2018 PCORI Annual Meeting *********************

Breakout Session Improving Care in the Community – How to

Effectively Deploy Community Health Workers

Presenters: Andrea Gelzer, MD, MS

Sinsi Hernandez-Cancio, JD Bradley Kramer, MPA

Judith Long, MD Moderator:

Cathy Gurgol, MS

SESSION TRANSCRIPT

This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) captioning is provided in order to facilitate communication accessibility and may not

be a totally verbatim record of the proceedings. Names might be misspelled. Opinions, positions, and statements presented are those of the individual participants and

not necessarily those of PCORI, its Board of Governors, or Methodology Committee, unless so indicated.

>> Good afternoon, everyone.

Thank you so much for attending our session.

I hope everybody is having a wonderful annual meeting so far.

We're really excited to present this panel about Community Health Worker.

My name is Cathy Gurgol and I'm working on our session called "Improving Care in the Community: How to Effectively Deploy Community Health Workers."

Before I introduce the panel I want to give a brief overview of PCORI's CHW portfolio to give you a little bit of context.

I have nothing to disclose.

As we started analyzing our CHW portfolio at PCORI, one of the initial questions we had was who are CHWs, what is their role?

Is there a definition?

What are we looking at here?

There are a few definitions out there, as you probably know, and many of them are similar.

With the main point one of the main points being that CHWs are trusted members of the community and have a close understanding of the community served, and serve as a link between the community and health and social services.

This definitions is from the American public health association.

And why are CHWs important?

As I'm sure most of you in the room already know, CHWs work to address health disparities by bridging the divide between communities and healthcare systems.

Because they are from the community, they have the ability to understand the community's culture and what the barriers to care are.

They often provide education and advocacy to address individual barriers to care, which may include social factors that affect health and healthcare access.

CHWs provide a link to community resources to address those concerns.

CHWs can play a role in improving health systems to provide patientcentered care and reducing disparities.

CHWs are being used more and more according to the Bureau of Labor Statistics there are more than 54,000 CHWs in the U.S., but there are barriers to full uptake of these types of workers.

All those states have initiated programs to promote sustainability of CHWs, such as state grants or some legislation.

There are still challenges regarding full adoption of CHWs and some of those challenges are just having a common understanding of what the role or the function is of these types of workers.

There are reimbursement issues and other barriers.

For the next few slides I'll briefly go over PCORI's Community Health Worker portfolio in terms of conditions and populations represented in the projects, as well as the functions of the Community Health Workers.

As of just last month, October 2018, PCORI has funded 79 comparative effectiveness research studies that use Community Health Workers in the intervention, and that's an investment of almost $300 million over the past five years.

One of the challenges in even getting a sense of the portfolio or even being able to identify the Community Health Worker portfolio is the variation in names for these types of personnel.

Just creates a challenge since not all investigators or providers use the same term Community Health Worker.

So because of the variation, we're going through each of the projects to make sure that the worker used in the project matches the definition of being closely linked to the community and understanding the community.

So if the role matched, we considered them to be Community Health Workers.

But you can see on the slide listed some at of the most common terms for Community Health Workers that investigators used.

So there are variations.

This slide just shows the health conditions that are represented in the portfolio of 79 projects.

You can see mental behavioral health, multiple chronic conditions, nutritional and metabolic diseases and cardiac diseases most prevalent.

This tracks fairly closely to PCORI's overall portfolio in terms of conditions represented or funded the most.

So just to provide a little bit of context into the conditions that some of the community health workers are works in PCORI's portfolio.

These conditions are not mutually exclusive, so some projects address more than one condition.

These are the majority of the populations included in the Community Health Worker portfolio of projects.

Many as you can see are populations at risk for disparities in health and healthcare and you may know that addressing disparities is one of PCORI's national priorities for research.

And PCORI, since Community Health Workers work to address disparities in health and healthcare access it makes sense that the portfolio reflects that in terms of targeting the populations at risk.

These are not mutually exclusive.

Some target more than one population.

And this just shows the spread of when projects are being completed.

So when can we expect results?

And many of them have completed in the past year or so and are completing this year as well.

And some down the road a little bit, a couple of years.

You'll hear about two of our completed projects during the course of this session, so we're excited about that.

And as you may know, PCORI makes all the funded research available online.

The results are available online to the public.

Of the CHW studies completed so far, PCORI.org has posted 22 project results so far and many are in the process of completing their peer review works and will be posted soon.

So you may visit PCORI's website to learn more about these projects.

And then we are also interested in learning about the functions or the roles that CHWs have in the projects.

We looked through the literature and through other sources to determine how CHW functions have been classified and many are listed up here in terms of providing social support, assisting in adopting health behaviors, leveraging culture, navigating the health system and so forth.

We're still analyzing our portfolio to see how the projects meet or how the CHWs in the projects are conducting some of these roles.

More to come on that, but just to give you a sense of how we're thinking about the roles at this point.

So that was just a very brief overview of the portfolio.

And I would like to introduce this outstanding panel.

I'm very excited about our panelists.

We have first up Brad Kramer, an asthma program manager at public health Seattle in Washington, and Maria Rodriguez, a CHW, who will be presenting, discussing their project that was PCORI funded.

It's called the Guidelines to Practice Study, and it looked at home visits from CHWs to treat and manage asthma.

Next we have Nadirah Rogers, CHW and long professor of medicine at the University of Pennsylvania to discuss their project on Community Health Worker support for chronically ill patients.

And we have Sinsi HernandezCancio director at families USA.

And Dr. Andrea Gelzer, chief corporate medical officer at AmeriHealth Caritas.

And we'll talk about community approach to care.

We're excited.

Thank you.

I'd like to introduce the first panel itself first panelists, Brad and Maria.

[Applause]

>> Bradley Kramer: Thank you, Cathy and thank you, PCORI.

I'm Brad Kramer, and I'm here with Maria Rodriguez, and we work at public health Seattle in King County, the regional health department there.

The objectives today are to learn more about Community Health Workers and improving health outcomes for asthma, how to include Community Health Workers in your research and program teams and stakeholder engagement that can support Community Health Workers.

I couldn't be here today without acknowledging our partners, PCORI and then also we have been working with our clinical partners, our Medicaid managed care organizations.

Of course our investigators and CHWs.

In this picture you can see Sophia Mohammad, Maria Rodriguez Joyce McCraney and PI, Dr. Jim stout, and myself.

The work we do in public health Seattle King County is building on the long legacy of work.

This work has a 20year history improving evidencebased with health workers led by Dr. Jim Creger, who left the health department, but he had been part of time plus research studies, mostly housed at the health department serving over 4,000 participants.

Most or all of our information is published on our website and you should explore that.

The CHW model has been proven by a lot of other folks as you saw from the PCORI portfolio and there's a portfolio with asthma CHWs and other folks in the room that work in the space.

I see an allied program manager and asthma CHW programs.

Health workers, lay workers from our community that share life experiences with their clients or their patients.

They share culture and language.

They sometimes share the disease.

They might have asthma or a child that has asthma.

They have this innate ability to build a trusting relationship with their patients and then they utilize to bridge community and clinic partnerships or connections to social service providers, and so they're always referring up and referring out.

And then they're also trained.

For professional development but also in the wealth of resources that are in our communities that they can utilize.

So the asthma program, our CHW model has three home visits over four months.

These are largely rooted in motivational interviewing, chronic disease selfmanagement, cultural competence.

And asthma, of course.

They focus on medication and technique.

They look to reduce triggers for asthma attacks, and this can be home and environmental remediations.

Vacuums are supplied to do that work, cleaning, and other resources.

These are based on the goals that are set by the individual patients.

So there's a lot of selfmanagement goal setting and peer coordination or referrals to other programs.

To get a sense of what the home visits are like, Maria Rodriguez wanted to share a story of a recent client of hers.

>> Maria: So I'm going to share 12yearold that I just finished working with, with a family, where her asthma was poorly controlled.

14 days out of 14 days, 14 nights out of 14 nights she had three ER visits in the last year.

She played soccer and was missing practices and games.

Her family, mom, dad, and fiveyearold sister, and they were all working together to help her with her asthma control.

The home environment, when I did the environment checklist, there was they had just purchased a used mobile home and had lots of mold.

The client had a cat, and she just loved to cuddle.

She would just grab him.

And this is from her fiveyearold sister told me she would grab her face, and, of course, she was allergic to cats.

And her little sister had 28 stuffed animals, big ones and little ones, just a lot.

So during our home visit we discussed the mold, and mom and dad, of course, they were wanting to do as much as they could, so removing the cabinets, because there were cabinets in the kitchen and the dining room, and they were just really moldy and the kitchen was even the wood was starting to get mold.

And so that was one of the goals.

And then, of course, we went over with my client, which was a 12yearold, about medication technique and adherence.

And we also talked about the cat.

Because, you know, she's allergic to the cat, so she made a goal to keep the cat outside and only pet it instead of, you know, just kissing it and bringing it to her face.

We also talked about dust mites and dust control and I gave her one of the vacuum cleaners that we hand out to them.

To help.

So by the third visit, the family had major improvements.

They had removed the cabinets from the kitchen and from the dining room.

They had replaced new wood that was rotted and moldy and wet.

And the fiveyearold had made a goal that she was just going to get she was going to keep three stuffed animals.

Ended up getting rid of all of them, which was just amazing.

My client, she was using she was on a controller and using her rescue inhaler as needed and she was just her technique was amazing.

Zero ER visits and zero symptoms out of 14 days and zero symptoms out of 14 nights.

So, this is why we do the work that we do.

[Applause]

>> Bradley Kramer: That's an amazing story and Maria demonstrates where the family was really locked in around improving the child's health, and everyone, including the fiveyearold who gave up her stuffed animals because they were loaded with dust, or dust mites.

But also you were telling me about how it wasn't all this rosy story where everyone is focused on the kid.

That's true, but the family was also struggling a bit and you had to provide some social support with the dad changing jobs and such?

>> Maria: So on our second visit, dad usually mom and dad usually their whole family but that day dad said, I can't be here.

So mom was just sharing.

This is where they have this trust in us.

She was just sharing really personal things and she was crying, and I was able to encourage her.

And, you know, because we are there, because they let us come into their homes.

I was able to help them and the family at the end to work together and this is why everything happened, because of family working together.

And I was just they just let me into their home.

So it was them, you know, doing it.

>> Bradley Kramer: Thank you, Maria.

I get these stories once a week and it's a real privilege and honor.

It's been amazing the past four or five years, just every day is really inspiring.

And so in a PCORI trial we utilized a CHW model that shows that it works, and I'll show you it works again.

And we tried to integrate that with primary care and tried to get a more integrated system.

So I'm going to tell you about our study design and the results.

So in the upper lefthand corner there's home visits, which we just described.

There's another care team or another and these are sometimes operating in silos, so maybe it's another separate care team that is a clinic, and these are the primary care clinics and our local QFCs.

We did quality improvement process with them and provided EHR templates or health record templates that had clinical decision support, and change package about nine items, included asthma action plans and lung tests and allergy testing, all around having a routine followup visit with their asthma patients.

We also worked with the plans down at the bottom and working with their care managers and doing trainings there.

But also getting access to some of the reporting mechanisms they had about emergency department hospitalization visits in realtime.

We try to integrate the care teams through common asthma management plan or shared care plan and built that into the clinics that we worked with and tried to have folks talk to each other through a common mechanism.

So we designed this trial called "guidelines to practice" and enrolled 551 patients with uncontrolled asthma.

These were Medicaid patients, income qualifications but also access to healthcare.

And they were age five to 75.

We randomized the CHW level.

But we also worked with the clinics and health plans.

We didn't randomize at the clinic level.

We did separate them in a feasibility study to look at the enhancements and some clinics and we focused on the four larger clinics and then additional clinics that had delayed training in the enhancements we did after the trial.

And we worked with the health plans.

So the bottom righthand corner, there's a complicated diagram that shows that randomized patients ended up in four buckets.

There's one, two, three, four.

Each of the quadrants, upper lefthand quadrant has everyone talking to everyone.

The health plan is all working together.

And then the bottom righthand corner is usual care, where maybe silos exist, maybe they don't, but usual care and they weren't assigned to any enhancements and then the inbetweens.

Everyone pretty much is evenly spread into those buckets.

These are preliminary results.

We haven't published the report and still working on our primary outcomes paper.

So, this is not a deepdive into the results.

Spoiler alert: CHW intervention had significant results and enhanced clinic intervention did not have significant results.

Again, it wasn't randomized.

It is as important.

It has some significant results and these are these are opportunities and shows that there is an enhancement with the CHWs are working with the clinics.

Mostly focused on the CHW findings today and their role in the research.

This is a bit about who participated.

So they're pretty evenly divided among the ages, half kids and half adults, mostly female.

About a third are folks identified as black, African American, and of all of our clients, about just over a quarter identified as Latino or Hispanic.

They spoke three languages.

About a fifth spoke Spanish and we had Community Health Workers that represented the three languages.

These are numerical results pairing CHW to the nonCHW arm across primary and secondary outcomes.

I'm going to show a graphical representation of this in a second but you can see along the right side P values are all significant and these are the differences numerically.

But this explains it in a more graphical representation.

So asthma related quality of life was improved.

There were additional improvements seen when you look at the enhanced clinics and the CHW versus nonCHW, and then more days free of asthma symptoms, physical health, status improved.

Fewer people had poorly controlled asthma, changing categories from defining control.

Fewer asthma related emergency department visits or urgent care visits.

Fewer nights awakened by asthma, and reduced use in rescue medicine.

This isn't possible without supporting the Community Health Worker.

So I do want to spend I think this is very important and I want to spend some time on how we make the how we support the Community Health Worker.

So at the center, the circle is the Community Health Worker and there's a lot of folks that are necessary to support them.

And so we have supervisors.

There's a program supervisor maybe, that's me.

And in this case, and sometimes as a clinical supervisor that does both, but the clinical supervision is also necessary and can be a nurse or social worker or physician.

I talked about ongoing professional development and training, and this is necessary on a weekly, monthly, quarterly level, but in addition to the ones we mentioned, we learned how trainings and supervisor support the Community Health Workers.

They're in the field 70% of the time.

When they're in that office for 30% of the time I want them to be some of the most positive experiences of their day.

It's really difficult out there sometimes.

There can be amazing it's emotional, so it can be heartwarming and motivating, and it can also be really hard.

We make sure to focus on selfcare and make sure the elements are there for them to have that experience and to really be able to still be present for their clients.

Of course, there's an evaluation with research, but this is also helpful in program delivery and maintaining metrics and fidelity, and then there's other support.

We happen to be lucky to be a county health department where we sit in the chronic disease and prevention realm, so we have programs nearby that provide a supportive environment.

And we have a community advisory board focused on the partnerships we make.

So partnerships are really important to our program and any of you who might be utilizing Community Health Workers or building CHW programs, particularly in the PCORI realm, these are essential elements that are needed to make the program function and to build a thriving team.

And so I talked to you about our home environment work, which is housed in the CHW unit, and we have clinics and the health plans, but some of our additional partners these are just examples, but ones we definitely utilize are 90% 80something percent of our clients rent and so if you go into their home and talk to them about the roof leaking and the mold that is causing an asthma trigger, they might talk to their landlord in fear of retaliation.

So we have to partner with medical legal partnerships or organizations to help make sure those impacts are not realized or to make things a little bit more successful.

Weatherization programs offer home improvements for low income folks and they have programs that can be helpful and also healthful, largely focused around energy savings, but it turns out that they keep out rodents and they keep out mold and they make the home breathe better, and that's healthful.

We also work with other points of care and other places where children spend most of their time.

So we have a strong evidence base that we built over 20 years, but this is not yet part of the system and sustainable funding.

There are some examples of that, but certainly not universal, and certainly something that has happened only in some regions.

I just told you about the weatherization program.

We have some contracts with the Department of State or state Department of Commerce doing weatherization plus health.

It's a unique program.

It could be replicatable, but teaming with weatherization to give asthma programming with these social or these other programs to reinforce the connection.

Medicaid managed care organizations do contract our CHWs.

We haven't successfully gotten a contract with MCO yet, we're working on that, but that's an example that I have seen across the state.

Integrated health the Medicaid reform processes Medicaid reimbursement.

The example I'm giving here is Medicaid 1115 waiver.

That's happening right now in Washington state.

The state is focused on chronic disease and utilizing Community Health Workers so we might have a role there.

We're coming out of our planning year.

But other states have had very successful avenues with that.

So those are just examples.

I'm going to leave you with that and I'm going to move on to the next speakers, but we're certainly here for the questions that will come up.

Thank you.

[Applause]

>> I'm Nadirah Rogers in Philadelphia.

I was lucky to be one of the six who worked with patients for the PCORIfunded trial with the program.

I just want to tell you all a patient story, and we'll just call him Mr. D.

Mr. D, who was 44 years old at his doctor's appointment.

During this meeting with his doctor he set a goal of lowering his blood pressure, over 180.

After his appointment I sat down with him to understand what was going on in his life.

In other words, what did he think was causing his high blood pressure and what did he want to do to reach that goal of lowering it?

Me and Mr. D hit it off right away.

He's from south Philly and so am I.

He's the kind of guy that is charismatic, people love to listen to him talk, he knows this, so he often used it to his advantage.

Charming people to get what he wants.

I knew in order to work successfully with him I had to be straightup.

So I told him, I'm from south Philly too.

You can't fast talk me.

[ Laughter ]

Mr. D started laughing and said, you're right, you're right.

He accepted me as somebody from around the way.

He talked to me like anyone else he would in the neighborhood.

Because of this, he opened up to me.

He told me about some of his challenges, both in the past and in the present, including that he spent time in jail, and the fact he didn't have health insurance or a job.

He also opened up to me about his cocaine use.

In our first meeting, Mr. D says something that really stood out to me.

He says, "it's the devil's playground."

Given he wasn't working, Mr. D had too much time on his hand.

I thought, hey, let me invite him to the gym.

He had a gym membership that he wasn't using, so we made a plan to meet at the gym twice a week at 8:00 in the morning.

Those workouts were good for his health and our game plan.

During the workouts, Mr. D talked to me about when he was in jail, he received a training in culinary arts and received a certificate.

He was proud of his accomplishments and he takes pride in his cooking.

He said that he was looking for an appointment and I had let him know about an upcoming job fair at onsite interviewing.

He was really nervous about attending this because his past criminal history.

Later on that week he called me and said, “Yo, Nah... I got the job at the restaurant.”

I said, what's up!?

I'm going to come past to see if you can really cook.

Of course he laughed.

He completed the program in the right direction.

A few months later I saw Mr. D in an art museum and he looked great.

He told me that he was still working out twice a week and still had the same job.

I looked at him and I say, "You look great, you are so decent!"

It was so amazing to see him doing a great job and know I was the person that helped him.

Mr. D is awesome!

[Applause]

>> Thank you, Nadirah.

And I think we have pictures of Mr. D, right?

I'm just going to here is when you first met him.

>> Yes.

[Applause]

>> So, thank you.

I'm excited to talk about our PCORI funded study.

Over the past eight years my colleagues and I have developed and refined the impact Community Health Worker model.

What makes this intervention, we feel, unique, but maybe not so unique after listening, because I think there's a lot of overlap you'll hear, are three particular elements.

First, it's very patient centered.

Our Community Health Workers are always asking the patients what they think they need to improve their health.

And then offer hands on tailored support.

You just heard a wonderful example of that.

In this picture, what you see is a patient who suggested that what she wanted to do was play basketball with her Community Health Worker, and this is a picture of them playing basketball.

And during the breaks, the Community Health Worker helped her apply for housing.

So a way of her setting the agenda and deciding which way they should go and how they want to work with the Community Health Worker.

Second, the impact model is very standardized at this point.

We have developed intervention guidelines for hiring, training and supervision and have been these have been codified in detailed manuals as well as inperson and online training.

We have a monthlong training for our Community Health Workers.

And software for documentation and reporting, as you heard in the previous presentation that supervision and support of your Community Health Workers is critical.

Finally, our impact model is evidence based also.

We conducted two prior single center trials that have established that the intervention improves outcome, mental health and quality of care across a range of diseases.

One of the things that we particularly went to do when we started to design this was to make this disease agnostic.

It doesn't have to be a specific disease.

But these trials were limited in they were all single center trials and a lot of Community Health Worker or other community based interventions have been difficult to replicate in different environments.

Like you make it for the environment, but then it's difficult to take it to another environment.

So I'm going to move on to our PCORI funded study, which we just had published last week in JAMA Internal Medicine.

We're proud about that.

[Applause]

Thank you.

And the objective was to determine if in a multicenter randomized controlled trial, whether six months of goal setting and Community Health Worker support leads to improved outcomes compared to goal setting alone.

And we conducted this in a VA medical center, a federally qualified health center, and an academic medical center.

Are participants were uninsured or publicly insured.

Residents of high poverty regions in Philadelphia and two or more of the following conditions.

Hypertension, obesity and tobacco dependence and at least one in poor control.

Any cigarettes is bad control, so that counted as bad control if you were a smoker.

Outcomes assessed at six months and at which time the intervention end and we followed them for another three months, so a total of nine months.

Our primary outcome was self rated physical health and this was chosen with our patients and Community Health Workers because the patients said "we just want to feel better."

Pre-secondary outcomes, mental health, chronic disease control, patient activation, quality of primary care and all calls hospitalizations, and we used intent to treat and analyze using equations to account for repeated measures.

So prior to the study starting, we did a process we do whenever we work with a different a new organization, as we spend about one to three months working with the stakeholders at that site to adapt our existing intervention materials to the site, which include tailoring the communication software and training for the local policies and preferences, CHWs delivered intervention at each site, so really embedded in the clinical teams at those sites.

And they all had work privileges, space and access to the site specific electronic medical record, which was different at all three sites.

Despite these adaptations, the core intervention was relatively consistent, and as I said, six months of tailored support with weekly minimum weekly contact from your community health worker and minimum monthly face to face meetings, but most people were out in the community meeting with the people their clients much more frequently than monthly.

Two study arms were basically very similar and baseline characteristics.

We enrolled 592 people.

Similarly 62% women.

I didn't put that on the slide.

They were middle aged, mostly mean age was 52.

94% were African American.

65% had a household income of less than 15 now a year, 15,000 a year and 98% reported a traumatic event on a trauma history question.

So a vulnerable population that has dealt with many life hardships.

Here are some examples of what our Community Health Workers have done.

And you already heard one example, but for 65yearold socially isolated veteran with PTSD and hypertension, the Community Health Worker, also a veteran, which was important, organize outings with other veterans, including bowling, movies and they planted an urban garden together.

And for a 32 year old single mother with asthma living in a moldy shelter basement, the Community Health Worker advocated for her to get a first floor room with a window to help with her asthma control.

So here are some of our results.

It's a little bit difficult to follow, so I'll just sort of summarize, but these are the differences over zero, six and nine months in our prespecified outcomes between arms.

So both arms had very similar improvements in self rated physical health, which was our primary outcome.

Mental health and chronic disease control.

But the intervention arm had much greater improvements in patient activation.

So the patients felt more able to take care of their own diseases, and they also were much more likely to report the highest quality of care pertaining to comprehensiveness and social and support for disease self management.

And then moving to hospitalizations, the intervention patients spent 155 days in the hospital versus 345 days in the control group, which is absolute rate reduction of 69%.

And nine months intervention patients had 300 hospital days compared to 471, which is a reduction of 65%.

And we look at what drove some of these differences.

What we see is they had a much shorter average length of stay, about 3.1 less days when hospitalized, which we think we don't know for sure that the medical teams were more comfortable discharging people when they knew that there was social support being provided by the Community Health Worker.

And what we also saw is a lower risk of repeat admissions, including 30day readmissions among patients who were hospitalized.

And as people know, in the healthcare business, 30day re-hospitalizations is a huge needle that healthcare providers and insurers want us to move.

So overall the intervention was replicated quickly across institutions.

It yielded benefits in a relatively short time horizon and demonstrated persistence of effect, minor.

We couldn't follow people for longer than the period of three months after the intervention was done.

But we feel that taken together they support the notion that social interventions can be a practical tool for healthcare organizations seeking to improve clinical outcomes.

This was very health care centered based.

So going on to kind of dissemination.

Impact is currently first of all, I will say the VA has continued to our academic health center and VA has continued the Community Health Worker program without PCORI funding, and the program is being widely disseminated.

We have provided care to over 7,500 patients in Philadelphia, and our tools and trainings have been accessed by over 1,000 organizations across the country.

And we are working closely with 20 healthcare organizations to help them launch their own Community Health Worker programs.

We were most recently named a gold status practice by the VA and are working with Iowa city VA to help them start an impact Community Health Worker program.

And then finally a little plug, if people in the PCORI audience are here, we have a pending PCORI DNI proposal, hopefully to work with two more VAs, the Pittsburgh VA and Wilmington VA and statewide Medicaid payer, so we're hoping that gets funded.

We'll give you results if it.

And if you want to learn more about our center or anything, that's the website there, and you can access and get a lot of the information I provided here.

Now I'm going to play a little of a movie we made for the VA, so very VA centered, again, sort of another story, and it's nice to see these things.

>> I was going to the VA because I had an alcohol problem.

I was an alcohol problem

>> I see when patients go home they tend to need a little more social support.

Some of them are alone, suffering a lot of mental health issues but.

I think they face a lot of challenges unique to that patient population

>> In 2014, a powerful solution at the VA medical center in Philadelphia.

Impact community health workers, trained lay people who share life experiences with our veterans.

CHWs do things that doctors, nurses and social workers don't.

They're out in the community, connecting veterans to resources and building important social connections.

For example, Tony Davis, a CHW at the VA had a group of socially isolated veterans together to build and tend an urban garden.

>> My mission at the veterans center is to help provide social support for members of our community, specifically veterans, to help guide them and help give them back their independence.

>> A multidisciplinary team has spent close to a decade building impact, standardized scalable Community Health Worker program that improves health and lowers costs.

>> Because of the way it's been set up, it's easy to be in the facility, irrespective of patient population characteristics.

>> That's the they were all my brothers.

Tony is our leader.

We look up to him.

He's...

[chuckles]

>> Thank you very much.

[Applause]

>> I got it.

It needs to be refreshed.

Sorry, I have a few more steps in there with that.

Hi, good afternoon.

How is everybody doing today?

I know it's kind of the end of the day.

We are just wrapping up and, I don't know, people should maybe move around or something to get some of the energy going.

My name is Sinsi HernandezCancio...

Wait, that would help.

Oh, my goodness gracious.

Sorry.

>> Sinsi HernandezCancio: The running joke in my office is that I have some sort of weird magnetic or something problem, because technology simply breaks down on me in ways that it just doesn't break down on anybody else.

Maybe just one too many MRIs or something like that.

So my name is Sinsi HernandezCancio, I'm really excited to be here because I think that CHWs have an enormous potential in solving a lot of inequities in this country.

I'm excited to say that we have just filing the contract to do engagement work with PCORI.

So that's my disclosure.

I did spend three years as a caregiver and consumer and patient representative in the disparities advisory committee.

I probably got the exact name wrong.

But what I want to talk about is two things.

I want to contextualize what we've been hearing around how CHWs are so important for addressing inequities and digging into the barriers to broader implementation and understanding how do we solve for the fact that there isn't sustainable funding right now for these incredible interventions that we know are so effective for so many different types of people and so many different types of conditions.

So first let me tell you about families USA.

We're a national nonprofit nonpartisan healthcare advocacy organization.

We've been around more than 35 years.

Most of the time we're really focused on coverage, on getting more people covered.

We were really involved in the Affordable Care Act and in getting it passed and its implementation, but the last few years we realized an insurance card is only the beginning and that it's a lot like a cell phone, right?

It's only as good as the network it's on, and a lot of places, the communities we're concerned about, there are literal problems with healthcare networks as well as a lot of more symbolic problems with networks in the sense of what is available for communities to be able to improve their health.

Is so we ex panned our work community engagement, our bread and butter focusing on healthcare value.

And I lead that intersection between health equity and healthcare value or transformation.

The way we're doing that right now is with two major projects.

One is our Community Health Worker sustainability collaborative, because our belief is that if you're thinking about when we transform and change the way healthcare is paid for to pay for things that are more valuable and efficient and effective and address disparities, one of the best examples of an intervention that is very effective yet not wellintegrated into healthcare system, not baked into how we do health is Community Health Workers.

So community health collaborative is really focused on talking figuring out how to get more Medicaid funding in particular because of the populations we're talking about to support Community Health Worker work across the country.

Incidentally just yesterday we had a webinar of the collaborative where we were looking at a couple interesting tools where we were trying to measure return on investment and other social impact of two specific Community Health Worker models that advocates from across the country can plug in their state information and come up with these estimates.

One of them was based on the impact model I'm sorry, one was based on the asthma model in Washington.

So we're excited about that.

I do want to give background where we come from thinking about health equity.

It's important to understand and I think Community Health Workers are one of the best examples of this, is that to achieve a common outcome, an outcome that we all want to achieve, which is have a more productive nation, is equality and equity are not the same thing.

Equality means that everybody gets exactly the same thing, whether or not they need it and whether or not it actually helps them.

Equity is all about making sure that people have what they need to achieve the goal that you are talking about.

For example, one way of thinking about this, professor John A. Powell at Berkeley talks about targeted universalism.

You have a universal goal.

You don't want to have separate standards for different people, but you need to have you need to target interventions and resources so that everybody can get up to that goal, so that everybody can, you know, pick that apple.

System health transformation is an enormous opportunity because it's about changing the boxes they're standing on.

It's about how do you allocate resources differently so that more people can take a bite of that apple.

And to do this, it's really important to understand that there's a whole spectrum of health that influence and determine your health opportunity and your health outcomes.

This is a piece borrowed I think a very good schematic borrowed from the Kaiser foundation.

I had from a perspective friendly amendments let the authors know that I had these amendments.

One of the principal ones is that food has to be bigger than that.

It's physical sustenance.

If you think about it, you need to worry about clean water and air as well.

It's a category of everything you're putting in your body, whether breathing, eating it, drinking it.

It has huge impact in health.

The other thing that was a little bit you know, didn't really fit what I understood and what health equity researchers understand is that it's not only the community and social context.

Discrimination affects stability and neighborhood and physical environment and every single one of these categories including provision of healthcare.

And then for those that are really focused specifically on changing healthcare systems, one fact that can be a little discouraging sometimes is the fact that the healthcare itself, the care you get is at most 20% the factor that produce your health outcome.

A lot of people think it's less.

By the way, if you're wondering, genetics, even less.

Right?

So what this means is that if you really want to change the really move the needle on health disparities and the outcomes of health for a lot of communities, you can't afford to just stay in that particular healthcare system column, right?

And so I did want to talk a little more about this issue of bias in the healthcare system.

Because there are some really relatively new information that I think is very important for all of us in this space to understand.

Around this time last year the Robert Johnson foundation, NPR, and the Harvard School of Public Health started publishing a series on research they had done on people's own experience with discrimination.

So this had never been done before.

There's been studies what people think about discrimination, whether it happens or not.

This was people being asked: "Have you or your family experienced this, this or this?

And they asked a whole bunch of different things on education and jobs and neighborhood and police.

And they also asked two questions on healthcare.

And so what this shows is that one in three African Americans have personally experienced discrimination or bias when trying to get healthcare.

And similarly, you know, one in five Latinos, almost a quarter of Native Americans, and you can see the other results there.

And that was, for me, actually, as a person of color, who has had to deal with the health system a lot, father with a primary care physician practicing in places he saw a lot of discrimination, that was not surprising to me.

What was surprising and concerning to me is the data on how many people decide to not go seek healthcare that they need because they don't want to have to deal with discrimination.

You know, having to go through that level of disrespect and, you know, harassment and isolation was not worth getting your healthcare your health taken care of.

And that is something that is critical for us in this country to address.

So I want to talk a little bit go ahead, yeah.

[Applause]

I used to work for a union, I'm all about the response.

So, I do want to talk a little more about discrimination on health, because it's not just one thing.

First of all, the fact that we live in what is a very, very segregated country still, racially segregated, you know, there's plenty evidence of that.

We haven't improved that much in the last 50 years when it comes to racial residential segregation.

It means there are a lot of communities who have a lot higher health risk.

Like the threats to their health are much higher than average.

At the same time, those and that's because of discrimination and how, you know, resources are allocated, how bad things are allocated, like dumps or bad air, you know, bad water.

In addition to that, they also have lower health opportunity, right?

So they have less access to medications, less access to care, less access to exercise, less access to, you know, better foods.

You know, things that are in many communities are, you know, common and available.

Then on top of that those are kind of systemic problems that discrimination produces.

In addition to that, there is a lot of evidence about the physiological and psychological effects of having to deal with daytoday discrimination.

And it's not just like, oh, put me in a bad mood or, you know, that kind of thing.

There has been very, very detailed evidence around the impact of adverse childhood events, for example, of the impact of what allostatic load means, this idea that your body when your body has to be in a fight, flight or freeze mode constantly, your brain and your body gets overloaded with hormones and a whole bunch of other issues happen that actually not only affect your mental health but actually affect your physical health over time.

And even damage your DNA.

So Arlene out of University of Michigan has been doing a lot of research around this issue of allostatic load and what she calls weathering, and comparing white middle age women to black middle age women she looked at the DNAs and found the telomeres I'm not a science person to that degree, but it's important in the aging process.

So the telomeres of same aged women, the black women had shorter ones than the white women.

And when they translate that into extra years of aging, it meant at middle age, black women are seven and a half years older physiologically than white women.

So this issue of figuring out how we deal with the interpersonal racism and discrimination is extremely important if we want to see longterm effective results.

finally, having all these issues, you go to the doctor and you're going to be dealing in many cases with bias in the healthcare system.

You know, it's a multifactorial problem but it's important for us to understand there are all these moving parts to this.

So, what that means is that if you are trying to improve health equity, there is a whole spectrum of health equity intervention points.

It's not like there's a magic bullet.

That's the bad news.

There's not one thing we can do to fix it.

But the good news is there is a lot of different things people could do to fix it, whether you're working in trying to improve poverty and better jobs and schools, you're making an impact.

Whether you're working on the other end like upstream, right?

If you're working on the other end and downstream and hospitals and clinics and so forth, there are plenty of things that need to be improved in the healthcare system.

But where I think there is incredible opportunity is how do we connect those two, how do we make it easier for those two sides of the equation to work together?

And that's exactly one of the places where Community Health Workers are extremely, extremely powerful and important.

So that means generally that, you know, you basically just have to figure out, what is the thing you want to do?

What is your lane?

You can have an intervention in any one of these along this whole spectrum and make a big difference in your community and overall.

So, why would we need to address racial inequities right now?

And one of the reasons that there's so much more attention in addition to, like, this really toxic political environment that we're in these days, is that on the one hand, they're very expensive.

Health inequities are a huge waste of resources.

So some of us really care about the moral cause, the fact there are so many million years of life years lost due to inequities.

For example, I think the latest statistic is around 200 African Americans die every month prematurely because of health inequities.

Most people don't think about it because it's not happening like that, but I can assure you if there was an airplane of 200 black people who crashed every day, we would want to be doing something about it, right?

And also huge economic costs.

Not just for the healthcare system, which is very expensive, but the whole economy of the country.

And the other reason it's urgent to deal with this right now is there's a demographic imperative to fix really fast.

As of 2011 the majority of birth in this country were of children of color.

Today, right now, all the children under the age of 10, the majority of kids of color.

What does that mean in terms of what is the future workforce?

Who is paying into taxes and Social Security?

Really important demographer, William Fray from the urban institute, talked about the fact when it comes to total growth in population, growth in workforce and the voting pool, the majority it's being driven by people of color for the foreseeable future.

The exact quote.

For the foreseeable future.

If our healthcare system can't figure out how to make sure these kids right now are healthy and thriving and able to contribute and help us all in our retirement when we're old and frail, then we really need to figure out how to solve this problem.

So, that brings me to why CHWs are so awesome.

First I should disclose that my mom was a prima doula when I was a kid.

I have an emotional connection hearing what she did in Puerto Rico from western Massachusetts.

Not just because my mom did it that I think it's great.

There's so much evidence about it.

It's important to understand this Trinity of how it is that Community Health Workers could add value and transform healthcare.

Because they improve health.

They reduce costs.

And they reduce disparities.

So this particular graphic kind of shows how these things connect with each other and interplay to be able to get really solid effective results.

But there are some barriers to options of Community Health Workers.

Some of them have already been mentioned.

For example, I think one of the big one is there is lack of awareness or knowledge of the value of including CHWs on healthcare teams.

And values can be like, we know they're valuable, but a lot of people want to know, how much money are we going to save by doing that?

And that is a challenge and a barrier as well.

Then we have also a lot of lack of clarity about what is a professional identity, how they work in clinical care teams.

Some people name a variable there's no standardized curriculum or training program.

Others say that's what's need. You need there should be some core competencies, but a lot of flexibility is required to serve such diverse populations who need so many different kinds of assistance.

And that there are a wide variety of models in prevention designs and have been cited as a barrier.

But, again, another way to look at it is that's a strength.

That's why they're so effective.

Finally, the lack of sustainable funding.

What I want to focus on for the minutes I have left are these two barriers.

Lack of awareness and lack of sustainable funding.

Lack of awareness of value, there are generations across the country and in this world about how Community Health Workers really add value to people's lives and to the healthcare system.

And so being able but being able to have patient centered outcomes and comparative research that kind of shows it and proves it to the skeptic so to speak is really important.

That's why I've been so excited to partner with PCORI on these issues.

Because a lot of people want to see be able to build a case especially trying to change policymakers' minds, they may have best intentions but at the end of the day they want to know what the economic value is, how much it's going to cost, how much it's going to save, what is the investment, and social value is great, but it's less convincing to the people who hold the paychecks, who hold the checkbook, right?

And then the other thing that the other thing we need is better defined research.

It would be helpful to have better defined research that focuses specifically on creating and building a narrative about this value.

And not necessarily just OR value, but like the example we heard today, to do it we have to tie that together in ways that the policymakers, the ones who decide who gets what, when and where, are convinced.

But the other issue is lack of sustainable funding, which is very tied to this.

And, you know, most of you know, right now it's largely grant based or squeezed out of general operating budgets, which means that, you know, you have a great intervention and three years in the grant is gone and there's a lack of continuity, which makes it really hard to establish a workforce that can sustain itself if you don't know if in two years suddenly you're there's not money for your job anymore.

And that, of course, also affects other barriers as well.

So what we have done at families USA is kind of really delineated what are some of the Medicaid funding pathways, some of which were referred to earlier, and we do provide some technical assistance with advocates and governments on, you know, how you might be able to do any one of these.

And just to finish off, also because I know we have a Medicaid managed care person in the room, there is one very excellent example that we found in working with our partners across the country of how in New Mexico they merged Medicaid management care hot spotting with CHW intervention.

Basically this looks complicated but what they did was really focus on that circle that is care coordinated that is I thought this laser pointer would be good, but, again is that working?

No, it's not.

Okay, whatever.

That circle, all the way don't worry about it.

That circle all the way there are the top 5% utilizers, and they get everything, critically pay support, very intense care coordination in addition to the community health support.

And what they were able to negotiate with the managed care Medicaid plan there was that they would get a separate this HQFC and university site were going to get a separate per member per month payment just for the top 5% utilizers for the family and individual supports department.

And then those Community Health Workers there could do whatever was necessary.

They didn't have to say exactly, you know, I'm doing preventive care, or XY intervention.

It was a pot of money they had for improving the health of those patients.

And the results were stunning.

Let me see if I can make this happen.

I don't know what is happening.

It's doing something very strange.

There's a blue circle just going around and around and around.

Well, it was a cool little graphic spinning around, maybe too much for this computer.

But I'll get to the punch line.

Can you hear me?

Which is they saved $4 for every dollar they spent.

And that pretty much was the end of my presentation anyway.

[Applause]

But I do encourage you all to now shut down the computer, so I'm just going to move away.

[ Laughter ]

And...

>> You broke it.

>> Sinsi HernandezCancio: And I'll never be invited again.

And I will encourage you to go to the families USA website and sign up for the Community Health Worker and sustainability collaborative to learn what we're doing on the payment front.

[Applause]

>> Good afternoon.

He's going to get my slides up for me, because I'm a technoboob, so I'm not going to try it.

That's it.

it's a real honor to be up here with this panel and interesting to see the I think the commonalities in all of these programs and all the ways we use Community Health Workers.

I will tell you I'm the only one up here, I think, that is not a PCORI grant recipient.

So we invest in Community Health Workers but we do it because we believe it's the right thing to do, and as you said, it is economically feasible.

And here we go, I think.

>> That's what I get...

>> While he's pulling this up, this is a Medicaid managed care company.

We started as mercy health plan in west Philadelphia in the 1980s, so we were at Misericordia hospital because they were having a problem with too many people showing up in the emergency room without a medical home, and so they started a plan to try to address that problem.

And is there a clicker?

Oh, this...

Okay.

There we go.

I have no conflicts to disclose.

We're now in 16 states and primarily Medicaid operations through our PBN and managed care plans.

The members we serve, or the members everybody has been talking about, the patients everybody has been talking about, they have complex, very complex physical behavioral health needs.

Many live in socially disadvantaged neighborhoods.

They're not just poor adults and the barriers that they face are significant.

Moms, babies, children, individuals with chronic disabilities lots of... whoops.

Lots of behavioral health literacy, polypharmacy, substance abuse, drug adherence issues.

And so they require intensive support.

So, increasingly we have placed care managers in the community and used community health workers or community health navigators, as we like to call them, to support our integrated care model.

And we're looking not the 5% of the population, we always say probably attributes to 50% of the medical cost, but we've developed our community care management teams are really constructed to address the needs of the super utilizers.

So these are the individuals in that red circle at the top of the pyramid, and they're individuals that maybe have had ten visits to the emergency room in a year or five inpatient hospitalizations.

And it's not just one year.

It's year after year after year.

And a lot of the reasons for those hospitalizations are because they're not engaged in their care, and the social barriers that they're facing are just too overwhelming.

So our community care management teams provide longterm high touch facetoface engagement.

And they are multidisciplinary teams.

So we have a medical director, we have a nurse, we have social workers, we have nutritionists, we have pharmacists, and we have Community Health Workers.

And also peer support specialists.

And they're there to address unmet social and behavioral health needs and they're there to engage the members that we can't reach otherwise.

So we...

Oops, I keep going too fast.

Excuse me.

So, really these are the hardest to reach individuals.

We know that if you don't engage a member, the outcomes are not good.

As has been said previously, these individuals live in the communities and the neighborhoods in which we're sending them out.

We also we've been using Community Health Workers, though, to find and engage members who haven't accessed care for many years.

So we called them our "cause team."

And what they would do, if somebody, in a managed care plan, you're continuously looking to improve your gaps in care for individuals with chronic disease, improve your HEDA scores.

And so if someone has not had a visit in six months, a year, we're trying to get them in for those visits, because we're measured on that.

And so these folks have always been going out into the neighbors and basically knocking on doors.

They help members identify and address barriers to care and we have always, in any of our programs, tried to be very provider collaborative.

We have also Community Health Workers have also been a part of our comprehensive asthma management program for several years now.

And we recently revamped the program in our asthma navigator training program, and we partnered with the Philadelphia health promotion council, and we now have 40 certified asthma trainers.

So they go in and they're looking for bed bugs and they're looking for, you know, they're addressing roach problems and dust mites, etc.

When we first introduced our community care management team programs, we tried to base the program with the super utilizers on Jet Brenner's work in Camden.

We used a lot of geocoding to identify hot spots where care is needed.

But with Community Health Workers, what we're also using the geocoding to identify hot spots of areas where we have large areas of individuals whose care can be impactable, whose care we think by sending these folks out, you know you have to have a critical mass and concentration for this to be economically effective.

And Community Health Workers are less expensive to employ and deploy than registered nurses or other licensed clinicians, but all of our communitybased programs are very resource intensive.

So we try to get the most bang from our buck.

We piloted our community care management program in Philadelphia in 2012.

And we've expanded it now to all of our markets except one across the country.

And we will be introducing in Delaware soon.

And we over 1500 members have been engaged for a period of at least six months in the program over the last five years.

Results from the community care management team program continue to be promising.

The first year we did this, you know, we saw a 40% reduction in patient hospitalizations.

The emergency room visits seem to lag a little bit.

It was tougher to tougher to really impact people from going to the emergency room.

But hospitalizations, preventable readmissions an total cost of care, we continue to see positive program results as we've expanded the program.

All of our community health workers complete a comprehensive training program, like do others.

We also I listed as a barrier the right level of training, and I think we're all still grappling with that.

It's very important you know, most of these folks have a high school diploma or a GED, and maybe they have had one or two other, you know, medical some kind of training in health, or some kind of class in health.

But we try to give them basic training, motivational training, engagement training, but in addition to that, safety training, and a lot of what we're doing is trying to ensure the personal safety of these folks, because they're going into neighborhoods that aren't so nice.

And we've had a couple of incidents where individuals were really in a hostile situation.

So we now actually do geotracking on folks and we use a geotracker app so we know where they are and we know where they're supposed to be.

And if so at least if somebody doesn't check in, we're going to be going out there.

But I think that's more and more going to be as these programs become more mainstream, it's going to be something we're grappling with.

We try to ensure health safety.

Bed bug training, vaccinations, all those sorts of things.

And as I said, how do we locate associates in the field.

Really, there is I know I'm the last person, and we want to have a little discussion here, but there's really no doubt that Community Health Workers are extremely effective in engaging members who haven't been accepted to other outreach methods like phone calls or text messages.

For some members that means engaging them multiple times, even if it means stopping by, you know, their house 20 times and on the 21st time they're finally receptive.

So, especially with our community care management team, it's a multidisciplinary team.

We have clinicians, the Community Health Workers get a lot of support, but really they're the first one in.

They're the first one in to establish the relationship with the member, and sometimes you know, I've heard our staff say that sometimes it can take up to six months to really, you know, get that person to open up, address the social issues that are going on before we can actually get our clinician care managers in to really get the patient to start to work on care to improve a physical chronic disease or some other condition.

The community based workforce requires supportive leadership.

I think it's already been said.

We certainly agree.

Most of our staff I mean, they're just this far away.

I mean, they are effective because they understand they understand what is going on in those communities and theythey're trusted.

But they're only that far away.

They've lived these.

They've lived in those patient's shoes before.

They've walked the walk, and, you know, it's very easy to fall back.

Provider partners and champions are also key.

We also embed Community Health Workers in some QHFCs in practices, but if you don't have a physician champion, we find that the Community Health Workers are often very underutilized.

So we're still learning, but we believe that the you know, we have reaped both personal on a member on an individual memberbymember basis, you can see that there are absolutely individuals who have been saved by these interventions, but we also see that the from a mostly from an inpatient hospital admission perspective, there is an economic ROI to using Community Health Workers and we continue to expand the programs.

So I think hopefully we have time for a couple of questions.

Thank you very much.

[Applause]

>> Thank you all so much.

That was all very informative, very inspirational presentations.

So thank you very much.

Now I would like to invite the audience to ask some questions.

We have some time.

Go ahead.

>> I come from a public library, library background professionally and I'm wondering if any of you there was a lot of mention of health literacy as a critical piece, but whether there are programs or plans or any of you have considered integrating public libraries into a community health worker landscape.

West Philadelphia has that same sense of the library is part of the community, a trusted place.

You could embed Community Health Workers there, for instance, and, you know, integrate people into kind of the social lifelong learning and other services that a public library provides.

I would be interested to hear thoughts on that.

>> I can say something on that.

While we haven't had Community Health Workers in libraries, which would be excellent, there is a robust movement to use public libraries as a place to deliver sort of community engagement, getting people into healthcare, getting them some basic information.

And there's actually a program in the libraries in Philadelphia to start training librarians to deliver.

So mostly focused through training librarians to deliver these types of mostly connecting people to services.

A lot of it is around mental health and substance use.

They're often used as places for people to, in cold weather, to sit or get out of the way.

But they are very trusted institutions.

So I think it's a great idea.

We haven't necessarily I haven't seen Community Health Workers, but more about training librarians to do some of the things that Community Health Workers are doing.

>> Are there any other questions?

>> In thinking about libraries and hearing somebody mention about faith based organizations, do you all utilize any places of worship in faith based organizations, any of the work you do, or having your Community Health Workers involved in that way?

Also, in hearing, as a parent of two now young adults with disability conditions, I'm not ever hearing anything so far or very lightly touched on when we talked about healthcare disparities, all the list of things you talked about with healthcare disparities and biases and whatnot, that could be a person with visible disability as well.

I know because I have a son who people have shunned based on his physical disability and appearance for his entire life.

And now the problems he is facing in transferring in to the adult healthcare services because of his special healthcare needs.

So I'm just curious, do you all have any overlap in training because disability cuts across all of what you have talked about?

>> I can speak to the first question about the faith based, and I's really I don't know if this is on or not there we go.

It's really different from community to community and the populations that you are serving, but we actually have a what we call a women's empowerment tour.

And so we do it in several different markets, and what and we called it the 40day journey, but really in some communities in the church, you know, the pastor's wife sits with the with women, for the most part, and they do nutrition, they do breast cancer, they do a number of different topics, but that's been very effective.

We have not used Community Health Workers in any of those programs, however.

I don't know if anybody can speak to the disabilities.

>> So you're absolutely right, and in a lot of the work that we do at families, generally we also have folks working in the disability community, working with us on our task force and health equity work.

That wasn't like the focus what I was going to talk about today, but you're absolutely right, there's a huge issue.

Also disparities in disability, right?

Communities of color are more likely to suffer disabilities as well.

So we always try to take a very intersectional approach to our work, looking at factors that can impact how you receive care, what your health can be like, including gender and sexual orientation and those factors as well.

And as far as the church question, I do know that, you know, we at families think of Community Health Workers in a Broadway, for example, also to include peers and community based doulas and things like that.

And we are aware of faith based groups not necessarily churches but faith based groups that have Community Health Workers working with them.

Jeff Brenner's Camden example, how thou engage with the community was by partnering with a faith based community organizing organization in Philadelphia.

To get the trust that they needed from the community there.

>> Good evening.

Great information.

Lynn Miller from Kansas City, Missouri, and I'm an advocate for a program there.

I work with teenagers.

And I was just wondering that's our next generation, and what are we doing?

What have you done especially with Community Health Workers to impact the next generation and maybe grow up a generation of young people who are more knowledgeable about healthcare and can transfer that information to their grandparents, parents, things like that?

>> Go ahead.

>> You can go.

>> We have a again, this is not necessarily using Community Health Workers, but when you talk we use Community Health Workers when we talk about the individuals we're trying to reach, they can be of any age.

But what we do have is what we call our GED program.

So individuals we we do support individuals in getting their GEDs and have care managers, and I guess, you know, really, ancillary support.

So a staff that they probably have the same level same level education as a Community Health Worker in the field, but we pair them with members who are interested in this program to help support them to get their GED.

So education is certainly huge.

And education is certainly huge for younger individuals rather than, you know, when you're in your 60s or 70s probably.

>> You bring up a good point having to intervene early.

A lot of the models, the reason they show a great ROI, because they have to show it in a year or year and a half, they're working with people that already have a lot of problems.

It's hard to show you're saving a bunch of money by intervening with teenagers so that ten years from now they don't get diabetes.

That's an inherent challenge getting this baked in the healthcare system.

There are excellent programs out there that employ some version of Community Health Workers with young people young adults and teenagers around maternal mortality, around reproductive issues, in addition to, like, conditions like asthma and, you know, the way we're seeing obesity and hypertension start earlier and diabetes start earlier and earlier.

So it's a very flexible model that way, as she was saying flexible model that way, as she was saying, but your point is well taken that we need to not wait until 17 things have gone wrong in this person's healthcare history before you start intervening.

>> I think we're

>> I want to say is there a question about people with disabilities?

We do work with people with disabilities.

I was working with one patient that needed a motor chair, and he left his regular wheelchair at the hospital.

I advocated for him, got him an appointment so he could actually get a new motor chair.

And our job is very supportive of us, so if we need additional training, they do not hesitate to bring someone in to train us on any patient, like new symptoms and stuff like that.

>> I would add to that I was going to emphasize training and engagement, but and we have a very similar story with patients getting durable medical equipment by partnering with their managed care organization and making sure that they're getting access to all the resources that they can.

But all of these are great ideas and I've jotted them down.

It's worth reaching out to folks to see if there's training opportunities and also see if there's engagement opportunities.

We offer a wide variety of trainings throughout.

We have a weekly training and other training schedules that to bring in additional resources, to I'm stuck with this analogy in my head about a sponge.

So... (chuckling)... just absorb information from the community, there's an incredible resourcefulness in our Community Health Workers.

So I think these are all great opportunities to engage to see if there's opportunities for co-training or availability to sit with either the staff there or to either train them or have them train back.

Also, it's an outreach opportunity.

A lot of when I worked in the different research setting, we didn't necessarily go out and disseminate our information or do outreach or health events, but when I came to the county, when I first came in, I watched the Community Health Workers going on to Spanish speaking radio.

We had a joke called KCHW was the radio network they were running, but I watched them spend a lot of time out in the field, and it was a very different and surprising environment, that there's a lot of resources and trust into our staff to go out into the field and to hold these educational events.

So we've been doing a lot more of that.

We have been doing that in some faith based settings, and we have been doing it in these apartment complexes where we saw a lot of referrals but not a lot of uptick of our program.

And so we targeted those and asked that their building managers, if they would be willing to have different training opportunities and they created venues and when they didn't create venues, we asked libraries if we could use their venue.

And we brought people together to just tell them about asthma or diabetes.

And it spoke to teens.

It spoke to families across the board.

And sometimes it would generate a client, but not usually.

I don't know if it was necessarily a client, but there was incredible energy for motivating us but also to get the word out to the public.

>> A lot of children were showing up, small little children were showing up just to hear about what we had, you know, what they would learn from us.

So that was really encouraging.

>> I'd like to we're just about out of time.

I would really like to thank our speakers again.

So really appreciate you coming here.

[Applause]

>> And sharing.

Thank you so much.