Achieving the Triple Aim: Success with Community Health Workers - May, 2015

 
Achieving the Triple Aim: Success with Community Health Workers - May, 2015
Achieving the Triple Aim:
Success with Community
    Health Workers

         May, 2015
ACHIEVING THE TRIPLE AIM                                                           March 2015

                     Success with Community Health Workers

F   or decades, community health workers (CHWs)
    have played a critical role in public health
efforts in Massachusetts to improve population                                   Improve
health and to ensure that all residents of the                                    Health
state receive quality services. The Massachusetts
Department of Public Health (DPH) has long                                       Reduce
been a national leader in supporting the CHW                                      Health
                                                                                Disparities
workforce through programmatic and policy                            Reduce
                                                                                              Improve
initiatives. Massachusetts’ comprehensive health                     Cost per
                                                                                                Care
                                                                      Capita
care reform, as well as national health reform
(the Patient Protection and Affordable Care Act),
explicitly created opportunities to employ CHWs                            The Triple Aim+
as part of achieving what has become known as
the Triple Aim. DPH is committed to assuring that      Evidence from research and the experience of
CHWs are integrated into primary care and related      numerous provider organizations in Massachusetts
health care teams.                                     and other states demonstrate that CHWs add
                                                       value to multidisciplinary care teams in the
To that end, DPH is working to ensure a                following ways:
quality CHW workforce through imminent state
certification of CHWs and approval of CHW training     1. Reduce costs
programs, as well as promoting sustainable                  •   Save costs through fewer emergency
financing of CHWs as part of healthcare teams.                  department (ED) visits and lower
This White Paper will help to inform healthcare                 hospitalization and readmission rates for
provider and payer decision-makers about the                    complex patients
growing evidence of CHWs’ multiple contributions
to achieving the cost, quality and health outcome      2. Improve health
goals of health reform, while reducing disparities          •   Help patients engage more fully in their
in health care and outcomes throughout the                      care and adhere to care plans
Commonwealth and the nation.
                                                            •   Help patients control chronic conditions:
                                                                increase asthma-free days, lower blood
Community Health Workers’ Critical                              sugar and blood pressure levels
Role In Practice Transformation
                                                       3. Improve quality of care
Health reform offers new opportunities for primary          •   Improve health and care utilization,
care practices to transform their staffing and                  reflected in performance measures and
delivery models to provide higher quality and more              standards promoted by the National
efficient services. CHWs, as part of integrated                 Committee on Quality Assurance (NCQA),
care teams, contribute to cost-effective services               such as Healthcare Effectiveness Data
that advance the Triple Aim for which providers                 and Information Set (HEDIS), and other
are accountable: improved health, improved care,                quality measures1
and reduced costs. CHWs also help reduce health
                                                            •   Improve retention in care through
disparities, a goal of health reform that is closely
                                                                outreach to reduce no-shows and
linked to achieving the more commonly highlighted
                                                                assistance with insurance enrollment
dimensions of the Triple Aim.
                                                                and retention

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Community Health Workers and the Triple Aim | March 2015

    •   Improve patient satisfaction through             How Are Community Health Workers
        better understanding of and help with            Trained and Credentialed?
        addressing their social needs
4. Reduce health disparities                             Massachusetts is a leader in advancing the skills
                                                         and recognition of the CHW workforce.
    •   Reduce health disparities and related
        costs by strengthening communication             hh Well-established CHW training centers exist
        with underserved patient populations and            in four regions of the state and there is an
        by diversifying the healthcare workforce            emerging center in a fifth region.

The value of CHWs in transforming health care            hh A Board of Certification of Community Health
was acknowledged in Massachusetts’ healthcare               Workers at the Massachusetts Department
reform laws in 2006 and in 2012, as well as in              of Public Health (DPH) will begin approving
the national Patient Protection and Affordable              training centers and certifying CHWs in 2015.
Care Act (ACA) of 2010. The Institute of Medicine’s      hh The Board, appointed by the Governor,
(IOM) report on health disparities recommends               developed ten detailed core competencies
integrating CHWs into multidisciplinary care                which define the field. The core competencies
teams as “a strategy for improving care delivery,           and other information related to certification
implementing secondary prevention strategies,               can be found at:
and enhancing risk reduction.”2                             http://www.mass.gov/eohhs/gov/
                                                            departments/dph/programs/hcq/dhpl/
Who Are Community Health Workers and                        community-health-workers/
What Do They Do?
                                                         How can CHWs help reduce health
Community health workers are trained frontline           disparities and related costs?
staff who bridge the communication and cultural
gaps common between low-income, underserved,             Health disparities in the United States represent
often high-cost patients and clinical staff. They        significant human and social costs for the
also help to address the social, non-clinical            communities that suffer from poor access to
challenges affecting patients’ health and care.          health care and from a lack of services delivered
hh CHWs are hired primarily for their special            by those who literally and figuratively “speak
    understanding of and ability to relate to the        their language.” There is also a high financial
    populations and communities they serve,              cost to healthcare systems as a result of such
    through shared socio-economic and cultural           disparities in access and care.
    backgrounds and experiences.3
hh CHWs establish peer relationships with                hh A disproportionate number of people with
   patients that encourage trust and openness.              poorly controlled chronic conditions, such as
                                                            diabetes, hypertension, and asthma, are
hh CHWs are trained to help patients deal                   low-income ethnic or racial minorities.4
   with social, economic, and other barriers to
   accessing and benefiting from services.               hh A high proportion of those who do not receive
                                                            timely preventive screenings and treatment for
hh CHWs provide services through outreach,                  cancer are also from these communities.5
   education, advocacy, and social support. Their
   services increase access to preventive care           hh CHWs play a key role in reaching
   by connecting people to medical homes and                the vulnerable and underserved. In
   teaching them how to prevent, reduce risks for,          Massachusetts over half of CHWs are
   and manage chronic diseases. CHWs support                themselves ethnic or racial minorities (23.7%
   patients to make healthier lifestyle choices,            African American, 20.6% Hispanic, 4.9% Asian
   help patients access needed community                    or Pacific Islander, 0.2% Native American 1.4%
   services, keep medical appointments, and                 one or more races). Fifty-eight percent are bi-
   increase adherence to treatment plans.                   lingual or multi-lingual.6

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Community Health Workers and the Triple Aim | March 2015

The Evidence                                              hh CHW roles: Home visits to assess needs,
                                                             appointment support and reminders, health
I. CHWs REDUCE COSTS                                         literacy education, advocacy, and assistance
                                                             to find medical homes, as well as to use
Evidence demonstrates that CHW interventions                 primary care and other services.
targeting patients with high resource utilization         hh Cost analysis: Authors calculated a net
result in savings to the medical system. In                  cost savings for the MCO of $1,522,722
2013, the Institute for Clinical and Economic                as a result of the CHW program: 1) The
Review (ICER) prepared a report for the New                  cost of the program for 25 months for 448
England Comparative Effectiveness Advisory                   patients was $521,343 (salaries, benefits for
Council (CEPAC) summarizing results of the best              management employees plus a per-member
quality studies, primarily randomized controlled             per-month payment to providers for services
trials, of interventions that include CHWs.7 The             of six CHWs); 2) Total cost reduction for all
majority of the fourteen cost studies reviewed               patients receiving CHW services (comparing
showed a net cost savings (i.e., “cost offsets from          Medicaid claims pre- to post-intervention) was
reduced healthcare utilization were greater than             $2,044,065. The utilization rates and costs for
the marginal costs of the intervention”) over six            the comparison group of an equal number of
months to two years follow-up. Most economic                 high-risk, high-cost patients also dropped but
analyses took the perspective of a Patient                   to a significantly lesser degree.
Centered Medical Home (PCMH) provider who
would be responsible for expenditures for services        hh Source of program funding: Private
and for financial risks incurred.8                           foundations supported the research and
hh Cost reductions were generally due to a                   startup phase until contract revenues
     reduction in urgent care use, including                 with Molina Healthcare began to pay for
     hospitalization.                                        the program. As a result of cost savings,
                                                             improved health outcomes, and positive
hh Leaders at most of the 32 Massachusetts                   member feedback, Molina Healthcare
   community health centers employing CHWs                   expanded the program statewide and to all
   that responded to a 2014 survey indicated                 of the 11 states in which they operate. Other
   that CHWs’ greatest value is in supporting                MCOs in New Mexico also adopted the model.
   high-risk, high-cost patients.9
                                                          The Community Preventive Services Task Force,
EXAMPLE 1: Molina Healthcare, Inc.                        an independent panel of public health and
Multi-state managed care organization (MCO)               prevention experts appointed by the head of the
providing CHW outreach, education, advocacy,              Centers for Disease Control and Prevention (CDC),
and referral services for high-risk patients. Study       recommends “the use of home-based multi-
services were offered in New Mexico.                      trigger, multi-component interventions with an
                                                          environmental focus for children and adolescents
hh Results: ED use, hospitalization, use of               with asthma, based on strong evidence of
   narcotic and other prescriptions showed a              effectiveness in improving overall quality of life
   statistically significant decline among 448            and productivity.” The Task Force economic review
   “high-risk” (those with three or more ED visits        of studies of such interventions also found they
   in three months, with chronic conditions and/          represent good value for the money invested,
   or substance abuse) Medicaid managed care              in part based on savings from averted costs of
   members receiving CHW services compared to             asthma care.11
   a matched comparison group of members.10
                                                          A number of strong studies have demonstrated
hh Healthcare setting: Six CHWs were located in
                                                          improved health and cost outcomes as a result of
   three healthcare sites, including one Federally
                                                          home-based pediatric asthma programs employing
   Qualified Health Center (FQHC), and overseen
                                                          trained CHWs as home visitors, including one by
   by a nurse and a care coordinator at the MCO.
                                                          the Asthma Program at the Massachusetts DPH.12

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Community Health Workers and the Triple Aim | March 2015

One systematic review of seven such programs                 of 102 patients enrolled in the program in
studied in randomized controlled trials found                the calendar year 2006, after controlling for
consistent decreases in asthma symptoms,                     changes in a comparable population without
daytime activity limitations, and emergency and              the intervention.15 The comparison group was
urgent care use.13                                           selected using similar criteria to those used
                                                             in the intervention sample and consisted
EXAMPLE 2: Boston Children’s Hospital Pediatric              of children with asthma from a neighboring
Asthma Community-Based Case Management                       community. There was a significant reduction
Program                                                      in hospital costs compared to those in the
Private urban hospital enhanced asthma case                  comparison hospital. The program cost
management with nurse-supervised CHW home                    of $254,871 was offset by an estimated
visits for low-income patients, primarily African            $349,790 in savings from decreased ED visits
American and Latino children on Medicaid.                    and admissions. The adj. ROI, calculated by
Children were selected for the enhanced care                 subtracting comparison from intervention
program based on recent hospitalization, one or              group costs, was 1.33.
more ED visits, or courses of oral steroids. The         hh Source of program funding: Currently the
program was initially piloted and evaluated in              program is funded by government grants,
four Boston ZIP codes (intervention group). Cost            the hospital’s Office of Community Health
analyses compared asthma hospitalization and                (community benefits) and private donations.
ED visit costs for children from the intervention with      Results were so impressive that they led
children from four demographically similar Boston           Massachusetts legislature to establish a
ZIP codes (comparison group).                               MassHealth bundled payment pilot for high-
                                                            risk pediatric asthma patients. This pilot is
hh Results: Two hundred and eighty-three children           set to begin in 2015 at several Massachusetts
   were served in the initial study. After twelve           pediatric medical homes, including Boston
   months there was a significant decrease in               Children’s Hospital, which will receive a per-
   asthma ED visits (68%) and hospitalizations              member-per-month rate to implement an
   (84.8%), and significant decreases in activity           enhanced pediatric asthma intervention that
   limitations, missed school days, and parental            includes CHW home visits.
   missed work time.14
hh Healthcare setting: Private urban hospital,           II. CHWs IMPROVE HEALTH
   with nurse case manager supervising CHW
   home visitors who were contracted through a           The CDC has highlighted the effectiveness of CHWs
   community-based organization in one of the            in improving chronic disease health outcomes, and
   targeted ZIP codes. The program has since             has therefore promoted their integration into care
   been institutionalized, with CHWs located             teams.16 The IOM17 and the American Association
   at the hospital as employees, for closer              of Diabetes Educators18 have also recommended
   supervision, coordination, and communication.         engagement of CHWs as part of multidisciplinary
hh CHW roles: CHW home visits provided asthma            teams. By helping patients remove barriers to
   education, assessment and coaching around             screening, treatment, care, and self-management
   medication adherence and environmental                CHWs have been found to cost-effectively prevent
   triggers, trigger mitigation resources (e.g.,         and manage chronic conditions such as diabetes,
   mattress encasements, low-emission                    asthma, hypertension, and cardiovascular disease.
   vacuums), and referrals to community
   resources. Supervising nurses coordinated             Leadership at 32 community health centers in
   care with primary care, specialty, and                Massachusetts responding to a recent survey noted
   community services.                                   that promotion of chronic disease self-management
                                                         is among the most common and important roles
hh Cost analysis: A subsequent cost‑benefit              that CHWs play in their organizations.19
   analysis was used to determine an adjusted
   return on investment (adj. ROI) for a subset

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Community Health Workers and the Triple Aim | March 2015

“Why is a nurse/CHW team so effective? One               hh CHW roles: CHWs reinforced NP instructions on
of our physicians told me there is a gap in care            lifestyle changes and medications and helped
many providers may not be aware of. They develop            patients design strategies for adherence and
a great plan that the patient is often not able to          behavior change.
follow through on. The CHW builds trust, helps the
                                                         hh Cost analysis: The study calculated
patient understand that plan, and links them to the
                                                            incremental cost effectiveness ratios: $157
resources they need—but they also help patients
                                                            for every one percent drop in systolic BP, and
feel more confident in their ability so they can take
                                                            $190 for every one percent drop in diastolic
care of themselves and do the self-management
                                                            BP; $149 per one percent drop In HbA1c, and
they need to do.”
                                                            $40 per one percent drop in LDL-C.
        Mark Lubberts, M.S.N, R.N.                       hh Source of program funding: Intervention
        Director of Community Health Education,             research was funded by the National Heart,
        Spectrum Health, Grand Rapids, MI                   Lung, and Blood Institute.
                                                         III. CHWs IMPROVE QUALITY OF CARE
CHWs Chronic Disease Care and Self-
Management                                               The Massachusetts Health Policy Commission’s
                                                         standards for PCMH certification emphasize the
Six of the eight rigorous quality studies reviewed
                                                         centrality of care coordination and integrated care
by CEPAC that looked at CHWs’ impact on diabetes
                                                         management. Quality measures include proactive
management revealed significant positive changes
                                                         management of preventive and chronic disease
in such measures as HbA1c and improved self-
                                                         care and support for self-care. High quality
reported dietary changes. Glycemic control, as
                                                         patient-centered care includes:
measured by HbA1c testing, is a performance
measure commonly used by healthcare providers
                                                         1. Open communication between patients and
and health plans. CHWs’ roles included education
                                                            providers
and support through home visits and/or group
sessions.20 Other research cited by the CDC              2. Culturally competent services
demonstrated the value of CHWs’ ability to improve       3. Support for chronic disease self-management
risk behaviors and health status measures related
to cardiovascular disease.                               4. High levels of patient satisfaction with care and
                                                            services
EXAMPLE: Nurse Practitioner (NP) and CHW                 CHWs are selected for their strength in these
Teams Working with High-Risk Patients                    areas and are trained in core competencies and
Two health centers in Baltimore Medical Systems          roles which enhance these abilities. As a result
had NP/CHW teams manage high risk patients               they have been shown to improve numerous
with cardiovascular disease, type 2 diabetes,            measures which are required of PCMHs, and in
hypercholesterolemia, or hypertension and levels of      MassHealth programs such as the Primary Care
low-density lipoprotein cholesterol, blood pressure,     Payment Reform Initiative (PCPRI). Such measures
or HbA1c that exceeded goals established by              are similar to or the same as NCQA-promoted
national guidelines.21                                   measures, including HEDIS and other performance
                                                         improvement measures used by most health
hh Results: After one year, compared with
                                                         plans and many providers. Under global and other
   enhanced usual care control patients,
                                                         alternative payment systems such performance
   patients in the NP/CHW group had statistically
                                                         measures will affect financial payments from health
   significant greater 12-month improvement in
                                                         payers to provider systems.
   total cholesterol, LDL cholesterol, triglycerides,
   systolic blood pressure, diastolic blood              In each of the examples from healthcare provider
   pressure, HbA1c, and perceptions of the               organizations below, the improvements in health
   quality of their chronic illness care. All of these   status and/or utilization represent measures by
   constitute NCQA/HEDIS measures of improved            which the quality of healthcare providers and
   quality of care.                                      health plans are increasingly judged.

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Community Health Workers and the Triple Aim | March 2015

CHWs Increase the Capacity of Primary                       “The physician’s patient volume will be enhanced
Care Teams to Provide Quality Care                          and can grow. The population we deal with has
                                                            lifestyle issues, challenges, socio-economic
CHWs help to expand the number of patients that             challenges, family pressures—someone has to
clinical staff can care for effectively, through their      be able to keep them focused on the piece their
role in education, care coordination, and engaging          provider is focused on. The work the community
patients in their care. Their contribution to care          health workers do can’t be left until the next time
teams allows clinicians to work “at the top of their        the doctor sees the patient. CHWs are extending,
license” by providing educational and supportive            enhancing the reach that providers have—and as
services that otherwise fall to physicians or nurses,       a result we are taking care of more people more
or go unattended.                                           effectively.”
                                                                     Jay Breines, CEO, Holyoke Health Center
    Selected Models for Integrating CHWs into
                                                                     Holyoke, Massachusetts
                Healthcare Teams
 There are multiple ways to include CHWs in
 healthcare teams. Here are three common                    CHWs Contribute to NCQA/HEDIS Quality
 models. Two are described in examples provided             Improvement Measures for Screenings and
 in this document.                                          Chronic Disease Care

 1. CHW services, independent or paired                     hh Multiple prospective controlled studies
    with those of a nurse, are contracted by                   involving CHWs resulted in statistically
    the primary care entity from a separate                    significant increases in breast cancer
    organization. Supervision is provided by                   screenings.23
    the contracting care entity and usually                 hh One study, led by an urban teaching hospital
    additionally at the organization where they                collaborating with six primary care practices
    are based;                                                 owned by the hospital, showed:
 2. CHWs are supervised at and conduct                           •   CHWs assigned to practices reached out
    some activities in healthcare settings but                       to patients by phone, mail, or home visits;
    spend much of their time with patients in                        provided support and education; met
    community settings; or                                           women at practices or imaging centers;
 3. CHWs are staff at the healthcare facility,                       and assessed needs and helped with
    where they are supervised, and their                             barriers including Medicaid coverage,
    services are provided primarily at that facility.                financial assistance, and transportation.
                                                                 •   Those receiving CHW services were
                                                                     nearly three times as likely to receive
EXAMPLE: CHWs in Care Teams and Community                            mammograms.24
Settings Working with Diabetes Patients
                                                            hh Six quality studies showed significant positive
Holyoke Health Center in Massachusetts integrated
                                                               effects of CHW interventions on rates of
CHWs into primary care teams through nurse
                                                               cervical cancer screening.25
supervision and team meetings.22
                                                            hh The Edward M. Kennedy (EMK) Community
hh CHWs reduced the percentage of diabetes                     Health Center in Worcester, MA, engaged
   patients not seen for a year from almost thirty             CHWs, resulting in a significant increase in the
   percent to six percent.                                     percentage of women who are up-to-date in
                                                               their Pap smears.26
hh After 20.6 months’ participation, patients saw
   clinically significant drops in HbA1C levels.            hh CHWs significantly improved immunization
                                                               status among Dominican children in New
                                                               York City (75% up-to-date) compared to the
                                                               usual care controls (50%). The CHWs provided
                                                               education, support, and home visits.27

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Community Health Workers and the Triple Aim | March 2015

hh In the EMK Community Health Center in               hh Results: The CHW patients were significantly
   Worcester, CHWs targeted children from                 more likely to obtain timely post-hospital
   families who arrived in the U.S. as refugees           primary care; report high quality discharge
   (primarily from Iraq, Bhutan, and Burma),              communication; and to show greater
   who had significantly lower rates of up-to-            improvements in mental health and patient
   date well-child visits compared to other               activation. Similar proportions of patients in
   children. This resulted in an increase in well-        both study arms received at least one
   child visits of 22 percent for children from           30-day readmission, but CHW patients
   Bhutan and Burma, and 20 percent for Iraqi             were less likely to receive multiple 30-day
   children, eliminating the marked disparities in        readmissions. Among the 63 readmitted
   comparison to other children.28                        patients, recurrent readmissions were reduced
                                                          from 40 percent to 15.2 percent among the
“Our program was focused on diabetic care--we             patients served by CHWs.
saw CHWs really help us with patient engagement-       hh CHW Roles: Worked with patients in hospital
-reduction in glucose levels, lowered HbA1c... I did      to prepare action plans for patients’ stated
not expect to see any impact in the three months          goals for recovery. CHWs provided support for
of the pilot, and we saw tremendous impact with           patients via telephone, text messages, or visits
this care model. Unbelievable! Because these were         for a minimum of two weeks. CHWs served as
patients who physicians have never been able to           liaison with patients, hospital clinical providers,
help to control their diabetes. Now we have the           and in some cases with primary care providers.
tools. The community health worker.”                      They were supervised by a masters-level social
                                                          worker in the hospital.
               Dr. Robert McGowen
               Regional Director of Primary Care       hh Source of program funding: The study
               Southcoast Healthcare System, MA           was funded by a variety of University of
                                                          Pennsylvania health improvement, Department
Community Health Workers Can Help to                      of Medicine and other private grants.
Reduce Hospital Readmissions
                                                       Conclusion
Avoiding hospital readmissions is one reflection of
successful care coordination within a healthcare       This document highlights numerous ways
system. Many see readmission rates as evidence         healthcare providers and payer organizations can
of gaps in discharge planning and in linkages to       benefit from integrating CHWs into their teams to
follow-up care. Medicare has begun to reduce           improve quality and outcomes while reducing costs.
payments for some types of readmissions,               Guidance exists to effectively make this transition.
which can expose hospitals and Accountable             If you are interested in integrating CHWs into your
Care Organizations to financial penalties if their     practice(s), the Resources section of this document
readmission rates are judged to be too high.29         provides information for three types of resources to
MassHealth also applies a reduction to inpatient       guide you in taking the next step. These resources
payment rates for hospitals with Potentially           are:
Preventable Readmissions that are higher than
expected.                                              1. Published CHW program best practice reports;
EXAMPLE: CHWs and Posthospital Transitions             2. Examples and contact information of healthcare
At two academically-affiliated hospitals in               organizations that have undertaken successful
Philadelphia, a randomized controlled trial               pilot programs, with cost savings or ROI
employed two CHWs to work closely with the                calculations; and
hospital-based care team to improve the care           3. List of experts who can offer information and
transition on release of high-risk Medicaid patients      assistance.
with multiple conditions.30

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Community Health Workers and the Triple Aim | March 2015

In addition, the Massachusetts DPH will provide        The experience of a large managed care company
a “how to” toolkit and technical assistance to         such as Molina Healthcare, Inc., cited above, is
primary care practices interested in integrating       illustrative. Molina Healthcare implemented this
CHWs into teams.                                       program with some initial grant funding, but largely
                                                       with their own funds, in response to underuse of
Healthcare provider organizations not yet ready to     primary care by members who instead repeatedly
hire or contract with CHWs due to the challenges       sought care for non-urgent, non-emergency
of covering them in a fee-for-service payment          conditions in hospital EDs. The program led to
environment can prepare for opportunities in           significant net cost savings and increased patient
global and other alternative payment systems. A        satisfaction. As a result, the plan institutionalized
recent Center for Medicare and Medicaid (CMS)          and expanded the CHW service model.
ruling (Jan. 2014) states that non-licensed health
providers (such as CHWs) can be reimbursed for         The Massachusetts DPH believes that integrating
preventive services which are recommended by a         CHWs into primary care and other multidisciplinary
licensed clinician.                                    teams will improve health outcomes and
Decisions about implementing changes made              reduce unnecessary and costly health care use.
possible by this ruling depend on state Medicaid       Community health workers also play an important
offices through their state plan amendment             role in reducing disparities in health care and in
process. This ruling is another indicator of how       health status, a goal which is an additional aim
opportunities for transforming practices are           of health reform, closely related to the Triple Aim.
increasingly facilitated by changes in payment rules   To that end, DPH is committed to supporting the
and systems.                                           widespread incorporation of this workforce into
                                                       health care.
Healthcare organizations are taking a range of
approaches to assess the financial viability of
integrating CHWs into innovative team practices.       Acknowledgments: This document was funded by
The following include strategies utilized by           the Massachusetts Department of Public Health
providers whose successes have been cited as           produced by consultants and staff at John Snow,
examples in this document. These offer additional      Inc. (JSI), in collaboration through a contract
ideas for next steps.                                  from the DPH Office of Integrated Policy, Planning
                                                       and Management and Office of Community
1. Review the health data for your membership or       Health Workers, in the Division of Prevention and
   patient populations to look for patterns of poor    Wellness. Terry Mason, PhD, consultant led the
   health or common conditions that can lead to        research and writing of the paper, with assistance
   costly ER use and/or hospitalization.               from Terry Greene and Kiely Houston of JSI in
                                                       design and editing. The Community and Healthcare
2. Review your data on preventable
                                                       Linkages Community of Practice and the Clinical
   hospitalizations, including readmissions,
                                                       Community of Practice provided suggestions and
   to assess where care utilization can be
                                                       feedback on this document. These Communities of
   improved;
                                                       Practice are part of the Massachusetts Partnership
3. Target a patient population for whom extra          for Health Promotion and Chronic Disease
   support for improving chronic conditions and/       Prevention.
   or care utilization seems warranted and plan a
   program or a pilot to track effects of a CHW        This document was supported by Grant Award
   addition to the care team on costs and quality      #5U58DP004813, funded by the Centers for
   indicators;                                         Disease Control and Prevention. Its contents are
4. Funding can be acquired through public or           solely the responsibility of the authors and do
   private grants, in combination with your health     not necessarily represent the official views of the
   system’s practice transformation funds, or,         Centers for Disease Control and Prevention or the
   when appropriate and in collaboration with          Department of Health and Human Services.
   community partners, using your system’s
   Community Benefits resources.

                                                   Page 8
Community Health Workers and the Triple Aim | March 2015

Resources
1. Published reports                                      2. Health systems with cost study experience
hh The Institute for Clinical and Economic Review              Molina Healthcare, Inc. Dodie Grovet, LISW,
   (ICER) offers Action Guides prepared by leading             Clinical Programs Training Manager
   policy experts to help provider organizations,              Dodie.Grovet@MolinaHealthCare.com
   payers, and policy makers interpret existing                Spectrum Health, Mark Lubberts MSN, BSN,
   evidence and apply recommendations for                      RN, Director of Community Health Education
   integrating CHWs into healthcare systems:                   Mark.Lubberts@spectrumhealth.org
   •   New England Comparative Effectiveness              3. Expert consultants
       Action Guide for Community Health                  hh Dr. Heidi Behforouz, Associate Professor at
       Workers (CHWs): Guidance for                          Harvard Medical School; Attending Physician
       Organizations Working with CHWs.                      at Brigham and Women’s Hospital Division of
       September, 2013. http://cepac.icer-review.            Global Health Equity
       org/wp-content/uploads/2011/04/Action-                hbehforouz@pchi.partners.org
       Guide-for-Employers_09_05_13.pdf
   •   New England Comparative Effectiveness              hh Project on CHW Policy & Practice, University
       Action Guide for Community Health                     of Texas Institute for Health Policy, Héctor
       Workers (CHWs): Guidance for Health                   Balcázar, PhD
       Insurers. September, 2013. http://                    Hector.G.Balcazar@uth.tmc.edu
       cepac.icer-review.org/wp-content/
       uploads/2011/04/Action-Guide-for-Health-           hh The Penn Center for Community Health
       Insurers_09-05-131.pdf                                Workers is also a source of consultation.
                                                             Consultation link:
hh Sinai Urban Health Institute. Best Practice               http://chw.upenn.edu/consultation
   Guidelines for Implementing and Evaluating
   Community Health Worker Programs in Health             hh Massachusetts Department of Public Health,
   Care Settings. January 2014. Sinai Health                 Office of Community Health Workers.
   System: Chicago Illinois.                                 http://www.mass.gov/dph/
   http://www.suhichicago.org/files/chw%20                   communityhealthworkers
   bpg_full_final.pdf
                                                               For technical assistance on CHW integration:
hh Penn Center for Community Health Workers                    Jessica Aguilera-Steinert
   http://chw.upenn.edu/tools                                  jessica.aguilera-steinert@state.ma.us

   •   Intervention Toolkit, guidelines for hiring,            All other inquiries: Gail Hirsch, Director, Office
       training course and manuals for CHWs,                   of Community Health Workers,
       managers, and directors                                 gail.hirsch@state.ma.us
   •   Online platform, CHW training videos,
       applicant screening tools and a cloud-
       based workflow management system

hh National Center for Chronic Disease and
   Health Promotion, Addressing Chronic Disease
   through Community Health Workers: A Policy
   and Systems Level Approach. A Policy Brief on
   Community Health Workers. Centers for Disease
   Control and Prevention: Atlanta, Georgia.
   http://www.cdc.gov/dhdsp/docs/chw_brief.pdf

                                                      Page 9
Community Health Workers and the Triple Aim | March 2015

Notes
1   HEDIS refers to the Healthcare Effectiveness       7     Institute for Clinical and Economic Review.
    Data and Information Set. HEDIS data are used            Community Health Workers: A Review of
    by the vast majority of health plans to measure          Program Evolution, Evidence of Effectiveness
    performance on important dimensions of                   and Value, and Status of Workforce
    care and service. They are also used by many             Development in New England. The New
    healthcare providers. http://www.ncqa.org/               England Comparative Effectiveness Advisory
    HEDISQualityMeasurement/WhatisHEDIS.aspx                 Council. Boston, Massachusetts: July, 2013.

    The National Committee for Quality Assurance       8     ICER CEPAC Report, p.24.
    (NCQA) is a non-profit organization widely         9     Auerbach, J and L Desrochers, Community
    influential in measuring and improving health            Health Workers in a Post-Health Care Reform
    care quality. NCQA promotes HEDIS and other              Era: The Current Practice in MA Community
    standards for use in accrediting, ranking and            Health Centers. Presentation at Unity
    monitoring quality of services in health care.           Conference 2014. May, 2014. Baltimore,
    NCQA standards are used to accredit patient-             Maryland.
    centered medical homes (PCMH). Other
    common measures include those devised by           10 Johnson D et al. Community health workers and
    Centers for Medicare and Medicaid Services               Medicaid Managed Care in New Mexico.
    (CMS), and the Agency for Healthcare Research            J Community Health. 2011;37:563-575.
    and Quality (AHRQ).                                11 The Guide to Community Preventive Services:
2   Institute of Medicine. Unequal Treatment:                The Community Guide. Asthma Control:
    Confronting Racial and Ethnic Disparities in             Home-Based Multi-Trigger, Multicomponent
    Health Care. Washington, DC: The National                Environmental Interventions Task Force
    Academies Press, 2003.                                   Finding and Rationale Statement Interventions
                                                             for Children and Adolescents with Asthma.
3   Anthony S, Gowler R, Hirsch G, Wilkinson G, eds.         Available at http://www.thecommunityguide.
    Community Health Workers in Massachusetts:               org/asthma/multicomponent.html
    Improving Health Care and Public Health.
    Boston: Massachusetts Departmentof Public          12 Smith LA, Sandel MT, Sadof M, Zotter JM.
    Health; 2009. p. 15. Available at: http://www.           National Institutes of Health. Reducing Ethnic/
    mass.gov/eohhs/docs/dph/com-health/com-                  Racial Asthma Disparities in Youth (READY)
    health-workers/legislature-report.pdf                    Study – Final Report. Unpublished final grant
                                                             report, Massachusetts Department of Public
4   Massachusetts Department of Public Health;               Health, 2012.
    Bureau of Health Statistics, Research,
    and Evaluation; Division of Research               13 Postma J, Karr C, Kieckhefer, G. Community
    and Epidemiology. Racial and Ethnic                      health workers and environmental interventions
    Health Disparities by EOHHS Regions in                   for children with asthma: a systematic review.
    Massachusetts, 2007. Available at: http://               Journal of Asthma. September, 2009; 26 (6):
    www.mass.gov/eohhs/docs/dph/ research-epi/               564-576.
    disparity-report.pdf                               14 Woods et al. Community asthma initiative:
5   MDPH, Racial and Ethnic Health Disparities by            evaluation of a quality improvement program for
    EOHHS Regions in Massachusetts, 2007.                    comprehensive asthma care. Pediatrics. 2012
                                                             March. 129(3): 465-472.
6   Ballester, G. Community Health Workers:
    Essential to Improving Health in Massachusetts,    15 Bhaumik U et al. A cost analysis for a
    Findings from the Massachusetts Community                community-based case management
    Health Worker Survey. Boston (MA):                       intervention program for pediatric asthma.
    Massachusetts Department of Public Health.               Journal of Asthma. 2013. 50 (3):310-317.
    March, 2005.

                                                   Page 10
Community Health Workers and the Triple Aim | March 2015

16 National Center for Chronic Disease Prevention       27 Barnes K et al. Impact of community volunteers
   and Health Promotion. Addressing Chronic                  on immunization rates of children younger than
   Disease through Community Health Workers:                 2 years. Arc Pediatri Adolesc Med.1999:153
   A Policy and Systems-Level Approach. A Policy             (5):518-524.
   Brief on Community Health Workers. Centers for
                                                        28 Personal communication Leah Gallivan, COO
   Disease Control and Prevention. Atlanta, GA.
                                                             EMK Community Health Center.
17 Institute of Medicine, Unequal Treatment, 2003,
                                                        29 CMS.gov.Centers for Medicare and Medicaid
   pp 17-18.
                                                             Services. Readmissions Reduction Program.
18 American Association of Diabetes Educators.               Available at: http://www.cms.gov/Medicare/
   Position statement: diabetes community health             Medicare-Fee-for-Service-Payment/
   workers. Diabetes Educ 2003; 29: 818–824.                 AcuteInpatientPPS/Readmissions-Reduction-
                                                             Program.html
19 Auerbach and Desrochers. Community Health
   Workers in a Post-Health Care Reform Era. May,       30 Kangovi S et al. Patient-centered community
   2014.                                                     health worker intervention to improve
                                                             posthospital outcomes: a randomized clinical
20 ICER CEPAC report p.15.
                                                             trial. JAMA Intern Med 2014;174(4):535-543.
21 Allen J et al. Cost-effectiveness of nurse
   practitioner/ community health worker
   care to reduce cardiovascular health
   disparities. Journal of Cardiovascular Nursing.
   2013:00(0):00.
   Allen JK, Dennison-Himmelfarb CR, Szanton SL,
   et al. Community Outreach and Cardiovascular
   Health (COACH) Trial: a randomized, controlled
   trial of nurse practitioner/community health
   worker cardiovascular disease risk reduction
   in urban community health centers. Circ
   Cardiovasc Qual Outcomes. 2011; 4 (6):595-
   602.
22 Liebman J, Heffernan D, Sarvela P. Establishing
   diabetes self-management in a community
   health center serving low-income Latinos. The
   Diabetes Educator. June, 2007;33 (Supplement
   6): 132s-138s
23 ICER CEPAC Report, p. 18.

24 Weber BE, Reilly BM. Enhancing mammography
   use in the inner city: randomized trial of
   intensive case management. Arch Intern Med,
   1997;157(20):2345-2349.
25 ICER CEPAC Report, p18.

26 Personal communication July 28, 2014, Leah
   Gallivan, Chief Operating Officer Edward M.
   Kennedy Community Health Center and internal
   Edward M. Kennedy Community Health Center
   quality improvement data.

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