT PROGRAM
Step 1:
Create an outreach team
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Identify the outreach worker
 IHS, tribe, NGO, etc
 Level of training
 Cultural, organizational, geographic constraints
Create care coordination SYSTEM
 Linkage is CRUCIAL
 Case management
 Documentation
 Supervision
Step 2:
Define the home-based intervention

Establish the role of the outreach worker
Deliver medications?
 Adherence coaching?
 Counseling?
 Directly observed therapy? Modified?
 Case management? Referrals?
 Always:

Social support
 Communicator
 Patient advocate

Step 3: Equip the outreach worker
with the necessary resources

Training
HIV content
 Counseling skills, motivational interviewing


Materials
Teaching / coaching materials
 Four-wheel drive?
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
Support
Access to care team
 Clinical “back-up” for challenging cases
 Support for their own wellbeing (burn-out, safety,
trauma)

Step 4: Match the intervention to your
population
 All
patients?
 High-risk only? (Clinical criteria? Psychosocial?)
 Tiered interventions depending on needs?
HOPE in Navajo: HIV Outreach
& Patient Empowerment

Hiring
 Health technician, GIMC
 Case manager, NAN
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Training
 Adherence Counseling
 Motivational interviewing
 Harm Reduction
 Wellness & self-care
o
Materials
o Patient flipcharts
o Pill boxes and keychains
o Transportation and food
vouchers
o Target population
o New diagnoses
o Not getting care
o Not virologically suppressed
o Team-based care
o Case management rounds
o Documentation
o Multidisciplinary team
HOPE in Navajo

Flipcharts:
 HIV basics
 HIV and nutrition
 HIV: Know my meds
 Taking my meds
 Harm reduction
 Health maintenance
 Exercise
 Coping with stress
 Caring for the caregiver
 HIV and substance use
 HIV and mental health
 Hepatitis C
 Tuberculosis
 Other sexually transmitted infections
 Communicating with my provider
Step 5: Get started!
ACKNOWLEDGEMENTS
GIMC
Bennie Yazzie, Paula Mora, Carla Baha-Alchesay
Bruce Forman, Maricruz Merino,
Jon Iralu, Bill Monroe, Watson Billie
Navajo AIDS Network
Brigham & Women’s Hospital / Partners In Health
Chip Thomas (B&W photo)
RX Foundation
Contact information:
[email protected]