Community Health Workers and the Triple Aim!

Heidi Behforouz, MD

CEO: AnansiHealth Associate Professor: Harvard Medical School

Physician Faculty: Division of Global Health Equity Brigham and Women’s Hospital

August 18, 2015 CSG-ERC Annual Meeting!

Triple Aim!

Improve the health and wellbeing of all people at affordable and reasonable cost with high rates of patient and provider

satisfaction!

Population Health!

• The health outcomes of a group of individuals (nation, state, county, city)

• With attention to the distribution of outcomes in that group (ie are there disparities and why?)

• What are the policies and interventions that produce good health outcomes and ensure health equity!

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!

High-Risk Patients (5%)

Rising-Risk Patients (15-35%)

Low-Risk Patients (60-80%)

Three Population Foci

At present!

• Our system is not designed to emphasize wellness or prevention and does not provide high quality, egalitarian, or patient-centered care that is cost-efficient

• Our current system is oriented philosophically and fiscally toward episodic disease management and has the hospital as its main driver of resource allocation and cost

• Health is often defined as the absence of disease rather than a state of wellness that is all-inclusive!

Rethinking the locus of care!

•  Locus of care should be the community •  Primary driver of care should be

primary medical and behavioral care linked with public health

•  Patient-CHW (formal/informal) dyad not the patient-doctor dyad should be primal

•  Focus should be on primary/preventative care with specialized/complex care management as needed

•  Hospitals/ERS and highly licensed/high cost medical professionals who specialize in ‘end-stage” disease management should be relegated to lesser roles!

Socioeconomic Factors ~ 40% of Health Outcomes

Access to healthy food,

exercise/recreation,

liquor stores, fast food,

crime

Providers, quality of care, trust, insurance

Where you live and work

Current glue !

• Nurses and social workers

• But they too have been over-speciated and “boxed in” according to financial/regulatory pressures emphasizing downstream care

• We are not developing the concept of or investing in a community-based person that is delegated/trained/supported to “accompany” an individual through his/her life course and continuum of care!

A return to an old paradigm!

CHWs as the new glue!

Patient activation and engagement

CHW Role

Social Support

Health System Navigation

Care Transition Support

Chronic Disease Support &

Health Coaching

Advanced Illness management support

Empower community

Education and Counseling

Normalize healthy lifestyles

Promote harm reduction

Address social and structural determinants of health

Why Community Health Workers?!•  CHWs live in the community in solidarity with

patients and have similar culture/language •  Take a holistic/contextual approach •  Understand/address social dets of health •  Effect value-based care/more cost-efficient •  Build social cohesion and change social norms •  Can work both upstream and downstream •  Promote meaningful workforce development

opportunities in under-tapped communities!

CHW Workforce!

•  U.S. presence since 1960s (IHS, Columbia Point CHC)

•  Outreach worker, navigator, ambassador, community health representative, peer educator, etc.

•  Only recently recognized as worker type by Dept of Labor (2009)

•  Large state-wide variability in CHW recognition/integration/and payment

•  Turf battles with nurses, social workers, PCAs, home health aides, etc.

•  Still no standard reimbursement through fee-for-service mechanism

•  Often underutilized and paid through soft money so very vulnerable workforce

•  Systems are not set up to develop and maximally utilize this work force!

But they are out there…!

• According to Bureau of Labor Statistics (May 2014)

• 47,880 CHWs nationwide (likely underestimated)

• Median annual wage $34,870

• Hired by government public health agencies, some clinics/hospitals, non-profit community-based organizations!

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But they are out there!

•  Nationwide!

!

High-Risk Patients (5%)

Rising-Risk Patients (15-35%)

Low-Risk Patients (60-80%)

Population Foci

Low Touch/High Volume

•  “Surveillance” •  Wellness & Health

Coaching

•  Tools – Community screening/linkage, Social Media

Examples of CHW success in promoting wellness!

• Cancer screening (breast, colorectal, cervical cancer) • Maternal/child health (including prenatal care, well child visit rates, positive parenting) • Immunizations • Disease screening (TB, HIV, HTN, DM) • Mental health • Addiction services/harm reduction!

One example… Felix HC et al, Health Aff 2011; 30(7):1366-1374!

• Rural Arkansas

• TriCounty Rural Health Network

• 6 full-time CHWs provided home-based outreach to 919 elderly and physically disabled adults over 3 year

• Compared to statistically matched cohort

• Spending growth was 24% lower in CHW group due to lower nursing home expenditures

• Reduced Medicaid spending by $3.5million

• Saved $3 for every dollar invested!

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!

High-Risk Patients (5%)

Rising-Risk Patients (15-35%)

Low-Risk Patients (60-80%)

Three Population Foci High Touch/Low Volume

•  Frequent interaction

•  Chronic Disease/Intensive Care Coordination

•  Tools – Complex Care Management Teams

Sources: Cohen, Steven B. and Namrata Uberoi. 2013. “Differentials in the Concentration in the Level of Health Expenditures across Population subgroups in the U.S., 2010.” Agency for Healthcare Research and Quality. http://meps.ahrq.gov/mepsweb/data_files/publications/st421/stat421.shtml.

Examples of CHW success in CCM!

• Diabetes • Asthma • HIV/AIDS • General high-risk populations!

One example… Johnson D et al J Community Health 2012: 37(3): 563-571!

• Medicaid MCO in New Mexico • Enrolled high-risk patients with 3 or more ED visits during a 3 month period • 6 CHWs provided accompaniment services to 691 patients • Compared claims for 448 of these patients vs 448 matched controls • CHW group with significant reductions in ER, hospitalizations, and prescriptions • Total program cost $559 pmpm • Extrapolation to NE Medicaid population per CEPAC analysis: 10% reduction in total spending at end of y3!

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Inconsistent Data on Utilization/Savings This is true even when looking at nurse care

management interventions which are considered “state of the art”

Few Medicare demonstration projects showed

reduction in unnecessary utilization and costs

Those that did only focused on top 5%

And overall cost savings could not be achieved unless costs were below

$125-150 pmpm

Which is hard to do with high-cost personnel

We need more implementation experience…!

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Challenges!

•  CHWs as a work force require attention •  Funding streams for CHWs are limited/soft •  Health care system with mal-aligned incentives

and payment structures •  Acculturation challenges: team-based, license-

based, evidence-based, CQI-based, clinic-based •  Scale-up challenged by silos; guild issues; risk

management; financial issues; structural/management issues

•  Biomedical model vs structural/psychosocial paradigm!

A new age!

•  Federal: ➢ CMMI grants ➢ Health home demonstration projects

•  State: ➢ Medicaid waivers and SIM grants ➢ Medicaid MCOs forming CCOs with quality contracts

•  Local: ➢ ACO formation with increased risk taking and global

payment/shared savings contracts ➢ Health care system and payer integration ➢ Increased employer involvement in health care!

What’s happening now vis-à-vis CHWs!

CHWs in Medicaid waivers •  Many Medicaid 1115 waivers mention CHWs and encourage (not mandate) their use for care

management and other services...these include Massachusetts, Texas, New Mexico, California, and Oregon.

•  Massachusetts has a waiver to get PMPM Medicaid reimbursement for its pediatric asthma program that involves CHWs, primarily in a home visiting and education role  

•  Oregon gets short-term federal funding for CHW training programs in its Medicaid waiver •  Rhode Island is considering filing a waiver for Medicaid reimbursement for CHWs.  •  Illinois has a pending waiver (not yet approved) to do CHW training and build up the CHW

workforce

Straight Medicaid payment via FFS •  Minnesota and Alaska are the only states whose Medicaid programs reimburse for CHW services

Other mechanisms •  Health Home State Plan Amendments in Maine, New York, South Dakota, Washington, Wisconsin,

West Virginia include mention of CHW care managers •  SIM grants pay primary care practices participating in reform initiatives to do care management

and share risk/savings: CHWs paid through global fees •  CMMI has a concept paper before OMB re support for care managers to address/pay for “social

determinants of health” •  CMS Preventive Services Rule which allows Medicaid programs to reimburse for community-based

preventive services provided by non-licensed practitioners!

Demonstrations!

•  Arkansas: SIM grant is funding primary care reform initiative with pmpm payment for care management and potential for shared savings. No CHWs in contracted CM companies. We are going to integrate CHW health interventionists in TCRHN and compare results. We hope that with success more primary care practices will purchase CHWs for their care management activities.

•  LA County: CCP project (paid for by LA County) with CHWs integrated into 5 county clinics to note improvement in outcomes among top 10% patients by risk/cost

•  North Hartford: CHWs as “community organizers” and “medical care managers” in poor zip code area. Using philanthropic dollars for small scale demonstration and hope for Medicaid interest and pick up!

How do we move forward?!

•  Funding for large scale demonstrations with creative financing and rigorous evaluation

•  CHW certification and training with regulations to recognize and pay them as uniquely skilled wellness interventionists

•  Technical accompaniment for systems to recruit, develop, and integrate CHW work force into other care management teams

•  Built the analytic capacity of implementers to document realized value of interventions via investment in robust community-wide HIE

•  Establish a system to document, disseminate, and replicate innovations at scale!

Context for demonstrations!

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•  Re-merging of health care delivery system with public health and welfare system

•  Global payments with shared risk/shared savings with payment for all stream costs

•  Coordinated care organizations (CCOs) that include health homes, public health/education, payors (public/private) and academia

•  Increased emphasis on building community infrastructure and solid primary care for all people

Inpatient Spend (Acute, Rehab, SNF) Outpatient Spend

Traditional Fee for Service

Outpatient Spend Inpatient Spend

Population Health

ManagementSpend

With Enhanced

Coordination

Conceptual Strategy for Population Health Management!

The time is now…!

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Selected References!

•  IOM Round Table on Population Health Improvement; “Bringing Community Health Workers into the Mainstream of U.S. Health Care;”February 2015.

•  ICER Review “Community Health Workers: A Review of Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England;” July 2013

• AHRQ Health Care Innovations Exchange; “State legislation supports professional development of community health workers, leading to greater professional recognition enhancements in training and funding;” 2013.

• CDC “Addressing chronic disease through community health workers: a policy and systems-level approach;” 2011.!

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