MDH HCH Learning Days 2018April 3, 2018 from 1:30 pm to 2:30 pm

St. Paul, MN

Partnering to PilotCommunity Health Worker Services

Made possible through support from theMinnesota Department of Health and the

Centers for Disease Control and Prevention(Community Wellness Grant)

Kristin Erickson, MS, APHN-BC, RNHealthcare Initiatives CoordinatorPartnerSHIP 4 Health

Jody Lien, BSN, RN, PHNAssistant Public Health DirectorOtter Tail County Public Health

Megan Nieto, Certificate-Holding CHWConsultant/President, CHW ServicesCHW Solutions

Panelists

Following this session, participants will be able to:• Detail how the partnership emerged and

developed the CHW Pilot• Identify the successes of the Otter Tail County

Public Health CHW Pilot• Recall lessons learned during the Otter Tail

County Public Health CHW Pilot

Learning Objectives

• Local Public Health and Community Partners in West Central Minnesota

• Statewide Health Improvement Partnership (SHIP) Grantee since 2009

• Centers for Disease Control and Prevention -Community Wellness Grant (CWG) Grantee since 2014– Address prediabetes and hypertension– Priority populations

• low-wage earners• ethnic minorities

PartnerSHIP 4 Health

Com

mun

ity H

ealth

Wor

kers

Increase engagement of Community Health Workers to promote linkages

between health systems and community resources for

adults with high blood pressure or prediabetes or at high risk for type 2 diabetes.

One of Fifteen CWG Strategies

No CHWs in our regionMinimal knowledge of CHW services

How?

• What is a Beta Test?• PartnerSHIP 4 Health contracted with CHW Solutions

CHW Beta Test

• Develop and implement a beta test work plan• A workflow based on best practices• CHW service reimbursement• Referral and communication mechanisms • Improved Client Self-Management Skills

Desired Beta Test Outcomes

A willing community partner… Enter Otter Tail

County Public Health Fergus Falls, MN

Lacked One Thing

• Establish Project Team• Define beta test location(s)• Identify target group(s)• Determine outcome measures• Develop short-term and long-term goals• Evaluate Beta Test• Prepare for Sustainability

Beta Test Tasks (7)

• PartnerSHIP 4 Health– Kristin Erickson, Jason Bergstrand, Carol Hagel

• CHW Solutions– Megan Nieto and Megan Ellingson

• OTCPH– Diane Thorson and Jody Lien

• MDH EHDI Grantees - Guests– Maryann Harris and Aline Muhimpundu

Establish Project Team

Define Locations

• Low-income and/or Somali or Latino– At risk for diabetes and/or hypertension

• Referred from organizations serving Fergus Falls and/or Otter Tail County clients:– Lake Region Healthcare - IHP Population– Ringdahl EMS Community Paramedics– Otter Tail County Public Health – Lakeland Mental Health Center

ID Primary Target Group(s)

• Low-income and/or Somali or Latino– At risk for diabetes and/or hypertension

• Referred from:– Sanford Health Clinic, Pelican Rapids– Essentia Health Clinic, Pelican Rapids– Otter Tail County Community Organizations

ID Secondary Target Group(s)

• # clients served and which services by: language, payer, referral source, condition

• Omaha System Knowledge, Behavior, Status Ratings and/or Ohio Pathways Completion

• # and amount of claims submitted• # and amount of reimbursement received• Staff perspectives on project

Determine Outcome Measures

SHORT-TERM GOALS (ten months): CHWs employed and embraced CHWs establish trust between communities and

organizations CHWs empower priority populations CHW interventions organized, measured, and

communicated using Electronic Health Records CHW services reimbursed

Develop Short-term Goals

LONG-TERM GOALS (3-5 years): CHWs employed in health and social service

agencies, and included and embraced as valuable team members CHWs viewed as a valuable resource to deliver

value-based care and address workforce shortages

Develop long-term Goals

Draft a brief summary of the beta test:• Experience• Outcomes • Proposed next steps

Evaluate Beta Test

• July 25, 2017:– Five Project Team

Members completed initial assessment

– www.sustaintool.org• Next Steps:

– Review July results– Complete a second

assessment– Draft Sustainability Plan

Prepare for Sustainability

• Original Timeline (Dec 1, 2016 – Sept 29, 2017)• Revised Timeline (Dec 1, 2016 – Oct 31, 2017)

Beta Test Revised Timeline

Boots on the Ground -How is this all going to work?Is this even going to work?How about a CHW Pilot?

Otter Tail County Public Health to the rescue!

Beta Test Reveals a Need

• PartnerSHIP 4 Health contract with Otter Tail County Public Health

• Engage CHW(s) to link priority populations to promote prevention of type 2 diabetes and self-management of high blood pressure

• Timeline: April 2017 - September 2017

CWG CHW Pilot Contract

Otter Tail County Public Health (OTCPH)• Lead Organization• Partners with Beta Test Project Team

OTCPH CHW Pilot Team

• Recruit CHW(s)• Identify CHW supervision and orientation and

training needs • Develop referral relationships and processes • Articulate staff roles• Develop service delivery and billing

workflows, including standing orders• Document interventions and outcomes

OTCPH CHW Pilot

Recruitment

Supervision - OrientationResource Summary

MCDPH CHW online training modules

COST: $80 - Topics: chronic conditions, HTN, diabetes and prediabeteshttps://chwtraining.mcdph.org/

MDH/ WellShare CHW HTN 90-minute video of training -https://www.youtube.com/watch?v=-kAiwHuJ-jM

MDH CHW Toolkit (2016) “Hiring, Onboarding and Supervision” (pages 30-39)http://www.health.state.mn.us/divs/orhpc/workforce/emerging/chw/2016chwtool.pdf

Ramsey County Email connection made with OTCPHIMPaCT Model and Manual Evidence-based CHW model (clinic-based) from

PhiladelphiaDownloadable http://chw.upenn.edu/toolkit

Volunteers of America CHW manual

Resources from IMPaCT and Ohio Pathways models, and VoA internal policies

CDC Prediabetes Screening Test

https://www.cdc.gov/diabetes/prevention/pdf/prediabetestest.pdf

COMMUNITY RESOURCES (MAKE A LIST FOR CHWs TO USE AND BUILD ON)

Plan A: Develop referral relationships and processes with local clinic

Plan B: Outreach to Community Organizations

Referrals

• PHN: supervision; clinical oversight; ordering provider; develops health messaging; mentor regarding outreach and client visit practices; quality improvement

• CHW: provide and document direct CHW services and outreach activities

• Billing: submits CHW claims to payers; troubleshoots claims processing practices and denied claims with payers

Staff Roles for CHW Success

• Standing orders• Best practice guideline for prediabetes• Best practice guideline for hypertension• Educational resources• Self-management resources• Competencies• Billing Workflow

Service Delivery - Workflow

• Client narrative drafted• Omaha System Excel Spreadsheet constructed • CHW practice and outcomes documented

using the spreadsheet• Documentation transferred into electronic

health records system (PH-Doc)– Goal: CHWs chart interventions and outcomes

directly into PH-Doc

Practice Documentation

Lived Experience

Practice Documentation

• CHW Solutions certificate-holding CHW• OTCPH CHWs

Pilot CHWs

• Meetings with Healthcare Settings

• Prediabetes Screenings in the Community

• Outreach at Community Organizations

• Individual Client Visits

Pilot Activities

• Trust and Connections• Referrals Lake Region Healthcare Otter Tail County Public Health Lakeland Mental Health

CHW Pilot Successes

CHW visit

Referral back to County Programs

Assist with process

Client Connected to Community Resources

Ongoing supports secured

CHW Pilot Successes

CHW Pilot Successes

Knowledge Behavior StatusBaseLine 1 1 1Discharge 3 3 2

0

1

2

3

4

5

KBS

Ratin

g

KBS Category

Omaha System Outcome RatingsNutrition

BaseLine Discharge

CHW Pilot Successes

Knowledge Behavior StatusBaseline 2 3 3Discharge 3 4 3

0

1

2

3

4

5

KBS

Ratin

g

KBS Category

Omaha System Outcome RatingsMental Health

Baseline Discharge

CHW Pilot Successes

Knowledge Behavior StatusBaseline 2 1 2Discharge 2 2 2

2 2 2

0

1

2

3

4

5

KBS

Ratin

g

KBS Category

Omaha System Outcome RatingsResidence

Baseline Discharge

CHW Pilot Successes

Time spent planning pays off Time spent learning pays off Start small

CHW Pilot - Lessons Learned

Be ready with Plan B Be ready to readjust your goals Make sure your outcome measures

are…measurable

CHW Pilot - Lessons Learned

Don’t go it alone Make connections Learn from others

CHW Pilot - Lessons Learned

CHW Pilot - Lessons Learned

Wrap Up• Questions?

ReferencesMartin KS. (2005). The Omaha System: A key to practice, documentation, and information management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.

Minnesota Department of Health. Office of Rural Health and Primary Care (2016). CHW Toolkit: A Guide for Employers. Retrieved from http://www.health.state.mn.us/divs/orhpc/workforce/emerging/chw/2016chwtool.pdf

Kristin Erickson, MS, APHN-BC, RNHealthcare Initiatives CoordinatorPartnerSHIP 4 Healthkerickso@co.ottertail.mn.us

Jody Lien, BSN, RN, PHNAssistant Public Health DirectorOtter Tail County Public Healthjlien@co.ottertail.mn.us

Megan Nieto, Certificate-Holding CHWConsultantPresident, CHW ServicesCHW Solutionsmegannieto@chwsolutions.com

Contact Information