Sunday, April 12, 2015

More Community Health Workers

Imagine that a public health worker goes into the home of a diabetic patient to explain the importance of eating a healthier diet.  While in the home he notices ashtrays overflowing with cigarette butts, empty liquor bottles strewn about, no food in the cupboards, the water has been shut off and the patient complains of anxiety and depression. If the worker just delivers their healthy eating message and leaves, the patient obviously will never be able to control their diabetes and will wind up in the emergency room. Medical care has a limited impact on a person’s health, while economic, social, educational, and environmental factors are much more influential.  About half of all health care expenditures go to treat the sickest five percent of the population.

In 2012 the Mid-Michigan District Health Department recognized that we needed to change the way we do business. We knew that the Mid-Michigan Health Plan, which we used to pay for care for people in our District, was going to go away.  The federal government was going to stop funding county health plans. At the same time, we were interested in starting to work with the sickest and most expensive people in the community. We thought that if we could reduce the cost of these patients we might be able to persuade other health plans to fund the work.

Thinking along the same lines, the State of Michigan began encouraging health departments to consider the Pathways Community HUB Model. Pathways was originated by Drs. Sarah and Mark Redding in 2004. The Reddings began by working with native Alaskans who had tuberculosis. When medical treatment failed to make a lasting improvement in their patient’s health, the Reddings recruited community members to help make changes in their living conditions such as adequate heat during the winter, a consistent food supply, and safe transportation to the health clinic. When the patients’ health finally improved, the Reddings adapted this model to their current medical practice in Mansfield, Ohio, where they applied it to low-income pregnant women.

Pathways uses lay Community Health Workers (CHWs) to address the social conditions that affect health.  Importantly, CHWs are not nurses or social workers, they are individuals from the community who share the life experiences of their clients, which means they often have more credibility. The CHWs find individuals at greatest risk, refer them to health and social services, make sure they actually get served, and document the results.  By carefully documenting their work CHWs make it possible to demonstrate the value of what they do in dollars and cents.

Another important part of the Pathways model is the Community HUB. It is where the database the CHWs use is housed and managed. It takes referrals, distributes them to the CHWs, creates reports on their work, and handles contracts and payments. The HUB holds the network of CHWs together.

In 2013, MMDHD convened a Tiger Team of health care and human services partners to consider launching a Pathways project. Looking at data from hospital partners, the Tiger Team was convinced we could reduce the cost of care significantly if we addressed the mental health issues of the most expensive patients. At the same time, health department staff (the Quality Vision Action Team) working on our strategic plan decided the concept was so important that they made it the center piece of the plan.  In March 2014, while we were working on the business plan, the Ingham County Health Department offered us a grant to hire a CHW. Ingham County was one of three sites in Michigan to receive large grants from CMS to launch Pathways projects and they decided to fund CHWs in neighboring Clinton (which we serve) and Eaton counties. Muskegon and Saginaw were the other Pathways sites. Along with a grant to cover the CHW’s salary, we would also get HUB services provided by the Ingham Health Plan Corporation and training provided by the Michigan Public Health Institute.

We hired our first CHW, Shelley McPherson, and her work had an immediate impact in Clinton County. Before long people from other agencies in the community were telling me hiring Shelley was one of the best things we ever did. And the stories of her work were very moving: saving a Veteran from losing his home, getting mental health services for someone who had never had them before, helping people get heat, food, medications, quit smoking, and the list goes on.


It was clear we needed to expand the program into Gratiot and Montcalm Counties. So we approached the Mid-Michigan Health Plan Board with a request for funding. The Plan had a fund balance, and they agreed to fund two positions which were filled by Molly Smith and Samantha Tran. Before long Shelley was so busy she had a waiting list, and the Health Plan agreed to hire another CHW for Clinton County and that position was filled by Angie Felton. All three of these CHWs were MMDHD employees who were looking for a way increase their involvement in the community.

Today our CHWs are working with over 100 people per month (Angie is just ready to be trained), and there are Pathways projects in 18 counties in Michigan. We got a peek at some embargoed data that CMS has on the performance of the CHWs. It shows that the cost and utilization of care definitely goes down when expensive patients work with CHWs. There is still one piece of the puzzle missing, however. Our CHWs are not yet able to bill health plans for their services. This will require policy changes by the State of Michigan. It is very important that the State make these changes before the Mid-Michigan Health Plan runs out of money. You can bet we are spending a lot of time in Lansing trying to make sure this happens as soon as possible.

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