Jane Calhoun, M.S.Director of Clinical and Field Services

jcalhoun@deltahealthalliance.org

The Medical Home Workforce:Creative Medical Home Team

Building in the Mississippi Delta

Presenter Disclosures Jane Calhoun

The following personal financial relationshipwith commercial interests relevant to this presentation existed during the past 12 months:

No relationships to disclose

Links the three major Delta universities with the University Medical Center and the Delta Council.

Applies the latest findings to create programs with local partners.

Delta Health Alliance

What is Delta Health Alliance?

Our goal is simpleOur goal is simple……

…to improve the health of the men, women, and children who call the Mississippi Delta their home.

Delta Challenges: Socio-economic and geographic barriers to c

• Underserved by primary care providers

• Lack of access to preventive care and education

• Reduced motivation for healthy lifestyle choices

• Working uninsured wages lost for healthcarevisits

• Estimates of uninsured rate vary from 18% -35%

• Approximately 39% population at poverty level

• Little or no access to public transit

• Low literacy level

Obesity

All higher than their national counterparts

Delta Challenges: Not Enough Physicians

Source: MSU Social Science Research Center

Generalist Patient Loads

Not enough Nurses and Nurse Practitioners

Source: Mississippi Office of Nursing Workforce

21st

Century Primary Care

Model for Chronic Disease

•

Transforming primary care practices in rural health clinics and free clinicsin target counties

•

Measuring impact on access to care,treatment outcomes, and provider/patient satisfaction

21st

Century Primary Care

Model for Chronic Disease

•

Assisting affiliated rural clinics in transitioning to a patient-centered medical home model using a systematic approach developed by TransforMED.

•

Utilizing an interdisciplinary team approach

•

Improving clinic quality and efficiency

•

Adopting new technologies

21st

Century Primary Care Model -

Project Goals

Goal 1: Improved Health Outcomes for people with Diabetes and Hypertension

Goal 2:

Increased Access to Care

Goal 3:

Increased Community Awareness

Goal 4:

To evaluate the effectiveness of the process and the outcome of a PCMH model in the Delta and itsimpact on overall health outcomes.

21st

Century Primary Care Model -

Interdisciplinary TeamAt each clinic site:•

CFNP

•

Nurse •

Patient Navigator

•

Community Health Worker

Supporting 3-4 clinics:•

Clinical Pharmacist

•

Registered Dietician

Interdisciplinary Team: Family Nurse Practitioner

Assigned duties/services in the Clinic

Serves as clinical “executive”

to the team of health

care professionals that includes both medical and non-medical personnel.

Spends time with new patients and those with medically complex conditions.

Assists with care coordination.

Ensures adherence to clinical best practices, and promotes the adoption of appropriate P&Ps by the clinic.

Leads team in adoption of new technology.

Nurse Practitioner challenges

1) Lack of experience in leading a clinical team■

Failure to delegate and fully utilize skills of team

■

Implementing too many changes at one time, resulting in overwhelmed staff

2) Challenged by volume of medically complex conditions among high uninsured population.

3)

Challenged by issues surrounding implementation of EHR.

Interdisciplinary Team: Clinical Pharmacist

Education and Training–

Medication Therapy Management (MTM) certification through APhA (American Pharmacists Association)

–

Pharmaceutical Care for Patient with Diabetes

certification through APhA

–

Certified Asthma Educator

–

US Diabetes Conversation Map®

Facilitator Training through Healthy Interactions and the American Diabetes Association

Interdisciplinary Team: Clinical Pharmacist (cont’d)

Assigned duties/services in the Clinic

•

Medication access services for patients

•

Preventive Care Programs

•

Medication Reconciliation

•

Retrospective Drug Utilization Review

•

Medication Therapy Management

•

Disease State Management

Clinical Pharmacist challenges

1)

Acceptance from providers (MDs, NPs) of the PharmD’s role in the clinic, and failure to fully utilize services in one clinic.

2)

Uncertainty from other clinic staff of PharmD’s role, and hesitancy to accept recommendations.

Interdisciplinary Team: Registered Dietician

Education & Training

Bachelor’s degree-

Nutrition/Dietetics

Registered Dietitian through American Dietetic Association

Licensed Dietitian through the State of MS

US Diabetes Conversation Map®

Facilitator Training through Healthy Interactions and the American Diabetes Association

Working towards obtaining Certified Diabetes Educator (CDE) certification

Interdisciplinary Team: Registered Dietician (cont’d)

Services in the Clinic

Individual & group education regarding diet and  disease management 

• DASH(Dietary Approaches to Stop Hypertension)  diet for hypertension

• Heart Healthy diet for patients with heart disease,  high cholesterol, high triglycerides, etc.

• Carbohydrate counting and diabetes diet for  patients diagnosed with diabetes mellitus

Interdisciplinary Team: Registered Dietician (cont’d)Delta Slim Down , a successful strategy to help patients

reduce the risk factor of obesity, has been utilized by Will Rowland, 21st

Century Registered Dietician.

Registered Dietician’s challenges

1)

No challenges regarding acceptance by otherstaff or utilization of technology (EHR).

2)

Challenges center around working with a mostly uninsured, low-income, low literacy patient population.

3) Residents lack access to fresh foods.

Interdisciplinary Team: Patient Navigator

Education & Training

Licensed Bachelor’s level Social Worker

Trained in use of Motivational Interviewing

Trained on The Pharmacy Connection (TPC)

Services provided

Facilitate patient-provider communication

Psychosocial assessment and referral

Coordinate the available resources to serve patients, including follow up and referral processes.

Promoting patient self-efficacy

Group education and group support facilitation

Patient Navigator (BSW) challenges

1)

PN role not fully utilized by 

some providers.

2)

Number of pharmaceutical assistance  applications.

3)

PN’s lack of supervisory experience.

Interdisciplinary Team: Community Health WorkerCHWs provide outreach services to link patients to the medical

home.CHWs initially worked under the direction of the Patient Navigator,

but now report to NP.

Services provided

•

Reinforcing chronic disease education (EMMI Solutions)

•

Encouraging disease self-management•

Encouraging compliance with appointments•

Assisting with application procedures for social, financial, and governmental services (i.e., pharmaceutical assistance, Medicaid, energy assistance, transportation assistance);

Interdisciplinary Team: Community Health Worker

Core skills training module (35-hours)Training provided by Susan Mayfield Johnson, PhD, of the University of Southern Mississippi’s Center for Sustainable Health Outreach.

Curriculum supports skills training in areas recommended by the federal Patient Navigator Act.

Orientation training at assigned clinicHIPAA compliance, patient confidentiality, use of HIT with regards to patient privacy and security of data

Skills Training prepares CHWs to provide:Skills Training prepares CHWs to provide:

Community Health Worker challenges1)

Uncertainty among staff about CHW role.

2)

Environmental pressures in the clinic 

tend to result in CHWs not being fully 

functional in their role.

3)

Current level of training offered may 

not be adequate.

4)

Past job experience and individual

character traits appear to  influence 

effectiveness.

Results for the MHIQ Assessment

Overall MHIQ Assessment Scores over time for Good Samaritan and Gorton Rural Health Clinics.

Total possible score is 341.

MHIQ: Module 5 (Practice-based Team Care)

The team care module addresses the essential elements of a physician led 

care management team.  Total possible score: 13

Preliminary Clinical Outcomes

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Assessed change in clinical outcomes: HbA1c, Blood pressure, LDL levels

■

Data is collected at baseline, 3 months, 6 months, and 12 months following enrollment in the study.

■

The results to date are encouraging, and suggest that improvements in clinical outcomes are associated with the adoption of the medical home model.

Decrease in HbA1c levels

■

One-third of the patients (36.6 or n=49) maintain or achieve excellent control over the study period.

■

Twenty-seven patients (61.4%) whose glycemic

control was considered “poor”

at baseline experienced no change.

■

These differences are statistically significant at p<.001.

Baseline

Followup Total

Excellent % (n) Good/Fair% (n) Poor % (n)

Excellent Control 69.4^(n=25)

27.8^(n=10)

2.8^(n=1)

26.9*(n=36)

Good/Fair Control 36.4^(n=20)

56.4^(n=31)

7.3^(n=4)

41.0*(n=55)

Poor Control 9.1^(n=4)

29.6^(n=13)

61.4^(n=27)

32.6*(n=44)

Total 36.6(n=49)

40.0(n=54)

23.7(n=32)

100(n=135)

Baseline

Followup Total

Not Under Control % (n)

Under Control % (n)

% (n)

Not Under Control

52.4^(n=65)

47.6^(n=59)

46.1*(n=124)

Under Control 23.5^(n=34)

76.6^(n=111)

53.9*(n=145)

Total 63.7(n=99)

36.3(n=170)

100(n=269)

Improvement in B/P Control using <140/90 as the cut-off for “Under Control”

The percentages reported reflect row percentages. *The percentages reported reflect column percentages. A chi-square test was performed.

Improvement in B/P Control

Values Given for 215 Patients

Analysis of 269 patients. Paired samples t-test, p<.001

Changes in LDL Cholesterol

Patients’

mean LDL level decreased from 112 at baseline to 110 at follow-up. This mean differencedid not achieve statistical significance at p<.05.

Lessons learned, as reported by staff….

•

Plan before diving into a new activityPDSA (Plan, Do, Study, Act)

•

Define team member responsibilities for change

•

Address one change at a time

•

Clearly define the responsibilities of team members with realistic expectations of workload

Lessons learned, as reported by staff….

•

Know when to let go of something that  doesn’t work, no matter how well you 

envisioned it would work.

•

When small changes are made rather than  trying to fix everything at once, more progress 

is made over time. 

Lessons learned, as reported by staff….

•

The addition of community health workers to the healthcare team requires staff time for supervision and coordination of referrals.

•

The level of training provided has not proven adequate for the community health workers to be effective health advisors. More comprehensive, targeted training is needed.

.

The Delta Health Alliance is gratefully acknowledged for supportof this project through HRSA Grant Number U1FRH0741. The Delta Health Alliance is a non-profit organization based in Stoneville ,MS that advocates, develops, and implementscollaborative programs to improve the health of citizens in the Deltathrough the support of partnerships that increase access and availability of health care, conduct and apply health research, or offer health education programs that foster healthy lifestyles for Deltans. For more information about the Delta Health Alliance visit www.deltahealthalliance.org.