PeerSupportinPrimaryCareEdwinFisher,PhD(Moderator/Speaker),DepartmentofHealthBehavior-UNCChapelHillLuzAdrianaMatiz,MD,NewYorkPresbyterian/ColumbiaUniversityMaryAnnHeran,RDH,BS,RhodeIslandParentInformationNetwork

EdwinB.Fisher,Ph.D.GlobalDirector,PeersforProgress,andProfessor,DepartmentofHealthBehavior,GillingsSchoolofGlobalPublicHealth,UniversityofNorthCarolina-ChapelHill

AdrianaMatiz,M.D.--AssociateProfessorofPediatrics,ColumbiaUniversityMedicalCenter,NewYorkPrebyterianHospital,NewYorkCity

MaryAnnHeran,R.D.H.,B.S.PeerCareCoordinator,RhodeIslandParentInformationNetwork(RIPIN),CoastalMedical-NarragansettBayPediatrics,Wakefield,RhodeIsland

BreakoutFPeerSupportinPrimaryCare

BreakoutFPeerSupportinPrimaryCareAgenda:IntroandOverviewTheCaseforPeerSupportandStrategic

BenefitsEdFisher(10min)IntegratingCommunityHealthWorkersintothePrimary

CareSettingAdrianaMatiz(15min) Questions:15min

PediatricPracticeEnhancementProject(PPEP)RhodeIslandsInnovativeMedicalHomeInitiativeMaryAnnHeran(15min) Questions:1-5min

GeneralQuestions25min

Overview Peer Support to Bend the Curve: Reducing Distress and Avoidable Costly Care,

and Reaching those Hardly Reached Edwin B. Fisher, Ph.D.

Global Director, Peers for Progress American Academy of Family Physicians Foundation

Professor, Department of Health Behavior Gillings School of Global Public Health

University of North Carolina Chapel Hill

Breakout F Patient Centered Primary Care Collaborative Washington, DC November, 2015

Disease Management & Prevention 8,760

8,766 = 24 X 365.25 6 hours a year in a doctors office or

with other health professional. 8,760 hours on your own

Healthy diet Physical activity Monitor status Take medications Manage sick days Manage stress Healthy Coping Arrange medical appointments and testing Sleep

What is Peer Support?Nonprofessionals trained to: 1. Help individuals take the goals they agree to with their

doctors and nurses and make them into a specific planE.g., walking 150 minutes a week is a goal, not a plan

2. Provide emotional support to help people Stay Motivated for disease management Cope with stressors that so often accompany health

problems 3. Link people with clinical care and community resources,

e.g., the foot ulcer is an office visit, not an amputation, or assistance in finding pleasant places for exercise

4. Ongoing support for problems that last the rest of your life

5. Provided by community health workers, promotores de salud, lay heal advisors, health coaches, Village Health Volunteers (Thailand), Lady Health Workers (Pakistan)

Peer Support in Anhui Province, China Zhong Xuefeng, Institute of Health Education, Anhui Center for Disease Control

Older adults in well defined residential settings in small cities in Anhui Province Group meetings led by peer supporters and health center staff Addressed self management and support

Informal support and shared activities through neighborhoods: shopping, exercise, fishing, etc. Significant differences from controls on fasting glucose, 2 hr PPG, reported complications

Zhong et al. Annals of Family Medicine 2015;13 Suppl 1:S50-8.

Human beings are more effective and happier when they have someone

they can talk to about personal matters who cares about them who can help them when they need help

The risk of death associated with social isolation is greater than the risk associated with cigarette smoking

House, Landis & Umberson. Science, 1988 241: 540-544. Holt-Lunstad, Smith, & Layton PLOSMedicine, 2010, 7: July e1000316

www.plosmedicine.org

Harlow, H.F., & Harlow, M. (1966) Learning to love. American Scientist 54: 244-272.

Fundamental Role of Social Connections and Support

Strengths of Peer Supporters

Not professionals Often have the health problem they are assisting with

e.g., people with diabetes helping others with diabetes Share perspectives, experience of those they help People believe them because they are like me Can teach how to implement basic self management

plans (e.g., healthy diet, physical activity, adherence to medications)

Have time!!!

Outcomes of Peer Support Major Reviews Dunn, J., Steginga, S. K., Rosoman, N., & Millichap, D. (2003). A Review of

Peer Support in the Context of Cancer. Journal of Psychosocial Oncology, 21(2), 55-67.

Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health, 35, 399-421.

Swider, S. M. (2002). Outcome effectiveness of community health workers: an integrative literature review. Public Health Nursing, 19, 11-20.

Tyus, N. C., & Gibbons, M. C. (2007). Systematic review of US-based randomized controlled trials using community health workers. Progress in Community Health Partnerships: Research, Education, and Action, 1(4), 371-381.

Viswanathan, M., Kraschnewski, J. L., Nishikawa, B., Morgan, L. C., Honeycutt, A. A., Thieda, P., et al. (2010). Outcomes and costs of community health worker interventions: a systematic review. Med Care, 48(9), 792-808.

WHO Consultation, November, 2007Australia Bangladesh Bermuda Brazil Cameroon Canada China Egypt Gambia India Indonesia Jamaica

Mexico Netherlands Pakistan Philippines Saudi Arabia Singapore Switzerland (WHO) Turkey Ukraine United Kingdom United Republic of

Tanzania United States

1. Key functions are global 2. How they are addressed needs to be worked out

within each setting

FourKeyFunctionsofPeerSupport

Emerging Resultsfrom Projects

Feasibility Sustainability AdoptionReach,EngagementEfficacy

Effectiveness

Implementedinall14

projectsites

MeanbaselineHbA1c=8.92%

ImprovedHbA1c,BMI,BP,QOL

Uganda,SouthAfricawithoutfunding; participation

WellMedextendsfrom15toall23sitesNHSinUKextendstoadditionalregionsFisher et al. Ann Fam Med. 2015;13 Suppl 1:S2-8.

Cost Effectiveness Encourage Program in Alabama (C.Campbell,PhDDissertation,UniversityofAlabama-Birmingham,2014)

59% probability of being cost-saving 55% to 93% probability of being cost-effective, depending on assumptions, inclusion/exclusion, e.g., higher

probability for those with depression or poorer baseline clinical status In FQHC in Denver (Whitleyetal.JHlthCarePoorUnderserved200617:6-15)

Shifted costs from urgent care, inpatient care, and outpatient behavioral health care Increase utilization of primary and specialty care visits. ROI = 2.28:1.00.

Diabetes Initiative of Robert Wood Johnson Foundation (Brownsonetal.,TheDiabEducator.200935:761-769) 3 of 4 projects in cost analysis emphasized peer supporters Cost per Quality Adjusted Life Year (QALY) = $39,563

(well below $50,000 criterion for good value)

Asthma CHW Project with Medicaid Covered Children in Chicago (Margellow-Anastetal.,J.Asthma201249:380-389) Three to four CHW home visits over 6 mos and liaison with care team ROI: $5.58 saved per dollar spent

Lifestyle Modification for Low-Income Latino Adults with Diabetes (Brownetal.,Prev.ChronicDis.20129:E140) CHWs and nurse educator: home visits, self-mgmt education, individual counseling $10,995 to $33,319 per QALY Especially cost-effective among those with HbA1c > 9%

Preventing Rehospitalization in Schizophrenia, Depression, Bipolar Disorder (Sledgeetal.,Psychiatr.Serv.201162:541--44) Recovery Mentors provided individualized frequency, mode, content of support Over 9 mos: 0.89 vs 1.53 hospitalizations, 10.08 vs 19.08 days in hospital (p < 0.05)

Reducing Depression/Anxiety Disorders in India (Pateletal.Br.J.Psychiatry2011199:459-466;Buttorffetal.201290:813-821) Education about psychological problems, ways of coping, and interpersonal therapy delivered by lay health

counselors with primary care and psychiatric back-up 30% decrease in prevalence, 36% in suicide attempts, 4.43 fewer days no work/reduced work in previous 30 days. Lowered time costs resulted in Intervention being cost effective and cost saving

Fisher et al., Ann Rev Public Health, 2014 35: 363-383.

Reaching the Hardly Reached

Peer Support in San FranciscoThomas Bodenheimer, University of California, San Francisco

Clinical Setting Six Departmentof Public Health safety-net primary care clinics serving patients covered by Medicare/Medical or SanFranciscos coverage foruninsured residents

Majority of patients were non-white, ethnically and culturally diverse

Patient Contact Patients had average of 7.02 interactions with their coach, including 5.37 telephoned calls

Outcomes Reduction in HbA1c by > 1 point: 49.6% vs 31.5%HbA1c < 7.5%: 22% vs 14.9%

Changes in HbA1c at 6 Months (p = 0.01)

-1.1

-0.83

-0.55

-0.28

0

Thom et al., Annals of Family Medicine 2013 11: 137-144.

InSanFrancisco,GreaterImprovementsAmongThoseWith LowInitialMedicationAdherence

Moskowitz et al. J Gen Intern Med. 2013 28: 938-942.

Reaching the Hardly Reached PS more effective among those low in self-reported medication adherence and/or self management (Moskowitz et al. J Gen Intern Med. 2013 28: 938-942.) PS more effective among those with low baseline diabetes support or literacy levels (Piette et al. Chron Illn 2013 Dec;9(4):258-67) PS more effective in reducing post-partum depression among women with household debt and/or lower levels of economic empowerment (Rahman et al. Br J Psychiatry 2012 Dec;201(6):451-457.)

PS more cost-effective among those with depressed mood or poorer baseline clinical status (C.Campbell,PhDDissertation,UniversityofAlabama-Birmingham,2014) PS effective in reaching 89% of low-income, unmarried mothers of Medicaid-covered children hospitalized for asthma and in reducing rehospitalization by 50% (Fisher et al. Arch Pediatr Adolesc Med 2009 Mar;163(3):225-32.) PS effective in reaching 87% of High Need adults with diabetes (HbA1c > 8%, Psychosocial Distress, Physicians Referral) at Alivio Medical Center, FQHC in Chicago PS effective in reaching and significantly reducing HbA1c among low-income Latino patients of FQHC, 43% of whom had 6th-grade education or less.

Peer Support,Psychosocial Distress,

and Avoidable Emergency/Hospital

Care

Lady Health Workers in Pakistan Reduce Post-Partum Depression

Manual based intervention, Thinking Healthy Programme

Promote change in thoughts likely to increase depression

Practical problem solving Collaboration with family

Rahman et al.Lancet 2008 372: 902-909Arch Womens Ment Health 2007 10: 211-219.

Lady Health Workers Completed 2ndry education Responsible for 100

households Primarily general health

education and preventive maternal and child care

Extending to TB and HIV detection and control

96,000 LHWs cover 80% of Pakistan rural population

Example from Rahmans Lady Health Worker Intervention for Post-Partum Depression

case where poverty and the husbands chronic unemployment were an underlying issue in the mothers depression, the LHW used CBT techniques to motivate her to take a small loan from the governments micro-credit scheme. The money was used to purchase a buffalo to sell its milk for profit (the LHW had personal experience of such a venture and was able to guide her). The woman was able to return the loan, gained tangibly from the intervention, both materially and in self-worth and confidence, and this led to marked improvement in her depressive symptoms

Rahman, A. Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan

a multi-method study. Archive of Womens Mental Health.2007 10: 211-219. p 217.

Jade and Pearl in Hong KongJuliana C. Chan and colleagues, Hong Kong Institute of Diabetes and Obesity; The Chinese University of Hong Kong; Prince of Wales Hospital

JADEStructuredCareManagement(Chan et al. Diabetes Care 2009 32: 977982.)

Algorithmandregistrybasedcare InitialappraisalandreporttoPCP Quarterlyreports,includingtopatient Initialpatienteducationsession

PEARLPeerSupport(Chan,AmDiabAssoc,June,2012) Peersworkthroughandtrainedbynurses Peersupportclasses Individualcontacts:

Protocol:12over12mos Averageof17

Nota Bene: JADE is the Control Group

Chan, J. et al. JAMA Internal Medicine. 2014 174: 972-981

20% Above Cut-Off for Appreciable Distress(Total Score on Depression, Anxiety and Stress Scale > 17)

DASS Depression Anxiety Stress Scale All ps < 0.05 (*Adjusted for DASS_Depression_Pre, DASS_Anxiety_Pre, and DASS_Stress_Pre)

DDS Diabetes Distress Scale

Change Scores

-12

-9

-6

-3

0

Structured CareStructured Care + Peer Support

Depression Anxiety Stress Total

Chan, J. et al. JAMA Internal Medicine. 2014 174: 972-981

20% with High Distress 40% Hospitalizations

Chan, J. et al. JAMA Internal Medicine. 2014 174: 972-981

0%

15%

30%

45%

60%

HighDistress HighDistress/PeerSupport

Likelihood of Hospitalization

"When I knew I had diabetes, I felt upset and that my life is meaningless. When I joined the peer support program, I found that many people have the same illness as me, but they lived very well. Some are more than 80 years old. This encouraged me. I also can live long and healthy if I can control my blood sugar and managed my life suitably.

(61-year-old female, Da Qing community) "I feel that the 'Peer Group' is like my second family. The people in the group are so kind. Normally, I did not like to talk about my illness with other people, but in here I can talk about my disease. We also discussed diet, activities, medicine and blood sugar control.......

(66-year-old female, He Yedi community)

ReachingPopulations

M o d e l o f P C M H - P S I n t e g r a t i o n

FQHC in Chicago, IL Serving 3,787 Latino

adults with Type 2 diabetes

Supported by the Bristol-Myers Squibb Foundations Together on Diabetes

3,787 PATIENTS WITH DIABETES

M o d e l o f P C M H - P S I n t e g r a t i o n

High Need Group Regular Care Group HbA1c > 8%, Psychosocial

Distress, Physicians Referral 471 of the 3,787 Bi-weekly contacts for 12 weeks Monthly contact for 6 months until

no longer meet criteria for High Need or until progress has stabilized

Quarterly thereafter

Quarterly contacts, encourage clinical care and use of resources (e.g., group classes) and self-management

Transition to High Need as needed

3,787 PATIENTS Reach and Effectiveness

M o d e l o f P C M H - P S I n t e g r a t i o n

Regular Need Group High Need Group

Compaeros reached 82% HbA1c change over 2 years

8.22% to 8.14%, p

Common Themes Reaching, engaging patients;

supporting regular care Self management; sustaining benefits

of patient education Integrating care and smoothing

transitions Support for individuals and families Patient support Adherence

Emphases on: Patient Centered Medical Home Chronic Health Homes Reducing Rehospitalizations Prevention and Disease

Management

Thank You!!

peersforprogress.orgedfisher@unc.edu

mailto:edfisher@unc.edumailto:edfisher@unc.edu

Integrating Community Health Workersinto the Primary Care Setting

Adriana Matiz , MD Associate Professor of Pediatrics

Columbia University Medical Center

Adriana Matiz, MD Associate Professor of Pediatrics Columbia University Medical Center

PRESENTATION OUTLINE

1. Background 2. Program Model 3. CHWs and the Patient Centered Medical Home 4. Key Findings 5. DSRIP Opportunity 6. Next Steps

BACKGROUND

WASHINGTON HEIGHTS AND INWOOD

COMMUNITY CHARACTERISTICS

270,700 residents 51% foreign-born 75% Latino (55% Dominican, many recent immigrants) 70% speak Spanish at home 43% of children live below poverty line

Schwarz et al. Asthma in New York City. NYC Vital Signs. 2008;7(1):14. Olson et al. Take Care Inwood and Washington Heights NYC Community Health Profiles. 2006;19(42):116

PROGRAM MODEL

COMMUNITY HEALTH WORKER MODEL

Regional Health Collaborative Hospital-Academic-Community Partnership Community Health Workers

Bilingual Community-based (4 CBOs) Peer support & education reinforcement Care Coordination and PCMH-based support Members of health care team

Peretz et al. Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative. American Journal of Public Health: August 2012, Vol. 102, No. 8, pp. 1443-1446.

PROGRAM OUTCOMES

Asthma: 1104 patients enrolled in year-long program Retention at 6 months: 77%, at 12 months: 65% ED visits and hospitalizations decreased by more than 65% among graduates Nearly 100% of graduates stated that they feel in control of childs asthma

Diabetes: 343 patients enrolled in year-long program Retention at 6 months: 90%, at 12 months: 81% Nearly 60% of graduates improved their A1C levels Nearly 100% of graduates stated that they are able to cope and reduce their

risk

CHWS AND THE PATIENT CENTERED MEDICAL HOME

PCMH SUPPORT AND EDUCATION

Implemented: February 2011 CHWs: Use non-clinical, peer-based approach to reinforce key

health messages Help patients understand diagnoses and uncover disease

management obstacles Participate in multidisciplinary meetings and rounding Accept on-site referrals for year-long care coordination

program Impact: 5421 patients have received practice-based support & education to date Matiz LA. Et al. The Impact of Integrating Community Health Workers into the Patient Centered Medical Home. J Prim Care Community Health. 2014 Oct;5(4):271-4.

.

KEY FINDINGS

KEY FINDINGS

CHWs based in the local community are uniquely positioned to build trusting partnerships

CHWs can move fluidly between community and health care settings

CHWs can be the voice of the community in the PCMH and bridge gaps in care

Successful integration requires on-going support and continuing education related to the role of the CHW

Community partner involvement in all aspects of the program development and evaluation is critical to program success

CONTACT INFORMATION

Adriana Matiz, MD Associate Professor of Pediatrics, CUMC

Medical Director, Center for Community Health Navigation 212 -342-1917

Lam2048@columbia.edu

mailto:Lam2048@columbia.edu

RI PARENT INFORMATION NETWORK (RIPIN)

Peer Care Coordination Project

Pediatric Practice Enhancement Project (PPEP)

2003

The PPEP was developed in 2003 to assist and support pediatric primary and specialty care practices in providing improved short and long-term health outcomes for CYSHCN and their families within a medical home. The project places and supports trained Peer Resource Specialists in clinical settings to link families with community resources, assist physicians and families in accessing specialty services, and identify systems barriers to coordinated care. The primary role of the Peer Resource Specialist is to create linkages between the family, pediatric practice, and the community as a whole.

Why the PPEP Project works

The PPEP model successfully demonstrated that utilizing a paraprofessional to reinforce healthcare messages, provide patient education and deliver care coordination is more cost effective than utilizing a licensed clinician, ie: a nurse or social worker. Furthermore, a paraprofessional matched culturally and linguistically is found more effective in improving health outcomes.

Due to the success of the PPEP project, RIPINs Peer Care Coordination Project was born.

In January 2015, RIPIN partnered with Rhode Island Foundation to conduct a one-year pilot, showcasing the Peer Care Coordinator role in two pediatric settings. Utilizing a Peer Care Coordination tool, developed by Dr. Richard Antonelli of Boston Childrens Hospital, this project was designed to capture and categorize all care coordination activities at each site into clinical and non-clinical supports.

The Peer Care Coordination project assists in providing a Medical Home for Children and Youth with Special Health Care Needs (CYSHCN) and their families to improve short and long-term health outcomes.

PEER CARE COORDINATION PROJECT2015

Due to the success of the PPEP project, RIPINs Peer Care Coordination Project was born.

In January 2015, RIPIN partnered with Rhode Island Foundation to conduct a one-year pilot, showcasing the Peer Care Coordinator role in two pediatric settings. Utilizing a Peer Care Coordination tool, developed by Dr. Richard Antonelli of Boston Childrens Hospital, this project was designed to capture and categorize all care coordination activities at each site into clinical and non-clinical supports.

The Peer Care Coordination project assists in providing a Medical Home for Children and Youth with Special Health Care Needs (CYSHCN) and their families to improve short and long-term health outcomes

WHAT IS A PEER CARE COORDINATOR? A Peer Care Coordinator is a parent or family member that has

navigated the system of care for their child/youth with special health care needs and assists families going through similar situations.

The Peer Care Coordinator assists physicians and families in accessing specialty services and identifies systems barriers to coordinated care. A Peer Care Coordinator provides non-clinical support and assistance to Nurse Care Managers or the primary care provider (PCP). Through our contract with the RI Foundation, the Rhode Island Parent Information Network (RIPIN), a non-profit family advocacy organization, conducts the recruitment, hiring, training and supervision of Peer Care Coordinators.

RIPIN Peer Care Coordination aims to enhance provision of coordinated and comprehensive care, recognize families as critical decision makers, and increase family understanding of health care delivery systems and community resources.

The integration of peer support through Peer Care Coordinators helps fill gaps in the Medical Home that were previously cited by providers (e.g. lack of time to address non-clinical issues, program eligibility, and knowledge of resources within families communities to provide a higher satisfaction from patients and their families.

The goal of our project is to demonstrate the time commitment that is needed by a multi-disciplinary team to facilitate successful comprehensive clinical care coordination. Also, at project end, we aim to document clinical vs non-clinical use of staffing to determine if the provided coordination is relevant to the clinical competence of the professional providing the service, ie: a doctor or nurse case manager assisting with a housing issue.

RIPIN is nationally known and valued for our innovative Peer Care Coordination programs. This model engages peers to help caregivers and individuals with special needs successfully access health coverage, navigate health care and educational systems, as well as providing other much needed assistance to improve social determinants of health.

RIPIN has a long standing reputation in assisting the community with improved empowerment. At the conclusion of the project, we will survey families who have collaborated with a RIPIN Peer Care Coordinator to determine if the higher level of supports that they received helped reduce stress, improved the patient/family experience, and helped them achieve better health outcomes through individualized care coordination, utilizing a multi-disciplinary approach.

Time for General Discussion!!

PeerSupportinPrimaryCareMaryAnnHeran,RDH,BS,RhodeIslandParentInformationNetworkEdwinFisher,PhD(Moderator/Speaker),DepartmentofHealthBehavior-UNCChapelHillLuzAdrianaMatiz,MD,NewYorkPresbyterian/ColumbiaUniversity