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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