North Philadelphia Safety Net Temple Health’s Approach to Population Health Presentation Goals

• North Philadelphia Demographics

• Delivery System Assessment and Need for Alliances

• Current Programs

• Community Health Worker Model

• Early Outcomes Temple Health

Key Facts: Organizations:

• Serves one of the nation’s • Temple University Hospital most economically • Jeanes Hospital challenged urban areas • Fox Chase Cancer Center • Highest volume of patients • Episcopal Hospital covered by Medicaid in • Temple Physicians Inc. Pennsylvania among full‐ • Temple University Physicians service hospitals • Major delivery sites are located in • Urban Renewal Area • Medically Underserved Area Population Health Management

• Goal is to improve health, reduce illness, and manage the use of health care resources

• Includes the full spectrum of activities from wellness, pp,revention, acute care, chronic care, and end of life decisions

• Each patient should have a single point of contact aadnd car e coord inat io n (C(PCMH ) Our Community

• Our primary population service area incldludes more than 750,000 residents • 62 % have < a high school education, compared to 44% nationally • 64 % have a household income of < $50,000 Health Burden

Most Prevalent Major Cause of Death Chronic Conditions – Trauma and Trauma Related – Heart Disease / Hypertension Conditions – Asthma / COPD – Cardiovascular Disease – Diabetes – Renal Disease – Renal Disease – Chroni c Dilialysi s – Obesity – Mental Health • didepression • psychotic disorders Social Issues – Medical Illiteracy Perinatal Issues – Overall Illiteracy – Late or no prenatal care – Substance Abuse – Pre‐pregnancy Obesity – Violence Elements of Our Plan to Improve PliPopulation HHlhealth • Primary Care – Patient Centered Medical Home – Electronic Medical Record • Care Management – Nurse Navigation – Disease Management – Community Health Workers • 24 / 7 Access Center – Appointment Scheduling • Urgent Care • Measurement of Clinical Outcomes, Quality and Utilization data – Individual and Population Based Current Programs

Partnership for Patients Self Funded Insurance Plan • Community‐based Care • Law Enforcement Benefit Transitions Administrators – PCA, Einstein, Temple – Asthma & Diabetes disease – Bridge Coach Model management program – All Diagnosis Medicare

CHF Navigation Program • Nurse Navigators North Philadelphia Opportunity

Potential Partners Aria Health Einstein Health Potential Partners Hahnemann University Hospital St. Christopher’s Hospital for Children North Philadelphia Health System Community Alignment

City Health Centers FQHCs Private Practices Temple Health Temple Health Acute Care Hospitals Temple Physicians Behavioral Health Urgent Care Centers Temple Health: Whom we serve Target Zip Codes: 19120,19121,19124,19125,19132,19133,19134,19140,19141,19144

SCHC

NPHS NPHS

HUH Sites of Care

Assisted Living Skilled Nursing Facility Nursing Home Home Care Hospice QQyuaternary Palliative Care LTACH Hospital Community Hospital Observation Emergency Department Urgent Care Center Walk in (Retail) Clinic Primary Care Office Health Care Professionals

Super Licensed Practical Nurse Specialist Nursing Assistant Primary Care Home Health Aid Physician

Nurse Practitioner Physician Assistant

Registered Nurse‐ Nurse Navigator

Educator/Nutritionist

Community Health Worker The Problem

• Ris ing hlhhealth care costs • Disproportionate resources used by a small percentage of patients

• Ineffective use of physician time Proposed Solutions

• Engage high users in preventive care

• Encourage the use of appropriate resources • Assist patients in removing barriers that cause missed appointments • Encourage patients to use the “right” resources, at the “right” time, all the time Community Health Worker (CHW)

Not a new concept Major Issues • No standardized name – Community health worker – Navigator – Lay health coach • No standardized curriculum • No standardized job descriptions • No standardized competencies • Minimal process and outcome data does not demonstrate ROI (HgB A1C, smoking cessation, cholesterol control, mammography, PAP smears, prostate exams, etc. ) Role of the CHW

• Enhance communication between the patient and the health care team • Encourage and promote positive behavior changes with the patient • Engage the patient in managing his own health care • Help the patient overcome barriers to meeting his healthcare needs Community Health Worker

The Community Health Worker (CHW), uses home visits, office visits, and phone contact to enhance communication between patients and the health care team. The goal is to improve patients’ participation in their own health care to ensure positive hhlthealth outcomes. IItnteracti on btbetween the CHW and the patient is designed to promote positive behavior changes, improve compliance, keep patients out of the ED and hospital. Minimum Criteria to Enter TlTemple CHW program • Commitment to 4 week full time training program • Minimum of high school diploma or GED • Demonstrated competencies in • math • reading • oral and written communication • computer skills • Desire to be a leader in the community Who becomes a CHW?

• Multiple backgrounds – High school graduate – College degree – Social work background – Other hhlthealth bbkackground • Medical assistant • Licensed practical nurse • Nurse aide • Registered nurse Training Partners

Each partner brought expertise to the training – Temple University Center for Social Policy and Community Development – District 1199C Training and Upgrading Fund – Camden AHEC – TlTemple HHlhealth System First Training • 350 candidates applied • 40 students entered the class • Training held summer 2012 • Four week full time curriculum • Homework assignments • Daily short quizzes • Writing samples • Final written exam • Final exam with simulated patients • 34 graduated • Temple University awarded certificate to graduates Community Health Workers Self Reported Annual Income Class of 2012

Mean: $13,300 Median: $9,000 Community Health Workers Length of Unemployment Class of 2012

Avg. length of unemployment= 16 mos. Community Health Workers Highest Level of Education Class of 2012

N = 34 6% 15% HS Diploma or GED Associate’s Degree

Bachelor’s Degree

Master’s Degree or Higher

47% 32% Core Competencies

• Communication skills • IlInterpersonal skills • Service coordination • Patient advocacy • HIPPA rules • Organizational skills • Remove barriers to care for patients • Transportation • Child care Funding of CHWs

Positions funded by – Medicaid managed care insurers

– Health systems

– Self insured entities Placement of CHWs • Primary care and pediatric practices – Temple – Jeanes – Hahnemann – AEMC – St. Christopher’s Hospital – Aria Health System • Specific disease management programs – CHF – Children with disabilities – Cancer programs • Hospital emerggyency departments On the Job Training

• How to hhdlandle viilolent patients

• Recognizing behavioral health issues

• Basics of diabetes education

• Options for career path training

• PACE program resources Impact of CHWs

• For ttehe Healt h System – Decrease the use of the ED for low acuity illnesses – Decrease rate of hospitalization for patients with chronic diseases – Connect patients with primary care practices

• For the Practice – Decrease no show rates – Reduce front desk overload – Increase physician productivity Impact of CHWs • For the Patient – Increase medication compliance – Provide a connection with the healthcare team – Improve health – Improve quality of life – Improve patient satisfaction – Connect to community resources • transportation assistance • meals on wheels • social welfare programs Case Study

• A CHW made a home visit to a female police officer on disability for severe back pain.

• While there, she discovered that the very obese husband, with CHF, had a broken CPAP machine held together with a rubber band.

• The husband had multiple visits to the ED, and was falling asleep during daylight hours.

• The CHW had the CPAP repaired and arranged for an appointment with a nutritionist/exercise aide.

• The hbdhusband is now under bbttetter contltrol and is sttiaying awake during the day. Preliminary Data

4 ED Visits Inpatient Visits CHW Intervention

3 s s 2 Visit

1

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2011 2012 2013 Mr. W is a 26 y/o, African‐American male, with a primary diagnosis of Congestive Heart Failure. The patient is morbidly obese, has had multiple ED visits and hospitalizations for CHF and has an ejection fraction of 10%.

Preliminary Data

4 ED Visits Inpatient Visits CHW Intervention

3 s t t 2 Visi

1

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2012 2013 Ms. T is a 64 y/o, African‐American female, with Heart Failure, COPD, Diabetes and Hypertension. The patient had multiple hospitalizations for uncontrolled hypertension, SOB and recurrent pneumonia. ** Patient called CHW with complaint of blood in stools. Patient sent to ED and hospitalized for 48 hours, no etiology found.

Preliminary Data 4 ED Visits Inpatient Visits CHW Intervention 3

2 its s s Vi

1

0 r r r r r r r r c c c v v v y y y y g g g n b n p n b n b n p n b n p ul ul ul ct ct ct a a a a a a a a p p p p p p p p e e e e e e a a a a a a a a o o o o o o u u u u u u a a a a a a aa e e e e ee ee ee e e e e u u u u u u J J J J J J J J J J O O O A A A A F S F F S F S D D D A A A N N N M M M M M M M M 2010 2011 2012 2013

Ms. J is a 57 y/o, African‐American female, with Congestive Heart Failure, Diabetes and Hypertension. Patient had frequent ED and inpatient hospitalizations for Hypertensive Heart Disease. The patient is morbidly obese. ** The patient developed edema due to fluid overload. She was directed to the ED, was given a diuretic, and sent home. Patient B.C. 4 ED Visits Inpatient Visits CHW Intervention 3

2 ss Visit

1 **

0 Jan Feb Mar AprMay Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar AprMay 2012 2013

Ms. B is a 51 y/o, African‐American female, with a primary diagnosis of Congestive Heart Failure. Patient also has Diabetes, Bipolar Disorder and Hy pertension. Patient has 2 previous hospitalizations and 2 ED visits over 2 months for fluid overload and CHF exacerbation. The patient’s heart ejection fraction is 20%. ** In Dec 2012, patient was homeless, ran out of food or opted for foods high in sodium, and entered the ED for diuresis. 30 Day Readmissions for CHF FY 13

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0% Baseline FY12 No interv ention CCPT CCTP & CHW “Super‐Utilizers”

• Using readmission data, TUH has identified 28 unique individuals who have been admitted a total of 351 times during fiscal year 2012

• Intervention includes Nurse Navigator and Community Health Worker

• Early results are promising High Risk Patients (7/12‐12/12)

32 30 No Show Outpt Visits 28

26 ED Visits 24 IP Admissions 22

20

18

16

14 stances nn I 12

10

8

6

4

2

0 abcdefghi j k lmnopqr s Patient Next Training Cohort

• CilCurriculum modifie d bbdased on lessons learned

• Seeking bilingual candidates

• Need to incorporate more experiential training Lessons Learned

• Ideal CHW candidate – Is ready to work – Naturally enjoys helping people – Does not go from training ppgrogram to training program • PtiPractices need to be ready to accept a CHW • On the job training is essential Long Term Goals of Training

• Offer 3 college credits at Temple University • Work with the Commonwealth to develop accreditation and certification program • Establish Temple as the training site for the tri‐state area • Export the program under the Temple banner to: – Other states – Create an online training ppgrogram • Create career track for MAs, HHAs, PAs, Military Veterans Research Goals

• Develop a robust data base • Collect and monitor process and outcome data • Monitor career advancement • Calculate return on investment • Collaborate with researchers: • Temple University School of Medicine • Fox Chase Cancer Center • Fox Business School