Community Health Workers in pediatric primary care May 2018 Learning Session

A little background… Community Health Workers (CHW) are a team who work to complete extensive population management for Gen Peds, Complex Care, Adolescent Medicine, and Transition Medicine patients. We are frontline staff who have made CONNECTIONS in the community and are becoming TRUSTED members of the community and clinic settings. Our overall goal is to continue to Build Relationships between the families, the community, and CCHMC resulting in IMPROVED HEALTH OUTCOMES for families receiving care. A large part of our QI WORK supports the Inpatient Bed Day Disparity Reduction team.

Our Areas of Work IPBD Newborns Specialty Clinics Thrive by Five All Referrals from Inpatient Bed Days Call All Newborn Referrals to 14 months IPBD Newborns All Referrals from Specialty Clinics of Primary Care All referrals age 18 months to 5 years Specialty Clinics Thrive by Five Community Health Worker Care Gaps SBHC Team with Population Management to Locate Families On site Support and Referrals from School Based Health Centers Population Management Care Management Support Report Management and Filtered Outreach All Referrals from Care Managers

Community Health Worker Key Driver Diagram   Project Leader(s):  Kristy Anderson, LISW-S, John Morehous, MD Revision Date:  04/30/2018 v4 GLOBAL AIM OUTREACH DRIVERS INTERVENTIONS Help Cincinnati’s children be the healthiest in the nation through strong community partnerships Engage families in a trusted space Develop and maintain caseload of Patient Referrals (support patients in navigating medical system, help in minimizing social barriers that would otherwise impede compliance with primary care) Project: PPC Newborns | Measure: % WCC Completed Project: Specialty Clinics | Measure: % Appts Completed Project: TCB Health Champions | Measure: % WCC Completed Project: TriHealth & UC Newborns| Measure: % WCC Completed Support families to remove barriers to care Families understand importance of preventive health care FY20 AIM (2) Implement Proactive Population Management System Project: Population Management (Filtered Care Gap Reports) | Measure: # patients contacted / records updated Project: Gen Peds Care Gap Referrals | Measure: % WCC Completed Health Care System designed around economic and cultural differences with family built solutions Thrive by Five: To increase percent of patients turning 66 months who have received all Thrive at Five bundle elements from 13.4% to 40% by 6/30/2020 Proactive Population Management (3) Establish presence in Community and develop connections Project: Food Pantry| Measure: # connections Project: Reading Bears| Measure: # connections Project: Price Hill Family Forum| Measure: # connections Care Delivery Teams and Families understand the role of the CHWs - serving as advocates, educators, connectors. (4) Create cohort of patients with medical disparities and work to help eliminate the disparity and to better understand our patients/families Project: ED Utilization| Measure: TBD Project: Diabetes| Measure: TBD POPULATION *Children aged 0-17 years in the Avondale, Lower Price Hill, and East Price Hill Neighborhoods (5) Create an education and assessment toolkit for the CHW to use when interacting with patients/families (e.g. Asthma, Lead, WCC, Endocrine, etc.)

Just some of our PDSA’s endocrinology

What we’re learning from our testing It’s CRUCIAL to build relationships for the sake of the relationship Key Learnings Small movement is STILL movement! Will strive to demonstrate IMPACT on medical/social goals This work takes TIME…meeting people where they are…

Just one slice of our data Measures and Results Just one slice of our data CHW Engagement Trending in the right direction

Kristy Anderson, LISW-S Our Team Allison White Alicia Reynolds Angie Reisert LaKeya McNary Lamont Tubbs LaToya Lemley Nikki Acosta Maya Wallace Kimberly Brown Stephen Fortson Sherria Evans Seleta Bishop John Morehous, MD Kristy Anderson, LISW-S Sue Stiles, LISW-S John.Morehous@cchmc.org Kristy.Anderson@cchmc.org Susan.Stiles@cchmc.org