Families USA Conference January 23, 2015 Joan Cleary, Executive Director - Interim Minnesota Community Health Worker Alliance Scaling Up Community Health Worker Strategies Workforce innovation for advancing health equity and achieving the Triple Aim

Presentation Outline  Introduction: What’s Keeping You Up at Night?  CHW Role  Overview of Minnesota CHW Alliance and our CHW Field-Building Work  Lessons & Observations  Selected resources

What’s keeping you up at night?

Sleepless in the Twin Cities Integrated Health Systems Impact of the Affordable Care Act and becoming an ACO Achieving the Triple Aim Dealing with the social determinants of health Getting more out of fewer resources East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

Sleepless in the Twin Cities Payers Cost of care while improving health outcomes for more people Addressing the needs of an increasingly disparate membership Counteracting and/or addressing the social determinants of health East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

Sleepless in the Twin Cities Policymakers Reducing costs associated with health care and burden on society Understanding and addressing the social determinants of health Addressing health disparities in culturally-appropriate ways Taking a less siloed approach to health care East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

Sleepless in the Twin Cities State Agencies Implementing MNsure (the state’s health insurance exchange) Best addressing health disparities while reducing costs Successful implementation of Patient-Centered Medical Homes (“Health Care Homes” in Minnesota) East Metro CHW Business Plan Project, MN CHW Alliance, 5/2013

Team-based CHW Strategies: Health Reform Trifecta! Advance health equity Help achieve the Triple Aim*…improving patient experience (including quality and satisfaction), improving population health, reducing per capita health care costs Grow and diversify our health care and public health workforce *Institute for Healthcare Improvement

CHW Role

Who are Community Health Workers? Trusted, trained and knowledgeable frontline health workers who share the culture and/or life experience of the communities they serve Educate and connect underserved communities to care, coverage and support Provide outreach, advocacy, patient education, care coordination, navigation, social support and informal counseling Address social determinants of health, working upstream and downstream

An emerging workforce Adapted from NM Dept of Public Health presentation Community Health Advocates Lay Health Advisors Outreach Workers Care Guides CHWs Promotoras Tribal CHRs Community Educators Patient Navigators

CHWs are uniquely equipped They typically reside in the communities they serve, and share the same language, ethnic, cultural and educational background Adapted from NM Dept of Public Health presentation Health & Social Service Systems CHWsCommunity

Focus on social aspect of care Adapted from NM Dept of Public Health presentation Providing culturally- responsive, cost effective health information Teaching and supporting families to learn the knowledge/skills needed to manage treatment and prevent disease Linking communities to health/social service systems of care and helping them to navigate the systems Advocating for services to meet community needs Empowering individuals and communities to advocate for their health

CHW strategies: Evidenced-based best practices to address health disparities Effectively address barriers related to culture, language, literacy, ability, place, socioeconomic and other factors Increase access and improve quality, cost-effectiveness and cultural competence of care Organize and advocate for healthier communities Well-documented outcomes: asthma, diabetes, HIV/AIDS, hypertension, maternal and child health as well as cancer outreach and immunizations

Examples of evidence-based CHW models Molina Health, New Mexico Reduced ER utilization Community Health Access Program (Pathways) Ohio Improved birth outcomes Sinai Pediatric Asthma Intervention, Illinois Improved child asthma management, reduction in asthma symptoms and ER use GRACE Model, Indiana and IMPaCT, University of Pennsylvania Reduction in hospital readmission rates and improve post-hospital outcomes Arkansas Community Connectors Program Averted nursing home placement

Recognized by leading public & private authorities American Public Health Association (APHA) Centers for Disease Control (CDC) Centers for Medicare and Medicaid Services (CMS) Health Affairs Health Resources and Services Administration (HRSA) Institute of Medicine U.S. Dept. of Labor Standard Occupational Classification (DOL)

What are we learning from recent CHW studies on Return on Investment?

Introduction to Alliance and Our CHW Building Blocks

About the Alliance We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a 13-member nonprofit board. OUR VISION Equitable and optimal health outcomes for all communities OUR MISSION Build community and systems’ capacity for better health through the integration of community health worker strategies

What are we trying to accomplish? Full integration of CHWs in MN systems of care Reduce health inequities Advance Triple Aim Adapted from NM Dept of Public Health presentation

Workforce Development Workforce Development Education Objective: Advance CHW knowledge & skillset and inter- professional education to better serve Minnesota communities Objective: Raise awareness of CHW impacts through research & evaluation Objective: Foster policies that promote healthy people and healthy communities Objective: Improve access to coverage and care Research MN CHW Alliance Help achieve the Triple Aim, address health disparities, expand & diversify the health care workforce and foster healthier communities through CHW strategies Policy

MN CHW Building Blocks Recognized by the Agency for Healthcare Research and Quality Recognized by the Agency for Healthcare Research and Quality CHW scope of practice developed (2004) Statewide standardized, competency-based 11 credit curriculum created by Healthcare Education Industry Partnership, leading to certificate (2003–2005); revised to 14 credit program (2010) MNCHW Peer Network formed (2005) for continuing education CHW payment legislation successfully introduced (2007) in follow-up to commissioned research on sustainable funding strategies (2006) MN CHW Alliance formed as outgrowth of CHW Policy Council (2010) and incorporated as nonprofit (2011)

Minnesota CHW Scope of Practice Role 1: Bridge the gap between communities and the health and social service systems. Role 2: Promote wellness by providing culturally appropriate health information to clients and providers. Role 3: Assist in navigating the health and human services system. Role 4: Advocate for individual and community needs. Role 5: Provide direct services. Role 6: Build individual and community capacity.

MN Standardized CHW Curriculum Model statewide curriculum based in higher education Offered at no charge to post-secondary schools in Minnesota Sold to over 30 organizations outside of Minnesota; online version now available Credits provide educational pathway for CHWs interested in other health careers Leads to certificate recognized by MN Dept of Human Services Over 600 graduates to date

Curriculum is competency-based Core Competencies: 9 credits Role, Advocacy and Outreach – 2 Organization and Resources – 1 Teaching and Capacity Building – 2 Legal and Ethical Responsibilities – 1 Coordination and Documentation - 1 Communication and Cultural Competency - 2 Health Promotion Competencies: 3 credits Practice Competencies – Internship: 2 credits

MN CHW Payment Legislation Timeline 2007 Legislation 12/19/07: Federal approval received Minnesota Health Care Program (MHCP) enrollment criteria: CHW certificate from school offering MnSCU-approved curriculum Supervised by a physician or advanced practice registered nurse Grandfathering provision 2008 Amendment 3/18/09: Federal approval of expansion of CHW supervision to the following provider types: Certified public health nurses within a unit of government and dentists 2009 Amendment Federal approval of supervision by Mental Health Professionals

MHCP CHW payment legislation Minnesota Statute (MS 256B.0625, Subd. 49)

CHW covered service: Diagnostic-related patient education Signed diagnosis-related order for patient education in patient record Face-to-face services, individual and group Standardized education curriculum consistent with established or recognized health or dental care standards Document all services provided

Provider types authorized to bill for CHW services Advanced Practice Nurses Hospitals Clinics Indian Health Services Facilities Critical Access Hospitals Mental Health Professionals Dentists Physicians Family Planning Agencies Public Health Clinic Nurses Tribal Health Facilities To learn more, contact:

What’s Next?

Priorities Fully integrate the CHW role into state-funded health and human services programs, local public health and human services, and health care systems redesign efforts such as MN’s Accountable Communities for Health model Continue to incorporate CHW workforce into: Health care home program Health Insurance Exchange (as assistors and navigators) ACO models Increase awareness of the role and its impacts Example: Success with CHWs online tool kit initiative Partner and grow to build our capacity to achieve our vision

Health system challenges and trends present opportunities for CHWs to make a difference Increasingly diverse and rapidly aging population ACA is increasing access to thousands of uninsured Focus on Triple Aim and team-based care Payment shift from fee-for-service to value-based purchasing and total cost of care Primary care shortage Health equity growing in priority

New England Comparative Effectiveness Advisory Council: Final Report & Action Guides, July 2013 BEST PRACTICE RECOMMENDATIONS INCLUDE: Getting started States and organizations can choose comprehensive or incremental approach to CHW implementation Program Funding Payors and providers need to work together on stable funding mechanisms, including CHW strategies in new payment models as well as existing case management and home visiting funding streams CHWs: A Review of Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England

Lessons &Observations CHW movement is accelerating under health reform Find key starting-points, partners and policy levers Recognize that CHW education is key to CHW financing Champions are needed at multiple levels Active involvement of CHWs is critical…build CHW leadership Practice transformation takes time Allies and working team-based models help address skepticism and occupational turf Success stories AND data are important State-level infrastructure needs to be created to support an emerging CHW profession Connect with CHW allies through APHA CHW Section

Implementing CHW Strategies City-wide and regional partnerships Example: Super Utilizers Local public health agencies Example: Family home visiting Hospitals & integrated health systems Example: Patient-centered medical homes, ER Community clinics Example: Outreach and education to improve screening rates Social service agencies, housing providers, schools Example: Address unmet health and social needs, link to coverage and care Companies Example: Occupational Health Dept

Selected resources Allen C, Brownstein JN et al. States Implementing CHW Strategies: A Technical Assistance Guide. CDC ASHTHO CHW Certification/Training Standards. 12/31/ certification-standards/ Cleary J, Lee J and Itzkowitz V. CHWs in Minnesota: Bridging Barriers, Expanding Access, Improving Health. Blue Cross and Blue Shield of Minnesota Foundation Pathways Model Wilder Research Center. CHWs in the Upper Midwest

For more information: Joan Cleary, Executive Director Minnesota Community Health Worker Alliance Thank you!