Transcript Michigan Pathways to Better Health

MICHIGAN PATHWAYS TO
BETTER HEALTH
MACMHB May 21, 2014
PRESENTERS
Barb Glassheim – Project Manager, Saginaw
 Judy Kell – HUB Director, Muskegon
 Linda Tilot – MIECHV HUB Project, Saginaw
 Lori Noyer – Project Coordinator, Ingham
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OVERVIEW OF PRESENTATION
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Objectives
Describe an effective model for integrating health care
and social services for high-risk populations
 Describe the role of a Community Health Worker
 Describe the role and benefits of a Community HUB
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Topics
Community HUBs
 Integrated service delivery
 Community Health Workers
 Working with high-risk clients
 Using technology to enhance service delivery
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MICHIGAN PATHWAYS TO BETTER HEALTH
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Funded by 3-yr CMS Innovations Grant awarded to MPHI to
demonstrate cost savings over usual care (7/1/12 - 6/30/15)
CMS Acknowledgement
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The project described was supported by Grant Number 1C1CMS331025
from the Department of Health and Human Services, Centers for
Medicare & Medicaid Services. The contents of this publication are
solely the responsibility of the authors and do not necessarily represent
the official views of the U.S. Department of Health and Human Services
or any of its agencies.
Implementation
 Ingham County HUB
 Muskegon County HUB
 Saginaw County HUB
MICHIGAN PATHWAYS TO BETTER HEALTH
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Supports Institute of Healthcare Innovation’s
Triple Aim by delivering better health and
access to quality care at lower cost
 Improve
individual’s experience of care
 Improve health of populations
 Reduce per capita cost of care
PROJECT GOALS

primary care-sensitive ED visits &
inpatient admissions
  utilization of primary care
 Connect clients to needed primary &
specialty care (mental health, substance
abuse services, dental, etc.)
 Connect clients to social services
 Social
determinants of health
SOCIAL DETERMINANTS OF HEALTH
TARGET POPULATION
Adult (age 18+)
 Enrolled in/eligible for Medicare &/or Medicaid
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2 or more chronic health conditions
 Live in Ingham, Muskegon, Saginaw & selected
adjacent counties
 High-risk (5 or more ED visits, 3 or more
hospitalizations in last 12 months)
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CHRONIC CONDITIONS
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Addictions/Substance
abuse
Alcohol abuse
Alzheimer’s disease
Anxiety disorder
Arthritis
Asthma
Osteoporosis
Parkinson’s disease
ADHD
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Bipolar disorder
COPD
Diabetes
Eating disorder
Personality disorder
Emphysema
Congestive heart failure
Dementia
Depression
Hypertension
CHRONIC CONDITIONS
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Autism
Hearing impairment
Hyperlipidemia
Aphasia
Ischemic heart disease
Kidney disease
Bipolar disorder
Obesity
Schizophrenia
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Cancer
Panic disorder
Stroke/Transient
ischemic attack
Tobacco abuse
Vision impairment
Atrial fibrillation
Amputation
Others
COMPONENTS
Community HUB
 Care Coordination Agencies (CCAs)
 Community Health Workers (CHWs)
 Pathways
 Technology
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COMMUNITY HUB MODEL
Developed by Dr. Mark Redding
& Dr. Sarah Redding
 AHRQ
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 http://www.innovations.ahrq.gov/g
uide/HUBManual/CommunityHUB
Manual.pdf
MEASURE OUTCOMES
1.
Find
2.
Treat
3.
Measure
Confirm connection to evidencebased care
Measure the results
CHWS
Meet with clients (at home) to conduct an
intake to determine unmet needs
 Conduct monthly home visits
 Establish goals and help clients meet those
goals through Pathways
 Help clients understand their chronic diseases
and how to manage them
 Supervised by nurses and social workers
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CHWS
Help clients make positive lifestyle choices to
promote health and well-being
 Help clients navigate the health and human
services systems to get them connected to
resources to improve their health and wellbeing
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CHWS
CHWs work with each client according to
specific structured checklists and Pathways
(protocols) to facilitate access to needed
human services agencies and/or healthcare
services
 CHWs track client progress to complete
Pathways sequences and reach milestones
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CHW TRAINING
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Initial one week training session that includes:
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Communication & Relationship Building
Chronic Conditions
Healthy Lifestyles
Client Education
Client Motivation
Additional training:
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Cultural Competence/Social Justice
5 As – Tobacco Cessation
Motivational Interviewing
PATH (Personal Action Toward Health)
Home Visiting Safety
Healthy Homes for CHWs
Mental Health First Aid
PATHWAYS
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Pathways document steps toward an
outcome:
 Primary
care appointment kept
 Utilities turned back on
 Housing obtained
 Health education received
PATHWAYS
Medical Referral
 Medical Home
 Medication
Assessment &
Management
 Social Services
Referral
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Health Insurance
 Smoking Cessation
 Pregnancy
 Post Partum
 Family Planning
 Education
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MEDICAL SERVICES PATHWAYS
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Primary care
Specialty care
Dental care
Vision care
Audiology
Pharmacy
Nutrition/Dietician
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Family Planning
Mental Health Tx
SUD Tx
COD Tx
Speech & Language
Services
DME (with script)
SOCIAL SERVICES PATHWAYS
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Family
Food/WIC/SNAP
Housing
Insurance
Finances
Medication
Transportation
Job/employment
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Child care
Medical debt
Legal issues
Parenting
Domestic violence
Clothing
Utilities
Translation services
COMMUNITY HUB
Serves as data and information clearinghouse
 Provides centralized client registry – avoid
duplication of services
 Receives referrals, screens clients, makes
assignments to CCAs; assures bi-directional
communication with referral entities
 Monitors project activity for quality, targeting,
safety, and productivity; submits monitoring
information to MPHI
 Reports outcomes to the community
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Community
HUB
Regional organization and
tracking of care
coordination
Care
Coordination
Agencies
HUB – Client Coordination
• Demographic Intake
• Initial Checklist  assign Pathways
• Regular home visits – checklists and
Pathways completed
• Discharge when Pathways complete
(no issues)
A CONNECTED COMMUNITY OF
SUPPORTS & SERVICES
CARE COORDINATION AGENCIES
 Recruit,
hire, supervise, deploy CHWs
 Accept referrals from HUB & assign CHWs to
clients
 Document care coordination provided by
CHWs using Pathways templates
 Transmit data from CHWs and Clinical
Supervisors to the HUB
TECHNOLOGY
At the HUB/CCA
In the field
MiPATHWAYS DATABASE
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Records client needs
and readiness to adopt
healthy behaviors
Documents services
provided
Documents clinical
outcomes
Suggests Pathways
Prevents Duplication
TAILORED TO EACH COMMUNITY
INGHAM
Lead Agency/Fiduciary – Ingham County Health
Department
 Community HUB – Ingham Health Plan
 Convener – Power of We
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INGHAM CCAs
Allen Neighborhood Center
 Capital Area Community Services
 Ingham County Health Department
 National Council on Alcoholism
 North West Initiative
 South Side Community Center
 Tri County Office on Aging
 Volunteers of America
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MUSKEGON
Lead Agency/Fiduciary – Muskegon Community
Health Project/Mercy Health Partners
 Community HUB – Muskegon County
Government Administrative Services
 Convener – Muskegon Community Health
Project/Mercy Health Partners
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MUSKEGON CCAs
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Access Health
Lakeshore Health Network
Community enCompass
Disability Connection of West Michigan
District Health Department #10
Every Woman’s Place
Hackley Community Center
Mission for Area People
Muskegon Community Health Project/Mercy Health Partners
Public Health – Muskegon County
Senior Resources
West Michigan Therapy
MUSKEGON REFERRAL PARTNERS
Pro-Med Ambulance
 Call 211
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Lead Agency/Fiduciary – SCCMHA
 Community HUB – SCCMHA
 Co-Conveners – Alignment Saginaw & MiHIA
 CCAs
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Covenant/VNSS
 SMM/Center of HOPE
 Health Delivery, Inc. (FQHC)
 Saginaw County Department of Public Health
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HUB CERTIFICATION
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National Demonstration Pilot Project funded by
Kresge Foundation grant
 HUB
standards
 CCA standards
 Policies
 QA Manual
MATERNAL, INFANT & EARLY CHILDHOOD HOME
VISITING (MIECHV) PROGRAMS
MIECHV HUB
Target population: pregnant women, children 0
– 5 & their families
 Provide referrals to HV agencies
 Eliminate duplication of services,  capacity of
HV providers
 Data system
 Collect & share info;  communication &
coordination across agencies
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PROJECT DATA
Source: MPHI 3/14
CHRONIC CONDITIONS
Self report through 3/7/2014
MOST COMMON PATHWAYS
5,000
4,000
4,044
3,393
3,000
2,000
1,196
1,000
0
Medical
Referral
Social
Services
Med.
Assessment
440
326
289
Education
Med. Home
Tobacco
Cessation
MOST COMMON MEDICAL REFERRAL PATHWAYS
2,000
1,500
1,421
1,071
1,000
511
500
288
147
0
Primary Care
Specialty
Care
Dental
Mental Health
Vision
606 OTHER MEDICAL REFERRAL PATHWAYS
Dietitian
 DME (requiring script)
 Family Planning
 Hearing
 Pharmacy
 Speech & Language Services
 Substance Abuse tx
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MOST COMMON SOCIAL SERVICE PATHWAYS
1460 OTHER SOCIAL SERVICE PATHWAYS
Child & family assistance
 Education
 Financial
 Healthy homes
 Household items
 Insurance
 Job/employment
 Medication
 Social support
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Successes & Challenges
VOICES FROM THE FIELD
SUCCESSES & ACCOMPLISHMENTS
Job creation
 + Impact on wellbeing of clients
 CHW Job satisfaction
 Community Support for program
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CLIENT FEEDBACK
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“My CHW has been readily available to me whenever I
needed anything. They have worked with me to help access
services and saw me through the processes until I got the
help I needed.”
“[CHW] is a gem. She always made me feel like I was the
only client she had and I know that is not true but she made
me feel that way. She helped me with my insurance
paperwork and prescription coverage and I am forever
grateful. She has helped me regain confidence in myself.“
“The [Pathways] program has really been helpful in
identifying programs and services that I otherwise would not
have found on my own.”
CHW FEEDBACK
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"I think my short time as a community health worker has
benefitted me as much or maybe more so than my clients.
This experience has enlightened me not only to the problems
we face as a community but also the great things we have to
offer; that to really be a "community" we have to work
together for - and with - one another. I am excited about the
possibilities".
“The [MPBH] program allows me to connect personally with
my patients to help them identify and access programs and
services they truly need in order to live healthier lives. It
makes me feel good to see the positive changes in patient’s
lives after helping them overcome the different barriers in
their way to staying healthy.”
PROVIDER FEEDBACK
“I just want you to know what a privilege it has been to work with you
in the Pathways Program. First of all my hope is this program will continue for a
long time.
When I think about the Community Health Workers involved with this
program, they perhaps have no idea how valuable they are. I am thinking of
two patients we referred from [hospital] and what an impact they have made in
their lives.
They have provided transportation, reminded of appointments, helped
self manage medications for those that live alone. Those three things alone
can prevent an unnecessary readmission to the hospital.
Secondly, many of this population that is served by your program, have
fallen in the cracks of health care. They may not know what social services are
available to them or what their "insurance" may or may not cover. If the
services are not covered they are directed to an agency that may be able to
assist. Thank you seems insignificant, but I am thankful for this service and
plan to continue to make referrals.”
CHALLENGES
Meeting grant enrollment targets
 Engaging reluctant patients
 Ongoing funding/sustainability
 Scarce community resources
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 Universal
– e.g., transportation
 Unique to each community – e.g., psychiatric
services
CMS ACKNOWLEDGEMENT

The project described was supported by Grant
Number 1C1CMS331025 from the Department
of Health and Human Services, Centers for
Medicare & Medicaid Services. The contents of
this publication are solely the responsibility of
the authors and do not necessarily represent
the official views of the U.S. Department of
Health and Human Services or any of its
agencies.
THANK YOU
Questions?
 Comments?
