When Michigan-based Spectrum Health discovered that its community-based care program was not adequately serving some of its highest-need clients, Spectrum revamped the program—with dramatic results, Karen Wagner reports for Hospitals & Health Networks.
Create a super-utilizer program
Spectrum Health originally designed its Core Health program to provide in-home education on general wellness topics for patients with early-stage chronic conditions, such as diabetes, heart failure, and chronic obstructive pulmonary disease.
But it became evident, Wagner writes, that the program in its original form wasn't meeting the needs of certain high-need patients, including those with more advanced diseases who also had cognitive and behavioral challenges.
Core Health Program Supervisor Bethany Swartz said, "We were challenged to shift the program to be able to serve those folks who were a little more clinically complex, a sicker population, those not so much in early-disease state."
How Spectrum made its program work for its clients
To better help clients, Spectrum hired a bilingual, licensed social worker. The program also began screening for depression and anxiety, and it developed a health risk assessment to see how social determinants of health—such as access to food, housing, and transportation—influence a person's health.
Spectrum also changed the program's curriculum. The original, yearlong curriculum was pre-designed by wellness topics—now it's modified to match clients' cognitive abilities, pace of learning, and personal goals.
In its new formulation, the curriculum doesn't have a set timetable either. Instead, the program is considered successful when clients demonstrate necessary self-care management skills. "We changed how we define success," Swartz said.
Picking the team
In addition to Swartz, the Core Health program employs six community health workers (CHWs); three full-time-equivalent registered nurses, who serve as care managers; and a full-time social worker.
Because they play a large role in the program's day-to-day operations, CHWs are carefully selected and trained, according to Mark Lubberts, manager of community health education for Spectrum Health's Healthier Communities outreach program. CHWs, he explained, are chosen because of their ability to relate to clients. "You're not looking for the person with the master's degree in public education," Lubberts said. "You want somebody who has lived the life of many of our clients."
Once selected, CHWs complete a rigorous training program developed by Healthier Communities and the Grand Rapids Community College. To complete the program and receive certification, CHWs must pass tests in eight competencies, including outreach and advocacy, communication skills, mental health, documentation and reporting, teaching, legal and ethical responsibilities, community and personal strategies, and healthy lifestyles. They also complete several Spectrum orientation programs.
The program in practice
The CHWs meet with three to four clients every day, spending an hour with each, a schedule that enables the CHWs to see each of the program's 300 clients once per month. During each meeting, the CWH checks the client's condition and works with the client on setting goals for eating or exercising. Those updates are then documented in Spectrum's EHR.
CHWs stay in contact with a client's Core Health care manager and primary care physician, seeking input about how to respond to health changes in the client, such as high blood sugar. For instance, CWH's submit a clients' care plans to their care manager for approval—which must be done within 24 hours. Care managers also conduct medication reconciliation for each client about every three months.
"Our ultimate goal is to get the client to a place where they're using their primary care doctor to make their health decisions," Swartz said.
When it comes to outcomes, Core Health in 2016 reported:
- A client satisfaction rate of 97 percent;
- 70 percent of clients had a mean increase of 26 percent on a measure of client success;
- A reduction in ED visits and hospitals stays among clients; and
- More than half of diabetes clients had lowered their A1c levels by an average of 17.2 percent during the time they participated in Core Health.
Swartz said a major takeaway was the extent to which non-physical factors influence a client's ability to manage a chronic condition. "Looking back at the original design of Core Health, the behavioral and social health needs of our clients were probably underestimated," Swartz said, as were the number of community members not receiving appropriate care and the acuity levels of clients' conditions.
The program "has impacted a lot of outcomes," Swartz said. "But still the most impactful elements within this program were the times when I would receive phone messages from clients describing how a community health worker made all the difference in their lives" (Wagner, Hospitals & Health Networks, 5/3).
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