Community Health Workers:

Enhancing Readiness for Value Based Care

2

Presenter:

Lisa Ladendorff,

LCSWNortheast Oregon Network

Executive Director

Community Health Worker

Community Health Worker

Trainer

Learning objectives

• Review of Community Health Worker (CHW) definitions, roles

and functions;

• Enhance understanding of CHW alignment with specific

Patient Centered Primary Care Home standards and goals;

• Explore how CHW implementation can further readiness for

Value Based Care Reimbursement for clinics and hospitals;

• Learn about specific CHW program return on investment

examples;

• Orient to and learn how to use a tool to help support

implementation of CHWs for individual sites and programs.

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Community Health Worker Definitions

and Roles

4

American Public Health Association

Definition

“A community health worker is a

frontline public health worker

who is a trusted member of

and/or has an unusually close

understanding of the

community served.”

• Liaison

• Link

• Intermediary

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Oregon’s Definition of CHWs

(ORS 414.025)

• Has expertise or experience in public health;

• Works in an urban or rural community, either for pay or

as a volunteer in association with a local health care

system.

• To the extent practicable, shares ethnicity, language,

socioeconomic status and life experiences with the

residents of the community where the worker serves;

• Provides health education and information that is

culturally appropriate to the individuals being served;

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Oregon’s Definition of CHWs

(ORS 414.025)

• Assists members of the community to improve their

health and increases the capacity of the community

to meet the health care needs of its residents and

achieve wellness;

• Assists community residents in receiving the care they

need;

• May give peer counseling and guidance on health

behaviors; and

• May provide direct services(e.g. first aid; blood pressure

screening)

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8

Promoting Health Equity

• There are distinctive differences in the CHW role in relation to other

health occupations.

• CHWs apply a broad range of skills to provide holistic or wrap

around services to community members.

• CHWs provide assistance to community members in a variety of

settings with a focus on where the community member is

comfortable. It might be a home visit, in the library or a coffee shop.

• CHWs focus on working with the community member and

empowering the community member to prioritize their own

concerns regarding their health and well being.

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• CHWs are involved in work

providing equitable and culturally

responsive access to information

and services for historically

disenfranchised populations and

individuals.

• Recruitment and training of CHW

has historically been driven by

culturally responsive practices

that identify the need to find,

empower, and support individuals

whom already work, live and

function within disenfranchised

communities.

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Traditional Health Worker Resource

Links

• Traditional Health Worker Registry:

https://traditionalhealthworkerregist

ry.oregon.gov/

• Traditional Health Worker OHA

Rules and Policies:

https://www.oregon.gov/oha/health

plan/Pages/thw-policy.aspx

• State Approved Training Programs:

https://www.oregon.gov/oha/oei/Pa

ges/thw-approved.aspx

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ALIGNMENT WITH PCPCH

STANDARDS

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PCPCH Core Attributes

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Core Attribute: Access to Care

Standard Description Example

In-Person

Access

PCPCH surveys a sample

of its population….and

meets a benchmark on

patient satisfaction with

access to care

CHWs increase access

satisfaction by being more

readily available, and by being

able to meet for longer periods

of time, and in patient homes.

Prescription

Refills

PCPCH tracks and shows

improvement for time to

completion for prescription

CHWs can assist with

advocacy and problem solving

for issues arising around refills,

especially with insurers. They

also serve a linking function

with pharmacists.

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Core Attribute: Accountability

Standard Description Example

Performance

and Clinical

Quality

PCPCH tracks,

reports and meets

benchmarks on two

measures from core

set and one from

menu set

CHWs can assist with meeting any

screening and care benchmarks,

whether immunization, cancer

screening or post partum care by

engaging and persuading those

patients with high no-schedule or no-

show rates to engage.

Patient and

Family

Involvement in

Quality

Improvement

Patient, caregiver and

patient –defined

family advisors are

integrated into the

PCPCH and function

in peer

support/training roles

CHWs are hired as natural leaders

from the populations they are serving,

and thus are natural patient advisors

and peers.

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Core Attribute: Accountability

Standard Description Example

Ambulatory

Sensitive

Utilization

PCPCH tracks selected

utilization measure and

shows improvement on

selected utilization

measures.

CHWs have the strongest

documented ROI evidence in the

area of reducing costly ER and

inpatient utilization, and

increasing outpatient utilization.

Many health plans and hospitals

assign CHWs to engage with

high utilizers or those at risk of

high utilization to engage in care

that can stabilize and manage

health conditions.

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Core Attribute: Comprehensive Whole

Person Care

Standard Description Example

Preventive

Services and

Preventive

Services

Reminders

PCPCH routinely offers or

coordinates 90% of all

recommended age and

gender appropriate

preventive services.

CHWs are especially useful

at engaging those patients

that refuse to schedule or

routinely no show regular

preventive care visits.

Medical

Services

PCPCH reports that it

routinely offers all of the

categories of care:

….coordination of care,

preventive services, patient

education and self

management support

CHWs can serve as excellent

patient educators and provide

self health management

support, either formally via

curriculums, or informally

according to the patient's

care plan.

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Core Attribute: Continuity

Standard Description Example

Personal

Clinician

Assigned

PCPCH meets a

benchmark in the

percentage of

active patients

assigned to a

personal clinician or

team

Many CCOs have patients assigned

who receive no medical care. CHWs

can be assigned to make contact,

develop relationships and work with the

patient to choose a personal clinician

and set up appointments for preventive

care.

Medication

Reconciliation

PCPCH provides

comprehensive

medication

management for

appropriate patients

and families.

CHWs can be a pat of the reconciliation

process by working with patients in their

home to understand and document their

understanding of how to take their

medications. This can be provided to

physicians for use in the reconciliation

process.

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Core Attribute: Coordination/IntegrationStandard Description Example

Complex

Care

Coordination

PCPCH develops an

individualized care plan for

patients/families with

complex medical or social

concerns. Plan includes self

management goals; goals of

preventive and chronic

illness care……

CHWS are ideal members of the

treatment team to work at goal

setting and implementation for

some of the highest medical and

social risk patients. They are

able to take the time in home

based settings to develop a

relationship that can lead to

effective goal setting and change.

Referral and

Specialty

Care

Coordination

PCPCH tracks referrals and

cooperates with community

service providers such as

dental, educational, social

service, foster care, public

health, etc.

A core role of CHWs is to provide

navigation and linkage services

to multiple community entities on

behalf of an in conjunction with

patients.

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Core Attribute: Person-and Family-

Centered Care

Standard Description Example

Language and

Cultural

Interpretation

PCPCH offers and uses

providers who speak a

patient’s/family’s language of

choice or uses interpreters.

CHWs, if hired from the

populations they serve,

will often speak the

same language, and can

be cross trained as

interpreters.

Education and Self-

Management

Support

More than 10% of unique

patients are provided patient-

specific education resources

and self-management

services.

A key CHW role is to

provide patient education

using standardized

sources and self health

management support.

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ENHANCING READINESS FOR

VALUE BASED CARE

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Rural Health Value

• Based at the University of Iowa

• Staffed by RUPRI and Stratis Health

• Tools and Resources to help support rural health care

transformation

• http://cph.uiowa.edu/ruralhealthvalue/

• Value-Based Care Assessment Tool

• http://cph.uiowa.edu/ruralhealthvalue/TnR/vbc/vbctool.php

• 121 value based capacities within eight value based care

categories

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Value Based Care Categories

Care Management

Clinical Care

Community Health

Patient and Family

Engagement

Performance

Improvement

• Health Information

Technology

• Financial Risk

Management

• Governance and

Leadership

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CHWS Assist to Meet the Following Care

Management Capacities:

• HCO assesses and

identifies patients at high

risk for poor outcomes or

high resources utilization,

and assigns care

managers to them.

• HCO offers chronic

disease management

services.

• HCO utilizes a broad

community resource

network in care

management.

• HCO engages a non-

traditional health care

workforce in care

management.

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CHWS Assist to Meet the Following

Clinical Care Capacities:

• Primary Care Practices

are accredited health

homes (PCPCH)

• HCO generates action

lists for providers of

patients who are

due/overdue for services.

• Medication reconciliation

occurs during each

patient encounter.

• For non-urgent clinic

visits, pre visit planning

occurs for complex

patients.

• Clinical practices offer

group visits, e-visits and

other alternative patient

encounters.

• Primary care practices

encourage advanced

care planning.

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CHWS Assist to Meet the Following

Community Health Capacities:

• HCO has implemented

programs in response to

needs identified in a

Community Health Needs

Assessment survey.

• HCO has implemented

community preventive

health programs .

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CHWS Assist to Meet the Following

Patient and Family Engagement

Capacities:• Specific strategic

programs with

measureable objectives

focus on improving

patient and family

engagement.

• Prior to each admission,

HCO staff provides and

discusses a planning

checklist.

• HCO generates reminder

for patients who are

due/overdue for services.

• HCO collects data

regarding patient and

family cultural/language

preferences.

• HCO modifies care based

on patient and family

cultural/language

preferences.

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CHWS Assist to Meet the Following

Performance Improvement Capacities:

• HCO actively works to

reduce potentially

avoidable

readmissions.

• HCO actively works to

reduce inappropriate

emergency

department utilization.

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SUSTAINABILITY AND ROI

MODELS

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Models for Sustainability (ROI)SUMMARY ROI FIND OUT MORE

Molina Healthcare

of New Mexico

(Medicaid

Managed Care)

Uses CHWs to

intervene with plan’s

highest resource-

consuming patients,

including those with

high ED usage and low

treatment adherence

Approximately $4 of

savings for every $1 of

cost.

http://www.ncbi.nlm.nih.gov

/pmc/articles/PMC3343233/

Denver Health Community Voices

outreach program

works with underserved

populations on issues

including appropriate

outpatient service

utilization.

$2.28 savings for every

$1.00 invested in the

program.

http://communityvoices.org/

assets/wp-

content/uploads/2014/02/R

OI-of-Community-Health-

Workers.pdf

CHRISTUS

Community Health

Care

Management for the

Uninsured Quality

Management

Committee Annual

Report

Average annual cost for

care among program

participants decreased

by $10,000 or 58%.

Over a three year

period, the ROI was

3.84:1

http://www.christushealth.or

g/CHRISTUSHealthComm

unityDedication

30

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SUMMARY ROI FIND OUT MORE

Social Return on

Investment: CHWs

in Cancer Research

Wilder Research

Center’s 2012

cost-benefit

analysis of CHW

services in

cancer outreach.

$2.30 in

return in

benefits

fro every

$1

invested

http://www.wilder.org/Wilder-

Research/Publications/Studies/C

ommunity%20Health%20Worker

s%20in%20the%20Midwest/Soci

al%20Return%20on%20Investm

ent%20-

%20Community%20Health%20

Work

A Community-Based

Asthma

Management

Program: Effects on

Resource Utilization

and Quality of Life

A CHW asthma

intervention in

Hawaii shows a

decline in

emergency room

visits and

increased quality

of life.

Asthma

related

per capita

charges

decrease

d from

$735 to

$181

See accompanying

research grid.

The Effectiveness of

CHWs on Healthcare

Utilization of West

Baltimore City

Medicaid Patient

with Diabetes

A CHW

intervention

outreach program

created savings

and improved

quality of life

Per

patient

savings of

$2,245 for

117

patients

See accompanying

research grid.

CHW Reimbursement

Fee for Service

• Direct reimbursement in a

fee for service model

from payers who have

included it as a covered

services.

Value Based

• NEON Pathways

Community Hub

• Transformation Grants

• FQHC/Migrant Health

Centers

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Indirect Reimbursement

Fee for Service

• Twinned with RN Care

Manager

Value Based

• Patient Centered Primary

Care Home Value Added

PMPM

• Medicare Chronic Care

Management

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CHW IMPLEMENTATION TOOL

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Tool

Categories • General Population

Demographics

• Population Health and

Social Needs

• CCO Metrics

• CHW Volume and

Workload

• CHW Cost

• CHW Revenue

Generation35

CHW Analysis Tool: Needs Assessment

Community Assessment

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CHW Analysis Tool: CCO Metrics

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CHW Analysis Tool: Workload

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CHW Analysis Tool: Budget

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CHW Analysis Tool: Revenue

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THANK YOU!

Please send any further questions to:

lladendorff@neonoregon.org

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Additional ResourcesRural Assistance

Center

The CHW Toolkit is

made up of several

modules concentrating

on different aspect of

CHW programs

https://www.raconline.org

/communityhealth/chw

US Dept of Health and

Human Services Health

resource and Service

Admin (HRSA), Office

of Rural Health Policy

(ORHP)

The CHWs Evidenced

Based Models toolkit

includes several

successful strategies

with rural communities.

https://www.hrsa.gov/rur

alhealth/pdf/chwtoolkit.p

df

Northeast Oregon

Network

The NEON website

includes information

about local health

outreach efforts and a

training schedule for

CHW trainings.

www.neonoregon.org

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References• Agency for Healthcare Research and Quality. (2013) Clinical-

Community Relationships Evaluation Roadmap and Clinical-Community

relationships Measures Atlas. Retrieved from AHRQ at:

http://www.ahrq.gov/professionals/prevention-chronic-

care/resources/clinical-community-relationships-measures-

atlas/index.html

• American Public Health Association (APHA). (2016). Community Health

Workers. Retrieved from the APAH Community Health Workers

webpage at: https://www.apha.org/apha-communities/member-

sections/community-health-workers

• Bovbjerg, R.R.; Eyster, L.; Ormond, B.A.; Anderson, T.; Richardson, E.

(2013). Integrating Community Health Workers into a Reformed Health

Care System. Retrieved from The Urban Institute online at:

http://www.urban.org/sites/default/files/alfresco/publication-

pdfs/413070-Integrating-Community-Health-Workers-into-a-Reformed-

Health-Care-System.PDF

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References• Mueller, K. J.; Alfero, C.; Coburn, A. F.; Lundblad, J. P.; MacKinney,

A.C.; McBride, T.D.; Weigel, P. (2015) Medicare Value-based

Payment Reform: Priorities for Transforming Rural Health Systems.

Retrieved from Rural Policy Research Institute at:

http://www.rupri.org/wp-content/uploads/FORHP-comments-km-

DSR-PANEL-DOCUMENT_PRD_Review_112315.clean-4_sn-3.pdf

• National Quality Forum. (2015). Performance Measurement for

Rural Low-Volume Providers. Retrieved from National Quality

Forum at:

http://www.qualityforum.org/Publications/2015/09/Rural_Health_Fina

l_Report.aspx

• Oregon Health Authority. (2016) 2017 Recognition Criteria for

Patient Centered Primary Care Homes. Retried from Oregon Health

Authority at: http://www.oregon.gov/oha/pcpch/Documents/2017-

PCPCH-Standards-Measures.pdf

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References

• Panning, A. (2015). Community Health Worker Financing. Retrieved

from Northwest Regional Primary Care Association website at:

http://www.nwrpca.org/news/211392/Community-Health-Worker-

Financing.htm

• Rural Health Innovations. (2015). Rural Hospital Toolkit for

Transitioning to Value-Based Systems. Retrieved from National

Rural Health Resource Center at:

https://www.ruralcenter.org/rhi/resources/rural-hospital-toolkit-

transitioning-value-based-systems

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