Community Health Educator Referral Liaison (CHERL): A

Potential New Role for Primary Care Practice

Jodi Summers Holtrop PhDMichigan State University Department of Family

MedicineGreat Lakes Research Into Practice Network (GRIN)

Our Story…

Of how CHERL was bornOf how CHERL was born

5 A’s Clinical Practice Guidelines for Health

Behaviors1

AssessAssess AdviseAdvise AgreeAgree Assist Assist ArrangeArrange

Practices were having trouble getting past the first two A’s (assess/ask

and advise) Assess, AdviseAssess, Advise

Tobacco – pretty good; diet/physical activity Tobacco – pretty good; diet/physical activity – some; alcohol - poor– some; alcohol - poor

Agree, Assist, Arrange Agree, Assist, Arrange Mostly not happeningMostly not happening Some studies MADE it happen – not Some studies MADE it happen – not

sustainablesustainable2,32,3

At the same time…Holtrop, et al., qualitative study of clinician Holtrop, et al., qualitative study of clinician

referral to a smoking cessation quit line – why referral to a smoking cessation quit line – why do they NOT refer? do they NOT refer?

Overwhelmed and gave upOverwhelmed and gave up Black hole phenomenon 4 4

“…I have a lot going on with the patients … other than smoking. If there’s a program in place that can actually track whether or not the patient is successful in quitting really is what I’m most interested in…” - clinician

Their IdeaTheir Idea

“…“…it’s wonderful to have a single referral it’s wonderful to have a single referral source that I can simply refer people to, source that I can simply refer people to, and it make the job infinitely simpler. And and it make the job infinitely simpler. And it actually makes it possible in my mind. it actually makes it possible in my mind. It’s almost impossible if within the context It’s almost impossible if within the context of our office we have to look up and see of our office we have to look up and see what the health plan is, and then try to what the health plan is, and then try to match that against the appropriate referral match that against the appropriate referral capabilities.”capabilities.” - Clinician - Clinician

We Need a Bridge!

Patients in primary care

Health behavior change resources

“CHERL”

What is a CHERL?

CommunityHealthEducatorReferral Liaison

Pronounced like CHERYL or SHARYL

CHERL – What we Proposed

Problem: Patients in primary care with poor health behaviors don’t get effectively connected with

services Behaviors not identified Patients not referred to services When referred, patients don’t follow through

Solution: CHERL coordinates the referral Practice identifies behaviors, refers to CHERL CHERL contacts patients, coordinates referral,

provides feedback to practice

Intervention - Practice15 Practices in Three Communities:

1. Identify health risks (diet, physical activity, tobacco, alcohol)

2. Refer to CHERL (fax)3. Review feedback letters

Perspective of Practices… Research project Totally NEW role NO money Don’t send us too many (only one 70-

80% CHERL per community)

Intervention – CHERL

CHERL:1. Develop relationship with community

resources and maintain resource guide2. Develop, together with the practice, a plan for

identification and referral of eligible patients 3. Accept patient referrals from practices4. Contact patients (all telephone) and refer

them to resources. Provide behavior change counseling if needed

5. Reassess patients at 3 and 6 months 6. Send clinician patient-specific feedback letter

(initial, 3, 6 months)

Our Results

Diversity of Patients

Mean age 48 (SD=13)

Female 70% African American 18%; White 78% High school education or less 39% Less than $15,000 income 25% Positive depression screen 42% One or more chronic diseases 88% No health insurance, Medicaid

or local health plan 28%

Most Practices Referred Patients to

CHERL Most practices Most practices

found at least some found at least some patients with health patients with health risks and referred risks and referred to the CHERLto the CHERL

One liked the idea One liked the idea so well, they hired so well, they hired their own “CHERL” their own “CHERL” type person (nurse type person (nurse practitioner)practitioner)

Practice Referral to CHERL

0

100

200

300

400

500

600

Diet PhysicalActivity

Tobacco Alcohol

797 Referrals*797 Referrals*

19

589

517

267

*Raw numbers of referrals for each behavior and total

Patients Reported Improved Health

Behaviors Once engaged, Once engaged,

able to change able to change regardless of age, regardless of age, race, gender or race, gender or SES SES

Patients Health Behaviors Pre-Post5

BaselineBaseline 6 6 MonthsMonths

Adj p-Adj p-valuevalue

Diet score; range 7 (best) – 21 (worst)

12.8 11.3 p<.001

Physical Act; median mins/7 days

Those w/goal to improve only

15083

180130

p=.277p=.015

Body Mass Index (BMI) 35.6 35.1 p<.001

Smoking (percent smokers) 30.9 25.6 p<.001

Alcohol drinks/occasion (past month)

1.0 0.9 p<.001

Health status; 1=excellent – 5=poor

3.2 2.9 p<.001

Days limited activity (out of past 30 days)

4.8 3.5 p<.001

N=446; intention to treat analysis

What we Really Learned

We Need a Bridge!

Patients in primary care

Health behavior change resources

“CHERL”

What the Bridge was Really Like6

Patients in primary care

Health behavior change resources

“CHERL”

Patient Referrals

0

20

40

60

80

100

120

140

Diet PhysicalActivity

Tobacco Alcohol

Phone Counsel

Group

Web

Facility

Book/Info

Other

446 Community Referrals446 Community Referrals

So Why Don’t We Just So Why Don’t We Just Have Practices Refer to Have Practices Refer to

Resources? Resources?

Why do we need a CHERL? Why do we need a CHERL?

Practices Need Support

Demands to see Demands to see more patients in less more patients in less timetime

Focus on doctor visit Focus on doctor visit for paymentfor payment

Lack of personnel to Lack of personnel to support preventionsupport prevention

Change can be Change can be difficultdifficult

CHERYL Offered “One CHERYL Offered “One Stop Shopping” Health Stop Shopping” Health

Behavior ReferralBehavior Referral

Easy for the practices Easy for the practices to refer patients to to refer patients to the CHERLthe CHERL

Patients Needed to be Supported Not Just

“Connected” Patients needed Patients needed

more just a pass-off more just a pass-off to another resource. to another resource. Follow-through Follow-through important.important.

““If it weren’t for you, If it weren’t for you, I would not have I would not have done this (quit done this (quit smoking).” – smoking).” – PatientPatient

CHERL Facilitated Use of Unused Existing

Resources““The diabetic educator comes to The diabetic educator comes to the clinic 1 day a week for 4 hours the clinic 1 day a week for 4 hours every Wednesday. Did you (the every Wednesday. Did you (the clinical staff) forget that she’s clinical staff) forget that she’s there? Did you forget that there? Did you forget that [diabetes] is their overall major [diabetes] is their overall major problem, and you/no one referred problem, and you/no one referred the patient to this wonderful the patient to this wonderful community resource we have that’s community resource we have that’s covered by insurance for the most covered by insurance for the most part?” - CHERLpart?” - CHERL

CHERL Facilitated Relationships with

Community Resources to Get Patients Engaged in

Using Them““I knew the person over at I knew the person over at the YMCA so I got a couple the YMCA so I got a couple people on the scholarship people on the scholarship program. Referring them program. Referring them over to Patty at the YMCA, over to Patty at the YMCA, and they were able to apply and they were able to apply for the scholarship and now for the scholarship and now they’re going to the YMCA.” - they’re going to the YMCA.” - CHERLCHERL

CHERL Filled in Gaps where There Was a Lack of

Resources Offering Behavior Change Support

““Then somebody has toThen somebody has toreinforce [behavior reinforce [behavior

change] change] long-term. So follow-up long-term. So follow-up

is is real important until real important until

people people ingrain those behavioral ingrain those behavioral changes into them and changes into them and

it’s it’s just something that just something that

they they do.” do.” - -

ClinicianClinician

CHERL Facilitated Motivation Not Just

Dispensed Information CHERL used CHERL used

motivational focus motivational focus rather than education rather than education focusfocus

Need for understanding Need for understanding on how to make changeon how to make change

““I needed someone to be I needed someone to be held accountable to other held accountable to other than myself.” - Patientthan myself.” - Patient

CHERL Addressed Other Patient Issues

Majority had chronic Majority had chronic diseasedisease

Almost half screened Almost half screened positive for positive for depression; co-depression; co-morbid mental morbid mental health an issuehealth an issue

Low-income and lack Low-income and lack of money to pay for of money to pay for servicesservices

As a Result…the Resource Guide

ChangedFROM – Alcohol, DietPhysical Activity, Tobacco

TO - Diabetes education,Mental Health, Food PantryReferral helpline (211),Financial Assistance

CHERL Supported Practices by Assisting with Difficult/Complex

Patients

“… “… it would actually it would actually help the entire staff help the entire staff because you would because you would be taking patients be taking patients that are frequently that are frequently frustrating to the frustrating to the nursing staff and the nursing staff and the physician …” - physician …” - CHERLCHERL

CHERL Supported the Patient-Physician

Relationship

““Working with the Working with the patients, I did a lot of patients, I did a lot of educating them to educating them to advocate for their health. advocate for their health. How did they ask their How did they ask their doctor questions? I gave doctor questions? I gave them a lot of tips like them a lot of tips like write things down before write things down before you go in to your you go in to your doctor…”-CHERLdoctor…”-CHERL

CHERLs had Different Training, but all Were

Successful

MSU

Amy(Dietitian/HE)

Deb (Nurse)

Laurie (Health Educator)

What is Unique about the CHERL Role?

CHERL is Many Roles…

Health care team memberHealth care team member QI facilitatorQI facilitator Health behavior change counselor/coachHealth behavior change counselor/coach Referral coordinator/resource guide Referral coordinator/resource guide

managermanager Relationship-builder Relationship-builder

(practice/patient/community)(practice/patient/community) Data collector (C-base)Data collector (C-base)

CHERL Implementation Challenges and Questions

Difficult to reach people via telephone Difficult to reach people via telephone Is it better to combine in-person and telephone counseling? Is it better to combine in-person and telephone counseling?

Limited scope of CHERL’s roleLimited scope of CHERL’s role Does CHERL only do health behavior or chronic disease self-Does CHERL only do health behavior or chronic disease self-

management (or other) also?management (or other) also? Managing the patient contacts and dataManaging the patient contacts and data

What systems support patient identification and referral? What systems support patient identification and referral? What systems assist CHERLs in counseling and referral to resources? What systems assist CHERLs in counseling and referral to resources? What data gets reported to clinicians/practices?What data gets reported to clinicians/practices?

Overwhelmed by patient loadOverwhelmed by patient load What is a reasonable/cost effective patient load? What is a reasonable/cost effective patient load?

Lack of follow-through - both patients and practicesLack of follow-through - both patients and practices How to improve reach to patients?How to improve reach to patients?

CHERL SustainabilityFunding at the practice level is key. Opportunities Funding at the practice level is key. Opportunities

include:include: Insured patients – Insured patients –

Pay for performance/PCMH initiativesPay for performance/PCMH initiatives Direct billing for care management for patients with Direct billing for care management for patients with

chronic diseasechronic disease Group visitsGroup visits Documentation improvement/billing for more Documentation improvement/billing for more

comprehensive carecomprehensive care Care management “delegation”Care management “delegation”

Other ideas – Other ideas – Employer/community resource contractingEmployer/community resource contracting Out of pocket paymentOut of pocket payment

Further Information

http://www.aboutcherl.org

Jodi Summers Holtrop, PhDJodi Summers Holtrop, PhD

Department Family MedicineDepartment Family Medicine

Michigan State University Michigan State University

B105 Clinical CenterB105 Clinical Center

East Lansing MI 48824East Lansing MI 48824

(517) 884-0432(517) 884-0432

Jodi.holtrop@hc.msu.eduJodi.holtrop@hc.msu.edu

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