Integrating CHW Services into Pediatric Asthma Care
22
August

By Adem Lewis / in , , , , /


We’re focused today on asthma care providers and home visiting programs. What this session is about is integrating community health worker services into pediatric
asthma care. We’re very happy to be meeting today at beautiful
Wilder Center. I hope you found us okay. We’re looking forward to a wonderful morning
of learning and exchange. A couple words about our program. Our program is part of a larger initiative
called Success with CHWs. It’s funded by the Saint Paul Foundation and
Minnesota Community Measurement. We’ll get a little bit more into Success with
CHWs later after the break, but our learning objectives for today are to increase familiarity with the CHW role
and its benefits to patients, to families, communities, and the healthcare
system; to share ways to integrate CHWs with members
of your asthma team and to effectively address asthma disparities; and to explore questions around CHW scope
of practice, education, financing, and supervision. Then a few words about our Alliance before
we get into the program at hand. Our Alliance is a partnership that has been
around for about a decade. A few years ago we incorporated as a nonprofit
in Minnesota. We have a voluntary board, and we build community
and systems capacity for better health through the integration
of community health worker services. We have a unique mission in our state. This program is prompted over concern, concern
I know that you share around asthma disparities in Saint Paul, in
the Twin Cities, in our state, and the opportunities we have to really add to our
tool kit and to begin to introduce effective CHW strategies to the care models
here to get better outcomes. We know that asthma can be prevented in many
cases. It can be better managed. We also know it’s highly serious. In talking with Debbie before the session
started, she mentioned that two students in her school
district died in the last five, six years from preventable
asthma. There are serious asthma disparities and there’s
a lot we can do better. With that focus on equitable and optimal outcomes
for all communities, that’s what we’re about. I’d like to introduce our guest presenters,
our faculty for this morning. I’m so delighted that we have Dr. Megan Sandel
and Anne Walton from Boston Medical Center joining us. A few words about each. Megan is a physician with a Master’s of
Public Health. She’s a pediatrician at Boston University
Schools of Medicine and Public Health, and she’s also Medical Director of the National
Center for Medical Legal Partnership and Co-Principle Investigator of the Children’s
Health Watch. She has expertise as a clinician, as a researcher, and especially as a nationally recognized
expert on housing and child health. She has written numerous peer reviewed scientific
articles and papers on how housing affects child health. She’s also served as principle investigator
for numerous NIH, HUD, and foundation grants, working with the Boston
Public Health Commission and the Massachusetts Department of Public
Health to improve the health of vulnerable children,
especially those with asthma. Joining Megan is Anne Walton. Anne is an RN
and a certified asthma educator. She’s the Asthma Care Coordinator and Research
Nurse at Boston Medical Center where she’s been involved in asthma research
and programming since 2009. Her work has focused on community health worker
asthma home visiting programs and asthma education in community based health
centers in primary care. In that capacity she’s developed a comprehensive
asthma training program for CHWs and a CHW supervisor training program. She has a background in critical care nursing
and health education. Prior to her work at Boston Medical Center
she coordinated educational programs for parents of children with asthma and allergies
for the Asthma and Allergy Foundation New England
Chapter. Please join me in welcoming Megan and Anne. When we think about the program objectives
overall for this morning, we’re hoping that we’ll increase your familiarity
with the community health worker role, really their
function, and the results and value that they can have
particularly in the area of healthcare reform. We’re going to specifically focus on asthma. We could have this discussion about diabetes,
cardiovascular, and others, but we’re really going to focus on asthma
today. I think we’re going to learn about a bunch
of different models. We’re going to describe the model that we’re
implementing at Boston Medical Center, but we’re also going to be discussing other
models both from public health departments, from more home
health agencies and other things that have been done across
the country. I think that we’re really going to explore
the question of related to outcomes teamwork, the training, and the supervision, and the
integration, and then finally try and address a little
bit about funding. Those are our three goals. You can see how
well we meet them by the end. Please interrupt with questions. This is meant
to be interactive. We’re not here to talk at you. We’re going
to talk with you. With that I’m going to take a little bit of
an audience survey. I want to get a sense of who’s in the room. What are the different roles that people play
in the audience? AUDIENCE: Asthma specialist. MEGAN: Asthma specialist, great. AUDIENCE: Community health worker. MEGAN: Community health worker, great. AUDIENCE: Nurse. Program manager. MEGAN: Program manager. AUDIENCE: School nurse. Community health worker. MEGAN: Another community health worker, great. AUDIENCE: School nurse. MEGAN: School nurse. Public health department
I heard, yeah. AUDIENCE: Asthma care coordinator. MEGAN: Asthma care coordinator. We’ve got asthma specialists, some community
health workers, program managers, school nurse, public health
department, asthma care coordinators, nursing student, health plan based people,
and then home agency based people, American Lung Association, ER physician. AUDIENCE: Nurse. MEGAN: Nurse. Thank you. ER nurse, but good
too. That’s awesome. All right. This is great. This is a really nice audience mix, and I’m
hoping we’ll be able to tailor our discussion so that it’s going to be useful for all your
different levels. I’m going to start first with, in some ways,
why we’re here. I live in Massachusetts and have practiced
there and I think the burden of asthma in Massachusetts
is pretty significant. I think it also is pretty significant in Minnesota
and this idea of the rising levels of asthma. The most recent comprehensive survey we have
is from a few years ago where one in ten people in Massachusetts,
close to 10% of adults, and about more than 10% of children have asthma. The hard thing here is that when we look at the Behavioral Risk Factor Surveillance Survey,
or BRFSS as some people call it, B-R-F-S-S, they will look at who would be
classified as not well controlled, or who would be classified
as poorly controlled. When you collapse those two categories together,
like 75% of adults are either not well controlled or poorly controlled. 65% of children would classify into that. We know that not only do we have increasing
rates of asthma, but we have increasing uncontrolled asthma, and that we’re not moving that dial enough.
Right? I think that what’s really clear is when we
start thinking about those gaps of care, we know that those numbers are even worse
among Black and Hispanics in our state. When we think about that, that’s a consistently
high rate of hospitalization so not just not well controlled asthma, but ending up in the emergency room in the
hospital. Really trying to think about what’s the way
to really try and address that. When the Massachusetts Department of Public
Health founded its Asthma Office in 2009, one of its main
goals was actually to use community health workers as a way to address disparities. You’ll hear Anne and I talk about the READY
Study, which is R-E-A-D-Y. Right? It’s Reducing Ethnic and Racial Asthma Disparities
in Youth. We really wanted to focus on young kids. We started at first at two to eleven at trying
to reduce those asthma disparities through a community health worker model. I’m going to start with what is a community
health worker. I actually want to here what people’s impression. We have a couple community health workers
in the audience. What is a community health worker? Who is a community health worker? What are
the key things you would describe? AUDIENCE: Somebody from the community. MEGAN: Someone who actually is from the community. Absolutely. I was going to say not only from
the community but perhaps having cultural and linguistic
competence. Right? Because they’re from the community
they may be able to have that knowledge. It is really interesting we’re going to talk
about the history of community health workers. Right? In some ways we’ll talk both about the designation, the professional designation, which has really
now been recognized by the Bureau of Labor as an actual professional
designation, but then also thinking about historically
people have been community health workers probably for centuries.
Right? In terms of it and being able to acknowledge
that. Absolutely. I think that one of the key things
that sometimes people will talk about is community health workers and their training. With that I’m going to actually have Anne,
turn it over and talk about the history of community health workers and
see if we can bolster that definition. ANNE: As Megan said, the role of community
health worker actually dates back to the 17th century where people were chosen
from the community and it was a position in society that was
well respected. It was generally the go-to person who had
information about healthcare, had ideas about what to do, where to go for
help, and helped people to understand how to access
the resources. It’s not very much different than what it
is today. The American Public Health Association, I’m
not sure when this happened, Megan might know, has a clear definition of
what a community health worker is. They say that it’s a trusted member of or
deeply understands the community served. They act as a liaison between health and social
services and the community. They work to build individual and community
capacity by doing outreach, by doing community education, sometimes they
do some informal counseling, they understand social support networks and
how to access those, and they work as advocates but they also work
to help people self advocate. That’s really important. What’s really distinctive about a community
health worker? I hear often, “What do I need a community
health worker for?” “Why do we need one more person on the team?
What can they possibly add?” I think it’s important to recognize that the
role of the community health worker is a very distinctive role. They generally
are not providing clinical care. I hear physicians and nurses say, “Well what
are they going to do?” “I’m the one that’s prescribing. I’m the
doctor. I’m the nurse.” That’s not what a community health worker
does at all. A community health worker primarily works
at building a relationship, a trusting relationship first and foremost. By doing that they can relate to the community partially because they’re of the community, they speak the language, they understand the
health practices and the cultural practices, and so once they’ve built that relationship they can work to help us to reinforce what
physicians order and what nurses teach. I feel like they’re that missing link. They
understand the culture and are perhaps better able to recognize why
there’s that disconnect. Why do we give prescriptions? Why do we hand out spacers, and then find
out that the child’s in the emergency room? Why are they not following our instructions
at home? Everything’s good. I’ve covered this. I’ve
covered that. I’ve covered the next thing, but yet something’s
not working. I really see them as that missing link. They generally do not hold a professional
license. That defeats the purpose in some ways. You want them to be viewed as one of the group. There was a study done that looked at eight
publications of community health workers and it was published in the Journal of Asthma. The focus was low income urban communities. They were looking at how CHWs could improve
asthma with regard to the environment. CHWs were really found to be very effective. Again, CHWs can be the eyes and ears of the
physician and the healthcare team. They can see things in the home, and I’m sure
the community health workers that are in the audience can verify this, that we’re never going to see unless we go
into the home. Oftentimes those things that are in the home
are the biggest barrier. It isn’t always transportation or the things
that we might think of. Not accessing insurance or funding for what
they need. Sometimes it’s the fact that asthma is the
lowest rung on the ladder in terms of their priority. By having a community
health worker go into the home and actually visualize what’s going on because
they have that relationship with the family, they’re going to almost become
a confidant. They’re going to hear things that we’re never
going to hear. We were at dinner last night and one of the
physicians at dinner said that she has trouble sometimes with full disclosure, because she
had a dad come into the office and he was embarrassed because he had recently
gone through a divorce. He didn’t know what was going on with the
child’s asthma. People come to our offices and they have a
certain amount of pride. They don’t want to say they have ceilings
falling in and water on the floor and roaches roaming. The community health worker is a really important
piece I think of the asthma care team. In Massachusetts we have a comprehensive outreach
education certificate program which we’re fortunate enough as Megan mentioned,
it was funded through the Department of Public Health and it was developed and implemented through
the Boston Public Health Commission. It’s a comprehensive core program that offers
seven separate trainings. I think it’s eight days or nine days. It’s
pretty intense. People who are in these trainings learn about
assessment skills. They learn how to look and pull out the important
information from a home visit. It doesn’t always have to do with asthma,
honestly. They learn about public health and the importance
of living in communities where there is a level of wellness. They learn some leadership skills. Not to come in and bulldoze the family into
doing what they think they should do, but rather how to gently guide a family to
doing what we hope they’ll do. They learn about cross-cultural communication. The importance of taking what they learn in
the home and translating that to their supervisor in
the medical home in a way that isn’t, “I said to do this, and the patient won’t
do it.” To bridge that gap between the cultures. They learn a lot about the whole process of
outreach in the community, the nuts and bolts of doing home visits. The training emphasizes three specific skills. Conducting educational sessions either in
a community based program in various cultural groups and also individual
settings, obviously the one on one with the home visit. It emphasizes expanding proficiency to providing
information and referrals on a range of health topics. I’ll get into a little bit later the specifics
of asthma training. This training is really just the overall nuts
and bolts core training. It prepares the CHW once they’ve got the etiquette
you might say of community health work, then they go into
the disease specific program. There’s a huge emphasis on taking the health
messages that come from physicians and nurses, and sharing them and
shaping them in a way that is going to be listened to. We don’t want our messages
to fall on deaf ears and part of that has to do with how we present
the message. For us in our program I think that we really
try to match up the culture of the family with the CHW. We have a large Hispanic and
Latino population and Haitian Creole. We have a community health worker who’s Haitian and we have one who’s actually Puerto Rican. When they’re going in to the home it’s much
different than if I were to go into the home. I think that I would get much more resistance
and much more skepticism thrown in my direction than they do. Issues do come up. We had a family just recently where the husband
had recently been deported to his country of origin, and the mom was very concerned that they were
looking for her too, that if they gave too much information they
were going to come out and get her. The community health workers, because of the
extensive training that they get, they’re really able to say, “I understand
your concern.” “But while I’m here perhaps we can talk
about that and I can look into getting you some reassurances, but let’s talk
about asthma.” With motivational interviewing skills and
various ways, they’re trained to, not to say twist the conversation, but turn
the conversation in the direction in which they want it to go. That’s why sometimes when we go in for asthma,
asthma is not what we talk about. In Massachusetts as well with the funding
from the DPH and the support of both DPH and the Boston Public Health Commission, we’ve developed a supervisor training program
as well. The supervision training addresses quality
assurance. It says three and there are actually four
things, but it does address three: quality assurance, communication and information, and creating a supportive environment. In
Massachusetts, community health worker supervisors are generally licensed practitioners.
They can be a Master’s in Public Health as well, but there’s a big push to have supervision
by a licensed person. One of the questions that has come up is how do I know that the community health workers
are doing the right thing? Part of that is dependent on the quality of
training that you have. As a supervisor myself I do observational
visits. I meet with the community health workers once
a week. I only work two days a week, but my phone
is always on. We text, we email. I pretty much know what
their patient caseload is. If there are any issues they know to call
me. Also, I went through the training that the
community health workers do for core training. I participated in developing it. I want to be there to see the way the community
health workers responded to the training. I think for supervisors to
supervise well it’s important that they understand the role of the person
they’re supervising. In Massachusetts, the supervisors, through one
of the programs that Megan is going to talk about a little
bit later – it’s a collaborative – they have come not only to the supervisor
training, but they’ve come to the regular core training
and the asthma training. The supervisors know what’s going on. Certainly for me, when I first heard of the
community health worker model, I immediately went, [slaps head] “Another
person trying to take my job.” I’d been a nurse since 1976 and I was told
that if you didn’t have this degree you were out the door. If you didn’t do this
or that or the next thing. I’m still here 30 some odd years later. I quickly learned when I began to understand
this model that that’s not the case at all. Community health workers do something I can
not do. I am not capable to build that relationship
with the cultural sensitivity that is required in a home setting doing visits
like they do. In Minnesota here it’s a little bit different
and Joan can step in if she’d like, but in Minnesota you have a standardized competency
based education which is based in the higher education community
colleges, 14 credit program. It’s classroom. It’s field based. It’s a certificate
program. There’s a lot of on the job training, and
we do that as well. We mentor. The more experienced community
health workers work with the less experienced. They observe
each other. They go on their first visits together so
they see how each other works and communicates with the family. There’s
a lot of on-the-job learning as well and that’s a big component of the Minnesota
training, and continuing education, which hopefully is
across the board. Supervision varies depending on the area of
practice, the setting. Community health workers who are working in
a government agency, according to the statute, are required to
be supervised by medical physicians, advanced practice nurses, dentists. Which
was really interesting for me because I’d never heard of a community health worker
in the role for a dentist practice. Then one of the community health workers that
had dinner with us last night was saying a lot of her patients have dental
carries. I could see that would definitely be a beneficial
use of community health workers. I’m going to turn the show over to Joan to
talk a little bit about the Minnesota Community Health Worker
Alliance, and how they work with their supervisors and
provide resources. JOAN: Thanks a lot, Anne. I’ll just add a
few words here to give you a spotlight on our Minnesota CHW building blocks, and it’s something I hope all of you in this
room will take pride in because Minnesota is one of the recognized
leaders in CHW field development, field building. What does that mean? It means
that a group of folks very much representative of the kinds of people
in this room got together a decade ago and together with CHWs, with
Health Department representation and representation by nursing and health plans
and community based groups and a wide range of partners, including educators, first developed a scope of practice for CHWs
that was based on an understanding of the CHW role that reflects three things. CHWs have a set of attributes. They have this shared life experience with
the people they serve which can be defined around ethnicity or race
or health condition. Being a veteran for example would be a shared
life experience, so again this can cut across many different
ways. Then of course training. The training that was built on this scope
of practice is competency based, it’s a state-wide program, the only one in
the US to date, and it’s offered in higher education. Why
would that be? Because we really wanted to make sure that
what we built here in Minnesota would be an educational
pathway for CHWs and not a dead end. The program is currently offered in a network
of seven schools, some community colleges. St. Kate’s offers the program here in Saint
Paul where it’s stand alone or part of a bachelor’s degree program. It’s also offered by Summit Academy in North
Minneapolis. It’s offered in Rochester and in Bemidji and
in Mankato. So we have some greater Minnesota sites as well. It’s available in face-to-face format by and
large, but our programs in Mankato and in Bemidji are either online or
hybrid online, in person. Scope of practice, standardized education
in post secondary schools leading to a certificate, and then that certificate
is recognized by our Minnesota Department of Human Services, that’s
our state Medicaid agency for specific CHW payment. Not the totality of the role
in all its many places where it can be helpful, but in provider settings in a wide variety
where there’s clinical supervision, and those can include clinics, dental offices,
local public health, Indian health service, hospitals. The visits can occur in an institutional
setting. They can occur in the home. They can be carried out in the community.
They can be one-to-one or they can be in groups. There is actually Medicaid payment for that
diagnostic related patient education. There are other functions that CHWs provide
that are very, very important, but they’re not all covered, but the significant
patient education piece is. Just as Anne said, clinical supervision is
very important. CHWs are parts of teams and that assurance
of training and supervision is really critical. The other thing I want to mention and I’ll
get to that question in a second is that we offer through the Alliance a CHW
supervisor’s round table. Bonnie Carlson from Saint Paul Ramsey Health
Department is here and is an active member of our group, and we meet in person
or by phone every other month. It’s a chance for CHW supervisors to grow
in their role, become stronger supervisors. They’re in a unique position because the role
is newer to a lot of mainstream provider organizations, so this is a great opportunity
to share lessons, share challenges. Anyone here, I would love to have you join
the Alliance and if you’re interested, join the supervisor’s
round table. Know that it’s a resource for you going forward. Two questions. One is about the duration of
the training. What does 14 hours relate to? The training typically is accomplished across
what would be a semester of work on a part time evening school
basis, or it can be accomplished as St. Kate’s has
offered it as a program across a full academic year that meets two days a week across
a whole year. It’s intensive. It’s foundational training. We call it the
liberal arts of the CHW field. If you’re a physician, you’ve had your medical
school training then you will specialize if you so choose. If you’re in nursing you
have your basic nursing training and then likewise if you’re going to go into
critical care or go into public health you’ll have on top of that additional training. This is generalist training. Keep in mind
we’re a leader so all around the United States there are very few states that have this kind
of training, and other states have been interested in our
training and folks from our education committee have gone out to visit
with other organizations that want to learn outside of Minnesota what
we’re doing. Now the CHW role is a relational role. Right? Face-to-face, coming from the community, so
online is not for everyone. We’re the first to say that. It’s the tension between wanting to provide
CHW training, provide access to the CHW role in greater
Minnesota. I do remind our folks from New England you
can fit the entire state of Massachusetts in St. Louis County. Okay? We have a lot of rural areas and we also have
diverse populations and communities all across our state. We have, as you know,
Native American reservations, Tribal Nations where there’s the CHR role,
it’s a CHW type role. Very eager for this training as well. That’s something we want to be really careful
about. Our faculty at the two schools that offer
the online do talk to students about that, and the Bemidji program offers, as I said,
also the hybrid, so there is some face-to-face as well. It’s balancing that need with the importance
of the relational role. I’m going to step back, and feel free to visit
with me at the break or afterwards if you want to learn more about
our Minnesota building blocks. ANNE: I just want to speak to the issue of
internet or online study. I have a son who has dyslexia and a learning
disability and he does his best learning online. I’m an auditory and a visual learner and so
I like to be present and interact, and I think it’s about balance. It’s about understanding that people who train
online do need to come and do some role playing with motivational interviewing
and with hypothetical situations and work things out. I don’t ever
think it’s an all or nothing situation. MEGAN: Transitioning more into this idea of
a professional designation. Right? What’s been established? We talked about the history of CHWs, the specific
roles, how do you train someone. Not anybody gets to put the words community
health worker on their resume. Right? This is something that someone should
have some type of formalized training. I think it’s really important to talk about
the generalist training, and then specialized training in asthma, and
then supervisor training for the community health worker. There are a lot of different
levels in terms of being able to say not only are you trained to do this work,
but what type of training did you get. The Department of Labor actually recognized
in 2009 that there’s a distinct occupation code for community health workers. They actually now track this across states.
They really identified it in four key areas. Assisting individuals in communities to adopt
healthy behavior. Healthy behaviors is a huge component – that
motivational interviewing, those discussions. We did additional training
with our community health workers around smoking cessation, and thinking about
way in which they can be trained in that. The second is really conducting outreach and
implementing programs in the community that promote, maintain, or improve individual
or community health. This is where we’re going to describe in a
minute the program that we adapted from Seattle King County, which is a very
rigorous standardized program. You have in your folder a lot of our materials. We have a regimented “visit one you do this,
visit two you do that” type of thing. The third is providing information on available
resources, providing social support, informal counseling. That’s where a lot of times community health
workers are really doing a lot more than just the education you’re asking them
to do, and really helping families connect to social
resources: food, energy assistance. Things like that. Identifying and advocating
for individuals and communities. I think to hear our community health workers
talk about how proud they are of people learning to problem solve on their
own so that it’s not that you continue to need
the community health worker, but that people think about it. We talk a lot about the asthma action plan
and the community health workers will take pictures on their phone of the asthma
action plan being up on the wall or being up on the fridge and things like
that. Being able to start to really utilize it. I want to stop for just a second and talk
a little bit about healthcare reform and opportunities. The Patient Protection
and Affordable Care Act did actually acknowledge community health workers. It actually
called out that they were recognized and important members of the healthcare
workforce. Then really acknowledged that there’s a lot
of evidence around how they improve health, access, outcomes,
strengthening healthcare teams, enhancing quality particularly for people
in poor and under-served and diverse areas. The summary of this is from a Health Affairs
article in July 2010. I think in Massachusetts we’re a little bit
further ahead of healthcare reform because we started it a little bit earlier. I’m going to just take a minute to talk about
two opportunities that we’re currently exploring. Actually three that we’re
exploring around long term funding sustainability. The first is what’s
called the bundled payment. How many people have heard of the word bundled
payment? Right? A couple. This is the idea that instead of being in
a fee-for-service world, so if you come to the doctor you send a bill
to the insurance company and they send back a fee. Right? We’re going more into you
have patients who are registered in your practice and you get a payment each
month to basically manage their care. Honestly it’s really capitation, just called
something different. The idea is that you bundle with that payment
an additional fee for asthmatics. You get an additional amount of money each
month to manage your asthmatics. Part of the ability of Massachusetts to do
healthcare reform earlier is we got a Medicaid waiver. We got a waiver from the
federal government to actually do innovative practice, to try and get everyone
insured. And written into our Medicaid waiver was this Massachusetts bundled
payment for pediatric asthma. It’s a 200 page document. One of the pages
describes this bundled payment. My understanding is it got a lot of scrutiny
from the federal government, but it did get passed. The idea was that, say a primary care practice
would manage their asthmatics with this fee, and understood as part of that
was that their high risk asthmatics would have a home visiting program with community
health workers. It’s not meant just to fund the home visiting. It’s meant to fund general quality improvement
within the practice, and then it have within that. Four practices are starting this pediatric
bundled payment pilot. There are two of them within Children’s Hospital
Boston, the actual hospital itself, and then one of
the community health centers in Boston, Martha Eliot, that the hospital runs, Tufts
Medical Center, and Lowell Community Health Center are the
four sites that are going to be piloting this. The second area of funding is that Massachusetts
passed its original healthcare reform legislation in 2006 and then passed an updated
version in 2010. During the update they actually wrote in something
called the Prevention Wellness Trust Fund. This is basically a tax on hospitals that
they pay money into this trust fund to do prevention. It’s interesting. The legislature
was really focused on prevention for things that would pay off quickly. They required that there would be a return
on investment for prevention. Which, any of you in the public health world
know, is hard. The bar of what got to be included as prevention
– they chose four topic areas. One was tobacco cessation, which has been
shown to pay off. The second is preventing elderly falls, which
has also been shown to pay off. The third is cardiovascular disease. The fourth was pediatric asthma. Communities could bid that they were going
to be part of the Prevention Wellness Trust implementation. They had to choose two of the four areas at
a minimum. Six of the communities actually chose pediatric
asthma as part of their pilot. Again, it includes both the idea of quality
improvement within the clinical practice and included asthma home visiting with community
health workers. We’re actually kicking off a learning collaborative
next month between the six cities that are going to be
doing this plus the four bundled payment pilot sites
to create the platform for understanding the implementation, the funding streams, and
others. Pam made a good point that we need to make
sure when we’re costing it out, it’s not just for the community health worker
salary. It’s for the supervision time, it’s for the
administrative time and other things. AUDIENCE: It seems as we’re going through
this, that this is a job almost a public health
nurse used to do. MEGAN: Yeah. The question was, I’m repeating
it for the camera, around the idea of isn’t this really what public health nurses
used to do? I think there’s no doubt in some ways we’re
– I don’t want to say reinventing the wheel – – but we’re redesigning the system to deliver
something that traditionally was there. I think that the reality is that you don’t
have enough public health nurses. Right? That’s my understanding and correct me if
I’m wrong, but the idea is thinking through ways in which
to design a system in which you could utilize the public health
nurse and use a community health worker as one of the extenders for thinking through
it and really complementing the public health nursing. It’s not replacing. Let’s be honest. We’re not talking about public
health funding here. We’re talking about healthcare funding, right? We’re talking about the idea of using a healthcare
dollar to do what is essentially a public health mission. When we think about
the disparity of funding – in this United States we spend $8,000 per
person and we get really bad outcomes. We are – out of 34 industrialized
countries we’re like 26th. We spend three times as much as everyone else and we get literally among the worst outcomes. Part of it is because we have not had healthcare
embrace its public health mission. We have not thought about ways to deliver
public health interventions through a healthcare dollar. In many ways when we’re thinking about this,
and I’m going to transition a bit to talking about the evidence, because for
a healthcare dollar they have to think about it the same way they think about pharmaceuticals
and other things, so we’re going to talk about that. I will also talk about some of the models. There’s not just one way to deliver this. We’re going to describe how we do it at Boston
Medical Center, which is where Anne is the supervisor. She
predominately stays in the office. She does limited supervision. From a quality
assurance point of view she goes on 5 to 10% of the home visits to
make sure that the community health worker is doing the job, but she’s not there all
the time, so I want to be clear about that. I’ll talk about another model called HARP where it’s a three-visit model, where the
first visit is done with the public health nurse and the community health worker together, and then the community health worker does
the follow up. That’s another way to try and think about
it. The third way that in Massachusetts we’re
exploring long term sustainability is through a case rate. This is an idea that
it’s still the fee for service world exists. Just like when you get a surgery you get a
case rate. You get an amount of money, a lump sum, and
you deliver a service within that lump sum. We are currently trying to negotiate within
some of particularly the Medicaid managed care plans a case rate for delivering
the service. For us the four visits, home visits, with
the environmental goods and other things – I think that it’s another way to try and fund
it. I think the population based – the bundled
payment is where the future is going, so I’m not convinced we’ll need a case rate
forever, but it may be until those are reality funding
streams. We’re going to negotiate both sides. I do think that there are very different models
coming down the pike around global payments, and you have to live within that
budget, versus more of these risk contracts, where you get an amount of money and you are
hoping that someone doesn’t come to the hospital. The
pharmacy side of things is very different. I will say just as an aside that pharmacy
is something that I always find fascinating. Right? We don’t blink at the $1,000 pill.
We don’t. Hepatitis C is the latest example where they
are literally paying millions of dollars monthly for a $1,000 pill. Right? What I think is important, and we’re going
to talk about the evidence, is the sticker shock around what it costs
to do four asthma community health worker visits with nurse supervision, with a vacuum
cleaner and other things. It tends to be about $1,300 when you start
full case rate. It’s a lot. People will sit there and go,
“Oh my god, it’s too much. We can’t possibly do it,” and then they won’t blink at paying $1,000. This is where the interesting thing is. There’s really good evidence of the persistence
of this effect. The Inner City Asthma Study published what
is very similar to a community health worker model – $1,500. And they showed
for two years a persistent benefit. That’s a great pill right? You would pay for
that pill every day of the week, and yet when we say that it’s somebody coming
to your house and giving you a HEPA vacuum, we won’t do it. I want to push back a little bit about the
cost because I think that we hold different standards. I’m going to get back on track
and I’m going… Anne is looking at me. The barriers to asthma control. What are some of the barriers that you guys
see in your practices? AUDIENCE: Access to medicine MEGAN: Literally just not being
able to access medicines. What else? AUDIENCE: I don’t know if they encountered
it, but teaching moments at the clinic. When there is tons of that. MEGAN: Yeah. A lot of misinformation around what
the medicines are for or other types of things. What else? AUDIENCE: I think sometimes literacy skills. MEGAN: Yeah. I think health literacy is enormous
in trying to think through ways in which to address it. You guys got most of them. Cultural health practices – so sometimes people
have very deep beliefs that other things are working. For some of
my Latino patients, menthol is something you slather on everything
and it’s really important. Being able to understand that and not viewing
it as an “either or,” like I’m either going to use the inhaler or
the menthol. This skepticism around “I’m not really sure
my kid has asthma,” certainly barriers to accessing healthcare, really minimizing the risk of poorly controlled
asthma, a lot of misinformation about asthma, worries about sometimes inhaled corticosteroids
and whether or not those will actually have long term side effects
I think is really important. A lot of social challenges. You’re worried
about housing. You’re worried where your next meal is coming. Taking that inhaler is just not as high on
your worry budget in terms of thinking, and then certainly language. Both literacy
and literally linguistic access I think are really important. ANNE: I would just like to share a little
anecdotal story about some cultural health practices and skepticism. We recently had a Haitian family who Kathleen,
our Haitian Creole speaking community health worker, visited. And she had
done the second visit and she was finishing up and the mom said
to her, “Well, you know I think it’s fine that you want to come, but I don’t really
think he has asthma. Anyway we’re going to Haiti and he’s going
to drink the blood of some kind of lizard.” Their practice is that there’s some particular
lizard that is prevalent in Haiti that they take a teaspoon of blood and they have the
child drink the blood. Their asthma is supposedly cured. Now you
can imagine that if that was something that was said to me my face would have said
it all. Kathleen said, “Well OK. When are you planning
your trip, and could we schedule our third visit after you come back?” She didn’t miss a beat, and I think that’s
one of the clear benefits of having a community health worker. MEGAN: Yeah. I think in a lot of ways it’s
being able to be more comprehensive about trying to address a lot of those barriers
I think can be important. I’m going to start diving into some of the
CHW models. Please ask questions if there are things that
are important. The first one is the READY Study which I introduced, it’s Reducing Ethnic and Asthma Disparities
of Youth. This is where we have clinical sites who will
refer either poorly controlled or really severe asthmatics. We typically
will both identify them through clinic referral or through a HIPAA waiver to be able to look
at our ER list and our hospitalization list. We can actually approach families directly
or we can receive a referral from their clinician. We typically do between four and five educational
visits with a community health worker. We began first where we did the asthma assessment
at the first visit and the environment assessment at the second
visit, and then did three follow up visits. We’ve now with a second round of funding collapsed
that to do the asthma and home assessment at the first
visit and then three follow up visits. We really try as much as possible to make
the asthma action plan the cornerstone of our asthma teaching. One of the things that we require of sites
that refer to us, or that we recruit from, is that we have access to the medical records
so that we can get the asthma action plan. Anne is credentialed at both Boston Medical
Center and three of our community health centers in Boston, so that she can
go in and get the asthma action plan. Then we really focus not only on asthma control, but we also focus on environmental control. Those two are not “either or,” but they’re
really viewed as both. We do provide low cost asthma supplies. We
do include a HEPA filtered vacuum cleaner. We do mattress and pillow encasements for
dust mite control. We do a set of natural cleaning supplies, so
these are things like baking soda or vinegar that we actually give
the patients with “green,” make your own at home cleaning
recipes. Then we do a pest control kit. A garbage can with a top on it, some copper
wire gauze you can stuff into holes, sticky traps or other things, and really large zip lock bags to help people
with storage so that they can store things in their home
without it becoming a harbor for pests. We also offer a lot of assistance and referrals. Things like housing code inspections, tobacco
control. Things like that. Then our nurse asthma educator Anne is the
supervisor for the program. We do a lot of key measure that you would
think of as urgent care use: number of exacerbations, we do an asthma control
measure based on two week recall of symptom days, rescue medication use, nighttime
wakening or activity limitations, we have a pediatric asthma care giver quality
of life score that was developed by Dr. Elizabeth Juniper. We also look at
environmental control measures. The community health worker does a walk through
at the beginning and at the end of the study to show we’ve made reductions
in the asthma trigger score. That scores six different asthma things: pets,
pests, tobacco, dust, mold, and I believe clutter. We also do a competing
priority scale trying to get at whether or not people are able to change some of their
priorities around kids’ asthma. Some of our preliminary data is really good, and as I said we adapted our model from the
Seattle King County model where we were able to show very similar results
to what they were. Huge reductions in symptom days from 4 days
out of 14, to 2 out of 14. Asthma control level improved across the board, so not everyone got to the well controlled,
but we moved a lot of people from very poorly controlled to not well controlled. ER visits, hospitalization, urgent care use
– a lot of different reductions. One of the nice things is this idea that I
think there’s a lot more than just the symptom days. I think the caregiver quality
of life becomes really important, and so our pre score was actually pretty low. If people aren’t familiar, it’s a scale of
one to seven, and so when they did this caregiver quality
of life score in Seattle, most people were a five and then they moved
them to a 5.6. Ours actually started at a 4.3 and we were
able to move them up to a 5, like a point difference is actually quite
significant. This is things like feeling helpless, family
needed to change plans, feeling frustrated, sleepless because of kid’s
asthma. Another model that was developed by Elizabeth
McQuaid in Providence, Rhode Island was this HARP, Home Asthma Response Program. This is a collaboration between St. Joseph
Hospital and Community Asthma Programs at Hasbro Children’s
Hospital. They’ve had a variety of different funding. We had funding for the READY Study both from
NIH and HUD actually has been a funder of ours
with the Mass Department of Public Health. They got some Rhode Island Department of Public
Health funding and then also recently we’re both part of
a Center for Medicare and Medicaid Innovation Award, a CMMI Award as part of
the New England Asthma Innovations Collaborative. HARP also focuses on young
children, on kids down to age two. After an ER visit with asthma, they also follow
home visits. I think what’s interesting is they do a three-visit
program where visit one does include the RN asthma
certified educator, and then the subsequent visits are with the
community health workers. They also provide supplies. The HEPA filter
vacuum, the bed coverings, the asthma friendly stuff. I should say that we don’t actually necessarily
do allergy testing. We don’t ask people, “Are you dust mite allergic?”
and then only give to those. We do it universally, which is consistent
with how it was first implemented in Seattle. They have also really nice outcomes. What’s interesting is a lot of the people
they initially met did not have asthma action plans, 77% of the people coming through the ER. They were able to show that by the end over
80% had an asthma action plan, reductions in daytime and nighttime activity. They’ve been actually starting to do a return
on investment analysis. What they’ve shown is that for every dollar
spent on the intervention they actually will save over two dollars in
the healthcare system. Children’s Hospital in Boston did a similar
one where for every dollar spent they saved $1.40 to the healthcare system. More and more this is not only showing that
it’s effective in terms of better health, but it actually may save money as well. I wanted to just highlight our Boston Public
Health Commission has been a real leader in the community health
worker movement. They began a Boston asthma home visiting collaborative. We’re blessed to have a bunch of different
home visiting programs: Boston Medical Center, Boston Children’s Hospital,
other community agencies that are doing it. What they really wanted to do
was create a place for collaboration where the home visitors could come together,
talk about different common barriers. They wanted to be able to standardize some
of the educational messaging and be able to think about it. They wanted
to think through – in the city of Boston we have a lot of different capacity issues. Haitian
Creole and Spanish are two of our languages, but we also need to think about
Chinese and Cape Verdean Creole and Portuguese and Hebrew or Russian or Chinese
and all these different things. They’ve been really thoughtful about getting
new funding sites so that they could have increased capacity
across the city. Then when we think about complimentary home
based services it’s not just the asthma home visiting, being
able to do the trainings, being able to have them available or other
things, but we also started the Boston Breathe Easy
at Home program, which is a collaboration between healthcare
sites like Boston Medical Center, the Boston Public Health Commission, and then
the Inspectional Services Department, the code enforcement agency in Boston. What we created was a web-based referral system for either if the community health worker
goes to the house, or if I as a physician am talking to a family and they disclose to
me that they have pests or mold in their house, I can refer directly to code enforcement and
then get email updates about how the case is going. Being able to think about
the complimentary home services to make the home visitors more effective has
been really helpful. Yeah? AUDIENCE: What happens with people who are
undocumented? MEGAN: There’s a lot of fear among the undocumented
community about any type of enforcement. Right? I think
there are two things. One is we’ve done extensive trainings with
particularly the inspectors around the idea that the Breathe Easy at Home
program is not families calling to report, it’s their healthcare provider calling and
saying that this is something that makes them sick. They actually include a flyer around retaliation, and the fact that if there is retaliation
for a family that they actually are able to access the
legal service system or others. The other thing is, as part of the Breathe
Easy at Home we have a flyer developed by our Medical-Legal
Partnership. How many people have heard of Medical-Legal
Partnerships? Okay, so not that many. Medical-Legal Partnership is really a healthcare
model where you integrate legal services as part
of your healthcare team. Bringing particularly a legal aid attorney. Someone who understands the law particularly
things like housing law or benefits or education law into the healthcare
setting so when you detect that someone has a legal need, you’re trained to
be able to detect that, you then will have easy, one-stop shopping
access. Our Medical-Legal Partnership – it’s actually
available on the city of Boston’s website, if you Google city of Boston Breathe Easy
at Home you’ll come up to our website page. We have a flyer developed for this very question
in terms of healthcare providers feeling confident that if they’re referring
someone that – I can’t say there’s never a risk associated
with it – but that there really have been no reported cases of someone being reported
by their landlord to the Immigration and Customs Enforcement
Agency, ICE. Just trying to help families think through
how to access what their legal rights are without fear of retaliation. These are the
lists of the Boston Asthma Home Visiting Collaborative. The Public Health Commissions, Boston Children’s, Boston Medical Center, the Environmental Protection
Agency in region one has been really supportive of this and provided
some seed funding for this. We have health plans like Neighborhood Heath
Plan that come around the table. Partners Asthma Center and Tufts, and Tufts was important because one of the
real gaps was the Chinese-speaking community, so we were able to actually train
asthma community health workers. Then Tufts was able to then bid on this bundled
payment pilot project because they had that capacity built in to
their clinic. What they do is monthly meetings where it’s
really about a support network. Right? These are asthma home visitors that
can come, receive some asthma education, be able to discuss difficult cases, be able
to learn some problem solving peer-to-peer support and other things. The goal around
it is standardization of service where people may deliver the asthma education slightly
different, but the common set of messages have all been agreed upon. When we think about that, it’s a really nice
role for a public health department to play in terms of how to sustain these programs
and standardize and ensure a certain amount of quality. This is the one
picture of the groups of the community health workers. I love them. The last one is there are some models out
there around having clinic-based community health workers. So the two or three models I’ve presented
so far have been very much home based. You go and you do everything in the home and
it supervises back. I forgot to mention that part of the READY
Study is that we actually put updates in the electronic medical record. After every visit the community health workers,
often during the visit or right after, will upload what the findings
are onto an online system. We actually do everything via an iPad that
has 3G access, it goes into a web-based data collection
system called REDCap, which is free, and you can literally put all the information. Anne then reviews the case records and then
is able to put an update into the electronic record so that the physician
will see a READY visit just happened, this is what’s happening, how many symptom
days is going on, what was done, and other things. What’s interesting is that there are some
models now, Tyra Bryant-Stephens Children’s Hospital Philadelphia
had a home visiting program that she’s recently brought more into the
clinic as an asthma navigator program. We’re piloting thinking about a similar program
at Boston Medical Center based out of our Pediatric Pulmonary Clinic. The thought here is that you would have someone
who can follow up with someone after the clinic, use the community health
worker, but still have the ability to go into the house, and be able to have that person
supervised by an RN-AC to do that. I didn’t mention, because we have an ER nurse
in the audience, another model is the Impact DC Program, which is Stephen Teach
out of Children’s National where, when kids come into the emergency room, they’re
enrolled in the Impact DC Program so that the community health worker
actually is part of the ER department. Because the primary care network in DC is
pretty frayed. And they have really, really nice documented
outcomes in terms of referrals and success. It’s a great model in the sense of, how
do you fill the disparity gap. Right? I think Minnesota sounds like it’s much
more advanced in the health home model. That’s not the ideal, right? Ideally you’d
get people to a health home. But I also think it’s interesting to think about different
platforms of care. To think about it. We don’t enroll everyone that we approach,
let’s be honest about that And part of that is reaching people. We will pull the ER list or the hospitalization
list. Oftentimes, especially if someone has been
hospitalized, we don’t approach them right away because they are pretty overwhelmed and we may approach them a week or two later
after the asthma hospitalization. And so once someone is reached and agrees
to be scheduled, we do have then a no-show rate for home visiting
too. We have done protocols around you have to confirm the night before or the
morning of because it’s incredibly hard for the community
health workers to drive out to the house and then no one be
home. We make a policy around, if you are scheduling
that you do have to confirm before the community health worker
goes out to the house. The “do not keep appointment” rate at
Boston Medical Center can be quite high. It can be thirty or forty percent in some
clinics. I would probably think that we have the same
no-show rate where you are not able to confirm the appointment. It is a good idea. One of the things that’s
interesting is, for some of the clinicians, I’ve heard this anecdotally that they like
the Community Health Worker Program because they feel like sometimes it’s easier
for the family to communicate what’s going on between appointments and it
sometimes can actually replace the follow-up visit in the clinic. For the family – the Director of the Pediatric Pulmonary Department
is Robin Cohen at Boston Medical Center. She and I have talked about
comparing kind of traditional clinical nurse case management versus a community health
worker model, that’s community based and patient-centered, where
they get to decide if they want to do home-based follow-up or clinic-based follow-up.
They decide if they want assistance with medication delivery to their house, they
want to decide whether or not they need other social supports. And I think when we think about redelivering
care, we were talking last night about telemedicine. Could you even have a
community health worker in the house kind of calling into the clinic and making
it easier from that perspective? I think that what is interesting is the… Anecdotally, I think the purely clinically
based community health workers, I am not sure are as effective as the ones that have
a home component. I think that is about relationship building and other things. The
thing that I’ve heard anecdotally is that the patients who are part of the Asthma Home
Visiting Program feel more tied to the clinic and actually keep their appointments
at the clinic more. They’re more likely to say, “Okay, I know need this. I know what
I am going to do. I know what I’m coming in to ask about” and other things. And they tend to be more integrated into the
health home, which is an interesting idea that they are getting home based services
and yet they feel more tied to the clinic itself. AUDIENCE MEMBER: Someone was addressing the
idea of shame around home conditions. MEGAN: It is really interesting, I’ll repeat
it just for the people on the video that they … There is some shame around kind of home visiting
and the conditions, but then there’s also sometimes really nice success that happens
fast. So chemicals in the home is actually an incredibly common trigger. About
90% of the patients, we go into their home, are using some noxious cleaning agent
like bleach or ammonia or other things, and you’d understand why they are
trying to do it, but those are asthma triggers, right? They may be using an air
freshener because they want to make the home smell nicer. Sometimes really simple stuff like switching
to a green cleaning agent and not using the air freshener, they’ll see a really
immediate difference. We actually had an NPR reporter come to the house and that’s
literally what the mom said was, “I didn’t believe the community health worker
that it would work, but she told me that she had used it herself and when I used
I,t it worked really well and I immediately saw that. I haven’t been to
the ER since, and I think it’s because I am now using this green cleaning agent.” Right? I sometimes think… Sometimes in medical
stuff, sometimes the medicine they don’t see that immediate response, right?
It’s partly why a controller is sometimes hard to remember everyday. They may remember
the Albuterol because they see the rescue, but it is harder to see that other
one, But the environmental stuff, sometimes they’ll see a difference really
quickly and that can be, again, this kind of building on success that I think is really
important. AUDIENCE MEMBER: This might be a better question
for Joan, but anything, any Minnesota or metro models for any use
of the community health worker now? MEGAN: I’m going to let Joan in. I do know
that they do utilize community health workers as part of the health home at Hennepin
Medical Center, but they are more generalists. They are not necessarily implementing
a rigorous asthma program, but I think that is an opportunity, right? It’s
not like they aren’t part of the health home, it’s that we want to think through what’s
an evidence-based way to implement them further. Yeah. JOAN: I think it is so interesting that typically
what we find is people are very interested in the evidence, the peer reviewed
evidence. We have evidence over a decade. Some of it comes out
of Seattle King County, from Doctor Jim Krieger, a whole series of evaluations
that he has conducted with successful outcomes for CHW models. But we also want
to know what is in our backyard? Where is it working, who else is doing this?
Very appropriate question, glad you asked that. What I am hearing at the Alliance – and the
Alliance is the go-to place for folks who are working on CHW strategies – as Megan
said, HCMC, through its Healthcare Home Program, has a team of nurse-led CHWs,
and part of their work involves interface with asthma patients, with an asthma
educator who I know works closely with Doctor Gail
Brottman. Very positive response there. We know the CHWs who are working through a collaborative agreement between
a mutual assistance association in Rochester and Mayo Health Clinic, have been
working on asthma, again, through health care home, and they work with the pediatric
department. Then WellShare International, which is a community-based organization
that has had for the last ten years out of its 30+ history, a domestic program
largely focused on the Somali population, has done some more, what you may
call more public health-oriented asthma education with the Somali community. So we have some examples here and there, but
what we don’t have is really a model that folks can get around and begin to roll
out to be able to begin to get better results that we are seeing, for example in
Boston and other places. What I might add is that this isn’t a sort of an outlier
or an unusual model for asthma. That really all across the country we are
seeing these models in many cities and in lower income communities, undeserved communities
where there is uncontrolled asthma among kids. What are some other examples? Well, I just
came back from the American Public Health Association meeting in New Orleans.
Heard about a fabulous program in New York City at the New York Presbyterian
Hospital, where for the last, I think, almost 10 years, they’ve had a program called
Win for Asthma that utilizes CHWs, and I think what you are hearing is
that the role is flexible and can be adapted to meet the particular community and institutional
needs. In that program, CHWs, when a patient, a
child is admitted for in-patient care related to asthma, a CHW makes a visit in
the hospital before that patient and family return home, to make that connection, and then
there are home visits that follow. Again, a supervised model. CHWs are not out
there hanging up their shingles or working independently, they are wrapped into
teams that are clinically supervised and they are bringing us – as Anne said
– their unique contributions. Chicago Sinai
Health, has had a great model, great success. So again, all across the country, we are seeing
these models develop. And, Jim, to your question – would like through
this conversation, build a network of people who would like to introduce
CHW models more broadly to address asthma disparities. MEGAN: It was announced, I think yesterday,
that the Massachusetts VNA is now part of Hennepin Health. You can imagine almost
having community health workers and visiting nurses working together for a package of services particularly if you integrate – no? Did I say it wrong? AUDIENCE MEMBER: It is MVNA. MEGAN: MVNA. Sorry, excuse me. Trying to think
about what are different ways… AUDIENCE MEMBER: Minnesota. MEGAN: Minnesota, thank you. Excuse me. Trying
to think about the – Thinking about what are ways in which you
could align existing resources and supplement existing resources. I do think
that whether or not it is clinically based nurses or whether it is public health nurses
or ER nurses or other things, I think that you could have respiratory therapists as supervisors, I think you can have a lot of
different visions of how you would implement them. I do think it will be interesting
moving forward as you think about almost the idea of managing a population,
so say at Boston Medical Center we have about 10,000 – 10,000 to 12,000
kids in our primary care practice. About 10% of them have asthma, so you imagine
1000 kids with asthma and then you start doing risk tiers, where you say,
“You are low risk.” Because I will say not everyone should have an asthma home visit,
right? It shouldn’t be for anyone with a diagnosis of asthma. Really talking
about how do you identify those high risk kids? Is it just that they’ve been in the
ER or the hospital? That’s one way to identify them. Or, are there other ways we
can think about it? They haven’t refilled their medicine or they’re really
symptomatic, or they clearly don’t understand things well and we are not really
able to control their asthma. They are coming in for multiple steroids bursts.
There are a lot of different ways you can think about identifying that high risk
pool. Then you make available to them kind of that. I think we are getting more
and more to what are the FTE Ratios? What are the Full Time Equivalencies of, okay,
you’ve got 1,000 kids with asthma, we think 150 of them are going to be high risk,
so that would be we need two community health workers to be able to do a 6 month
intervention with them and you kind of roll your case list. I think we will get closer
and closer to what’s the supervision, because Anne right now, on 16 hours, supervises
two full time community health workers, so it is not a one to one ratio.
It is a piece of Anne’s time with a – being able to supervise them and move it forward. AUDIENCE MEMBER: I am wondering if you have
talked more about any of the school nurse models? MEGAN: Yeah. I think that’s great. No, I’ve
not talked about school based models, so I want to thank you for that prompt. And
yes, I do that think where you base the community health worker does not have to be
just health based, right? It definitely could be school based, it could be public
health department based. There are a lot of different ways in which you can think about
it. In Boston, it’s interesting, when they designed their Prevention Wellness Trust
Application, they really zeroed down in actually schools and early education centers, as where they wanted to focus their biggest energy because of the
huge disparities in the zero to four population. We’re talking about fourfold rates
among black kids, zero to four, going to the ER for asthma than white kids,
right? So what they’ve really done is a lot of that tri-fold linkage:
home, school, clinic. And being able to make sure that you have the asthma action
plan, you’ve got the medicines on site, you are doing the education, that the teachers
get education around understanding the symptoms and being able to make sure that
parents are there. I think absolutely school-based models – and
there are a lot of great evidence based stuff. I also think it’s really interesting that
the rates of school absenteeism among kids with asthma will make your hair curl. I mean,
it’s really … It’s unbelievable. What I sometimes will talk about is you can
have the best educational reforms you want, if kids aren’t showing up, or if they
are not staying long enough in the school, they are churning from one school to another,
because their families are, let’s say, not able to work because the kid has asthma
and so they end up being evicted, and then they move, think about that. In some
urban school districts, 50% of the kids are absent more than 10% of the year. In some
urban schools, the churn rate can be a third of kids. There was one school in
Tacoma, Washington, where they turned a classroom of 20 kids over with 56 different
kids churning through that school. It’s 179% churn rate. A lot of it can be really
simple things, like just making sure kids are in good asthma control. I think that … I am a pediatrician, I am focusing a lot on
the health outcomes, but the educational outcomes may be another way to
sell the idea of why an asthma community health worker – and I like the idea of connecting the school and the home and the clinic together and,
again, I think community health workers are a really good work force to help supplement
the school nurse programs. ANNE: We are going to pick up where Megan
left off and I am going to talk a little about the training that we do in Boston
and the supervision, and then Megan is going to briefly talk about how you can
integrate this program into your setting. In Massachusetts, we have a specific asthma
training session for community health workers. I worked to develop that and I am
part of the implementation of that. It is funded through the Department of Public
Health – Massachusetts Department of Public Health and implemented by the Boston
Public Health Commission. It serves as a building block for the comprehensive
education that community health workers get that I spoke of a bit earlier.
They go through that first and then asthma builds on that training. It is a four-day
home visiting training. It covers not only the nuts and bolts of asthma, which I will describe
in a minute, but there is a day and a half that is specifically devoted to environmental
triggers, how to do some integrated pest management control, and there is a session that is almost a full
day on motivational interviewing, where these are role-play, very, very interactive
sessions. As I said earlier, one of the things that I found really helpful, even though I
had worked to develop the curriculum, was to participate in it. I was able to see
how it worked and to sort of gauge how the community health workers benefited or
didn’t benefit from the program and we’ve tweaked the training based on
needs assessments from the community health workers. We have really tweaked it a fair
amount. We also have a two-day refresher course that
is offered annually and in between, based again on the needs that
are described by the community health workers, we have added little trainings.
I recently did a medication – we called it an advanced medication training
– and it came from a previous continuing ed training on medications, that
I really challenged the community health workers not to say, “Oh, he is on Flovent”,
but to be able to recognize that there is a difference in color that’s all very
important, but when you are talking about Flovent, you are actually reading the label
and saying, “This is Flovent 44 or this Flovent 110.” So that you are not just relying
on the same things that patients are relying on. They
found that very, very helpful. We also do – there is a group that meets that
does community, excuse me, quarterly support groups. They are also involved in
support phone conversations. They share their experiences. We’ve had some issues around
safety. One of our community health workers was actually
locked in the apartment and someone was standing in front of the door
saying you are not leaving. That prompted us to look at the issue of safety,
so we do a lot around safety and at these quarterly meetings they can share those
experiences. Because hopefully that will be a one of a kind experience. We haven’t
had any problems since, but at least they have a sense of ways they can keep themselves
as safe as possible. Under development is a mentorship program.
We talked a lot about how do you know whether or not the community health worker
is doing what you want them to do, and what are the standards and scope of their
practice? By providing mentorship, hopefully that will ease people’s minds. And as Megan said, observation skills assessment. If you look in your packet, I included in
your packet a page that looks like this. It is a grid. We do four, depending on which
study, four to five visits. When I do an observation visit, these are the key points
that I keep in mind and they’re visit by visit. You can take a minute to briefly look over
them, but it’s important from the most simple things like making sure that the
community health worker is wearing their badge. I would never let someone into
my home unless I knew exactly who they were and they had their credential with
them. To how do I assess whether or not they did the asthma training appropriately?
I don’t want to spend a lot of time on that but that is one of the tools we use for
supervision. Getting back to the training, if you look,
there is a… There’s a checklist and this is just there
to show you what we do at each visit. In order for community health workers to
complete the visit according to protocol, what they learn in their training is very
extensive relating to asthma. We go over basic anatomy and physiology, they do the ACT test,
they understand the control issues. I heard last night, the rule of two,
two night time awakenings with asthma per month, two symptom days per week, or two inhaler
uses a year. So simple ways that they can ask simple questions and get really
important data. We do go over medication and delivery systems.
Again, this is hands on. They practice, I do demonstrations, we go over asthma action
plans. Sometimes I hear, “Why do they need an asthma
action plan and how effective is that really?” I think with anything, it
is a recipe. It is a kind of a recipe. It is a go to place. Where knowing that is
on the refrigerator, as Megan said. When a child is symptomatic or getting sicker,
the family doesn’t go, “What did she tell me to do? I don’t remember. Oh
my.” They have a go to. I think that is really helpful. We found that it’s been really
helpful and the families have really liked it and have started to… As
the visits progress, they actually start to refer to it. At first it’s like, “I don’t
need one because I know what asthma is all about.” It takes a little bit of reinforcement. We have the community health workers talk
about flu shots and simple wellness things. Keeping their healthy visit appointments,
communicating things with their doctors, and feeling okay, not feeling shamed,
understanding that wellness is important, and well visits keep you well,
you don’t only go and access health care when you’re sick, and the benefits of that.
Good communication: they learn how to contact me if there is an issue. We go
over documentation, how to be very succinct in what they write. Megan talked
about the online program REDCap, which is where they collect data. For me on
that checklist you’ll see lots of blank lines. That’s where they will give me little
bullets of things that are of concern to them. Communication is also key in terms of understanding
and feeling confident about what they’re doing in the field. We talk a lot about sort of reconciling what
our expectation is of a visit and what the family’s expectation is. What do the families expect of their child?
Megan’s done a lot of research on this. If you have a parent who thinks that having
a cough all the time is just the way my kid is, you need to somehow reconcile that, so there’s a lot of role playing, again, and instruction on how do you best
do that. We talk about what’s available. The resources
that are available, such as… Megan already spoke about it, so I’m not going
to spend a lot of time on in it, but many times people don’t understand what
is available. I told a brief story to Sylvia just a minute ago about, I presented
at a conference in Portland, Oregon, and I was asked to speak about medication
and how people can get their medications funded. Of course from Massachusetts,
I said “Well, that’s not really a problem because meds are covered under our
health care.” I did all this abundant research and I presented this little program
and people in the audience, from Portland, were so grateful because they
had no idea that some of these things were available. We live in this world of perpetual
motion and sometimes we don’t stop to see what is right in front of us. Helping families to see what is available
and understanding how to access that and utilize it without fear of repercussion. A lot of motivational interviewing, so much
so that the supervisors have been encouraged not only to attend motivational
interviewing trainings, but also to utilize motivational interviewing with their
community health workers. Does everybody have a sense of what motivational
interviewing is? Raise your hand if you’ve heard of motivational
interviewing. Okay, it’s the idea that you are not going
in there and saying, “I think you should do this, I think should do that.” It’s more,
you know, “How are things going? Can you tell me about your child’s asthma?” And
then, if the family says, “Well, he is waking me up four nights out of the week.”
“That sounds tough. It doesn’t sound like he’s having good nights.” Reflecting
back what they say and then initiating a conversation whereby you say, “What are
some things do you think we could do to help resolve this situation?” You are
pulling them into the conversation as part of the solution and not going there – you
know I have been a nurse since 1976 and the old model for me was, “Go in. You
are the patient, I’m the nurse. I know what you need. Here’s the list, do it and
you will get better.” That’s how we all operated and I think part of that is the wisdom
of aging, but also recognizing that that does not work. Doesn’t work whether
you are doing it with your kids, or whether you are doing it with your patients.
People have to feel “part of” in order to embrace what you are trying to share
with them. Motivational interviewing is huge. As far as community health workers being prepared
for emergencies in the home, I will give you a little scenario and I think
we are probably a little bit ahead of time, but you know what, look at just the case
study with David. David was a young boy. I think he was 12 or 13 and he was on school vacation this
past February and our Haitian community health worker went to visit David and his
family. David was Haitian. David was really sick. I happened to be on
an observation visit that particular day and it was clear to me when we walked in that
he needed a couple puffs of his inhaler. We encouraged him to just take – he wasn’t
feeling well, we established that. We encouraged him to take some Albuterol,
and without giving the story away, his mom was very upset with David, and Kathleen
asked him several questions which are part of the protocol, and we uncovered
that David had been telling his mother that he had been taking his medication when
in fact he hadn’t. This little scenario is something that we
use for the training for the community health workers and I’ll pose that question to you.
You come into a home. The child is really sick. You certainly want to treat the
child. Mom is really upset because David told this lie about the medication and how
he had been taking it, when he really hadn’t been. Mom lays it to David and is very,
very upset with him, shaming him, just making him really kind of hang his head
low. As the community health worker, what do you suppose is the most important
issue there – was there to address? The relationship. Anybody else? Do we all agree it was the relationship? I think what happened was his older sister
was there and his mom was there and they just literally, I’ve never seen anybody
yell at somebody in front of, you know, people from outside. They were really upset.
And I learned from Kathleen that in the Haitian culture, lying is like – you
don’t lie. You do not lie. That is wrong. So Kathleen needed to finesse the situation
and explain to mom that, could she see that David was struggling to breath? Try to
turn her from, yes, I understand that, however David is really sick. Perhaps he … The ultimate excuse was that he lost his medication
and that is why he hadn’t taken it. So mom got angry that, why didn’t you tell
me? But when he tried to speak to mom, mom was very authoritarian and you know, just
not interested in talking with him. Kathleen tried to make her see that that’s
important. Your child shouldn’t lie to you, however, do you recognize that he is sick?
His sister was there and his mom was there and neither of them really recognized
how sick he actually was. Long story short, we worked through that and spent a
great deal of the visit talking about recognizing symptoms. You know, he was dragging,
he was having shortness of breath, you could hear him wheeze. Sometimes parents have to be in partnership,
especially with older kids, because parents tend to take responsibility when the
child is young, but when they get older it’s like, it is their responsibility. And I think
guidance, sometimes when you are not feeling sick, you don’t always do what’s
right. Kathleen spent a lot of time with mom, a lot of time with the older sister and
a lot of time with David helping him to understand that by being proactive and
honest with his mom, number one he was going to feel better because he’d get
his medication sooner, and it would help him in that he was approaching his mom so
then he would have support of his mother as well. During that visit we did a couple of things.
He didn’t have his controller medication. He had a nebulizer that didn’t work and
he had Albuterol. It was a Friday afternoon and we actually set him up with an appointment
for the company to come and replace the nebulizer. We called the clinic. In this case, I called the clinic. But had
I not been at the visit, Kathleen would have called me and I would have transmitted that information
to the clinic. What I usually do is call the triage nurse and then the triage nurse
takes care of whatever is necessary. I think, in terms of assessment skills, certainly,
they do not have the level of assessment that a licensed, registered nurse
would with advanced degrees, et cetera, but I think part of the training is recognizing
that and if you can transfer that training into the home, you can tell when someone is
not breathing well. What is important is to know what to do with that information
and that – going back to the asthma action plan – that is a good tool for the
asthma action plan, to be utilized when somebody thinks, “I’m not sure what
to do but I am going to go here and I’m going to do it.” The community health worker
knows what they can do within the home and knows when to access support on the outside. In terms of the supervisor training, it is
a two-day training. Again, we encourage people to go through the
community health worker training, so that they understand what their community
health workers are doing. We look at the scope of practice and talk
to community health workers about how you don’t alter anything on an asthma
action plan, you don’t make recommendations about changing medications
or anything like that. As I said, the supervisors go through motivational
interviewing and are encouraged to use it with their community
health workers so that it’s kind of a role model, role play. They go through asthma basics. We’ve talked
a lot about the different types of supervision and it is important that whoever
is supervising a community health worker understands asthma so that they can
pick up on those key messages when something isn’t going well. Supervisors
are also, especially in a clinic based setting, it’s important for community health workers
to have an assigned role – and in your packet there is a job description – that the
supervisors not only help to integrate them into the health care team, but also to
prevent them from being the go-to person, “Would you do this for me and would
you do that for me?” They have a defined role and they need to
stay within that role. They also go out for observation visits for
quality assurance and we have supervisory support calls, sharing ideas,
sometimes we even share patients because someone may not fit our model so we
will refer a patient off. I already did that. Megan is going to talk a little about how
you integrate them into various settings. MEGAN: I sometimes will talk about the keys
to success for community health workers are the “C” then the “S” then the “I”,
right? The C is certification, so making sure that community health workers have been trained,
being able to make sure that they meet certain competencies and other things.
The S is supervision, right? These community health workers do not practice solo,
that they are well supervised. That the supervision goes through training.
That they are able to think about what their role is within a team, so that
really community health workers don’t practice solo, that they’re members of a
team. Then the last one is this idea of integration. I think that more and more there
are lot of different ways – behavioral health integration is something
that people are talking about. How do you integrate into primary care or into home based
services? In many ways, I think there are a lot of different ways that community
health workers can be integrated. One of them is in the medical home in the
delivery of care where they’re a recognized kind of trusted member of the team. This is
where it is really important that even if the community health worker is predominantly
doing home based services, I still think they need to check-in in the medical
home. For instance we started at Boston Medical Center, but expanded to one of the
largest community health centers in Boston, called East Boston Neighborhood Health
Center. We actually brought over both community health workers to meet key
clinical staff so that when clinical staff talk about, “Oh I am going to refer you
to Benita”, they’ve met Benita, they know who Benita is. They’ve met Kathleen, they
know who Kathleen is. It is very clear to them who is which community health worker
and that they’re able to feel confident that they are part of the East Boston team. We are currently in the third year of the
grant from the Center for Medicare and Medicaid that funded that expansion. The community
health center is already talking about how are they going to continue this
program after funding because they feel like they do not want to go back. They now have
seen what it is like to be able to have this available as part of their resource,
and they want to think about it as if the person would become an East Boston Neighborhood
Health Center employee. They want to think about how they are going to be able
to do that. But a medical home is not the only place that they necessarily could be
integrated. I think public health departments can employ community health workers.
That’s one of the models we have in Boston to fill some of the gaps around
language access. I think that in many ways, when you think about it, you may have
five or six languages that you need. You need Somali, Hmong, you are going to need
Spanish, you are going to need other ones, so that it is going to be hard for you
to employ enough people, so you could think of where a public health department
can become a base for a one-stop shopping for contacts, where you are able
to say, “Okay. We are going to be able to pool resources so that we can have the linguistic
and cultural capabilities and be able to do that.” The other benefit of being integrated at a
public health department is that you are integrated with other services. You are integrated
with inspectional services, and code enforcement that the boards of health
typically do. You may be integrated with public benefits and other programs. We’ve
had really nice partnerships around particularly younger kids that may have Healthy
Start nurses going into the homes for after babies are born and things like
that, and having the community health worker who’s been specially trained with the
environmental stuff and other things do joint visits together and being able to
potentially even prevent some of the wheezing because you are able to prevent the
triggers earlier and save a child’s life. The last piece of integration is that I feel
like especially as many medical homes are going to electronic health records, is that
it’s really important to view this as part of care. One of the things that I think is
really important is not just to have either a mailed copy of what happened or a faxed copy,
but to actually put a note in the electronic record so that a clinician can
see that this happened, what happened at the visit, so that they recognize that this
service is going on. I think sometimes if it’s partnering with a social service agency where
you don’t get that feedback loop, you can understand why someone wouldn’t
utilize the program because you don’t know what is happening with it. I didn’t put on this “integration” – integrating
into the school environment. We think about where kids of school age spend the most
time. They often spend the most time at school, so thinking about ways in
which to integrate, not only for the parents so that the parent knows what is going on,
but then also integrating back to the clinical environment and making that a seamless
transition. And there sometimes are some barriers around HIPAA, about being able
to share information, but those are overcomeable. Those are models that can be
done, that can be really important. ANNE: If the community health worker went
in the home and first of all found that the child’s technique with a discus,
say, wasn’t good, they would contact me and say, “You know, perhaps he is not feeling
well because he is not getting his medicine. He does not know how to use this thing.”
Then I will call the triage nurse or I will contact the physician and say we had a home visit
and this is what happened and I am leaving it in your hands to make a decision as to
what you want to do. Let me know and then we will go back and reteach. Kids will be
diagnosed with asthma and they’ll be sent home with Abuterol. When I scan the medical
record, I see that the child’s had three, sometimes four, burst of steroids in
a year and I kinda go like that. Then when the community health worker comes
back with documentation, they really know “Controller, controller. Rescue. Controller.” They are taught to know that asthmatics should
on controllers, so they’ll usually point that out to me,
I’ll also see it in the REDCap data, because there’s a list of medications, how
frequently they’re supposed to be taken and how frequently they actually are taken. If there’s a disconnect, I will usually check
with the community health worker that it wasn’t just an error. I will often say “Can
you call mom and just clarify are they taking this or are they not? Do they really not have
a controller?” So I have my data aligned, my ducks in a row. And then I’ll call the physician and I’ll
say “Okay. I had the community health worker double check with the family. This is what
mom reports. I see in the medical record that you’ve ordered this and there was no
sign of that. Perhaps they were on it at one point, they ran out and didn’t refill it.”
And then I go back to the community healthy worker, “Can you call mom again and ask
her, or can you schedule that second visit a little earlier?” and check in to really
establish what is really happening. Sometimes we find people who – they run out
of Flovent and they have some med that the child was on two years ago, and they
will pull that out of the drawer and start using it. There is a lot – again, being the
eyes in the home can tell you so much. Ultimately what they see, if there’s a disconnect
there, they report it to me. I make the judgment as to whether or not – I
look at the medical record to see what the actual orders are and make sure that is
what’s being followed in the home. MEGAN: I think what’s key is the community
health worker and really Anne don’t make a clinical treatment decision. They bring
it back to the treating physician and say, “Here is some information. Like in the last
note it said you went up for Flovent 220, but so you know, the patient is reporting
to us they are still using 110. What do you want us to do? Do you want us to tell them
to get the 220, and start using it?” or, “They seem to be doing pretty well on the
110, what do you want?” The other piece we uncover a lot is they have
not just one asthma action plan, they have three asthma action plans. The have
an asthma action plan they got from the ER, they have the asthma action plan they
got from their specialist, and they have the asthma action plan they got from their
primary care doctor, and they’re not the same. They are all different. We will
go back to, frankly, the doctor – and this is where it sometimes gets difficult.
Which doctor do we go back to? So we tend to say the ER doctor gets the least
– because they were not part of the continuity team, so then we’ll go to the
asthma specialist and the primary care and say, which one is the right one? Tell us which you want us to be teaching,
right? I really want to emphasize that it’s really
information gathering, not clinical decision making. This is why I really emphasize the
integration piece, is that the only way you know that is if somebody at Anne’s level
has access to the medical record and can look and see what’s reported to be what’s
supposed to be going on. Then the eyes and ears of this community health
worker report back what actually is going on. There are definitely times when
patients will actually do what you ask which is bringing your medicines from home.
That is – we almost put in a slide. So Robin gave us
literally the most beautiful slide which was like, twenty inhalers. Twenty different
inhalers of five different Flovents, some Advairs, some Albuterols, ProAir, and non-HFA
and HFA and literally – they have the baggie of stuff and nobody knows
kind of what’s new and what’s not. The community health worker sometimes will
be like, “OK, this is expired.” Or if it doesn’t have a counter, they may
still be puffing and have no medicine in it so we got to get rid of that. So just trying, again, not to make decisions,
but just be able to implement the plan that you made in the office in a much more
effective way. ANNE: When we first started this, there was
a question to whether or not the community health workers themselves would
document in the record, and it was decided that that would not be the case, and
I’m actually happy about that because it gives me a higher level of review of what
they’re writing, and understanding what’s going on. I do a couple of things. At Boston
Medical Center, I free-text about a visit and I am pretty precise. At the neighborhood
health clinics, three of which we have patients enrolled from, I use a template,
so it’s pretty straight forward. I can free-text into the template if I want to add
something. I will also add there that “patient was taking wrong medication. I
checked with physician and this is the plan” or whatever. It’s basically the visit number,
visit one or visit four, it’s the date, it’s whether the child – they do the asthma control
test at every visit, so that is included there. After I do that, is the child
well controlled, not controlled? And then there is a drop down menu where if I say the
child is not well controlled it will say, “What was the advice given? Did you call
the clinic while you were at the visit? Did you suggest two days of Albuterol and have
the family call the clinic to schedule a follow-up appointment? Did you call the emergency
room?” There is a whole drop down menu. There is a drop down menu for environmental
triggers, for the products that we bring in, what was delivered,
so that the nurse practitioner in the clinic will ask the family, “Are
you using the vacuum cleaner and how do you like the fact that you have natural cleaning products? Is that working for you?” So again, there’s this incredible connection, and
as I said, there is an opportunity to free-text whenever I want. MEGAN: I think I can’t emphasize enough
that two-way communication and that someone at the appropriate licensing level
is putting the information in. For me, I think our community health workers
are actually amazing, but I wouldn’t want to put that burden on them. I think it
is better for Anne in her supervision will review what is written from the REDCaps.
We are trying to make the seamless communication real time. We are able to see
what time the information is entered into Red Cap. We are able to do that, and
then be able to translate that into the electronic record. Sometimes if there is a
more urgent thing, like what controller do you want them on? She can either flag the
physician using the electronic record and then make the change, or if it is more emergent,
page the physician or call the nurse for the clinic. Janelle in the back and then… AUDIENCE MEMBER: On the family, the Haitian
family, into look at as far as support groups for the family goes… MEGAN: The question was really related around
support systems for the family itself and not just thinking about the individual,
but thinking about the family, whether it be support groups, or connected to faith based
organizations, or other things. I would say absolutely. We have actually started looking
into would you look into, “Could you do a case rate that is family based
instead of individually based?” So you sometimes will have parents and kids
that have different forms of insurance, right? One will have one Medicaid
managed care and another one will have a different one and maybe there is a
third one, and that can make it more difficult. But if you did a line where you
had – everyone had Neighborhood Health Plan, you could imagine. Because that would actually
then – potentially be able to spend more time in the home, be able to treat everyone’s
asthma, because we know that this can be familial, where oftentimes you
have a parent with asthma and a child with asthma, and be able to do it. It’s tricky because trying to think through
– with that complexity, not everyone goes to the same health home, so you can imagine
having to communicate with multiple health homes for it. I totally agree with
you. I think that in many ways, when we think about this intervention, we shouldn’t
just think about it on the individual level, we should think better on the family level. The other thing that is really interesting
is starting to think about community health workers in a more community level, right?
So the idea that there is a lot of evidence now about the interplay between individual
health and community health. One of the things that our community health
workers spend a lot of time on is frankly legal issues, housing code enforcement or
other things. They’ve been trained by legal aid attorneys and things like that,
and there’s more evidence around – this was work that was done in Cincinnati
around the idea of, you can spot kind of individual landlords that aren’t
doing what they are supposed to be doing and then you can track those landlords and
then potentially force the landlords to make the buildings better. The flipside is you can actually track communities
and look at what’s the density of code violations in that community. Can you
actually see a heat map around the concentrated areas where there are more code
violations and then look at whether individuals are more likely to end up in the
emergency room based not on your home but the homes around you? Andy Beck is the first author on those papers.
One was published in pediatrics, one was published in health affairs. I think you’re
right. What we are describing, in some ways, is a
very simplistic, unilateral view of how a community health worker could be viewed. We
are describing an intense model. Again, not every asthmatic is going to need
it. But I think it starts to speak more towards thinking on the more population level.
And community health workers – there have been examples where community health
workers are doing more community health, particularly out of community
health centers, using that platform as a way to not only promote for the individual
patient they’re seeing, but for an entire community as well. Janelle, you have a … AUDIENCE MEMBER: Yes, I am just wondering
about the medication technique. Have you asked the family, “Show me how you use that medication?” MEGAN: One of the nice things is Neighborhood
Health Plan in Massachusetts did ten different languages of visual pictorials
of how to use asthma medication. These are wonderful and they’re available
on the web, you don’t need to be from Massachusetts or anything like that,
so I really encourage people. They’re really helpful in terms of trying
to do techniques, but I do think that – again, the community health worker would only
do a small piece of that. That would be something that a more medical
professional would follow up with and or bring them back to the clinic to be
able to do it more intensively. I am going to keep going because I want to
make sure we have time for our breakout. One of the frequently asked questions we get
a lot is “Will community health workers replace public health nurses?” and
the answer to that is no. You couldn’t replace a public health nurse. I think in
a lot ways, I tend to think of them as public health nurse extenders. I described the heart model, the home asthma response where they have the health nurse
and the community health worker do the first visit together and then have the
community health worker do the follow-up visits. I definitely want to make sure that
no one walks away today with the impression that we think community health workers can
replace public health nurses. Can I trust what community health workers
do in the field? I think supervision in the field is important.
Not for every single visit, but for sporadic quality assurance purposes. Going out even
5% or 10% of the time just to see how things are going works for both levels. Works
for not only helping the community health worker with their competencies, but
feels that it is important. We can tell real time from when someone uploads the data, so
we know what time the visit happened because they uploaded data from that, but
then there have been times when there have been questions about what a community health
worker is doing and that is when we can really utilize the same things that anyone
would around home visiting and other things. We talked about handling emergencies. I think
safety is a big thing. We actually modified our protocols around
the first visit – now is done in pairs where a community health worker does not go out
by themselves. Two community health workers or a community health worker and an
observer go out because then the family can be assessed for how safe it is for the
community health worker to be there by themselves. I really have emphasized to my
community health workers that at any point they don’t feel safe, they should
leave. We have code phrases that they have been taught
around how do they leave a situation that they don’t feel safe in.
I think that is used in any home visiting, whether you are a public health nurse or other things, those are important things and we really emphasize those. And then clinical emergencies. How do you
call 911? How do you get someone into a clinic? Or other things, and being able to
reinforce that. We do have Anne as a backup anytime they are in a home and they
have a question they can reach her by cell. I want to go over a breakout session
that we tried to think about. In your packets you’ve got a who, what,
where, when, why and how kind of sheet. What we are hoping is that over the next 15
minutes or so people will take some time to kind of start to think about who would
be a patient population that you would want to target if you were thinking about adding
a community health worker to your healthcare asthma care team? What would be
the type of intervention you would envision a community health worker doing,
right? When and where would they deliver the service or the intervention? Why would you do it?
What goal would you set? What’s your goal in doing it? And then start
thinking how you would move forward with it. When we convene back, people can share some
of their different things, and Anne and I will be walking around to see
if we can help you. Joan can talk about some of the Alliance’s
funding for pilot grants to be able to use a toolkit to try to move this forward. So
this is meant as an exercise to help you get those juices flowing and try and think about
it. We’ll do this for about fifteen minutes
and then wrap up. ANNE: I just want to quickly give you the
website for this because I don’t think it is – I don’t think it is included in your packet.
The website is Neighborhood Health Plan and it is www.nhp.org. And … You click on
providers and then, a little box comes up on the right hand side of the screen and says
“Clinical Resources” and I think it’s the fourth or the fifth topic. It says “asthma
resources for education.” You click on that and you will have a choice of a number of different
handouts. We pass out colored copies so that families
can use them and the community health workers use them in their teaching. MEGAN: So I just want to walk through
the who, what, where, when, why, and how. And if people are willing to share
some of the stuff that they were thinking. I think the first is kind of who? Who would
be patients that you may want to target with adding a community health worker as part
of your asthma care team? AUDIENCE MEMBER: The schools and obviously
the poorly controlled students. Obviously we’re going to look at ethnicity. MEGAN: Yeah, absolutely. So you’re going
to look at uncontrolled asthma and whether or not that is hospitalizations or ER visits
or whether or not it’s just by symptom reports, you want to able to target the highest
risk people. Absolutely. What else? AUDIENCE MEMBER: [inaudible] MEGAN: Yeah, age is a huge disparity. We talk
a lot about disparity by racial and ethnic lines but in asthma, age is actually
huge. We talked about how in Boston we’ve targeted the zero to four population because
they are largely sometimes out of care in their home and they can have huge asthma
disparities around it, so certainly age targeting is another way to think about it. The thing we’ve kind of danced around, and
I want to kind of talk about it head on, is the cost differential. A community health
worker doesn’t cost as much as a public health nurse, and so I don’t want to say
replacement but when we think about time, a community health worker can spend more time
with a family sometimes and that I think it is a huge thing. If you have someone
that has cognitive barriers. For instance, in some of our families, an
asthma action plan as it traditionally is laid out, doesn’t work. We literally have done
low literacy asthma action plans with like, a sun, and a picture of the inhaler, and the
number two. Then literally a moon and a picture of the inhaler and a two. You’ll
literally kind of walk through what an asthma action plan green zone looks
like with the family, to be able to do that, and I think that’s something our community
health workers asked for, and we were able to help develop it with them. All right, so the “who” – you guys have
a lot of good identifications of the who. So the “what.” What types of interventions
would you want a community health worker to be helping with? AUDIENCE MEMBER: A healthy home assessment. MEGAN: Yeah. Being able to be your eyes in
the home, walk through. Be trained to identify environmental triggers
that families may not be willing to report to you, but are pretty evident when
you are walking through the house itself. AUDIENCE MEMBER: In combination with a healthy
home specialist. MEGAN: I was just about to say. And this is
where an inspector could be doing the more rigorous assessment and the community
health worker may be the one to help with the education component. A culturally,
linguistically appropriate follow up education. Because a lot of the healthy housing
stuff is structural but a lot of it is behavioral, right? What do you do with your
dishes, what do you do with your food preparation and where do you store the food?
Where do you store the garbage? Are there ways we can get rid of the clutter
or other things? So yeah, being able to think of that educational
follow up is great. What other ideas? No asthma education? I will say I forgot. Anne did bring an example.
We do our asthma education using a validated asthma education tool called “You can control
your asthma.” And that was developed by the Asthma and Allergy Foundation of America.
We actually translated it to Haitian Creole because we felt that was
a gap, so it is available in English, Spanish, and Haitian Creole. It has a kid booklet and
an adult booklet. Very low literacy and really nice, but I think that could be important. This is what it looks like and we can have
it in the front for people who want to look at it. All right, the when and where. When and
where would you want to be able to think about adding the community health worker? AUDIENCE MEMBER: At the neighborhoods, let
them come to the neighborhood, sort of like a moving clinic. MEGAN: There definitely are really nice models.
There is one developed in L. A. with a mobile van going around to particularly
increase access. I do think that… AUDIENCE MEMBER: An environmental team. MEGAN: I was going to say. So that’s what
I think is hard. I am going to argue I think a home-based component is really effective. That’s what the research kind of shows,
is that – but if you can get into the home – and that’s
a big if, so I want to say – but I think that’s where we think of community health
workers as being potentially a specialized workforce, one that could get in the home
better because of their cultural background, their linguistic background. I think that
sometimes being able to talk as from having a physician say, “I think this
is a good idea, I am going to have the program contact you,
tell you more about it,” has been something we have found effective. Cold calling families doesn’t always work
as well as if we have a physician endorsement, and then thinking about that. Thinking, again, about the targeting of who
you want to reach out to, that high risk pool. They’ve already come to the ER and
hospital. It was a kind of a seminal event for the family. Can we think about ways to
follow up with them? Anne made a good point. One way we can get
into the home is the incentives. At the first visit you get the mattress covers,
at the second visit you get the pest kit with the home cleaning supplies, at the third
visit you get the vacuum cleaner. It is not that we don’t think that the vacuum
cleaner should be there at the first visit, we just delay it so that it helps us get into
the homes. Being able to think through ways to use incentives, not only for your
intervention, but also to get into the home itself. As Anne alluded to, the incentives
match the intervention, right? We are telling them about food storage and then we give them
three Tupperware containers, large Tupperware containers, where they can put cereal or rice
or other types of dry goods that they want to store or things like that.
And then we do include… Partly we have because it’s a research study,
we’re able to get a grocery card as a final incentive to complete the program. One of the things that we have been struggling
with is sustainability with Medicaid. Being able to get those as reimbursable, durable
medical goods. I probably jumped Pam’s question that she
was thinking, but it is this idea of… And I think we will get there. It will probably
be part of a bundled – sorry, a case rate where you’ll be able to figure it out. We
have been able to figure out how do we order these things from Boston Medical Center, and
figure out the storage of them, but it’s an interesting kind of sustainability
thing, because I think the services are important, but I think the goods are as important
to supplement the service in the long run. Lastly, why would you do it? What
metrics would you do or what are ways in which we would think about – what would
you be tracking to change? Yeah. AUDIENCE MEMBER: Does the Juniper quality
of life scale have any kind of metrics for asthma self-advocacy management? MEGAN: Yeah. So it’s a good question. The
Juniper scale does not include an efficacy scale within it. Some of the studies – We decided our questionnaire was too long,
so we did not do an efficacy scale. That being said, some other asthma community
health workers studies have, and have shown improvements in efficacy
scores. In fact, I think the Yes We Can program, when they published it,
did include an efficacy score as something they improved. I will say this. So we ask two questions around
asthma action plans. We ask, “Do you have one?” And about 60%
of the time someone yes to that at our baseline. And then we ask, “Do you use
it?” And so the “do you use it” question, you
drop off about twenty to thirty points. One of the things we are proud of is that
by the end of our study at least 80% of the people we say are using the asthma action
plan as their game plan every day. “What am I going to do today? Am I going
to use the green zone because my kid looks pretty good? Am I going to use the yellow
zone, my kid is starting the get sick? And then – my kid doesn’t look good, I
need to go to the hospital.” And what’s really great is – we know we’re
successful when the community health worker comes back and says, “You know what?
They told me the kid had a cold. And he started wheezing more, and they used
the asthma action plan, and they didn’t have to go to the clinic, and the
kid’s better now.” Right? So they used it the way it’s supposed to be used. And so, I
do think that this is – it’s hard in an office setting to have enough
time to get someone to that point. And that’s why, again, I think of the community
health worker as an extension of me and my practice. I come up with the asthma
action plan, I typically negotiate it with the family, but then I need someone to
help them implement it.


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