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.

Saturday, April 4, 2015

Cross-Jurisdictional Sharing

The State Innovation Model
Banner of State Innovation Model Report

I want to return to an important topic: the fact that the way in which preventive services are delivered is undergoing a profound change in Michigan, as it is in most states. In particular, I want to focus on one way in which local health departments can get ready for these changes called Cross Jurisdictional Sharing. The Cross Jurisdictional Sharing (CJS) model helps health departments find ways to maintain or expand services by sharing them (I'll define "sharing" below).  It was developed by the Center for Sharing Public Health Services with funding from the Robert Wood Johnson Foundation and has been championed by our professional association, the National Association of County and City Health Officials (NACCHO). But I further want to argue that we often misunderstand the sharing of services as simply being a way to make due with less, when in fact, sharing can be one way to truly realize healthier communities by meaningfully expanding the services we offer. Health departments that want to grow their capabilities need to be thinking about sharing.

Many changes in health and health care are being driven by the Affordable Care Act, which aims to improve health while reducing the cost of health care. In Michigan one of the most important manifestations of the Affordable Care Act (the Act or Obamacare) is the State Innovation Model, The State Innovation Model (Innovation Model) is a detailed blueprint for how public health and health care will work together in the future to truly achieve a healthier population. Other examples of the Act at work in Michigan include Pathways to Better Health projects, increasing reliance by local health departments on billing for services, changes in the way programs are funded, partnerships between health departments and hospitals in community health assessment and improvement, and more. These changes are compelling health departments to rethink how they are organized. The CJS model says health departments need to share, that is, to adopt more programmatic and administrative innovations that extend beyond their local jurisdictions and more often include partners outside public health. Cross jurisdictional innovations may allow public health to fully play its designated role in assuring that robust population health services endure and opportunities for preventing disease and injury increase, so that the goals of the Affordable Care Act are realized.

CJS is often promoted by State or local governments primarily as a search for increased efficiencies due to decreasing budgets. The goal is to maintain a basic set of traditional preventive services like food and water programs, communicable disease, immunizations, and a few others by delivering the same amount of services at lower cost per unit. These are the traditional public health services developed in the 19th and 20th centuries which led to steep declines in mortality. In Michigan the delivery of these services was generally governed locally by cities and counties and that is more or less the basis of local public health today. Let’s call this the scarcity model of CJS. Honestly, the scarcity approach has accomplished some great things.  It has led to some of the most important innovations in public health in Michigan, including the formation of district health departments (like the Mid-Michigan District Health Department, where I work) involving multiple counties, and some health departments have reworked and automated business processes to gain efficiencies. Indeed, at least in the data we have looked at, health departments are maintaining service levels at a reduced cost.


However, CJS may also be looked upon as creating opportunities for public health to expand into new areas of work to meet modern public health challenges, and we can call this the expansive model of CJS. Expansive CJS may include alternative governance models such as intergovernmental agreements, the creation of new not-for-profit organizations and public-private partnerships. Examples of the expansive view of CJS in Michigan include the development of a network of public dental clinics associated with health departments, local health led federally qualified health centers and school-based clinics, the cooperative establishment of funds for the private financing of health department construction, the establishment of county health plans to provide a health benefit for uninsured people, hospital partnerships for health assessments and the sharing of personnel, and participation in the Pathways projects. Obviously there isn’t a simple distinction between the two visions of CJS—efficient health departments are probably more able to innovate—the point is the expansive form of CJS already has deep roots in Michigan.

Now public health is being challenged to respond to new demands for leadership and innovation. The Innovation Model envisions a network of Community Health Innovation Regions that both complement and support clinical medicine. Community Health Innovation Regions (Innovation Regions) will complement traditional health care by providing community-based population health services, and Innovation Regions will support traditional medicine by participating in care-coordination activities, particularly those that provide community-based supports for basic needs and lifestyle changes that are required meet the goals of primary prevention. It is clear in the Innovation Model that health departments will not be the Innovation Regions. Rather the Regions will be broad-based, inclusive collaboratives. Health departments will perform the fundamental public health function of assurance—assuring that Innovation Regions exist, and providing leadership where required.

What local health departments will have to do in the Innovation Regions will be completely different from what they did in the past. In the 19th and 20th centuries the role of health departments was based their statutory authority to compel people to stop doing things that made other people sick. For example they could quarantine a person with a communicable illness, or stop someone from serving contaminated food. These functions are still important, but the future will demand much more.  In an Innovation Region, a health department will need to be able to act as the public health component of an integrated system of preventive care that sprawls across political jurisdictions following medical trading areas. For example, in an Innovation Region, health departments will need to work on developing an enhanced capability to manage population health data; electronically exchange data on shared clients with health care systems; demonstrate the return on investment of community-based prevention to Region investors; or bill for services to sustain care coordination activities. In most health departments these capabilities are just beginning to be developed, and the capability to do it regionally has only been experimental.

I want to close by pointing out that it is not a simple thing to move from the jurisdictions of the 20th century to some new, future configurations.  For example, at Mid-Michigan, we just examined the financial benefit to our counties of being part of our district health department. We discovered that each county is probably saving half a million dollars by being part of the district health department versus going it alone. You can look at this in two ways: one is that with that kind of benefit at stake, counties will be reluctant to experiment with CJS. But the other way to look at it is that it is proof of the value of sharing, and that even more benefits are possible if we search for them.