What is Health?a presentation on community health in broad terms and

what it means for you as an Americorps member… Given by

Sherri Ohly ~ sherri.ohly@gmail.com

Shari Galitzer ~ shari.galitzer@gmail.com

September 11, 2013Stevens Point Wisconsin

Asthma A day in the life

Who are you? Why are you here?

What will you be doing with your Americorps year?

(In one minute or less!)

Introductions

Video clip - http://www.whatispublichealth.org/what/index.html

Public Health vs Clinical Care

Public Health vs Clinical Care

Video clip - http://www.whatispublichealth.org/what/index.html

Public Health vs Clinical Care

The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world. ~ World Health Organization

Social Determinants of Health

How about this one….

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Healthy People 2020 (Centers for Disease Control)

What?!?!?!?!?

Availability of resources to meet daily needs (e.g., safe housing and local food markets)

Access to educational, economic, and job opportunities

Access to health care services Exposure to crime, violence, and social

disorder (e.g., presence of trash and lack of cooperation in a community)

Transportation options

For example….

My favorite…..

Creating conditions for everyone, every day, everywhere to haveequal chances and

fullest choices to be healthy and thrive and

live well and long, from generation to generation.

~ Magda Peck

200 countries200 years

4 minutes

How does poverty effect health?

The Burden of Chronic Disease

1. Heart Disease2. Cancer3. Chronic Lung Disease4. Stroke (CVA) 5. Unintentional Injuries (Accidents) 6. Alzheimer’s Disease7. Diabetes Mellitus8. Influenza and Pneumonia9. Kidney Diseases (Nephritis) 10. Suicide

Leading Causes of Death, U.S. - 2008

1.Tobacco (435,000 deaths; 18.1% of total deaths)2. Poor diet and physical inactivity

(365,000 deaths; 15.2%) 3. Alcohol consumption (85,000 deaths; 3.5%)4. Microbial agents (75,000)5. Toxic agents (55,000)6. Motor vehicle crashes (43,000)7. Firearms (29,000)8. Sexual behaviors (20,000)9. Illicit use of drugs (17,000)

Actual Causes of Death in US

Actual causes of death in the United States, 2000.JAMA. 2005 Jan 19;293(3):293-4.

A look at how Diabetes impacts Wisconsin….

The fine art of navigation...

How do we make sense of all this?

A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

American Public Health Association CHW Section, Policy Statement 2009-1, November 2009

Community Health Workers

Improving health outcomes and reducing acute care needs and avoidable hospitalizations in people with chronic diseases, including diabetes, asthma, hypertension, heart disease and cancer by improving knowledge, promoting early detection, increasing access to resources and encouraging self-management behaviors in their priority populations

Assisting  people in accessing health care (especially primary care) and social services, embracing treatment strategies, and reducing risk by increasing healthy lifestyle behaviors

Conducting outreach to difficult-to-reach populations and in-reach to improve the appropriateness and quality of health care and social services systems

Helping community members recognize and address broader cultural, environmental, and lifestyle issues that impact their health through community organizing and capacity-building

Helping individuals, families and communities to build social capital and combat social isolation

What do CHWs do?

Bridging cultural mediation between communities and the health care system;

Providing culturally appropriate and accessible health education and information, often by using popular education methods;

Assuring that people get the services they need; Providing informal counseling and social support; Advocating for individuals and communities within

the health and social service systems; Providing direct services (such as basic first aid) and

administering health screening tests; and Building individual and community capacity.

7 Core Competencies for CHWs

How is your role like that of a CHW? How are you like a CHW? How are you

different? What other information would you find

helpful in order to carry out your job responsibilities?

Discussion

Know the resources Or know how to get the information you need Ask lots of questions Learn about chronic diseases, healthy

inequities, and evidenced based solutions If you are from the community you serve, or

not, always approach families and communities with cultural humility

How can you as an Americorp member impact chronic disease?

The distinctive features of the population to be served (age, race, ethnicity, physical challenges, lifestyle) 

The distinctive features of the social and physical environment where the population lives(neighborhoods, housing arrangements, mobility issues) 

The distinctive features of providing services to that population (Cannot generalize populations)

(Coward, DeWeaver, Schmidt, & Jackson, 1983).

Three Factors to Consider to Meet  Service Needs

Illness may be punishment Death is not the end of life- blessing Spiritual healers( shaman, healers, elders,

faith leaders, prayer) Non-customary healing remedies (herbs,

liniments, oils, incense, coining,) Mistrust of Traditional Medicine/ Doctors

Some Cultural Beliefs about Illness and Healing

Elicit information about nontraditional customs or interventions in non-judgmental way: What do you call the problem? What are your fears about what might happen? What do you think caused the started or caused the

problem? Why do you think the problem started? What do you think is happening and why? What kind of treatment do you think should be given/

why?

Strategies to Address Cultural Differences

Health illiteracy Economical factors Under-insured/ uninsured Inadequate pool of providers Language barriers with providers Location/geographical Institutional biases / lack of inclusivity Insufficient awareness of available resources Prior negative experiences/ perceptions

Health Care Access Barriers

The Affordable Care Act and The Health Insurance Market Place

It’s a whole new world……

Shari Galitzer’s presentation on navigation HP Freemen style…..

So you have access to health care now what?

So, through the ACA, you have access to health care Insurance now

what?

Patient Navigation Moves to this:

You’ve heard to term – maybe? Health and Human Services (HHS) $67 million grant to fund

‘Navigators’ to serve as an in-person resource to assist in enrolling in plans in the Health Insurance Marketplace beginning this fall.

This is Financial Navigation – removing financial barriers In the news http://

online.wsj.com/article/SB10001424052748704487904576267503361027560.html?mod=wsj_share_linkedin

http://www.cnn.com/2013/04/06/health/patient-navigation-new-field/index.html

But what is it? A Care Coordination Approach that removes barriers so individuals

can access timely and appropriate care. It works in the white space, connecting people to health care providers and resources.

HP Freeman? In 1990 Dr. Harold P. Freeman founded and pioneered a program in

Harlem, using what he called Patient Navigation, to reduce disparities in access to diagnosis and treatment of cancer, particularly among poor and uninsured people.

Patient Navigation:

Report to the Nation on Cancer and the Poor

In 1989, the American Cancer Society, conducted a series of hearings throughout the country to hear the testimony of poor Americans who had been diagnosed with

cancer.

American Cancer Society Cancer in the Poor a Report to the Nation 1989

Report to the Nation on Cancer and the Poor, 1989

Findings: Poor people meet significant barriers when they

attempt to seek diagnosis and treatment of cancer. Poor people often do not even seek care if they cannot

pay for it. Poor people experience more pain, suffering, and death

because of late stage disease. Fatalism about cancer is prevalent among the poor and

prevents them from seeking care. Poor people and their families must make extraordinary

and personal sacrifices to obtain and pay for care. Current cancer education programs are culturally

insensitive and irrelevant to many poor people.

Health illiteracy Economical factors Under-insured/ uninsured Inadequate pool of providers Language barriers with providers Location/geographical Institutional biases / lack of inclusivity Insufficient awareness of available resources Prior negative experiences/ perceptions

Remember Sherri’s List Health Care Access Barriers

Freeman Institute Summary: Financial Communication Fear and Distrust Health Care System Barriers

PRINICIPAL BARRIERS TO HEALTH CARE

But it’s not a perfect market - economics perspective - the ‘gold standard’ for resource allocation: (Applying Economic Principles to Health Care R. Douglas Scott II, et al)

1) many buyers and sellers with no single economic agent influencing the exchange of goods among market participants; 2) a homogeneous or standardized product (i.e., goods that individual producers cannot alter or differentiate to collect a higher price); 3) no barriers to movement of firms into or out of the market; 4) perfect information about market conditions that is available to all market participants; and 5) a fully defined system of property rights in which ownership of allproducts and productive resources is assigned.

Specialization leading to fragmentation

Profit-driven

Barriers Inherent in Our Market-based Health Care System

Related to these findings the first “Patient Navigation” program was conceived and initiated in 1990 at Harlem Hospital Center.

The purpose - to reduce disparities in access to diagnosis and treatment of cancer, particularly among poor and uninsured people.

Supported by a grant from the American Cancer Society

Patient Navigation Arrives

The Principles of Patient Navigation HP Freeman Institute

1. Navigation is a patient-centric health care service delivery model.

2. Patient Navigation serves to virtually integrate a fragmented healthcare system for the individual patient.

3. The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.

4. Patient Navigation should be defined with a clear scope of practice that distinguishes the role and responsibilities of the navigator from that of other providers.

The Principles of Patient Navigation HP Freeman Institute

5. Delivery of patient navigation services should be cost-effective and commensurate to navigate an individual through a particular phase of the care continuum.

6. The determination of who should navigate should be determined by the level of skills required at a given phase of navigation.

The Principles of Patient Navigation HP Freeman Institute

Organizing and empowering the consumer/patient perspective

Providing a network for fragmented elements, allowing local focus and innovation, (analogous to the Internet)

Economics of improved health care, reflected by ACA meaningful use incentives.

Patient Navigation Aligns with Market-based Approach

DHS GUIDING PRINCIPLES - http://www.dhs.wisconsin.gov/aboutdhs/oos/fundamentals.htm:

We serve the citizens who have entrusted us with important responsibilities and funds they earned.

Our healthcare costs are not sustainable at current levels. We need new models for care delivery, regulation development, prevention strategies, risk sharing and purchasing.

In this transformation, we must enhance the role of our citizens as primary stakeholders in managing their health and associated costs.

Competition, choice, and transparency are critical elements to these emerging models if we are to increase the value of healthcare to our citizens.

Public programs shall complement rather than compete against the private market. We will work to eliminate cost shifting to the private sector and among different systems (acute, mental health, long-term care).

We will continue to provide support systems to help vulnerable people lead fulfilling, self-directed, healthy lives that promote independence, while recognizing the value of and utilizing supports from families and the community.

We will actively promote collaboration in pursuit of innovation, increased value and improved outcomes for the benefit of all our citizens.

We will align resources to achieve positive outcomes and hold ourselves accountable for achieving results.

Aligns with WI

Benefits of Patient NavigationResults from the Cleveland Clinic

Change in no-show rate: -3% on an average of 165 appointments per month

Change in completed appointments/month: +5 (165 x 3%)

Each individual appointment gain $1,409 in revenue after reimbursement

Change in revenue: $7,045/month ($1,40985) or $84,540/yr ($7,045812)

Patient Navigator cost per year is ~$35,000; part time navigator is $17,500. yearly net revenue gained per full time PN: ($84,540-$35,000) = $49,540

Part time Navigator return on investment happens in 2.5 months

Impact of Screening & Patient Navigation on Breast Cancer 5-year Survival Rates

Harlem Hospital Cancer Control Center (BECH)

Five

Yea

r Su

rviv

al R

ate

0% 10% 20% 30% 40% 50% 60% 70% 80%

39%

70%

After access to sceen-ing & patient naviga-ton (1995-2000)**Before access to screening & patient navigation (1964-1986)*

*Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. Cancer, 63(12), 2562-2569.

Oluwale/Freeman, Journal of American College of Surgeons, 2003

Panel Discussion Melissa Harris-Perry, Dr. Harold P. Freeman

http://video.msnbc.msn.com/mhp/51124049#51124049

Discussion and Stories

HP Freeman Framework

3 kinds of Navigation: Financial Clinical Community

Compare to Other Allied Health Professionals it’s a role, not a title; and it’s a perspective Social Workers, Case Managers, Health

Educators, Patient Advocates, Community Health Workers

Patient Navigation & Other Roles

Children’s Hospital Milwaukee – growing, currently approx. 8 community navigators Well Women Program Allied Wellnes Center – Madison Allied Drive neighborhood

http://www.alliedwellnesscenter.org/ South Madison Promise Zone Adams County Partnership Grant Aurora Health, Aurora Women’s Health Care UW Carbone Cancer Center – wip, for Commission on Cancer

Comprehensive Cancer Accredidation in 2015 requires a patient navigation program

American Cancer Society WI Pink Shawl Initiative, http://www.dreamthecure.org Healthy Hmong Women – addresses breast and cervical

cancer disparity issues affecting the Milwaukee Hmong

Patient Navigation Examples in Wisconsin

WI Health Exchange Navigator Grant Recipients – Financial Navigation

Partners for Community Development, Inc.Hispanic and Hmong and other hard-to-reach Door, Kewaunee, Manitowoc, Ozaukee, and Sheboygan Counties.

Northwest Wisconsin Concentrated Employment Program, Inc.21 Wisconsin Job Centers libraries, Senior Centers and college campuses.Legal Action of Wisconsin, Inc./SeniorLAWlocated in Milwaukee serving Southeastern Wisconsin. To individuals age 60 or over

National Council of Urban Indian HealthUrban Indian Health.

National Healthy Start Associationthrough the federal Healthy Start programs. uninsured population

R&B Receivables Management Corporation DBA R&B Solutionsconnect uninsured and underinsured individuals with coverage options to help them afford health care.

Children's Hospital and Health SystemCommunity Health NavigatorThe goal of the Community Health Navigator role is to improve health outcomes for persons within identified communities through linking identified community need with available resources. Navigators partner with Community Services leadership to facilitate integrated service delivery for residents of assigned community(ies). Navigators must have demonstrated good standing within their community and an interest in improving outcomes for their neighborhood(s). Demonstrates skills in creative problem-solving, and has in-depth knowledge of the assets and challenges of the community to be served. Has the ability to work with medical professionals to ensure follow up and coordination of recommended medical management. Requires a High school education or equivalent. Some college preferred. Experience with community programs or health organizations.

Current Position Description

The Star – Combating chronic disease epidemic Impact equation that measures the benefits of a

seamless approach to community health, including metrics for patient empowerment and market value of health.

Unites medical, public health and social science professions, nonprofits and faith-based and community organizations for an ‘all-hands-on-deck’ approach to public health.

Lay care-coordinators critical operational element Potential sustainable model, results to be published

later this year.

Accountable Care Community Austin BioInnovation Institute in Akron

Deliver integrated medical and public health models to deliver clinical care in tandem with health promotion and disease prevention.

Robust health information technology infrastructure Care Plans Data Mining Infrastructure support to scale Infrastructure support for resource management Metrics for continuous improvement and inform

stakeholders.

Critical Components of ACC

Start with neutral party – may need to be the neutral party.

Point of agreement - e.g., reduce inappropriate ER visits, particularly uncompensated visits, Diabetes management

Point of measurable cost - e.g., reduce inappropriate ER visits, 911 calls.

Note – the alignment with community navigation

Note – community development opportunity

Critical Starting Points of ACC

Applied to a Promise Zone

41 people screened, 5 required near-term navigation

1. Son in need of an ultrasound2. Spanish speaker needing two week follow up

no insurance or money3. Screening results conflicted with recent study

results, confused patient with no insurance4. Man with bullet in leg 5. Insured man asked for help since not sure

how to ‘re-access’ health care to get primary physician.

Kidney Screening Pilot – the people

Clinical review directions: clarified, serve as a referral

Simple next steps on envelop

Seems important opportunity to have navigation when screening

Kidney Screening – The System

Harold P Freeman Patient Navigation Institute an intensive 2-day in person in New York City,

or self-paced online training program that includes 10 modules, plus practicum (patient interaction) and case studies.

http://www.hpfreemanpni.org/the-program/ Scholarships available Possible in person locally in Wisconsin in 2014 Certificate of Completion

http://healthadvocateprograms.com/masterlist.htm

http://advocatecredential.org/

Learning Patient Navigation

Learning Patient Navigation cont.Center for Patient Partnerships at UW Law School - Certificateshttp://www.patientpartnerships.org/education/opportunities/certificate-programs/courses-sequence-pacing

/

Learning Patient Navigation cont.Colorado Patient Navigation Training- 7-week online

traininghttp://patientnavigatortraining.org

Sample modules: Overview, Origin and Historical Perspective of

Patient Navigation Developing and Implementing a Patient Navigation

Program Patient Navigation Models: Outreach, Diagnostic &

Treatment, & Survivorship and Legal Barriers Resource Allocation Cultural Competence, and Effective Communication

Contact Shari Galitzer, shari.galitzer@gmail.com or Institute directly at http://www.hpfreemanpni.org/ Amber Paquette, 1-646-380-4060info@hpfreemanpni.org

Harold P Freeman Institute Training Scholarships available for Americorp

Members

Discussion – It’s complicated

Public health programs often disease specific Community navigation is individualized Accountable Care Organizations and Medical Homes are clinical entities but

responsible for prevention and health promotion. ACA – medicare contract for cost/savings sharing Medical Home – accreditation by The Accreditation Association for Ambulatory

Health Care (AAAHC) to provided physician-led coordinated care.

CHWs in Patient Navigation Systems Creating Accountable

Care Communities

Creating conditions for everyone, every day, everywhere to haveequal chances and

fullest choices to be healthy and thrive and

live well and long, from generation to generation.

~ Magda Peck

Improving health outcomes and reducing acute care needs and avoidable hospitalizations in people with chronic diseases, including diabetes, asthma, hypertension, heart disease and cancer by improving knowledge, promoting early detection, increasing access to resources and encouraging self-management behaviors in their priority populations

Assisting  people in accessing health care (especially primary care) and social services, embracing treatment strategies, and reducing risk by increasing healthy lifestyle behaviors

Conducting outreach to difficult-to-reach populations and in-reach to improve the appropriateness and quality of health care and social services systems

Helping community members recognize and address broader cultural, environmental, and lifestyle issues that impact their health through community organizing and capacity-building

Helping individuals, families and communities to build social capital and combat social isolation

What CHWs do and What You Can DoLeveraged By Navigation

Thank you for listening Thank you for the work you are doing as

Americorp Members Thank you for thinking about and sharing in

your host communities how Navigation Systems can shift the paradigm and reduce health care disparities.

Discussion