Community Health Workers: Their Role in Preventing and Controlling Chronic Conditions

Community Health Workers: Their Role in Preventing and Controlling Chronic Conditions

>>Welcome, everyone,
to today’s webinar. I am Betsy Rodríguez,
Deputy Director of the National Diabetes
Education Program at CDC. First of all, thank you for the
tremendous support and interest in today’s webinar that
surpassed 1,100 participants. This is very exciting. Today, we have one of the best
panels I have seen in years, all experts in the
community health worker field. We will begin with
Dr. Alberta Mirambeau, who is with the Division
for Heart Disease and Stroke Prevention at CDC and co-leads the CDC Community
Health Workers Workgroup. Then we will have Dr. Nell
Brownstein, who just retired from the Division for Heart
Disease and Stroke Prevention at the CDC, and Dr. Brownstein
is considered one of the leaders in community health
worker research. Following her we will have
Dr. Bina Jayapaul-Philip, who works for the Division of
Diabetes Translation at CDC and co-leads the CDC Community
Health Workers Workgroup. She is also a key member of the HHS Community
Health Workers Workgroup. Then we will conclude with our
guest community health worker, Pamela Smart, from the
Northeastern Vermont Regional Hospital, who is the coordinator of the community health worker
team in St. Johnsbury, Vermont. Welcome to all. Before I give the microphone
to the first presenter, I would like to go over the
purpose of today’s webinar. Who are community health
workers and what are their roles in preventing and
controlling chronic conditions? We will also describe
the CDC’s strategies to engage community health
workers in the prevention and control of conditions and policy development,
among others. Our speakers will discuss
the history and evolution of community health workers
at the national level, highlighting the experience of some organizations
implementing the community health worker model, and
lessons learned on how to work effectively with them to address chronic conditions
while achieving health equity. So, we have a very ambitious
agenda in front of us. Today’s conversation is about
addressing many of the questions that most of you
have around roles and emerging issues
related with the use of community health workers
in chronic care and beyond. Here we can see an example
of the questions that some of you shared with us during
the registration process. For example, “Who are
community health workers?” “Is there a national
scope of practice for community health workers
available or being developed?” “How are they trained
to know the limits of the education they provide,
like not giving medical advice?” This is just an example of the many questions we
have received from you all. Now we are going to do a poll. Please answer the following
question in your computers. Our first question today
is: How are you engaged with community health workers? You have here several options. For instance, “I am a
community health worker.” “I supervise community
health workers.” “I train community
health workers.” “I work with community
health workers,” and “Other.” I see the responses coming up. We have 250 responses so far, so let’s wait a little bit
before we stop the poll. Wow, 335 responses. We are closing the poll. As we can see here,
the big chunk of people, 47.8, is in “Other.” So we will have to figure out,
panelists, what “Other” means. On the other hand,
we have “I work with community health
workers,” 29 percent. “I train community health
workers,” 17 percent. “I supervise community
health workers,” 12 percent, and “I am a community health
worker,” 16.7 percent. So let’s move to our next slide. But first, let me share with
you some basic information. Here you can see the
official definition of community health
workers, coming from APHA that has been used far and wide
for many, many organizations. My dear colleague,
Dr. Brownstein, will say there has been a lot of effort putting
together this definition, so we would like to
share this with you. There are many out there,
and we decided to share with you the one that
is coming from APHA. I’m not going to
read the whole slide, but from this definition I’d like to showcase
several key words, such as “frontline public health
worker,” “trusted member,” and “trusting relationship.” And while building the capacity
of individuals and communities through increased knowledge and
self-sufficiency via many ways like outreach, community
education, inform and counseling,
social support, and advocacy activities. So we have here another
question. Read the question and send your
answers through your computers, and this is the question that
we have for you all right now: In what setting do you work with (or regarding)
community health workers? Community-based organization,
health system, faith-based setting,
federal government, state or local government,
and others. We are getting our
responses here. 294 responses so far. Let’s give it a couple
of minutes. I guess we can close the
poll, and what we have here? Community-based organizations,
22.8, versus state or local government, 29.9. We compare that to federal
government, 6 percent, and faith-based organizations,
1.4 percent. In “others” we have 20.8. I guess that this
is demonstrating how community-based organizations
is one of the biggest areas where most of community health
workers are working right now. Let’s move forward
to our next slide. Where and to whom do community
health workers deliver their services? A community health
worker is distinguished from other health
professionals because he or she is hired primarily
for his or her understanding of the populations or
communities he or she serves. Therefore, they conduct outreach and outreach represents
a significant portion of their time, and
they’re experienced in providing services in
the community settings. So they are performing a
range of important activities to promote, support, and protect
the health of individuals, families, and communities. Here in the slides are some of
the examples of the settings and audiences, like
hospitals, health agencies, community organizations,
people at home, rural migrant and seasonal farm workers, vulnerable populations,
and tribes. From this slide you can tell that community health
workers have many names and many job titles. The name of their job titles and
their functions is as diverse as the cities in which
they operate or the funders or payers where they work. In this slide we’re
showcasing the core role of community health workers. In 1998 the National Community
Health Advisor Study was done, and Nell Brownstein
was part of that group. And they identified
the seven core roles of community health workers. These are core roles that
are commonly used today in the community
health worker field. You can see that community
health workers have a variety of roles, and they include
things like closing the gap between communities
and health care to providing culturally
competent information, advocating for access to
service, provisional services, and building capacity
for communities. Now I would like to leave you
with Dr. Alberta Mirambeau, who will present an overview of the Community Health
Worker Workgroup housed in the National Center for Chronic Disease
Prevention and Health Promotion. Alberta?>>Thank you, Betsy, thank you for that very thorough
introduction about community health workers. I will just take a few
minutes before my colleagues, Dr. Jayapaul-Philip
and Dr. Brownstein, speak a little bit more about
community health workers, and what I would like to
talk to you about is what we at CDC identified as an
opportunity to create synergy and streamline our
approaches related to community health
worker guidance. So, to begin I want to start by sharing what the
mission of the workgroup is. It is primarily to
facilitate, support, and advance community
health worker initiatives that help accomplish
public health goals. Just to give you a little bit
of background on the workgroup, it’s comprised of
about nine divisions that make up the center. So, for example, our center
is made up of a Division of Diabetes Translation, a
Division for Heart Disease and Stroke Prevention;
you also have a Division of Cancer Prevention
and Control, Physical Activity and Nutrition. And within all of these
divisions we started to see that there was a natural
overlap in terms of the work that was being done around
community health workers and that we were all promoting
very similar strategies. So this presented an
opportunity for us to streamline the
approach in which we used to provide technical
assistance in support to our funded partners. On the next slide,
here we present to you what we found were the
three key areas of the work that the divisions were
doing within the center. One of the ways in which
we help promote the field of community health
workers is providing support to our partners, and we do
that mainly in three ways; either through funding,
training, and/or technical assistance. We’re also very involved
in looking at and conducting evaluations that specifically address
financial sustainability, interventions around
health promotion and disease prevention,
and also looking at how community health
workers have been integrated into the health care systems. Pamela Smart, who will
conclude this presentation, will speak a little bit
more about a program that we evaluated where community health
workers are integrated into their system. We are also very involved
in developing products such as training tools,
health education materials, and also peer-reviewed
publications. And just to share with you, here
are a few of the key activities that our workgroup is
engaged in as we come together and identify ways to enhance
opportunities for collaboration. In the summer of last year we
came together and identified that there are two key
areas that we can focus on, and that was primarily to
look at how the interaction between CDC programs, and state and local grantees
can be improved. And we also wanted to look
at how we could enhance and create a community
health worker infrastructure through collaboration. The workgroup has also
created an environment so that the disparate members of
the divisions can come together and look at how we can
better coordinate our efforts and share information around
our different projects. One example of this is last
spring-almost a year ago-we conducted a project
officer training. So, for our colleagues
here within CDC, we provided them
information related to community health workers so that all project officers are
receiving similar guidance-the same and/or similar
guidance-to share with their funded
program partners. We also created a document
that took an inventory of all the community health
worker-related activities taking place within our center, and we
hope to provide this document and make it available publicly
so that you have a chance to also see the scope and
spectrum of work taking place. And then I also want to share
what are some of the pending and ongoing activities
of the workgroup. We meet regularly to
serve as a central and coordinating
entity for the center. We’re also helping to field TA
requests and provide guidance and expertise to our
different program partners. And currently what
we have planned is to develop a community health
worker resources webpage. Right now, if you go to CDC,
you will find a plethora of resources related to
community health workers, but they are spread throughout
different websites of CDC. So we’re now working to compile
and have all of these resources on one webpage for our
funded program partners as well as the public. We also plan to have a round
two of our project officer forum and are looking and
beginning discussions around developing
standardized evaluation measures for community health workers. At this time I would like
to go ahead and turn it over to my colleague,
Dr. Nell Brownstein.>>Thank you. I’m going to try and answer
some of the many questions that were raised as I go
through my presentation. There is considerable
research evidence at this point that community health
workers do enhance individual and community health literacy
through their teaching and educating and coaching. We have heard feedback
from providers that work with diverse populations and
have community health workers as part of their team. They state that their own
cultural competency has really improved. We also know that community
health workers can significantly improve health outcomes of
patients and care teams. There aren’t too many
cost-effectiveness studies, but I wanted to bring your
attention to six recent return on investment studies,
which show a 3 to 1 net return or better. As you can see, we’ve
got a Medicaid HMO, a couple of community-based
programs, Langdale Industries is here in
Georgia, and we have a number of hospitals in Texas that
have demonstrated return on investment by employing
community health workers. Hospitals, in particular, are engaging community
health workers in patient discharge teams to ensure patients follow
instructions and stay out of the hospital, and that’s because hospitals
are now penalized if a patient comes back in within 30 days
of being released. Some exciting new and important
work that is coming out from CDC in 2015 are two community
guide reports. The first will be
on hypertension and the second one on diabetes. I think they will have a big
impact and make it easier to promote community health
workers and their services, specifically for cardiovascular
and for diabetes work. Several years ago,
several members of our Chronic Disease Center
conducted two community health worker systematic lit reviews,
and they were published in 2006. That was on diabetes. We found an increase in
knowledge about diabetes and improved health behaviors, but not very many specific
improvements in A1C. In 2007 we came out with
a hypertension review that revealed significant
improvements in blood pressure in 13 out of 14 studies. The way we found that community
health workers were effective is they kept people in care and having their blood
pressures measured over time and they kept people
on medications. We even found one large study
that showed decreased mortality from cardiovascular disease. While the community guide staff
have thoroughly reviewed all the current literature, there are
31 Cardiovascular Disease (CVD) papers that will show
significant improvements in patients with blood
pressure and high cholesterol, and I believe there are about 51
papers that are going to be part of their diabetes paper, again,
showing significant improvements in AIC and intervention
involving community health workers. I know we have others
that are going to talk about our national program. I just wanted to mention that
a lot of you had questions about integration of
community health workers into health care teams. This is really a
work in progress. There have been publications
out, and CDC hopes to learn much, much more
about this whole process and how community health
workers really work to link community members and
patients to community resources. Bina is going to talk
in a little while about our new TA
guide for the states on integrating community health
workers into health care teams. I think if you consult that, a lot of your questions
will be answered. In 2009 I moderated an APHA
session, and Gail Hurst from Massachusetts and
Ann Willard presented about the progress in their
states, and I said, “You know, we ought to write
this up,” and we did. In 2011 we had two publications
that came out as well as CDC’s community health worker
policy and systems change brief. Well, Massachusetts has really
been an early innovator. The health department has worked with community health
workers since the seventies. They built and promoted and sustained a community
health worker association, and then in 2010 they
came out with a report that basically says that states
can’t be one-trick ponies. They’ve got to work on
comprehensive systems and policy approaches in order to move the community
health worker field forward and to sustain the workforce. There are a number of
different approaches to this comprehensive method. Infrastructure development
is really important, and state health departments
can help facilitate this along with their partners. I’m talking about
infrastructure, for example, with regard to helping build and support community health
worker associations in the state because those associations
are prime stakeholders. They do training
for their members and they’re very important
advocates for themselves. The other infrastructure piece
is community health worker stakeholder networks,
coalitions, or alliances-different states
call them different names. This is a group of stakeholders, along with the state
health department, community health workers, community health worker
employers, insurers, federally qualified
health care centers, Area Health Education
Centers (AHECs), offices of rural health,
colleges, and many, many more. One of you asked about, what do
you do in a rural health area? Really, contact your
office of rural health. The National Rural Health
Office has been very supportive, for many years, of
community health workers. So that’s a good place
to start in rural areas. In terms of workforce
development, we’re looking at developing core
skills and competencies and providing training
and continuing education for community health workers
that have to find answers to give their clients. Also, training for supervisors
is really important for people who have never supervised
community health workers. To answer your question, no, there is no national
core training curriculum, nor a clearinghouse at the
state or national level, although a number of state
health departments have a lot of good materials
on their websites. Texas State Health Department and Massachusetts State Health
Department particularly have a lot of resources about
community health workers. In terms of what a core
curriculum looks like, there certainly is a lot of
focus on communication skills, and they certainly
address confidentiality and the Health Insurance
Portability and Accountability Act
(HIPAA) requirements, and they also focus
on the core skills for community health workers. Just to give you an
example, Massachusetts, two AHECs-and that’s an Area
Health Education Center-do all the training for the community
health workers in that state. And Texas five AHECs all
use the same curriculum, and they train all of the community
health workers in Texas. In Minnesota, colleges
and community and technical colleges
do the training for its state-wide curriculum. Minnesota also sells its
state-wide training curriculum, and every community
health worker that wants to be reimbursed by
Medicaid must take that state-wide training
curriculum. Also, community-based
organizations do a lot of training as well. Just to give you one brief
update, there are two groups that are currently working on
updating the roles and skills of community health workers,
and the results will be out in the fall,
some recommendations. In terms of occupational
regulation, if you’re not knowing
exactly where to start, occupational regulation
is not the place to go. There is a lot of
other work to do first. There are some cons to credentialing
community health workers that people may not be aware of. For example, how
do you fairly deal with volunteer community
health workers and those who have many years
of experience but no standard training? How do you deal with
all of this fairly? I know three states-New
York, Massachusetts, and Minnesota-have been working on this whole credentialing
issue very thoughtfully for at least a couple of years,
and hopefully they will come out with some recommendations
in the near future. No, there is no national
scope of practice for community health workers. Most states don’t have a
scope of practice, either. A scope of practice is what
specifically community health workers are allowed to do. Moving on to evaluation. As Alberta said, it is
very, very important to do. We need more information
about the effectiveness and the cost effectiveness
of community health workers. Then, in terms of
financing mechanisms, a lot of you had questions
about reimbursement. Let me just cover a few things. There are a lot of ways that
state health departments and their partners can play
a critical role in supporting and advocating for reimbursement of community health
worker services. There are public
payers, such as Medicaid and the Children’s
Health Insurance Program. There are private payers
who pay for fee-for-service. I know that Blue
Cross/Blue Shield of Minnesota is very supportive,
and so is Molina Healthcare. Then there are ACOs,
accountable care organizations. The advantage of becoming an
accountable care organization is that you can bundle all
of your services together. So you can bundle the community
health worker services in along with all of your other services. I know that a number of federally qualified health
care centers have become or are in the process of becoming
accountable care organizations for that very reason. There are a couple of new
models in practice that I want to bring your attention to. One is a linked community-based
organization clinical practice in which community
health workers are trained and supervised by a
community-based organization. The reason this is done is so that community health
workers are seen as still part of the community and not just a
cog in the health care system. Also, the community health
workers are contracted through the community-based
organization by the health care settings, and
they get supervision on the job as well as more training,
and there is communication between that CBO and
the clinical entity. There also is something else
that you may not be aware of. A couple of years
ago HRSA (Health Resources and Services Administration)
and the Department of Labor got together, and they
gave funding to the Texas AHEC to do a community health
worker apprenticeship program where community health workers
got training in the classroom and then they also got
on-the-job training. This was seen as a mode of getting community health
workers-of really building up the workforce more quickly. And there is a call for funding
announcement from the Department of Labor, which has an April
1 deadline, and it calls for public/private
development and implementation of apprenticeship programs, and that can include
community health workers. So for those of you that are up
for that that is an opportunity. I think those are models that
are going to continue to grow in the future, this linked
model between CBOs and clinics and apprenticeship programs. I want to remind you, one of the resources CDC has is
an e-learning community health worker reimbursement course. It is being updated and should
be out at the end of the month. It is very helpful. It will be on CDC-TRAIN
(CDC TRAIN is a gateway into TRAIN National, the
most comprehensive catalog of public health
learning products.), and you will get Certified
Health Education Specialist (CHES) and Continuing Education
(CE) units if you desire. I want to talk a little
bit about all the work that CDC has been doing-our
center has been doing-on community health worker policy. We’ve been tracking and
have done state analyses. We have a summary of laws. Last summer we released
a database that has all of the legislation
throughout the United States. If you’re interested, this
is the place to go and look. One important caveat is that
it is absolutely essential that everyone involves
community health workers in all aspects of this work. There have been some
hard-learned lessons that you cannot impose on
another workforce occupation; whatever you like,
you really need to get them involved
at all levels. We have a survey question next. Do you know about
the new Centers for Medicare & Medicaid
Services (CMS) ruling of 2014?>>327 responders so far.>>62 (percent) of you do
know of the new ruling. I’ll spend a little more
time talking about that. A number of you had
questions about reimbursement, and specifically
Medicaid reimbursement. There are a number of ways
that states can get reimbursed for community health
worker services. For example, I’ve heard that states are renegotiating
contracts with their state
Medicaid offices. There’s a reference at
the bottom of the paper that will give you a
lot more detail on all of these different techniques. There are demonstration
projects that are funded. For example, there are projects
in which they are working with community health workers in
patient-centered medical homes. That is just one example. States can apply
for 1115 Waivers. For example, Minnesota
has had an 1115 Waiver for over eight years. It is the first state
that negotiated directly with Medicaid for reimbursement for community health
worker services. Then this year, in 2014, the State Plan Amendment
Rule came out. This really opens the door
for supporting expanded roles for non-clinicians, such as
community health workers. CMS has told us in our
conversations that they know of seven states that
are currently working on a state plan amendment. I have to add that these are all
states that have infrastructure. They have training in place. They have community
health worker associations and they have state coalitions. We see other states are really
scrambling to find partners to work on specifics
on training. It will probably take
them a good couple of years before they’re ready to
put in a state plan amendment. States can define what
non-clinical people they want to put on the plan and what
their qualifications are and what kind of services
they will provide. CMS is willing to review draft
state plan amendments regarding community health
workers and others. So if you send it to them, they will send it
back with a critique. So that should be
helpful to folks. Further information about-again,
states will need to work with their state
Medicaid offices on these state plan amendments
that will be going to CMS. And again, the states have to do
the standard Medicaid policies. They would have to provide
community health workers statewide and have a freedom
of choice of providers. A very important caveat that
a number of you asked about: Credentialing is not required
by CMS, not at this point. They do want to know if
you are credentialing, but they don’t require it. But, very specifically,
there is no template to provide-that CMS has
provided-since this is the first round of this new ruling,
but they do require that states provide what the
qualifications are of the people that they’re promoting, what
required education they have, their training and experience. Just a couple more points
about state plan amendments: community health workers
will not automatically be put on them. It is going to require
partnership and advocacy to get them on state
plan amendments. There are other parties that
are really pushing-around the country-for medical
assistants to get on the state plan amendments. So people will have to work
together to accomplish this. There are some questions
about the difference between a community health
worker and a patient navigator. The short answer is that
navigation is a role that all community health
workers play in the community and in clinical settings. Some programs even have titles
called community navigator. We consider community
health workers navigators under the umbrella term of
community health workers, but realize that patient
navigators can also include other professions, like
nurses and social workers, and they do their work
strictly in the clinic, they’re not out in
the community. A big takeaway is: please
remember the importance of networking and partnering
and getting involved with your state health
department, and if your state
health department is not well-experienced with
community health workers, ask them to play a role in facilitating the critical
policy and systems changes. I want to wind up by
just mentioning some of our resources. A number of you asked
questions about what kind of training is available, is there any lifestyle
risk factor training, etc. I want to bring your
attention to the first resource. I spent part of the last
two years at CDC working on a CDC evidence-based
training resource for preventing heart
disease and stroke. It is a national specialty
training that is very useful to use with integrating
community health workers with a health care team. There are 15 chapters;
they include all of the lifestyle risk factors. They include a chapter
on cholesterol, a blood pressure chapter that even includes a
pictorial instruction on how to take blood pressure
measurements. There is a very large diabetes
chapter, which integrates all of the CDC diabetes info
and more information that Betsy will tell you about. We have chapters on
heart attack, stroke, atrial fibrillation
(AFib), heart failure, how to talk to your doctor,
how to take meds, and a chapter on teens and kids, and it will
soon be available in Spanish. It is now on CDC-TRAIN,
and you can get credit for taking the course. Again, our e-learning course, and then Community Health
Worker Brief is coming out, updated, later this month. It will give you a
highlight of CDC programs with community health workers. It also will have a
completely updated list of state community
health worker networks and state community
health worker associations. Now I would like
to turn the program over to Dr. Bina
Jayapaul-Philip.>>Thank you, Nell, for
a very thorough overview on the state of the CHW field. The next set of slides are based on community health
worker interventions in the CDC cooperative agreement
State Public Health Actions To Prevent And Control Diabetes,
Heart Disease, Obesity, And Associated Risk Factors
And Promote School Health, referred to as 1305 for short. Patient interventions
are in two domains of the cooperative agreement:
Domain 3, which focuses on health systems, and
Domain 4, which focuses on community-clinic linkages. Under health systems,
the intervention focuses on engaging CHWs in
multidisciplinary care teams within health care systems. In Domain 4 there are
two interventions. One focuses on engagement
of CHWs in delivering and supporting diabetes
self-management education, or DSME programs. The other intervention
focuses on engaging CHWs to link patients to
community resources for the control of
blood pressure. There are performance
measures related to each of these interventions that state health department
grantees will report on annually. Two of the performance measures
are focused on the proportion of health systems
that engage CHWs. The Code 1 will focus
on proportion of DSME programs
that engage CHWs. For a picture of the states
implementing CHW interventions, fully 36 states are implementing
at least one intervention in this cooperative agreement. Nineteen of the states are
doing two interventions, and there are three states that are doing all the
three CHW interventions. Regarding the type
of interventions, 24 states are implementing
the intervention related to linking patients to community
resources, 20 are engaging CHWs in multidisciplinary
health care teams, and 17 state grantees
are engaging CHWs to deliver and/or
support DSME programs. Here is a picture of
the country in terms of CHW interventions
being implemented in this cooperative agreement. The darkest blue
is the three states that are implementing all
three of the interventions, and the next shade of
blue is the 19 states that are implementing
two interventions, and the lightest blue is the 14 that are implementing
one intervention, the white being those states that don’t have a
CHW intervention under this cooperative
agreement at this time. To get to a picture of
sample grantee activities to promote CHW roles within
this cooperative agreement, it is appropriate to
think of them as falling under three categories:
One is working with state-level entities, two
is working with health systems and providers, the third
is working with CHWs and CHW organizations. Under working with state-level
entities, the activities focus on participating with community
health worker collaboratives to create sustainable state-wide
models for reimbursement, working with CHW training
programs to establish pathways for certification, and
adapting CHW curricula for use in the state. Working with health systems
and providers, the focus is on developing and
implementing communication plans to inform providers, payers,
policy makers on the role of patient navigators and CHWs. Increasing availability and
awareness of existing curricula and trainings on inclusion
of CHWs in care teams, and providing tools to assist
in the adoption of policies, protocols, and processes to
support the implementation of team-based care models like Patient Centered
Medical Home (PCMH). As far as working with CHWs and
CHW organizations, collaborating with CHW organizations
to develop and implement culturally
appropriate strategies to connect patients to clinics. Training CHWs to provide
or support delivery of DSME programs, and
develop marketing materials and training tools
and resources for CHWs to promote community
resources for patients. To take a look at the
reach of CHW interventions or give an idea of the
extent of the effort, based on currently available
data, Texas has 27 DSME programs that are currently engaging
CHWs in the delivery and support of programs. Rhode Island plans to increase
from the current eight programs to 40 programs over the
five years of the FOA. Massachusetts and Michigan
are currently engaging CHWs in 10 health care
systems to link patients to community resources
and have a five-year goal of at least doubling
that number. Our newest cooperative
agreement is 1422 that incorporates
CHW interventions. Under the community
clinic linkages component, the intervention is to engage
CHWs to promote linkages between health systems and
community resources for adults with high blood pressure
and adults with prediabetes or who are at a high
risk for type 2 diabetes. Here too, we have two
associated performance measures. One focuses on the number of
health systems that engage CHWs to link patients to
community resources for high blood pressure control. The other one focuses on
number of health systems that refer persons to the National Diabetes
Prevention Program. Some of the technical assistance
resources that we have available for the implementation of
these interventions are: a draft Driver Diagram For Community Health Worker
engagement in DSME programs; a Technical Assistance Guide
that we recently put out, and that Nell mentioned,
that is broadly aligned to the interventions in
this cooperative agreement and should provide answers
to a lot of the questions that were asked by
webinar registrants; and we’re also planning to bring out shortly some Emerging
Practices Documents on CHW interventions based
on grantee experiences. I want to also provide
a brief overview on the draft driver diagram for
CHW engagement in DSME programs. Over on the left side we
have the performance measure proportion of DSME programs
engaging CHWs in the delivery or support of DSME programs. We think there are
three main drivers for this performance outcome:
DSME program readiness to engage CHWs, awareness and
implementation of CHW roles in target DSME programs, and CHW
sustainability in DSME programs. Those drivers are
further detailed by the intervention components
that comprise these drivers. DSME program readiness to
engage CHWs would focus on enabling the recruitment of
CHWs in these DSME programs, enabling the training of CHWs
for program delivery and access to information and resources. As far as awareness and
implementation of the CHW roles within the DSME programs,
these would focus on some of the core CHW roles,
including program delivery, conducting outreach to
participants to bring them into the DSME program,
being a liaison for referral from the health systems to the
programs, and providing support for program participants. The last driver of CHW
sustainability in DSME programs: engaging with state and
local stakeholders for items like the training curricula
and delivery processes to identify certification
and credentialing processes, and then to identify sustainable
financing mechanisms. Now I’ll turn it
over to Pam Smart.>>Good afternoon. Thanks for giving me
the opportunity to talk about our team-based approach
using the community health worker here in rural Vermont. We have created this team-based
approach and it has been up and running for about
seven years now. You can see, I will show
you on our first slide here, this is a diagram of our
community health team. You can see that it is
interconnecting circles because we are interconnected, there is no one point
of entry for anybody. We are all able to
enter through any door. The big team, which we call
our administrative core team, is comprised of our
doctors, practitioners, our behavioral health
specialists, care coordinators, Support and Services At Home,
which is a program coordinated with our rural housing providers where there are SASH
coordinators-Support and Services At Home-but
they also function as community health workers. They do provide care
at home to people. I know one of the questions
mentioned people with dementia; these folks provide care to
anyone with Medicare, so yes, there are some services there. We also connect with our
community-based partners, which are all of our agencies,
and anyone providing service to an individual as well as community members
attend this team meeting. We meet once a month and
all of us come together in a room for an hour. In the middle of the team
is the important community health worker. The community health worker is
really the one that navigates and connects people to
all of the resources, but follows through to
be sure they get them. We work in a holistic manner. We field things like housing. All of the things that
need to be addressed to have a healthy lifestyle
are addressed: food, health, housing, anything
that contributes to keeping someone healthy. This team was formed-we
did it as part of a pilot. We then proved our results
of improving quality of life and decreasing costs
for hospital care, and now every hospital area in
the state-there are 14 hospitals in Vermont-have implemented a
community health team approach. The components of our team are that large team I
told you about. The functional team
are the people that are doing the
direct service, the people really involved,
the care coordinators, the community health workers, the behavioral health
therapists, and we also meet monthly as
well as whenever necessary to pull a team around a patient. If a patient desires
to have a small team, the patient identifies who
they would like on their team. We meet as a team
with the patient to see how we can provide
and improve services. That community connection team
is your community health worker group, and also our
primary care physicians and our SASH people are
part of our direct service. So within our program
there are several things that affect the implementation:
the relationship, communication, and collaboration, and
that is going very well. We have formed communication and
collaboration with our partners as well as with our patients. We have behavioral
health therapists located in the practices, as well as
chronic care coordinators. The behavioral health
has been a huge part of the primary care
practice team also. We all have a commitment
to patients and to clients, and the providers
have bought in. The providers actually
love the model. They feel like they never used
to ask the question such as, “Where are you going
to sleep tonight?” Or, “Do you want
to stop smoking?” They felt that it took
so much time, then, to access the services
that were needed for that. Now they call a community
health worker and things are put
in place instantly. We have a community health
worker who specializes in chronic disease, and
particularly we look at diabetes, hypertension,
and asthma. She works closely with
the diabetes educator and with the physicians
and the care managers to help the person get what
they want to have happen. It’s all about self-management. She works to help
provide the education. She may shop with the
individual; she will work to be sure that person
has access to the treatments they need. Some people don’t
have insurance; we work to get them insured. We work to get them the
meds that they need, and then whatever they
want to have happen. It may be an exercise program
or a nutrition program; she would connect
them and follow them. She meets with them regularly to be sure they’re getting
what they need and also keeps in constant communication
with the provider and the diabetes educator. So the factors affecting the
implementation of our program? Navigating the health care
record, the computer record, has been a bit of a
challenge for communication. We find that many partners are
on different systems and so that has been an ongoing issue. The time and workload of the community health
worker is always an issue. We try to balance that
out using interns. We currently have two
interns working with us. And, of course, the individual’s
readiness to change, the stages that they’re
at, what do they want. If they’re not ready, we still
work with them and follow them and support them in
whatever way they may want. If they decide at some
point they’re ready to take that next step, we’re
there with them. Funding silos in community
resources-that has really come a long way. In the beginning,
people that were part of the team were afraid
to share their funding, were afraid that we were
going to receive funding that they might have
had in the past. So it took a lot of reassurance
that we are not competing for funding or duplication
of service. And lack of clarity in the
chronic care coordinator and the behavioral health
roles were also an issue. Those have pretty much become
a non-issue at this point. Thank you for giving
me this opportunity.>>Thank you, Pam. We have been getting
a lot of questions. We will try to do our best
with the time that we have, but rest assured, we have a
commitment already made here that our internal group
will go over the questions, and we will be working
on a Q&A document that we will share
with all of you. We will try to do our best to
answer some of the questions that we have here
in the chat box. I will start with Pam. Pam, there is a question here that I think that
you can answer. The question says, “What community organizations
have health systems that have been found
to further the role of community health workers?”>>We particularly partner with
the Agency of Human Services and with our mental
health system here in Northeast Kingdom
Human Services and with our housing partners. Our housing partners, I think,
have found the most success. They used to function on
just bricks and mortar, and now they focus on the rest of the support services
needed-not just housing someone, but housing them successfully.>>Thank you, Pam. I have another interesting
question coming from Marion. I would like to give
this question to Dr. Alberta Mirambeau. The question is,
“Many states want to explore expanding
reimbursement from January 24 CMS rules
about prevention services. If the workgroup could
provide some TA about how to effect those policy
changes in the states, that would be a huge help. The Florida Community Health
Worker Commission is working on the issue, but we want
to make much progress.” By the way, TA stands
for technical assistance.>>Thanks, Betsy, and
thank you, Marion. I think that is a
timely question. The workgroup has identified
this as an area of need for our state-funded
program partners. We are currently in
discussions now with CMS to talk about identifying what are the
common questions that are coming up from states as they prepare
for their state plan amendments. We have invited them, and plan
and hope to provide a lunch and learn or similar webinar
format where CMS will be able to share updates in terms
of different approaches or specific suggestions for how
states can prepare a successful state plan amendment. So all that to say that we
are fully aware of this need, and we’re in discussions
for planning on how we can better meet this
need for our program partners.>>Thank you, Alberta. Nell, I have a question for you. “How do I get the studies
showing benefit of CHWs work on CV (cardiovascular)
diseases?”>>We have our literature
reviews from 2006 and 2007 that are available. I can provide the information on
the return on investment studies and then again, in
2005 and fairly soon, the Hypertension Community Guide
Report will be out with all of the studies and
recommendations. And then just a little bit later
this year the Community Guide on Diabetes will be out. So look for those. But we can supply some
of the older data.>>I think you have
another question, Nell.>>Somebody asked, “can community health
workers be clinical, such as a health
care coordinator RN?” I think it is essential that
there are career ladders for community health workers. For example, community health
workers that have been promoted to supervising other
community health workers, and I think there will be a
lot more potential for them to become leads in
case management. Some community health
workers have gone on and become nurses as well. There are a lot of
opportunities in the future as they become integrated
into health care to be able to have-to go up the ladder.>>There is another question
here, and I think, Nell, that you are better positioned
to answer this question. “Are there any examples
of language to include in a state Medicaid that covers
community health workers?”>>In terms of language
for state plan amendment? I don’t know what the
language specifically would be. Alberta, do you want
to address that?>>And Bina, please chime in. Based on the preliminary
discussions that we’ve had on this topic, it is very early
and CMS is really just getting into the throes of identifying
and working with states on their state plan amendment. So they are also identifying
what are the best practices for moving this forward. Bina, is there anything
you want to add to that?>>I don’t think we have any
specific language to provide to those who are
implementing CHW strategies, but I think that we are planning on technical assistance
documents on an ongoing basis, and some of these will
include experiences of states that have made some advances
in that direction and so that might provide
some guidance.>>I think you have
another question, Bina. Can you address that question? It’s a question about the
map that you were showing.>>I think it’s a question
about the three states that are implementing all
three CHW interventions under the 1305 cooperative
agreement. Those are Maryland,
Michigan, and Delaware. I think there was one other
question about specific TA for state health
departments employing CHWs. I just want to point to
a couple of the resources that I mentioned in
one of the slides. The Technical Assistance
Guide that we put out a few months back
that is broadly aligned to the cooperative agreement
intervention should provide more guidance.>>We don’t have time to
answer any more questions, but I want you to rest assured that after this webinar you
will be getting an e-mail with the slides. So everybody will get
a set of the slides and as I said we will answer
all of these questions. That will take some time
because there are way too many, but rest assured that we
will work very diligently to have those answers
available for you. We showcased some of the
resources that we have in the National Diabetes
Education Program. I just want to highlight
the Hazlo por ellos! Pero por ti tambien. Do It for Them, But for You Too. That has become a
very popular resource around diabetes prevention. We also have some CDs/DVDs, Movimiento Por Su
vida and Step by Step. Those are good strategies to
increase physical activity. The Step by Step is for
African Americans; Movimiento is for Latinos but at
the end is music, but I bet it will
work for everybody. Then we have The Road
to Health Toolkit, one of the most popular
resources in the National Diabetes
Education Program; this is to start a
community-based organization program on diabetes prevention. It has been developed by
community health workers for community health workers. In the slides you have
my contact information; if you have any questions,
that’s my e-mail. You also have the e-mails
of all the presenters. Feel free to send
e-mails with some of the questions
that you may have. And this concludes
our webinar for today. I’d like to thank everyone
that joined us today. You have seen our contact
information during the Q&A session so please feel
free to contact us. I also invite you to check out
the updated NDEP/CDC website by visiting Thank you Alberta, thank you
Nell, thank you Bina and Pam for sharing your expertise
and words of wisdom.

Author: Kennedi Daugherty

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