Transcript Improving Care Transition of Older Adults with Community

Dr. Cheryl J. Dye, Professor, Clemson University
Dr. Deborah Willoughby, Professor, Clemson University
Dr. Begum Aybar-Damali, Assistant Professor, Winona State
University
Gerontological Society of America 62nd Annual Meeting
November 19, 2009
Presentation Outline
 Definition and role of community health worker
(CHW)
 Research support for effectiveness of CHW
 Policy and legislative support for role of CHW
 Research support for effectiveness of CHW as care
transition coach; findings from HRSA research
 Opportunities, challenges and solutions to the
institutionalization of CHWs
Background
 Community health workers (CHWs) are an important
component of programs addressing the health care needs of
communities (HRSA, 2007).
 Involving CHWs in health care delivery is a cost-effective
strategy as they have contributed to enhancement of
individuals’ adherence to recommended health behavior
changes, self-control of their health conditions, and their
access to health care (Brownstein, Bone, Dennison, Hill, Kim, & Levine, 2005).
 The CHW workforce is among the most rapidly growing lines
of work (HRSA, 2007) and is projected to continue growing.
 The addition of CHWs into the health care team is a creative
approach to prevention and control of many health
conditions. However, an understanding of the role of CHWs
and their incorporation into the health care delivery system
remain a major challenge.
Community Health Worker (HRSA 2007)
Community health workers are lay members of communities
who work either for pay or as volunteers in association with
the local health care system in both urban and rural
environments and usually share ethnicity, language,
socioeconomic status and life experiences with the community
members they serve.
They have been identified by many titles such as community
health advisors, lay health advocates, “promotores(as),”1
outreach educators, community health representatives, peer
health promoters, and peer health educators.
CHWs offer interpretation and translation services, provide
culturally appropriate health education and information,
assist people in receiving the care they need, give informal
counseling and guidance on health behaviors, advocate for
individual and community health needs, and provide some
direct services such as first aid and blood pressure screening.
Community Health Worker
Effectiveness with Older Adults
• Hypertension control (Brownstein, et al., 2005, Cordery et al., 1997; Krieger,
Collier, et al, 1999) ,
• Appointment keeping, continuity of care (Brownstein, et al, 2005);
• Development of a “therapeutic alliance” between patient,
•
•
•
•
provider, and family/community support systems;
Risk reduction; and improving patterns of health care
utilization (Nemcek, 2003);
Diabetes control (Norris et al., 2006; Cordery, et al, 1997; Krieger, et al, 1999);
Increasing the use of preventive services, keeping
appointments, increasing adherence to recommended
regimens, promoting appropriate use of health services
(Witmer, et al, 1995); and
Linking older clients to social services (Forti & Koerber, 2002).
Institutionalization of
Community Health Worker
• 1999 - CHW training and certification legislation was passed in Texas.
•
•
•
•
•
•
The bill also mandated that pilot projects using CHWs in Medicare
managed care be conducted.
2000 to 2006 - similar bills passed in New Mexico, Massachusetts, and
Virginia.
2001 - National Rural Health Association issued public policy
statements supporting expanded roles for CHWs.
2001 - Similar statements to NRHA issued by the American Public
Health Association
2003 - Similar statements to NRHA issued by the American
Association of Diabetes Educators.
2005 - Patient Navigator bill signed into law as the first major CHW
legislation adopted at the Federal level.
2009 - The Medicare Care Transitions Act of 2009a was introduced to
reduce hospital readmission rates by improving the follow-up care
patients receive after leaving the hospital. The bill would create a
nationwide network of community-based transitional "care coaches"
whose duties would include helping patients self-manage their
condition and medications over time, providing personal follow-up
care, and serving as an access point when patients change care settings.
The Transitional Care Model (TCM)
TCM emphasizes coordination and continuity of care, prevention and
avoidance of complications, and close clinical treatment and management –
all accomplished with the active engagement of patients and their family and
informal caregivers and in collaboration with the patient's physicians
Community Health Worker as Care
Transition Coach
• HRSA funding to test use of community health worker,
called “Health Coach”, as a care transition coach for
discharged home health services patients
– Guidance provided by research supporting need for:
• Careful recruitment of potential CHWs,
• Comprehensive training, effective oversight, and evaluation.
• Clear definition of CHW role, effective documentation of CHW
activities for evaluation purposes (Swider, 2002; Reininger, Dinh-Zarr, Sinicrope and Martin, 1999)
• The role of the community health worker not only reduced
emergent care of discharged home health services patients,
but also fulfilled the needs of more healthy and active older
adults seeking opportunities for meaningful civic
engagement in their community.
Research findings to support CHW
as Care Transition Coach
“Helping Rural Elders Transition from Home Health to
Chronic Disease Self-Management through
Paraprofessional Outreach”
Dr. Cheryl Dye, Dr. Deborah Willoughby, Dr. Begum
Aybar-Damali
Funded by Health Services and Resources Administration,
Rural Health Care Services Outreach Grant Program 1 D04RH0678901-00, 5-2006 to 4-2009, no-cost extension 5-2009 – 4-2010
Oconee County, SC
OMH Emergency Department Visits, >65 Yrs - 2003
Diseases of Circulatory
System Diagnosis*
# of
Visits
Total
Charges
# of
Visits
Total
Charges
Diabetes with
Complications
45
$136,585
12
$23,472
# of
Visits
Total
Charges
293
$2,469,620
Diabetes
Acute Ischemic Heart
Disease
8
$32,829
Angina Pectoris
9
$30,797
Diabetes without
Complications
Arteriosclerotic Heart
Disease
83
$700,067
Selected Diseases of
Respiratory System
Cardiac Dysrhythmias
134
$898,501
Influenza*
Congestive Heart Failure
123
$648,904
Pneumonia (All Forms)
Heart Attack
69
$984,852
Hypertensive Heart
Disorder
5
$91,147
Pulmonary Heart Disease
16
$416,244
Other Heart Disease
33
$380,272
Total: # of visits= 480 Total
Charges= $4,183,613
*Diagnoses with fewer than 5 visits are not reported.
OMH Inpatient Hospitalizations >65 yrs - 2003
Diseases of Circulatory
System Diagnosis*
Acute Ischemic Heart
Disease
# of
Visits
4
# of
Visits
Total Charges
Diabetes
$20,635
Diabetes w/
Complications
37
$433,234
5
$22,556
Acute Myocardial
Infarction
111
$3,187,507
Diabetes w/o
Complications
Arteriosclerotic Heart
Disease
189
$6,500,866
Selected Diseases of
Respiratory System
Atherosclerosis
18
$368,477
Influenza*
Cardiac Dysrhythmias
154
$2,705,225
Congestive Heart Failure
161
$1,992,979
Hypertensive Heart
Disease
9
$108,785
Pulmonary Heart Disease
28
$799,308
Other Diseases of the
Arteries
8
$247,373
Other Heart Diseases
63
$1,516,368
*Diagnoses with fewer than 5 visits are not
reported.
Pneumonia - All Forms
# of
Visits
341
Total Charges
Total Charges
$4,774,305
Total: # of visits=745
Total Charges= $17,447,523
Summary of Findings
Health Coach clients with no emergent care –
19/33 = 57.6%,
Comparison group with no emergent care –
17/38 = 44.7%
Cost of emergent care for Health Coach clients $11,161 per client
Cost of emergent care for comparison group –
$22,584 per patient
Health Coach clients – no admissions for falls
Comparison group – four admissions for falls
Health Coach clients – one admission for pneumonia
Comparison group – four admissions for pneumonia
clients
= 33
Clients with No Emergent Care N=19/33 (57.6%)
Health Coach Clients with NO Emergent Care
N clients = 33
Client
#
140
121
137
60
61
139
19
991
17
80
15
133
136
35
33
210
81
51
122
Age Enrolled in
HH
86
8/20/08
79
2/14/07
80
3/22/08
77
1/25/07
76
10/1/07
66
8/7/08
82
3/12/07
78
12/30/07
83
4/19/07
63
8/5/07
81
2/6/08
84
3/11/08
71
2/25/08
77
4/24/08
66
5/10/07
72
6/14/08
84
4/25/08
68
3/6/07
80
7/25/07
Clients with No Emergent Care N=19/33 (57.6%)
Enrolled in
HC Program
9/26/08
8/13/07
7/1/08
8/13/07
11/19/07
8/26/08
8/13/07
6/6/08
6/12/07
9/27/07
6/12/07
7/14/08
6/13/08
6/19/08
7/23/07
9/8/08
5/28/08
7/20/07
7/20/07
HH
Diagnosis
CHF, CVD
CHF, CVD
CVD
CVD
CVD, DM
CVD, DM
DM
DM
DM
DM
DM, CVD
DM, CVD
DM, CVD
DM, CVD
DM, CVD
DM, CVD
CVD
CVD
CVD
ER / OMC Visits –
Cost of
Updated: October 8
Care
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
NO EMERGENT CARE
$0.00
Sub Total: $0.00
Health Coach Clients with Emergent Care
N clients = 33
Clients with Emergent Care N=14 / 33 (42.4%)
Client
#
21
135
13
22
Age Enrolled
in HH
91 8/22/06
73 12/3/07
61 8/23/06
96 9/8/06
Enrolled in
HC Prog.
11/30/06
6/17/08
3/1/07
3/8/07
26
28
14
27
92
84
71
63
3/15/08
4/16/08
2/15/07
4/5/08
4/23/08
6/13/08
2/22/07
6/15/08
132
86
2/28/08
4/22/08
10
69
9/25/07
11/8/07
34
75
4/21/08
6/6/08
130
68
1/30/08
3/6/08
23
70
78
62
3/18/07
7/8/07
6/15/07
9/25/07
HH Diag.
ER / OMC Visits –
Updated: October 8
CVD
10/28/07 END STAGE RENAL FAILURE, HTN, ANEMIA
DM
9/20/08 URINARY PROBLEM
DM
10/5/07 CHF, ACUTE RENAL FAILURE
CHF
1) 6/14/07 WEAKNESS; 2) 8/15/07 ABP PAIN; 3)
9/2/07 NOSE BLEED; 4) 9/15/07 NOSE BLEED
CVD
6/24/08 AMS (ALTERED MENTAL STATUS)
CVD
7/15/08 ABD PAIN DEMENTIA, INCONTINENCE
DM, CVD 9/12/07 ADM: GI BLEED
DM
1) 6/21/08 DEHYDRATION, DIARRHEA, 2) 7/13/08
RESP/FAILURE, COPD, CHF
CVD, CHF 1) 8/31/08 TIA (TRANSIENT ISCHEMIC ATTACK), 2)
9/4/08 LTC, 3) 9/26/08 KNEE PAIN
CHF, DM, 1/29/08 PNEUMONIA, CHF, COPD
CVD
CVD, DM 1) 7/25 BLOOD IN URINE – SIGNED OUT AMA
2) 7/28/08 ANEMIA, CRD, HYPONATREMIA, DM
DM, CVD 1) 3/16/08 BLOOD SUGAR PROBLEM, 2) 4/7/08
DIZZNESS,
DM
12/04/07 DM, WEAKNESS, HTN
CVD, DM 12/15/07 DIABETIC KETOACIDOSIS, MI,CRI
Cost of Care
(n=14)
$9,643
$897
$6,482
1) $1,542 2) $715 3) $765
4) $1,039
$1,696
$4,368
$29,380
1) $16,430 2) $22,283
1) $10,761 2) $10,635, 3) $988
$1,063
1) 0
2) $5,362
1) $178, 2) $2,911
$5,111
$23,999
Sub Total $156,248
Average Cost of Care (per person) $11,161
CELLULITIS: Infection of skin, often related to diabetes and poor circulation / DSYPNEA: Shortness of breath /
SYNCOPE: Brief loss of consciousness / OCB: Obstructive Chronic Bronchitis / HYPERKALEMIA: Greater than
normal amount of potassium in the blood; seen frequently with acute renal failure.
Comparison Group with NO Emergent Care
N Comparison = 38
No Emergent Care, N=17/ 38 (44.7%)
Patient
#
10806
7440
10980
11776
13484
12491
13884
12437
11518
11861
11714
13056
9911
11158
11622
13425
12425
Age
83
68
87
73
87
86
73
91
80
83
62
72
91
81
89
68
71
Enrolled in
HH
10/29/06
12/13/06
12/13/06
6/13/07
6/18/08
6/22/08
8/30/08
11/6/08
4/14/07
7/1/07
5/27/07
3/17/08
3/30/07
1/25/07
7/2/07
6/6/08
10/27/08
HH
Diagnosis
CVD
CVD
CVD
CVD
CVD
CVD
CVD
CVD
CVD
DM
DM
DM
DM
DM
DM
DM
DM, CVD
Emergent Care/Adm to
Hospital
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
NO EMERGENT CARE
Sub Total
Cost of
Care
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Comparison Group with Emergent Care
N Comparison = 38
Patient
#
10608
11067
12723
11574
Age
Comparison Group with Emergent Care N=21 / 38 (55.3%)
91
73
62
84
Enrolled
in HH
9/14/06
7/26/07
1/5/08
1/8/08
HH
Diagnosis
DM, CHF, CVD
DM
DM
DM
12863
13077
13343
13745
10508
11130
11776
11255
12179
10344
83
64
84
63
87
85
73
82
73
80
2/5/08
4/24/08
5/19/08
8/6/08
8/24/06
1/18/07
6/13/07
2/20/07
2/13/08
7/14/06
CVD
DM, CHF, CVD
CVD, DM
CVD
DM
CVD, CHF
CVD
CVD, CHF
DM
CHF, DM, CVD
13175
9298
61
87
4/14/08
11/30/06
CVD
DM, CVD
11267
11229
72
77
2/21/08
2/13/07
CHF, CVD, DM
DM, CHF, CVD
12154
5155
10549
73
72
73
9/6/07
3/23/07
8/30/06
CHF
CVD
DM
Emergent Care/Adm
to Hospital
1) 10/5/07 PNEUMONIA, 2) 10/20/07 FLU LIKE SYMPTOMS
1) 8/1/07 NAUSEA/VOMITING, 2) 9/2/07 PROFOUND WEAKNESS
3/14/08 SEIZURE
1) 3/16/08 FALL, 2) 4/30/08 LEG PAIN, 3) 5/1/08 LEG PAIN
4) 5/6 OPO CVA/TIA, 5) 5/18, 6) 6/9/08 TIA, 7) 7/20/08 CONSTIPATION
2/7/08 GROIN PAIN/SWELLING
6/26/08 COPD, PNEUMONIA
8/27/08 FALL
9/8/08 RIB/HAND PAIN
1) 1/4/07 FALL FX, 2) 1/22/08 CVA DECEASED
9/07 SYNCOPE*
6/29/07 DIABETES, WOUND HTN
7/22/07 EMS LOW BLOOD SUGAR
8/29/08 TIA
1) 11/13/06 HYPERKALEMIA, CKD, DM, 2) 11/17/06 EMS RESP/
DISTRESS/ DECEASED
1) 7/15/08 HAND INJURY, 2) 9/20/08 AFIB, PNEMONIA, CHF
1) 9/20/07 FALLS, 2) 9/29/07 DSYPNEA*, R/O PE, 3) 9/5/07 CHF, AFIB,
COPD
1) 6/18/08 CHF, HTN , 2) 7/12/08 BACKPAIN , 3) 8/19/08 BREAST PAIN
1) 5/13/07 ELEVATED BLOOD SUGAR, 2) 6/18/08 ELEVATED BLOOD
SUGAR, 3) 9/27/08 RESPIRATORY FAILURE
4/18/08 CELLULITIS*, PNEMONIA, COPD,CVD
7/25/07 OPO CHEST PAIN
12/6/06 CELLULITIS*, OSTEOMYELITIS, DM, DIABETIC FOOT
WOUND/AMPUTATION
Cost of Care
(n=21)
1) $46,250, 2) $917
1) $1,433 2) $5,214
$13,233
1) $1,892, 2) $2,370 , 3) $1,523, 4) 9,534,
5) $2,983, 6) $23,837, 7) $548
$639
$18,794
$389
$3,618
1) $11,600, 2) $29,661
$363
$1,780
$367
$31,327
1) $3,835, 2) $722
1) $130 , 2) $65,608
1) $1,970 2) $6,047, 3) $47,392
1) $12,493, 2) $292, 3) $724
1) $755 2) $28,379, 3) $40,737
$19,721
$13,846
$23,347
Sub Total $474,270
Average Cost of Care (per person) $22,584
CELLULITIS: Infection of skin, often related to diabetes and poor circulation / DSYPNEA: Shortness of breath /
SYNCOPE: Brief loss of consciousness / OCB: Obstructive Chronic Bronchitis / HYPERKALEMIA: Greater than
normal amount of potassium in the blood; seen frequently with acute renal failure.
Pneumonia & Fall (Comparison and Clients)
Patient # Enrolled
in HH
12154
9/6/07
HH
Diagnosis
CHF
13175
10608
4/14/08
9/14/06
CVD
DM, CVD, CHF
13077
4/24/08
DM, CVD, CHF
Emergent Care/Adm to Hospital
4/18/08 CELLULITIS PNEUMONIA,
COPD,CVD
9/20/08 AFIB, PNEUMONIA, CHF
1) 10/5/07 PNEUMONIA
2) 10/20/07 FLU LIKE SYMPTOMS
6/26/08 COPD, PNEUMONIA
Total Cost:
Patient # Enrolled
in HH
11574
1/8/08
HH
Diagnosis
DM
10508
8/24/06
9298
13343
11/30/06
5/19/08
Emergent Care/Adm to Hospital
10
Enrolled
in HH
9/25/07
$19,721
$65,608
1) $46,250
2) $917
$18,794
$151,290
Cost of Care
3/16/08 FALL
$1,892
DM
1/4/07 FALL FX
$11,600
DM, CVD
DM, CVD
9/20/07 FALLS
8/27/08 FALL
$1,970
$389
Total Cost:
Client #
Cost of Care
HH
Diagnosis
CHF, DM,
CVD
Enrolled in ER / OMC Visits –
HC Program Updated: October 8
11/8/07
1/29/08 PNEUMONIA CHF, COPD
Total Related Cost:
$15,851
Cost of Care
$1,063
$1,063