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Health Care Home Spotlight: Early Lessons and Results from CHW Integration Promoting Patient Centered Care and Community Health. Tara M. Nelson Intercultural Mutual Assistance Association Community Health Worker Jean M. Gunderson Mayo Clinic Employee Community Health

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Health Care Home Spotlight:Early Lessons and Results from CHW Integration Promoting Patient Centered Care and Community Health

Tara M. Nelson

Intercultural Mutual Assistance Association

Community Health Worker

Jean M. Gunderson

Mayo Clinic Employee Community Health

Community Engagement Coordinator

Minnesota Community Health Worker Alliance Statewide Meeting

June 5, 2014

  • Illustrate the impact of CHW home visits on the understanding of the patient experience through descriptions of goal setting, self-management, and acts of resiliency
  • Review the collaborative infrastructure and funding aligning CHW capacities promoting community health
  • Describe the building of teams integrating CHWs in a certified Health Care Home
  • Examine the community based co-supervisory CHW model integrating patient centered team based care
challenge as opportunity
Challenge as Opportunity
  • 1990’s influx of immigrant and refugee populations
  • Public program and funding transitions
  • Unmet and uncoordinated patient/consumer needs across a continuum of care
  • Recognition of the social determinants of health and community oriented primary care
  • Navigation, communication and engagement


local collaborative response
Local Collaborative Response
  • The Multicultural Health Care Alliance (1997)
  • The Olmsted County Health Care Access Taskforce in 2005 (access; context)
  • The Olmsted County Community Health Care Access Collaborative in 2007 (community priorities; workgroups)
  • The Coalition of Community Health Integration in 2012 (formalization of systems, policy and funding)
  • The United Way of Olmsted County (alignment of early intervention: behavioral health, oral health, medical home)


local chw workforce development
Local CHW Workforce Development
  • Standardized, competency-based CHW curriculum offered at Rochester Technical & Community College (2006 and 2012)
  • CHW Workgroup (2008); small study (2009)
  • 90 hour CHW internships at lead partner sites (2006 and 2012)
  • MN CHW Employer Forum in Rochester (2009)
  • CHW Employer Consortium (2011)
  • Community Based Co-Supervisory CHW Pilot (2013)


chw curriculum
CHW Curriculum
  • Standardized, competency based 11 credit curriculum (2003-2005)
  • Revised to 14 credits (2010)
  • Core competencies (9 credit hours)
  • Health promotion competencies (3 credit hours)
  • Internship (2 credit hours)
  • CHW certificate upon graduation


  • CHW Role, Advocacy and Outreach, Organization and Resources, Teaching and Capacity Building, Legal and Ethical Responsibilities, Coordination and Documentation, Communication and Cultural Competency
  • Healthy Lifestyles, Heart Disease and Stroke, Maternal and Child/Teen Health, Diabetes, Cancer, Oral Health, and Mental Health


  • The United Way of Olmsted County
  • The Mayo Clinic Office of Population Health Management
  • Potential: Team based care in the Accountable Care Organization Model
  • Potential: Care Coordination/HCH
  • Testing: Minnesota Health Care Program (MHCP) Medicaid fee-for-service option


chw pilot co creating transdisciplinary team based care
CHW Pilot:Co-Creating Transdisciplinary Team Based Care
  • Internship and Pilot aligned and co-created with lead Care Coordinators and leaders in Mayo Clinic Employee and Community Health (ECH) Health Care Home
  • Specific service areas: Primary Care Internal Medicine (PCIM), Integrated Behavioral Health (IBH) and Community Pediatric & Adolescent Medicine (CPAM)
  • Referral Criteria: complex care needs, eligible for or enrolled in care coordination (recognizing health determinants)
  • Expanded programming: DIAMOND, EMERALD, COMPASS, and EPSDT (C&TC) complex care needs utilizing two lead Care Team RNs


chw role
CHW Role
  • Navigator
  • Advocate
  • Liaison
  • Knowledge- Bearer: community relationships, local lived experiences, cultural, linguistic and language needs
  • Connector to community resources
  • Educator: reinforcement and support
  • Walker of the Margins


quality dimensions asset based and holistic team based care
Quality Dimensions:Asset Based and Holistic Team Based Care
  • Community based co-supervisory CHW model
  • Order by Proxy options (Primary Care orientation)
  • Team huddles, patient conferences and consults
  • Telephonic support
  • Patient home visits and at other community based sites
  • Non Visit Care coordination supports
quality dimensions asset based and holistic team based care1
Quality Dimensions:Asset Based and Holistic Team Based Care
  • Social Determinants data identified in partnership and reported utilizing patient language
  • Patient centered visit schedule (service, frequency & number)
  • Referral, patient goals, and self-management skills tracking
  • Transdisciplinary teaming (relational practice)
  • Secondary partner sites reporting every 3 months
chw pilot current status
CHW Pilotcurrent Status
  • Total patients served: 181
  • Total Visits: 452 (since July 1, 2013)
  • Active patients: 103; Average CHW caseloads: 50 patients
  • Average number of visits per patient: 2.5
  • CHWs working with ECH teams: 2-3 FTE
  • Care Coordinators in the Pilot: 24
  • Lead Care Team RNs: 2 (EPSDT)

Weekly reporting 5-19-2014

who are we serving1
Who are we serving ?

* Documentation and tracking are challenging due to insurance enrollment status,

patient and internal reporting, and when multiple payers per patient exist

who are we serving2
Who are we serving?
  • Often multiple comorbid conditions exist
who are we serving3
Who are we serving ?

Minnesota Department of Human Services and the Hennepin County Ryan White Program HIV/AIDS Medical Case Management Standards (Appendix C, HIV/Aids Acuity Assessment, pages 24-26)

what are we doing top direct care themes patient directed goals
What Are We Doing?Top Direct Care Themes-Patient Directed Goals
  • Daily Living
  • Healthy Living
  • Independence
  • Care of Chronic Conditions
  • Social Support
  • Public Programs
  • Safety
  • Spiritual Needs
non visit care themes areas of impact
Non Visit Care Themes: Areas of Impact
  • Basic Human Needs
  • Patient Engagement/Communication
  • Insurance/Coverage of Services
  • Referrals to Direct Health-Related Services
self management themes
Self-Management Themes
  • Budgeting: figure out expenses, find bills, set-up a financial consult, track bank account
  • Social Activity: get outside more, call churches, volunteer, get involved in an activity, obtain a computer, find a buddy system for the Laundromat
  • Goal setting and Planning: use a journal, calendar, or a list
  • Advocating for Self: communicate with teams, home care agencies, and PCAs, being assertive and setting rules
  • Gaining Independence: organize paper work, find a home, schedule transportation, go to work regularly, understand care plan
  • Managing health: check BP, journal, relaxation breathing
lead patient education tools
Lead Patient Education Tools
  • PHQ-9
  • Asthma Control Test
  • Asthma Control Assessment
  • Asthma Action Plan
  • Peds Quality of Life Form
  • Goal Setting
  • Goal Map
  • Journaling
  • Log books (BP, Diabetes, Activity)
satisfaction and assurance data
Satisfaction and Assurance Data
  • Patients , Care Coordinators and CHW satisfaction data collected using surveys (mail and on-line, interview option with CHW team)
  • Integration of human stories/cultural narratives
  • Review of lead reporting tool: CHW Visit Form
  • Monthly case consultation with CHWs & ECH teams
  • Bi-monthly co-supervisory meetings at IMAA site
  • MN CHW Alliance & MN CHW Alliance Supervisor Roundtable
patient experience
Patient Experience
  • Cultural narrative
lessons learned the art form of holistic care within relationship
Lessons Learned:The Art Form of Holistic Care Within Relationship
  • A fillable PDF CHW Reporting Form would create improved outputs in reporting and in-direct time.
  • Home visits are critical in understanding patient/family experiences, assets, needs, and health determinants
  • Use of one’s language, literacy, and culture remain significant factors within care, healing, and health outcomes
  • Mixed methods analysis is important when reviewing and reporting patient data
  • Community based CHW services are essential in the integration of community contexts within team based care.
reflection on the a ha moments
Reflection on the “A-HA” Moments
  • Market community based non-profits
  • Integrate collaborative funding
  • Recognize the impact of team champions
  • Living the mantra: systems, tools, teams, processes (process outputs/the collective flow)
  • Model how specialized training impacts observation, interviewing, documentation, reporting and referral (the transdiciplinary practice lens)
  • Align resources to envision and deliver
  • Recognize transformation as both challenge and opportunity
next steps
Next Steps
  • Continue to develop CHW billing processes, integrating both fee-for-service and shared revenue cost saving options
  • Maintain the evaluation of CHW programming addressing complex care needs and the social determinants of health
  • Expand the CHW reporting and referral pathways to include additional Care Team RN leads and Social Workers.
  • Build the SE MN CHW Regional Pipeline with collaborative partners and expand local CHW programming
  • Maintain CHW specialized training and cross-training across the care continuum
  • Thank you!
    • 507-289-5960, ext.102
    • 507-538-8458