pathways to asthma: creating your community health worker...
TRANSCRIPT
Pathways to Asthma: Creating Your Community Health Worker (CHW) Lane
Megan Nieto, CHWCHW Solutions
10/19/2018
.
• Launched in 2016
• Based in St. Paul with a state-wide service area
• Dedicated to developing sustainable models for Community Health Worker (CHW) services
• Service buckets
• Direct CHW services
• Clinical oversight and claims submission
• Technical assistance and consulting
Ohio Pathways Model
• Helps eliminate health and social disparities by finding those at risk, connecting them to care, and measuring the outcomes
• Developed in 2001
• Patient-centered tool to identify and translate patient risks
• Addresses social determinates of health
• 20 Pathways
.• Adult Education
• Employment
• Health Insurance
• Housing
• Medical Home
• Medical Referral
• Medication Assessment
• Medication Management
• Smoking Cessation
• Social Service Referral
• Behavioral Referral
• Developmental Screening
• Developmental Referral
• Education
• Family Planning
• Immunization Screening
• Immunization Referral
• Lead Screening
• Pregnancy
• Postpartum
Patient
Housing
Medication Management
Education
Social Services
Medical Home
Health Insurance
The Role of the CHW
• Delivers services face-to-face with clients in a community setting, including the home
• Connects patients to community resources, social services, and health services
• Helps patients build self-management skills, understand diagnosis, treatment, medication, complications, risk factors, prevention
• Works collaboratively with primary care teams, social workers, care coordinators, and case managers in a variety of settings
Scenario #1
• 32 y/o female “Mary”
• Clinical Asthma diagnosis
• Facing eviction
• Recent layoff resulting in loss of insurance
• Hx of medication non-compliance
• No Asthma action plan (self-report)
• No high school diploma or GED
Identified Pathways
• Adult Education
• Education
• Employment
• Health Insurance
• Housing
• Medication Assessment
• Medication Management
• Medical Referral
• Social Service Referral
Facing Eviction
Recent job layoff resulting in loss of health insurance
History of medication non-compliance
No Asthma action plan (self report)
Recent job layoff
Recent job layoff
No high school diploma or GED
Clinical Asthma diagnosis
Adult Education Pathway
• GED Programs
Education Pathway
• Asthma education
• Education materials
• Videos
• Worksheets
• Talking points
• Cleaning demonstrations
• PCP messaging
• Best practices
Employment Pathway
• Connect Mary to employment resources
• Workforce Center
• Hennepin County Employment Counseling Services
• Online job search platforms
• Resume assistance
• Public libraries for WiFi and computer access
Health Insurance Pathway
• Connect Mary with a MNsure Navigator
Housing Pathway
• Connect Mary to housing resources
• If emergency housing is needed connect to shelter system for intake
Medication Assessment Pathway
• Record all medications patient is currently taking, including Rx from other providers
• Record what client says in her own words
• Send chart to Mary’s new PCP
.
.
.
.
Medication Management Pathway
• Mary has Rx from multiple providers
• Assist Mary in contacting all provider to obtain lists of medications
• Complete Medication Assessment Chart with Mary
• Fax to current (new) PCP
• Follow up with PCP and Mary
Medical Referral Pathway
• Mary mentioned that she does not have an Asthma Action Plan
• Assist Mary in scheduling an appointment with her PCP
Social Services Pathway
• Connect Mary to the County
• Cash Assistance
Scenario #2
• 10 y/o male “Joey”
• Clinical Asthma diagnosis
• Frequent ED visits
• No PCP
• Exacerbations at school
• Asks school nurse for extra food to take home
• Currently uninsured due to failure to send in updated household income
Identified Pathways
• Education
• Health Insurance
• Medical Home
• Social Services
Clinical Asthma diagnosis, Frequent ED visits, Exacerbations at School
Currently uninsured due to failure to send updated household income
No PCP
Asks school nurse for extra food to take home
Education Pathway
• Asthma education for kids
• Triggers
• Appropriate ED use
Health Insurance Pathway
• Connect Joey (and his parent) to a Navigator
Medical Home Pathway
• Help Joey and his family choose a clinic for Joey
• Use Motivational Interviewing to identify what is important to the family when choosing medical care
Social Service Pathway
• Joey has asked the school nurse for extra food to take home
Community Outreach
• Screening tools help CHWs identify clients in the community
• Standing Orders
• Can be used to begin services
• Best Practices
• Background on condition
• Education messages
• Resources
• References
• Documentation
.
.
Contact Information
Megan Curran de NietoCHW [email protected]
Megan EllingsonConsulting [email protected]
David RakEvaluation [email protected]
www.chwsolutions.com