1. Community Health Workers in pediatric primary care
May 2018 Learning Session

2. 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.

3. 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

4. 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.)

5. Just some of our PDSA’s
endocrinology

6. 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…

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

8. 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