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Hospitals trying to revamp care via community health workers



For Kaiser Health News


Donnie Missouri, 58, doesn’t have medical training. He started his health career in the linens department in Johns Hopkins Hospital. Now, he works on the front lines — one of the hospital’s non-medical workers who reaches out to patients who doctors think are at risk of suffering setbacks that will force them to return.

One recent day at the end of March, he visited Vincent Berry, a 28-year-old man who’s paralyzed from the waist down, a condition resulting from a years-ago gunshot wound after a drug deal went sour. Berry’s doing well medically, but he lives with his aging grandmother, in the upstairs bedroom of a narrow apartment where he relies on help from friends and family to be able to leave. Missouri has been trying to help him secure independent, wheelchair-accessible housing that will make it possible for him go to school or pursue other activities that might move his life forward.

Right now, “I can’t get out and go to school every day,” Berry said, adding that he just tries to make the best of everything. “I just — I know I want to be in a house. It doesn’t have to be the best house.”

Missouri’s goal is to connect people like Berry with resources like housing, transportation and other government benefits — factors that influence health but aren’t the doctor’s focus.

What’s Missouri’s secret? It’s a combination, he says, of building rapport, meeting patients at home and, most importantly, understanding the challenges — medical and not — his neighbors face.  “You have to know your community,” he said of the East Baltimore neighborhood where he lives and works. “If you don’t … it ain’t going to work.”

What Missouri does is hardly a novel concept. For decades, community health workers have tried to fill the system’s gaps. Often hired by the local health department, they take on diverse public health initiatives — running diabetes or nutrition education programs, counseling patients to stick to their medication regimens or teaching new mothers about vaccinations.

But now, hospitals across the country are turning to them in a bid to revamp patient care. They are using these aides to strengthen their relationships with patients and surrounding neighborhoods — improving the community’s health and, along the way, their own finances.

Part of it is spurred by the 2010 federal health reform, which introduced a number of changes in how Medicare pays hospitals.

Similar efforts are underway on the state level, through Medicaid payments and health insurance regulations. Health insurers, too, are starting to show interest in figuring out how they might pay for these services.

“We need to do things differently than what we had been before,” said Ken Fawcett, a physician and the vice president of the community health worker initiative at Spectrum Health in Grand Rapids, Mich. “People are starting to recognize there are non-health care related variables that have a profound impact.”

Challenges persist, though, in figuring out how to finance community health worker programs and regulate the growing workforce.

How It’s Done

Preliminary research suggests health systems are seeing returns on these investments. Patients stay healthier. Fewer are readmitted. That reduces how much expensive, often-not-profitable care hospitals need to give, yielding a financial payoff.

“Because of this new policy environment, health care systems are going to be held accountable” for people’s health, said Shreya Kangovi, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine, who directs its center for community health workers.

The American Hospital Association doesn’t systematically track how many health systems have launched community health worker programs. It’s becoming “much more common,” said Ken Anderson, chief operating officer of the hospital trade group’s Health Research and Education Trust. “This area of interest seems to be very much front and center for hospitals.”

Community health workers are often uniquely positioned to help their clients — the hospital patients.

Frequently, workers have had similar life experiences — maybe addiction, navigating the criminal justice system or simply facing difficulties gaining access to care or other neighborhood’s challenges — so they can connect with patients in ways doctors and nurses don’t, said Scott Berkowitz, Johns Hopkins’ senior medical director for accountable care.

For Missouri, that’s invaluable. When visiting patients, he avoids business clothes that might render him unapproachable, opting for a shirt and lanyard showing he’s from Hopkins, but also jeans and brown walking shoes. He jokes with Berry’s grandmother, and recognizes his dog. After fist-bumping Berry goodbye — they’ll check in later by phone, they confirm — he can cross the street to his next client, a woman with substance abuse problems. He’s a recovering addict himself.

How do programs work? Take the University of Pennsylvania’s Perelman School. Community health workers — who are full-time hospital employees — are assigned patients. They assess patients’ needs and develop relationships spanning months. An early study of the program found patients who participate are less likely to keep returning to the hospital and have better outcomes.

Penn is betting these efforts will ultimately mean savings, so it’s investing upfront: funding the program through its own operating expenses. Some health systems are using grants from private foundations or the federal Centers for Medicare & Medicaid Services to get started. New York Presbyterian Hospital, affiliated with Columbia University, started its community health worker pilot a decade ago, using grant funding. Since then, program leaders have convinced the hospital not only to pay for the program but to expand it, citing healthier, more satisfied patients.

Hopkins got a federal grant from the Center for Medicare & Medicaid Innovation to launch its program in 2012. The funding is ending this year, but it is planning to continue anyway.

In Maryland, the state has taken steps to reform hospital payments — rewarding health systems for keeping patients healthy enough that they don’t need hospital treatment. That adds financial incentives for Hopkins and other hospitals, encouraging them to use strategies such as outreach by community health workers.

Federal policies also add appeal. The University of Maryland Medical Center, in West Baltimore, for instance, started its community health worker project last year after it was penalized by Medicare for failing to meet national standards regarding how many patients it readmitted within 30 days of discharge.

The hospital’s seen readmissions drop by about half, said Zina Kendell, the program’s manager, but the program doesn’t save enough to offset the cost of running it. Still, the hospital is looking into expanding it, said Charles Callahan, vice president for  population health. “We have a model we believe in,” Kendell said.

Meanwhile, state and federal regulators are grappling with how to set standards for community health workers’ training and certification.

More than 20 states have instituted regulations or created oversight committees, according to Sharon Moffatt, interim executive director of the Association of State and Territorial Health Officials.

But there’s no consensus on the best level of scrutiny for community health workers.

Take background checks, an idea that “comes up all the time,” said Carl Rush, who heads the Project on Community Health Worker Policy & Practice at the Institute for Health Policy at the University of Texas Health Science Center at Houston.

Though well-intentioned, that standard can be counterproductive, he said. “There is a legitimate argument to be made that people who have exposure with the corrections system or criminal justice generally are better-equipped to work with people” coming through community programs.

Institutions like Penn and Hopkins train workers before sending them into the field. But Missouri, the Hopkins community health worker, said knowing the city, its resources and residents matters most.

“A lot of people sit in their office and talk about how they’re all about community,” he said. “[But] when’s the last time you got into it and found out how your community works?”

Making community health workers part of the medical team


For Kaiser Health News

Month after month, Natalia Pedroza showed up at the doctor’s office with uncontrolled diabetes and high blood pressure. Her medications never seemed to work, and she kept returning to the emergency room in crisis.

Walfred Lopez, a Los Angeles County community health worker, was determined to figure out why.

Lopez spoke to her in her native Spanish and, little by little, gained her trust. Pedroza, a street vendor living in downtown Los Angeles, shared with him that she was depressed. She didn’t have immigration papers, she told him, and her children still lived in Mexico.

Then she mentioned something she hadn’t told her doctors: She was nearly blind.

Pedroza’s doctor, Janina Morrison, was stunned. For years, Morrison said, “people have been changing her medications and changing her insulin doses, not really realizing that she can’t read the bottles.”

Health officials across the country face a vexing quandary – how do you help the sickest and neediest patients get healthier and prevent their costly visits to emergency rooms? Los Angeles County is testing whether community health workers like Lopez may be one part of the answer.

Lopez is among 25 workers employed by the county to do everything possible to remove obstacles standing in the way of patients’ health. That may mean coaching them about their diseases, ensuring they take their medications or scheduling medical appointments. Their help can extend beyond the clinic walls, too, to such things as finding housing or getting food stamps.

The workers don’t necessarily have a medical background.  They get several months of county-sponsored training, which includes instruction on different diseases and medications, as well as tips on how to help patients change behavior. They are chosen for their ability to relate to both patients and providers. Many have been doing this job for friends and family for years – just without pay.

“By being from the community, by speaking their language, by having these shared life experiences, they are able to break through and engage patients in ways that we as providers often can’t,” said Dr. Clemens Hong, who is heading the program for the county. “That helps break down barriers.”

For now, they work with about 150 patients, many of whom have mental-health issues, substance-abuse problems and multiple chronic diseases. The patients haven’t always had the best experience with the county’s massive health care system.

“They tell us, ‘I am just a number on this list,’” Lopez said. “When you call them by name and when you know them one-on-one … they receive that message that I care for you. You are not a number.”

By spring, Hong said he hopes to have hundreds more patients in the program.

Community health workers have been used for decades in the U.S. and even longer in other countries.  But now officials in various counties and states — including Massachusetts, Pennsylvania and Oregon —  are relying on them more as pressure grows to improve health outcomes and reduce Medicaid and other public costs, experts said.

“They are finding a resurgence because of the Affordable Care Act and because healthcare providers are being held financially accountable for factors that occur outside the clinical walls,” said Dr. Shreya Kangovi, assistant professor of medicine at the University of Pennsylvania and director of the Penn Center for Community Health Workers.

Kangovi said community health worker programs, however, are likely to fail if they don’t hire the right people, focus too narrowly on certain diseases or operate outside of the medical system. They also need to be guided by the best scientific evidence on what works.

“A lot of people think… they can sort of make it up as they go along, but the reality is that it is really hard,” she said.

Hong, who designed the program based on lessons learned from other models, said Los Angeles County is taking a rigorous approach. It is conducting a study comparing the costs and outcomes of patients in the program against similar patients without assigned workers.

The patients are chosen based on their illnesses, how often they end up in the hospital and whether doctors believe they would benefit.

To Lopez, 43, the work is personal. A former accountant from Guatemala, Lopez has a genetic condition that led to a kidney transplant. Like some of his patients, including Pedroza, he is now on dialysis.

He tries to use his experience and education to get what patients need. But even he runs into snags, he said. One time, he had to argue with a clerk who turned away his patient at an appointment because she didn’t have identification.

“The hardest part is the system,” Lopez said. “Trying to navigate it is sometimes even hard for us.”

Lopez and his fellow community health worker, Jessie Cho, sit in small cubicles in the clinic at Los Angeles County-USC Medical Center, the county’s biggest and busiest public hospital. Throughout the day, they accompany patients to visits and meet with them before and after the doctor does. They also visit patients at home and in the hospital, and give out their cell phone numbers so patients can reach them quickly.

Cho said the patients often can’t believe that somebody is willing to listen to them. “Nobody else on the medical team has it as their job to provide empathy and compassion,” she said.

Morrison, the clinic physician, said both workers have become an essential part of the health team.

“There is just a limited amount I can accomplish in 15 or 20 minutes,” Morrison said. “There are all these mysteries of my patients’ lives that I know are getting in the way of taking care of their chronic medical problems. I either don’t have time to get to the bottom of it or they are never going to really feel that comfortable talking to me about it.”

Natalia Pedroza, who wears a colorful scarf around her head and speaks only Spanish, is a perfect example.  Morrison said before Lopez came on board, “I wasn’t getting anywhere with her.”

Initially, Lopez had a hard time helping her understand her health conditions and overcoming her distrust of the system. When they first met, Pedroza believed the dialysis that kept her kidneys functioning was the cause of her health problems. And she didn’t get why Lopez was always around.

But he helped her — by getting her appointments, for instance, and helping arrange for Pedroza to get pre-packaged medications so she wouldn’t have to read the directions. Now Pedroza thinks Lopez is helping her to get better.

On a recent afternoon, Lopez sat down with Pedroza before her medical appointment.

“How are you feeling?” he asked in Spanish.

Pedroza responded that her hair was still falling out and that she still felt sick. She also said she hadn’t been checking her blood sugar because she didn’t know how to use the machine. Lopez calmly demonstrated how the machine worked, and then the two spent several minutes chatting about her job and her neighborhood.

Lopez said he believes he has a made a difference for other patients as well. On a recent Sunday, a 43-year-old patient with chronic pain who initially refused his help texted that he planned to go to the emergency room because of a headache. Lopez reached Morrison, who agreed to squeeze him into the schedule a few days later. And the patient didn’t go to the ER.

Lopez persuaded another patient, a 56-year-old woman, to take her blood-pressure medication before her appointments so that when she arrived, the doctors wouldn’t get worried about her numbers and send her to the hospital.

In one case, his ability to bond with a patient almost undermined his goal of getting the man the help he needed. The patient, who was depressed, said he didn’t want to go see a mental health counselor because he was more comfortable talking to Lopez.

“It was touching,” Lopez said. “I was about to cry.”

Blue Shield of California Foundation helps fund KHN coverage in California.

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