what is health? a presentation on community health in broad terms and what it means for you as an...
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Who are you? Why are you here? What will you be doing with your Americorps year? (In one minute or less!) IntroductionsTRANSCRIPT
What is Health?a presentation on community health in broad terms and
what it means for you as an Americorps member… Given by
Sherri Ohly ~ [email protected]
Shari Galitzer ~ [email protected]
September 11, 2013Stevens Point Wisconsin
Asthma A day in the life
Who are you? Why are you here?
What will you be doing with your Americorps year?
(In one minute or less!)
Introductions
Video clip - http://www.whatispublichealth.org/what/index.html
Public Health vs Clinical Care
Public Health vs Clinical Care
Video clip - http://www.whatispublichealth.org/what/index.html
Public Health vs Clinical Care
The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world. ~ World Health Organization
Social Determinants of Health
How about this one….
Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Healthy People 2020 (Centers for Disease Control)
What?!?!?!?!?
Availability of resources to meet daily needs (e.g., safe housing and local food markets)
Access to educational, economic, and job opportunities
Access to health care services Exposure to crime, violence, and social
disorder (e.g., presence of trash and lack of cooperation in a community)
Transportation options
For example….
My favorite…..
Creating conditions for everyone, every day, everywhere to haveequal chances and
fullest choices to be healthy and thrive and
live well and long, from generation to generation.
~ Magda Peck
200 countries200 years
4 minutes
How does poverty effect health?
The Burden of Chronic Disease
1. Heart Disease2. Cancer3. Chronic Lung Disease4. Stroke (CVA) 5. Unintentional Injuries (Accidents) 6. Alzheimer’s Disease7. Diabetes Mellitus8. Influenza and Pneumonia9. Kidney Diseases (Nephritis) 10. Suicide
Leading Causes of Death, U.S. - 2008
1.Tobacco (435,000 deaths; 18.1% of total deaths)2. Poor diet and physical inactivity
(365,000 deaths; 15.2%) 3. Alcohol consumption (85,000 deaths; 3.5%)4. Microbial agents (75,000)5. Toxic agents (55,000)6. Motor vehicle crashes (43,000)7. Firearms (29,000)8. Sexual behaviors (20,000)9. Illicit use of drugs (17,000)
Actual Causes of Death in US
Actual causes of death in the United States, 2000.JAMA. 2005 Jan 19;293(3):293-4.
A look at how Diabetes impacts Wisconsin….
The fine art of navigation...
How do we make sense of all this?
A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.
American Public Health Association CHW Section, Policy Statement 2009-1, November 2009
Community Health Workers
Improving health outcomes and reducing acute care needs and avoidable hospitalizations in people with chronic diseases, including diabetes, asthma, hypertension, heart disease and cancer by improving knowledge, promoting early detection, increasing access to resources and encouraging self-management behaviors in their priority populations
Assisting people in accessing health care (especially primary care) and social services, embracing treatment strategies, and reducing risk by increasing healthy lifestyle behaviors
Conducting outreach to difficult-to-reach populations and in-reach to improve the appropriateness and quality of health care and social services systems
Helping community members recognize and address broader cultural, environmental, and lifestyle issues that impact their health through community organizing and capacity-building
Helping individuals, families and communities to build social capital and combat social isolation
What do CHWs do?
Bridging cultural mediation between communities and the health care system;
Providing culturally appropriate and accessible health education and information, often by using popular education methods;
Assuring that people get the services they need; Providing informal counseling and social support; Advocating for individuals and communities within
the health and social service systems; Providing direct services (such as basic first aid) and
administering health screening tests; and Building individual and community capacity.
7 Core Competencies for CHWs
How is your role like that of a CHW? How are you like a CHW? How are you
different? What other information would you find
helpful in order to carry out your job responsibilities?
Discussion
Know the resources Or know how to get the information you need Ask lots of questions Learn about chronic diseases, healthy
inequities, and evidenced based solutions If you are from the community you serve, or
not, always approach families and communities with cultural humility
How can you as an Americorp member impact chronic disease?
The distinctive features of the population to be served (age, race, ethnicity, physical challenges, lifestyle)
The distinctive features of the social and physical environment where the population lives(neighborhoods, housing arrangements, mobility issues)
The distinctive features of providing services to that population (Cannot generalize populations)
(Coward, DeWeaver, Schmidt, & Jackson, 1983).
Three Factors to Consider to Meet Service Needs
Illness may be punishment Death is not the end of life- blessing Spiritual healers( shaman, healers, elders,
faith leaders, prayer) Non-customary healing remedies (herbs,
liniments, oils, incense, coining,) Mistrust of Traditional Medicine/ Doctors
Some Cultural Beliefs about Illness and Healing
Elicit information about nontraditional customs or interventions in non-judgmental way: What do you call the problem? What are your fears about what might happen? What do you think caused the started or caused the
problem? Why do you think the problem started? What do you think is happening and why? What kind of treatment do you think should be given/
why?
Strategies to Address Cultural Differences
Health illiteracy Economical factors Under-insured/ uninsured Inadequate pool of providers Language barriers with providers Location/geographical Institutional biases / lack of inclusivity Insufficient awareness of available resources Prior negative experiences/ perceptions
Health Care Access Barriers
The Affordable Care Act and The Health Insurance Market Place
It’s a whole new world……
Shari Galitzer’s presentation on navigation HP Freemen style…..
So you have access to health care now what?
So, through the ACA, you have access to health care Insurance now
what?
Patient Navigation Moves to this:
You’ve heard to term – maybe? Health and Human Services (HHS) $67 million grant to fund
‘Navigators’ to serve as an in-person resource to assist in enrolling in plans in the Health Insurance Marketplace beginning this fall.
This is Financial Navigation – removing financial barriers In the news http://
online.wsj.com/article/SB10001424052748704487904576267503361027560.html?mod=wsj_share_linkedin
http://www.cnn.com/2013/04/06/health/patient-navigation-new-field/index.html
But what is it? A Care Coordination Approach that removes barriers so individuals
can access timely and appropriate care. It works in the white space, connecting people to health care providers and resources.
HP Freeman? In 1990 Dr. Harold P. Freeman founded and pioneered a program in
Harlem, using what he called Patient Navigation, to reduce disparities in access to diagnosis and treatment of cancer, particularly among poor and uninsured people.
Patient Navigation:
Report to the Nation on Cancer and the Poor
In 1989, the American Cancer Society, conducted a series of hearings throughout the country to hear the testimony of poor Americans who had been diagnosed with
cancer.
American Cancer Society Cancer in the Poor a Report to the Nation 1989
Report to the Nation on Cancer and the Poor, 1989
Findings: Poor people meet significant barriers when they
attempt to seek diagnosis and treatment of cancer. Poor people often do not even seek care if they cannot
pay for it. Poor people experience more pain, suffering, and death
because of late stage disease. Fatalism about cancer is prevalent among the poor and
prevents them from seeking care. Poor people and their families must make extraordinary
and personal sacrifices to obtain and pay for care. Current cancer education programs are culturally
insensitive and irrelevant to many poor people.
Health illiteracy Economical factors Under-insured/ uninsured Inadequate pool of providers Language barriers with providers Location/geographical Institutional biases / lack of inclusivity Insufficient awareness of available resources Prior negative experiences/ perceptions
Remember Sherri’s List Health Care Access Barriers
Freeman Institute Summary: Financial Communication Fear and Distrust Health Care System Barriers
PRINICIPAL BARRIERS TO HEALTH CARE
But it’s not a perfect market - economics perspective - the ‘gold standard’ for resource allocation: (Applying Economic Principles to Health Care R. Douglas Scott II, et al)
1) many buyers and sellers with no single economic agent influencing the exchange of goods among market participants; 2) a homogeneous or standardized product (i.e., goods that individual producers cannot alter or differentiate to collect a higher price); 3) no barriers to movement of firms into or out of the market; 4) perfect information about market conditions that is available to all market participants; and 5) a fully defined system of property rights in which ownership of allproducts and productive resources is assigned.
Specialization leading to fragmentation
Profit-driven
Barriers Inherent in Our Market-based Health Care System
Related to these findings the first “Patient Navigation” program was conceived and initiated in 1990 at Harlem Hospital Center.
The purpose - to reduce disparities in access to diagnosis and treatment of cancer, particularly among poor and uninsured people.
Supported by a grant from the American Cancer Society
Patient Navigation Arrives
The Principles of Patient Navigation HP Freeman Institute
1. Navigation is a patient-centric health care service delivery model.
2. Patient Navigation serves to virtually integrate a fragmented healthcare system for the individual patient.
3. The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.
4. Patient Navigation should be defined with a clear scope of practice that distinguishes the role and responsibilities of the navigator from that of other providers.
The Principles of Patient Navigation HP Freeman Institute
5. Delivery of patient navigation services should be cost-effective and commensurate to navigate an individual through a particular phase of the care continuum.
6. The determination of who should navigate should be determined by the level of skills required at a given phase of navigation.
The Principles of Patient Navigation HP Freeman Institute
Organizing and empowering the consumer/patient perspective
Providing a network for fragmented elements, allowing local focus and innovation, (analogous to the Internet)
Economics of improved health care, reflected by ACA meaningful use incentives.
Patient Navigation Aligns with Market-based Approach
DHS GUIDING PRINCIPLES - http://www.dhs.wisconsin.gov/aboutdhs/oos/fundamentals.htm:
We serve the citizens who have entrusted us with important responsibilities and funds they earned.
Our healthcare costs are not sustainable at current levels. We need new models for care delivery, regulation development, prevention strategies, risk sharing and purchasing.
In this transformation, we must enhance the role of our citizens as primary stakeholders in managing their health and associated costs.
Competition, choice, and transparency are critical elements to these emerging models if we are to increase the value of healthcare to our citizens.
Public programs shall complement rather than compete against the private market. We will work to eliminate cost shifting to the private sector and among different systems (acute, mental health, long-term care).
We will continue to provide support systems to help vulnerable people lead fulfilling, self-directed, healthy lives that promote independence, while recognizing the value of and utilizing supports from families and the community.
We will actively promote collaboration in pursuit of innovation, increased value and improved outcomes for the benefit of all our citizens.
We will align resources to achieve positive outcomes and hold ourselves accountable for achieving results.
Aligns with WI
Benefits of Patient NavigationResults from the Cleveland Clinic
Change in no-show rate: -3% on an average of 165 appointments per month
Change in completed appointments/month: +5 (165 x 3%)
Each individual appointment gain $1,409 in revenue after reimbursement
Change in revenue: $7,045/month ($1,40985) or $84,540/yr ($7,045812)
Patient Navigator cost per year is ~$35,000; part time navigator is $17,500. yearly net revenue gained per full time PN: ($84,540-$35,000) = $49,540
Part time Navigator return on investment happens in 2.5 months
Impact of Screening & Patient Navigation on Breast Cancer 5-year Survival Rates
Harlem Hospital Cancer Control Center (BECH)
Five
Yea
r Su
rviv
al R
ate
0% 10% 20% 30% 40% 50% 60% 70% 80%
39%
70%
After access to sceen-ing & patient naviga-ton (1995-2000)**Before access to screening & patient navigation (1964-1986)*
*Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. Cancer, 63(12), 2562-2569.
Oluwale/Freeman, Journal of American College of Surgeons, 2003
Panel Discussion Melissa Harris-Perry, Dr. Harold P. Freeman
http://video.msnbc.msn.com/mhp/51124049#51124049
Discussion and Stories
HP Freeman Framework
3 kinds of Navigation: Financial Clinical Community
Compare to Other Allied Health Professionals it’s a role, not a title; and it’s a perspective Social Workers, Case Managers, Health
Educators, Patient Advocates, Community Health Workers
Patient Navigation & Other Roles
Children’s Hospital Milwaukee – growing, currently approx. 8 community navigators Well Women Program Allied Wellnes Center – Madison Allied Drive neighborhood
http://www.alliedwellnesscenter.org/ South Madison Promise Zone Adams County Partnership Grant Aurora Health, Aurora Women’s Health Care UW Carbone Cancer Center – wip, for Commission on Cancer
Comprehensive Cancer Accredidation in 2015 requires a patient navigation program
American Cancer Society WI Pink Shawl Initiative, http://www.dreamthecure.org Healthy Hmong Women – addresses breast and cervical
cancer disparity issues affecting the Milwaukee Hmong
Patient Navigation Examples in Wisconsin
WI Health Exchange Navigator Grant Recipients – Financial Navigation
Partners for Community Development, Inc.Hispanic and Hmong and other hard-to-reach Door, Kewaunee, Manitowoc, Ozaukee, and Sheboygan Counties.
Northwest Wisconsin Concentrated Employment Program, Inc.21 Wisconsin Job Centers libraries, Senior Centers and college campuses.Legal Action of Wisconsin, Inc./SeniorLAWlocated in Milwaukee serving Southeastern Wisconsin. To individuals age 60 or over
National Council of Urban Indian HealthUrban Indian Health.
National Healthy Start Associationthrough the federal Healthy Start programs. uninsured population
R&B Receivables Management Corporation DBA R&B Solutionsconnect uninsured and underinsured individuals with coverage options to help them afford health care.
Children's Hospital and Health SystemCommunity Health NavigatorThe goal of the Community Health Navigator role is to improve health outcomes for persons within identified communities through linking identified community need with available resources. Navigators partner with Community Services leadership to facilitate integrated service delivery for residents of assigned community(ies). Navigators must have demonstrated good standing within their community and an interest in improving outcomes for their neighborhood(s). Demonstrates skills in creative problem-solving, and has in-depth knowledge of the assets and challenges of the community to be served. Has the ability to work with medical professionals to ensure follow up and coordination of recommended medical management. Requires a High school education or equivalent. Some college preferred. Experience with community programs or health organizations.
Current Position Description
The Star – Combating chronic disease epidemic Impact equation that measures the benefits of a
seamless approach to community health, including metrics for patient empowerment and market value of health.
Unites medical, public health and social science professions, nonprofits and faith-based and community organizations for an ‘all-hands-on-deck’ approach to public health.
Lay care-coordinators critical operational element Potential sustainable model, results to be published
later this year.
Accountable Care Community Austin BioInnovation Institute in Akron
Deliver integrated medical and public health models to deliver clinical care in tandem with health promotion and disease prevention.
Robust health information technology infrastructure Care Plans Data Mining Infrastructure support to scale Infrastructure support for resource management Metrics for continuous improvement and inform
stakeholders.
Critical Components of ACC
Start with neutral party – may need to be the neutral party.
Point of agreement - e.g., reduce inappropriate ER visits, particularly uncompensated visits, Diabetes management
Point of measurable cost - e.g., reduce inappropriate ER visits, 911 calls.
Note – the alignment with community navigation
Note – community development opportunity
Critical Starting Points of ACC
Applied to a Promise Zone
41 people screened, 5 required near-term navigation
1. Son in need of an ultrasound2. Spanish speaker needing two week follow up
no insurance or money3. Screening results conflicted with recent study
results, confused patient with no insurance4. Man with bullet in leg 5. Insured man asked for help since not sure
how to ‘re-access’ health care to get primary physician.
Kidney Screening Pilot – the people
Clinical review directions: clarified, serve as a referral
Simple next steps on envelop
Seems important opportunity to have navigation when screening
Kidney Screening – The System
Harold P Freeman Patient Navigation Institute an intensive 2-day in person in New York City,
or self-paced online training program that includes 10 modules, plus practicum (patient interaction) and case studies.
http://www.hpfreemanpni.org/the-program/ Scholarships available Possible in person locally in Wisconsin in 2014 Certificate of Completion
http://healthadvocateprograms.com/masterlist.htm
http://advocatecredential.org/
Learning Patient Navigation
Learning Patient Navigation cont.Center for Patient Partnerships at UW Law School - Certificateshttp://www.patientpartnerships.org/education/opportunities/certificate-programs/courses-sequence-pacing
/
Learning Patient Navigation cont.Colorado Patient Navigation Training- 7-week online
traininghttp://patientnavigatortraining.org
Sample modules: Overview, Origin and Historical Perspective of
Patient Navigation Developing and Implementing a Patient Navigation
Program Patient Navigation Models: Outreach, Diagnostic &
Treatment, & Survivorship and Legal Barriers Resource Allocation Cultural Competence, and Effective Communication
Contact Shari Galitzer, [email protected] or Institute directly at http://www.hpfreemanpni.org/ Amber Paquette, [email protected]
Harold P Freeman Institute Training Scholarships available for Americorp
Members
Discussion – It’s complicated
Public health programs often disease specific Community navigation is individualized Accountable Care Organizations and Medical Homes are clinical entities but
responsible for prevention and health promotion. ACA – medicare contract for cost/savings sharing Medical Home – accreditation by The Accreditation Association for Ambulatory
Health Care (AAAHC) to provided physician-led coordinated care.
CHWs in Patient Navigation Systems Creating Accountable
Care Communities
Creating conditions for everyone, every day, everywhere to haveequal chances and
fullest choices to be healthy and thrive and
live well and long, from generation to generation.
~ Magda Peck
Improving health outcomes and reducing acute care needs and avoidable hospitalizations in people with chronic diseases, including diabetes, asthma, hypertension, heart disease and cancer by improving knowledge, promoting early detection, increasing access to resources and encouraging self-management behaviors in their priority populations
Assisting people in accessing health care (especially primary care) and social services, embracing treatment strategies, and reducing risk by increasing healthy lifestyle behaviors
Conducting outreach to difficult-to-reach populations and in-reach to improve the appropriateness and quality of health care and social services systems
Helping community members recognize and address broader cultural, environmental, and lifestyle issues that impact their health through community organizing and capacity-building
Helping individuals, families and communities to build social capital and combat social isolation
What CHWs do and What You Can DoLeveraged By Navigation
Thank you for listening Thank you for the work you are doing as
Americorp Members Thank you for thinking about and sharing in
your host communities how Navigation Systems can shift the paradigm and reduce health care disparities.
Discussion