1 DSRIP 291: CHW Program Empowers Community to Manage Chronic DiseasesPresented by: Rosalinda Jimenez EdD, MSN, APRN, FNP-BC, PMHNP (c) Wendy Forrest, MSA

2 Objectives: Describe the necessity of patient navigation programs for chronic disease management Describe DSRIP program Explore the role of a Community Health Worker integrated to educate in a community Identify positive trends resulting in intervention of Community Health Workers

3 Barriers Met Health Literacy includes the ability to:1. Access needed services 2. Complete health information forms 3. Engage in chronic disease management 4. Read labels Patient engagement 1. Change in address 2. Change in contact numbers 3. Various perceptions of self-efficacy Wendy Literacy can be defined as a persons ability to read, write, speak and solve problems at a level to function in society- Low literacy levels impacts a persons ability to hold a job, and grow and develop as an individual in achieving personal goals. Health literacy is the degree to which an individual has the capacity to “obtain, process, and understand basic health information” (U.S. Department of Health and Human Services Healthy People 2010) This includes the person’s ability to access necessary health care services U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion Quick Guide to Health Literacy Health literacy affects a persons ability to: 1. Locate providers and services 2. Fill out insurance and health history forms 3. engage in chronic disease management 4. Reading labels- both nutrition and prescription and measuring medications

4 Low Health Literacy Risk FactorsEducation Low Income Age Ethnicity Language Resources Health Status Wendy According to DHHS- approximately 9 out of 10 lack some of the necessary skills to manage their health and prevent disease Health Literacy Risk Factors leading to poor health outcomes with higher rates of hospitalization and less frequent preventative health screenings Education levels- less than high school or those holding a GED certificate Poverty- those with low incoe Age- Older Adults Ethnicity- Language- Non- native speakers of English Resources- access to transportation, Compromised Health Status

5 DSRIP 2.9.1- Patient Navigation Program4 Community Health Workers Serve as patient navigators Home visits, clinic visits, education & empowerment 1 Data Coordinator Data mining Works with statistician 161 current patients with chronic diseases (HTN, Diabetes, COPD, Cancer, Pulmonary diseases, Obesity, Psychiatric & Mental Health illnesses) Enrolled 325 since inception through 12/31/16 Lubbock County-approximately 900 square miles 1/3 Medicaid; 1/3 Medicare; 1/3 Self-Pay

6 Purpose of Program Gain access to health careConnect with a PCP Decrease unnecessary emergency room visits and hospitalizations Educate patients Increase health literacy Empower patients to manage their chronic diseases Transformational Care Model Advocate for patients’ needs Home needs, supportive services

7 Program Details Criteria Length of the Program50 years old or above- PLUS 3 or more emergency room visits the past year 3 or more hospitalizations within the past year 1 or more 30 day readmission within the past year Length of the Program Transformation of Care Model 2 years to show significant efficacy Shorter if patient shows self-efficacy Longer if patient struggles with self-efficacy

8 CHW Education Various programs available Additional Education4-12 month programs On-line, hybrid or face-to-face Certification as Community Health Worker Additional Education Chronic disease modules HTN, CAD, COPD, Asthma, Diabetes, Obesity Psychiatric response modules Bipolar disorder, Depression, Anxiety Safety Safety measures during home visits

9 Key Players- Why it worksTTUHSC School of Medicine Office of Strategic Initiative Internal Medicine Physicians TTUHSC School of Nursing Combest Community Health & Wellness Clinic Nurse Practitioners Community Health Workers Data Coordinator TTUHSC School of Pharmacy Pharmacists

10 Quantitative Program SuccessPresident’s Excellence Award for Interprofessional Collaboration Goal of 15% reduction for DY5: 315 in Emergency Room visits (Actual 231, 37.74% reduction) 10% increase in the SF‐12 score over the baseline Goal of 15% reduction for DY5: 127 in Inpatient Admissions (Actual 98, 34.23% reduction) 152 unique patients who now have a PCP/medical home and had appointment with PCP in DY5 (Actual 196 patients)

11 Program Success- Qualitative PerspectivePatient demographics Underpriviliged, no medical insurance (self pay) or medicaid Some medicare Positive outcomes & Advocacy Diet and exercise opportunities initiated and implemented “I feel like I can manage my diabetes” “I am so grateful I have someone who can teach me how to take my blood pressure and my blood sugar” “My navigator goes to my appointments. I love it! She helps me do what my doctor wants me to do- in case I forget, she is there with me”

12 Patient Story Mr. Q Hx of Bipolar Disorder, HTN, Diabetes and illiterate Hx of being exploited by children and girlfriend Learned to read, able to read medication labels, able to read street signs Learned to manage his medications, remaining compliant with medication regimen Not dependent on children or girlfriend Self-efficacy scale 10 in approximately 1.5 years

13 Reflection on our journeyBefore DSRIP- HRSA grant began a PN program; successful DSRIP holds us accountable to specific goals Future endeavors will include: CMS encourages community collaboration- Partnership & collaboration with other PN programs Partnership & collaboration with other health care entities Propose 1 large PN organization managed by all of community health care leaders Strength in numbers

14 References: Arte Sana. (2015). Victim advocacy and prevention SIN Fronteras. Retrieved from sana.com/tx_victim_advocacy_prevention/power_promotora.htm Beckham, S., Brdley, S., Washburn, A. (2008). Diabetes management: Utilizing community health workers in a Hawiian? Samoan population. Journal Health Care Poor Underserved, 19(2), Campbell, M.K., James, A., Hudson, M.A. (2004). Improving multiple behaviors for cancer prevention among African American church members. Health psychology, 23(5), Gary, T.L., Bone, LR., Hill, M.N..( 2003). Randomized controlled trial of the effects of nurse case manager and CHW interventions on risk factors for diabetes-related complications in urban community. Preview Medicine, 37(1), IOM. (2003). Evaluating health disparities. Retrieved from Gielen, A.C., McDonald, E.M., Wilson, M.E. (2002). Effects of improved access to safety counseling, products, and home visits on parents' safety practices: Results of a randomized trial. Archive Pediatric Adolescent Medicine, 156(1), Guzys, D., Kenny, A., Dickson-Swift, V., & Threlkeld, G. (2015). A critical review of population health literacy, BMC Public Health,15:215, DOI /s Krieger, J.W., Takaro, T.K., Song, L. (2005). Seattle-King County Health Homes Project: A randomized controlled trial of CHW. American Journal of Public Health, 95(4), Silver, E.J., Ireys, H.T., Bauman, L.J. (1997). Psychological outcomes of a support intervention in mothers of children with ongoing health conditions: The parent-to-parent network. Community Psychology, 25(3), UNICEF. (2003). Child inequities. Retrieved from U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy: Health Literacy Basics. Retrieved: 4/1/16 from U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy: Strategies to Improve the Usability of Health Information. Retrieved: 4/1/16 from