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April 17, 2018

Reproductions of this manual are not permitted without express written permission of:

Dr. Shreya Kangovi, Penn Center for Community Health Workers, 423 Guardian Drive, 13th Fl. Blockley Hall, Philadelphia, PA 19104

Cite as: Kangovi, S. K., Chanton, C., Feldstein, J. (2018). IMPaCT (Individualized Management for Patient-Centered Targets) Outpatient CHW Manual. http://chw.upenn.edu

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CONTENTSOverview Our Purpose IMPaCT goal-setting

ProfilesThe ArcTips for Success

Your RoleStructure of IMPaCT

Overview of Steps Step by Step Guide Your Priorities Safety Job Expectations Supervision and Support

Forms IMPaCT Info Sheets Goal Card Meet the Patient Interview Roadmaps Patient Calendar Next Steps Follow-up Interview Pre-Doctor's Appointment Coaching Interview Doctor's Appointment Interview IMPaCT Graduation Diplomas

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OVERVIEWOUR PURPOSE

Every day, doctors care for patients from low-income communities. They try their best to help them control chronic diseases like diabetes or high blood pressure. However, the goals that doctors set for their patients often do not line up with the realities of daily life for patients who may worry: “How can I afford the medications my doctor ordered?” “How can I cut down on salt when I get my food from a pantry?”

We believe that the people who can best help low-income patients achieve their health goals are Community Health Workers (CHWs). CHWs are people who come from the communities they serve, who understand the problems patients face, and who use their knowledge of the community to help patients meet health goals.

The purpose of IMPaCT Outpatient Care is to help low-income patients achieve health goals that they set with their doctors.

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IMPaCT GOAL-SETTING

IMPaCT is built on the science of goal-setting. Most people are better at reaching goals if they are broken down into baby steps, or short-term goals, so they have a clear path to follow. IMPaCT CHWs help patients work backwards from a long-term health goal and create a Roadmap for reaching that goal.

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ROADMAPS are plans that use a patient’s resources to achieve short-term goals that patients feel confident about achieving. These short-term goals will eventually lead to the long-term health goal.

Example:

1. LONG-TERM GOAL: Patients start by choosing a long-term health goal that is clear and measurable. This is something that patients can do with the help of their health care provider using the Goal Card (in the Forms Section). For instance: “I want to stay out of the hospital for the next 6 months” or “I want to get my blood pressure to 140/90.”

2. SHORT-TERM GOALS: You will ask the patient what they think they will need to do to reach this long-term goal. These are the patient’s short-term goals.

3. ROADMAP: After helping the patient identify short-term goals, you will help patients create action plans, or Roadmaps, for each short-term goal. Roadmaps have five components. See the Roadmap chart on the next page.

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IMPaCT ROADMAPS

ROADMAP SECTION DESCRIPTION SPECIFIC EXAMPLE

SHORT-TERM GOAL STATEMENT

CHWs work with patients to create a specific, measurable goal, so that they will know when they have accomplished it.

“In order to lower my blood pressure, I need to learn how to cook a low-salt recipe.”

CONFIDENCE

IMPaCT CHWs ask patients how confident they are that they’ll be able to reach that goal by using this picture “How confident are you that you can

cook a low-salt recipe?”

Patients score their confidence using a scale of 1-10. If patients score below 7, the CHW should go back and ask them to pick a slightly easier goal.

RESOURCES

The things, people, or ideas that the patient thinks might help them achieve their goals.

“My sister and I like to cook together and she’s interested in low-salt recipes as well.”

CHW has a copy of a low-salt recipe book.

PLAN

The concrete next steps that need to get done to make sure the goal is reached. The Plan gets updated every time the CHW talks to the patient. CHWs make sure each plan has a ‘who, what, when, where.’

CHW to help patient find low-salt recipes by Monday.

CHW to cook low-salt meal with patient and his family by next Friday.

RESOLVED?Has the patient achieved their short term goal? CHWs make goals specific and measurable from the beginning, so they know when they’ve been achieved.

When patients can demonstrate that they have reached a goal, the Roadmap is resolved.

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PROFILES

Through our research, we have found that there are generally four types of patients, which we call Profiles A, B, C and D. During the Meet the Patient interview, CHWs get a sense of which profile fits their patient, and uses this knowledge to tailor their support to the patient over the course of the IMPaCT program.

PROFILE DESCRIPTION CHW SUPPORT FOCUS

PROFILE A

• Traumatic experiences (jail, sexual assault, murder, etc.)

• Social/family dysfunction• Mental illness• Substance abuse• Housing instability• Disabled• Already uses resources like

disability check, Parole Officer, case worker, etc.

• Comes to the hospital a lot (more than 5 times in 6 months)

• Not very motivated to work on Roadmaps

Emotional Support:

• CHWs should listen to these patients and get to know them. They should not force them to make short-term goals they are not ready to make.

• CHWs should focus on providing emotional support, helping them to find meaning in life, and connecting them to supportive people to help them when the IMPaCT program is over.

PROFILE B

• Supportive family• Caregiver burden: lots of

friends/family are also sick or have problems. The patient cares for them, often more than they care for themselves

• Job stress: patients have to get back to work which makes it hard to recover when they are sick

• Can’t afford medications or medical care

• Very motivated to work on Roadmaps but struggles to find time

Instrumental Support:

• CHWs should connect these patients with community resources, insurance, etc.

• CHWs should help them get things done and reach their short-term goals.

PROFILE C • Medically complex, frail and often elderly

• Terminal condition like end-stage cancer

End of Life Support:

• CHWs should talk to the care team with

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• Going back and forth to the hospital often for severe illnesses that are not just due to social issues

the patient to understand their prognosis

• CHWs should help the patient to think about the end of life, and talk about it with their family or friends

• CHWs should connect patient to support for the end of life, including home nursing or hospice.

PROFILE D

• Independent• Relatively healthy and may not

have a deeply rooted cause of their health problems

Inform and Empower:

CHWs should respect that this patient may not need or want much support. Provide whatever information or support they ask for, but otherwise back off!

Don’t talk down to these patients. Do the opposite: ask them to be a role model for other patients or share their strategies at group

Of course, not all patients fall neatly into one of these Profiles. The idea is to run through these and make sure you have a sense of what type of support might best fit your patient.

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THE ARC

A CHW-patient relationship should ideally progress through four stages.

-Listen. You should listen INTENTLY to the patient. Talk to caregivers and the medical team. Try to get a ‘Snapshot’: a sense of who is this person, what is important to them (hopes/fears) and what, if anything, is the root cause of their health problems.

-Snapshot. As you listen, reflect, and ask questions, you will develop your Snapshot. It may not always be crystal clear at first and can evolve with time. Ideally the Snapshot is something you develop with the patient, reflects both strengths and challenges, and continues to be refined over time. As you do the Meet the Patient Interview, and throughout your relationship, talk about your Snapshot out loud to see if the patient agrees: “Ms. Jones it seems to me that you are a strong, caring mama-bear. You’ve lost your son recently and that’s been so hard that you picked up smoking again. Now you’re looking for a quick, convenient stress release to replace the cigarettes.”

-Roadmaps. List the goals that you and your patient set for your time together. Prioritize the goals that make sense given their Snapshot and best address the root cause of their health troubles. Map out a Roadmap to each goal using the Roadmaps form.

-Do it now! For each Roadmap, try to get as much done as you can right there in the moment. Make calls, look things up on the internet, get busy. Putting things off takes the wind out of everyone’s sails.

If you follow these stages, you’ll have a better chance of spending your time wisely and doing work that really make a difference for your patient. If not, you may spin your wheels with busy work that doesn’t link back to your patient’s core needs.

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TIPS for SUCCESS

To be a good CHW, you need to be good at motivating people. Here are some big picture tips:

1. Don’t forget the Arc: Listen, get a Snapshot, create Roadmaps that make sense given the Snapshot and Do it now!

2. Get started on a Roadmap DURING your first meeting with the patient. Call a housing program, start a food diary, schedule a nutrition appointment etc. Early victories will jumpstart the patient’s motivation!

3. Complete a WHOLE Roadmap in your first week together. Then praise the patient for their success! This feels like a reward and also gets them confident to make changes in their life!

4. Be a fun person who the patient loves to talk to. When you call the patient, connect with them as a person and joke around for a few minutes before you get down to business. Bring them a silly picture or article you clipped out of a magazine! Do a fun activity together! Send them a card! Be creative. If you bring fun into the relationship the patient will stay motivated to work with you.

5. Never lecture a patient or act disappointed that they didn’t do the things they planned to do. This can feel like punishment and may make patients avoid you. Instead, when the patient tells you they didn’t do something they said they’d do, praise them

for being honest! It’s hard to admit you messed up! Ask the patient what made it hard to do. Ask the patient what they learned from not being able to get it done. This could help them

succeed next time. Ask the patient what they plan to do next.

6. Depression, anxiety, substance use, chronic pain and lack of sleep are frequent roadblocks to success on health goals Ask the patient if they ever feel stressed or depressed. Ask if they have ever considered talking

to someone about it. Be direct about discussing mental health with your patient. It is crucial to get comfortable talking about substance use. Be direct but not disapproving or

judgmental. If a patient has chronic pain or can’t sleep, ask their doctor for help or a referral.

7. Motivational Interviewing is an important skill to help patients reach their health goals. If a patient is thinking about changing a habit (e.g. quitting smoking) but hasn’t done it yet help them to list the pros and cons of the habit. For example, a pro of smoking: “it’s fun to take smoking breaks at work with my friends.” A con: “I hate the taste in my mouth.” Then, in a very non-judgmental way, help them to start to focus a little more on the cons, especially any physical sensations they may not like.

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YOUR ROLESTRUCTURE OF IMPaCT

IMPaCT programs follow a standard basic structure:

SET GOALS: As an IMPaCT CHW, you will work with patients and their providers to set health goals that are important and achievable. Then you will help patients create tailored action plans that will lead to their goals.

SUPPORT: Throughout the program, you will provide hands-on support towards helping patients achieve their goals.

CONNECT: You will also work to connect patients to a source of long-term support in order to prevent the voltage drop that often occurs after an intensive program.

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You are working in the Outpatient program, the IMPaCT program targeted towards patients seen in the doctor’s office. You’ll enroll new patients in the doctor’s office, stay in touch with them for six months through weekly visits and calls, and help them connect with a support group of other patients.

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OVERVIEW OF STEPS

This list will give you the basic idea of your workflow, which will be described in the next section in more detail.

1. First thing every morning: check in with your Manager, log on to HOMEBASE, IMPaCT’s secure computer program for CHWs, and determine if it will be an On-Call day or a home visit day.

2. Gather the interview guides and forms.

3. If it's an On-Call day, go to clinic with the patient’s Goal Card.

4. Introduce yourself to the patient and explain IMPaCT.

5. Conduct the Meet the Patient interview and fill out the patient calendar.

6. Once you leave a new patient interview, enter notes into HOMEBASE. Run the List: discuss patients with your Manager.

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7. Attend Multidisciplinary meetings with the Outpatient Team.

8. Follow up with all your patients.

9. Get patients help if clinical issues arise from home.

10. Coach patients to get the most out of their doctor's appointments.

11. Attend important doctor’s appointments with patients.

12. Run Group Sessions.

13. Prepare for Graduation.

14. Graduate patients when they have completed the intervention.

STEP BY STEP GUIDE

1. FIRST THING EVERY MORNING: CHECK IN WITH YOUR MANAGER AND LOG ONTO HOMEBASE AND DETERMINE IF IT WILL BE AN ON-CALL DAY OR HOME VISIT DAY.

Each day at 9am, text or call your Manager to check in.

Check the calendar to see whether or not today is an On-call day. An On-Call day is a day when you are assigned new patients to enroll at the doctor’s office.

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If it is not an On-call day, you can focus on home visits, community visits (e.g. working out with a patient at the YMCA), making phone calls, etc.

If it is an On-call day, you should stay near the clinic and be prepared to meet new patients. The coordinator will let you know when they enroll a new patient. You should be picking up 1-2 new patients per week.

2. GET ORGANIZED AND GATHER THE INTERVIEW GUIDES AND FORMS FOR YOUR DAY.

Here is our system for organizing your time:* Start your day by printing your online calendar. * Throughout the day, when you say ‘I will do that…’ make a [] on your calendar so

that you can keep track of what you’ve committed to doing. If you say you will do something at a specific time, check your calendar to be sure you are available.

* At the end of the day, review your checklist to make sure you got everything done. Transfer new appointments to your online calendar.

* You can also do all of this directly on your phone or tablet, as long as you have it with you at all times.

Here is our system for organizing your stuff:* Your Manager should have a team binder at your clinical site. This should have a

copy of this manual and multiple blank copies of each form.* You should carry a ½” thick binder which should include a Table of Contents and

1-2 blank copies of each form. This binder shouldn’t contain any identifiable patient information.

* Keep separate folders for each patient. Try to minimize the amount of identifiable information you carry. Upload documents into HOMEBASE and shred as soon as you can.

Make sure you have all your interview guides and other things you need including:* Binder* Pillbox* Your calendar* Cell phone* Laptop

In order to get started with a patient’s Roadmaps ASAP, you will want to have key resources on hand. Your Manager will make sure you have links for common resources in your area such as:* Programs that help pay for prescription medications* Low-cost medication formularies for local pharmacies* Health centers that serve low-income and uninsured patients* Public benefits office

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* Area agency on aging* Low-income cellular phone program

3. IF IT IS AN ON-CALL DAY, GO TO THE CLINIC WHEN YOU ARE NOTIFIED BY THE COORDINATOR.

Coordinators meet patients at their doctor’s appointments and offer enrollment into the IMPaCT program. You will get a text from the Coordinator to let you know when a new patient has enrolled. Once you get the text, you should head over and meet them within 10 minutes; otherwise a patient might have to leave and it’ll be harder to catch up with them later.

Your working relationship with your colleagues at the clinic is one of your patient’s greatest health assets. Make sure to introduce yourself using this one-liner to EVERYONE who is new to you:

Hello, my name is _____ and I am an IMPaCT Community Health Worker. My job is to support patients from the community in reaching their health goals.

(Give them an IMPaCT Info Sheet if they have more questions, and use this to walk them through what you do.)

If any team member asks you to enroll a patient, let them know that the fastest way to refer a patient is to call the IMPaCT Referral Hotline. The Coordinator will screen the patient to see if they are eligible for IMPaCT.

Sometimes, you might enroll a patient who has been in IMPaCT before. Read any old notes and think about:

* What were the Roadmaps? Were they accomplished? If not, why?* What went well working with this patient? What were some of the

challenges?* How might the patient or their situation have changed since the last time

they had IMPaCT?* Pay attention to safety concerns from old notes.

4. INTRODUCE YOURSELF TO THE PATIENT AND EXPLAIN IMPaCT.

You’ve found your patient! This is the time to use your natural instincts for being a caring, friendly person to make this person feel comfortable.

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The Coordinator and doctor will use the Goal Card to help the patient to set a long-term health goal to work towards over the next 6 months. You should write down that goal.

Once the patient is done setting a goal and talking to their doctor, ask the patient if they would mind spending some time talking with you. Remember patients are busy folks who are just here for a doctor’s appointment. They may be thirsty, tired or in a rush! Offer them a bottle of water and help them feel like they want to settle in with you! If they are in a rush, offer to walk with them. Do as much as you can to spend time with them that day to establish a bond.

Explain your role using the IMPaCT Information Sheet. When talking about your role, make sure to explain that you are not a clinical provider. Also explain that you will keep their information confidential except for discussions with your Manager and the clinical team or if you witness child or elder abuse, or the patient seems like they are a threat to themselves or others.

Ask for permission to talk about their case with others (family members, outside doctor’s office, etc.) and if so, ask them to sign a HIPAA form. Finally, make sure they know that you will be providing support for 6 months. This will make it a bit easier to say goodbye once the program ends.

If at any point a patient behaves inappropriately or is threatening to you, please report it to your Manager or Director (See ‘Safety section’). Their case may be terminated.

There may also be patients who are not “with it” and too confused to talk to you. If that happens, ask the doctor or medical assistant for contact information for the patient’s designated family member or caregiver and go through the IMPaCT process with that person. The most important thing for these patients is to make sure you have contact information for designated family/caregivers and also know how to get in touch with the patient once they leave the office.

If you realize early on (before or soon after the Meet the Patient interview) that you know the patient personally, are related to the patient, or live in the same 1-2 block radius as the patient, PLEASE DO NOT ACCEPT THIS PATIENT. This has a small chance of threatening the patient’s privacy and/or your safety. Instead, explain to the patient that because you know them outside of the clinic, it will be better for another CHW to accept their case and remain objective. Let your Manager know and arrange to re-assign the patient to another CHW.

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Sometimes, you will be assigned a patient who is a family member of another patient who is already in your care. There are two options for this situation:

1. Sit down with each patient individually and ask their permission to care for both in a family-centered way. The family approach can be really powerful. But in order for this to work, both patients need to be comfortable with sharing their personal information with each other and need to sign a HIPAA waiver. It will just be too difficult for you to keep their privacy if you are working with two people in the same family.

2. Assign the newer patient to another CHW. This makes it easier to maintain privacy.

5. CONDUCT THE MEET THE PATIENT INTERVIEW

Once you have identified and met the new patient, conduct the Meet the Patient Interview. The goals of this interview are:

Listen. You should listen INTENTLY to the patient. Talk to their caregivers and medical team. Try and get a ‘Snapshot’: a sense of who is this person, what is important to them (hopes/fears) and what, if anything, is the root cause of their health problems.

Snapshot. As you listen, reflect and ask questions, you will develop your Snapshot. We call this a Snapshot because it’s a quick image of your patient as a person. The Snapshot may not always be crystal clear at first and can evolve with time. Ideally the Snapshot is something you develop with the patient, reflects both strengths and challenges, and continues to be refined over time. As you do the Meet the Patient Interview, and throughout your relationship, talk about your Snapshot it out loud to see if the patient agrees: “Ms. Jones it seems to me that you are a strong, caring mama-bear. You’ve always wanted to see your kids graduate and worry about the streets getting ahold of them. You’ve lost your son recently and that’s been so hard. Now you need a quick, convenient stress release to replace the cigarettes that have helped you to deal with stress for so long.” Be concise, honest and positive. Reflecting the Snapshot out loud with your patient:

* Helps you to understand what your patient is saying* Allows your patient feel heard, which builds trust* Confirms what’s important in the patient’s life, which will shape the

goals you create together Roadmaps. You should choose the top few goals that your patient has told

you about during the interview. Prioritize the goals that make sense given their Snapshot and best address the root cause of their health troubles. Map out a Roadmap to each goal using the Roadmaps form.

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Do it now! For each Roadmap, try to get as many Next Steps done as you can right there in the moment. Make calls, look things up on the internet, get busy. Putting things off takes the wind out of everyone’s sails.

Take notes as you conduct the interview. Most CHWs prefer to do this on paper rather than typing so that they can keep eye contact with their patients. Make sure to collect multiple sets of contact information. When you get their primary phone number, tell them that you are going to call it now so that you have it in your phone. Make sure it works, and that the voicemail is set up. If not, politely ask them if they would set up the voicemail with you, so that you can reach them.

Prepare a patient calendar for your patient. Mark your patient’s IMPaCT Graduation date on the calendar, and write in his or her health goal and any Roadmaps the patient has created. Add any upcoming medical appointments from the medical record or that the patient told you about.

When you are done, ask the patient if they need help getting any measurement equipment (scale, BP cuff, glucometer/strips etc.) to help them track progress towards their health goal. If they don’t have this equipment, ask the doctor for a prescription (sometimes insurance will pay for it). Also do your research to find some low-cost options in case the patient’s insurance does not cover this equipment.

Finally, set a time to call/visit the patient as soon as possible. You will need to have 3 face-to-face visits with the patient in the first month and then make contact at least once every week for the next 6 months.

After meeting with the patient, take a look at their chart in the electronic medical record (EMR), focusing on the diagnosis list and discharge document. Make sure you aren't missing anything important like mental health or substance use issues. If you learn new information in the EMR that did not come up in the interview, add a Roadmap to explore this with the patient.

Then, text the doctor right away but do not include any confidential information about your patient:

Hi Dr. ___, this is ___, an IMPaCT CHW from the practice. My role is to provide social support, advocacy and navigation to patients. I just met with one of your patients and would like to talk with you to get some advice. Could you please call me? Thank you!

When you talk to the doctor on the phone, include the following: * Explain your role and how long you will be working with the patient. * Give a 1-2 sentence Snapshot of the patient.

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* Ask the doctor:- What do you think I should know about this patient?- What concerns do you have? - What do you think we should be working on?

Don’t wait too long to talk to the doctor. If completing the Meet the Patient Interview is delayed, you may need to talk to the doctor before you have a chance to complete it.

Just to be thorough, also send a message in the EMR to the patient’s doctor, as well as to any other members of the care team involved in your patient’s care (social worker, chronic care Manager, nurse practitioner, etc), letting them know that you have enrolled the patient in the IMPaCT program. Copy your Manager on the message. You can use a standard note such as this:

Dear team, My name is ______ and I am one of your clinic’s IMPaCT Community Health Workers. My job is to provide high-risk patients with intensive support in order to help them reach their health goals. Over the next six months, I will be working with (Patient Name) to help him reach his health goal of (long-term goal).

In order to reach this long-term goal he has told me that he will need to achieve some short-term goals: (list Roadmap goals). I will be providing support with these goals and may contact you if we run into medical questions along the way. Please let me know if I can be of help. My cell phone number is (your cell #). Please do not hesitate to call if you need help in conducting outreach to the patient or have any questions.

Best wishes,(Your Name)

Make sure to always check your EMR inbox and email each day and respond to any messages people have sent to you.

6. ONCE YOU LEAVE A NEW PATIENT INTERVIEW: ENTER NOTES INTO HOMEBASE. THEN RUN THE LIST: DISCUSS YOUR PATIENTS WITH YOUR MANAGER.

Find a quiet spot to enter your notes into HOMEBASE

Enter any important dates into your calendar (upcoming appointments, home visits and phone calls to your patient). Write the patient’s one, three and six month anniversary of joining IMPaCT on the calendar.

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Destroy paper notes with any patient identifiers (names, room number, contact info, etc.).

Run the List with your Manager: discuss each of your patients. This is crucial, so make time for this. But don’t wait on this to get going. When you meet with your Manager to run the list, you should already have completed some Roadmaps with the patient. Your Manager is there to hear about your patients and to support you. Your Manager will help you create a Next Steps list, which is a to-do list based on the plans for each of your patients. This is a great tool to help you organize what you need to do. Always keep it with you in your binder.

7. ATTEND MULTIDISCIPLINARY MEETINGS WITH THE OUTPATIENT CARE TEAM.

• A fun and important part of your job is meeting with other care team members. Your Manager will ask the practice manager in your clinic to organize a team huddle each week to discuss your patients with a nurse or chronic care manager, physician, and social worker. If there is no formal team meeting, your Manager can try to set one up. The goals of the huddle are to decide who should get a CHW and to provide case updates for existing patients. Below is an ideal structure for these huddles, although they may be different at each site.

o Before huddles, take about 10-15 minutes to prepare what you’re going to say about each of your patients. Quickly look through your notes in HOMEBASE and check the EMR. Write down or print out upcoming appointments. This way you will be up to date on what is going on with the patient. Prepare notes ahead of time. Don’t wing it!

o During these meetings, start by introducing yourself with your one-liner, even if you think you know most people. There will often be someone new on the team, and since your role is so unique and special, introducing yourself will help them to understand it. Speak up and don’t be shy.

o As a group, go through a list of patients that the practice has flagged as “high risk.” Every clinic will have different criteria. Discuss each patient and their needs, decide what the best interventions are for them 1) IMPaCT, 2) Telephonic nurse management, 3) home care, etc. For patients who will be referred to IMPaCT, use the referral hotline or send an EMR message to the Coordinator.

o Provide updates on patients on your existing caseload. Below is a sample script that should take 1-2 minutes per patient:

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Patient name One line description of who she is (ex: Ms. Smith is a 56-year-old

woman with depression and diabetes who loves to dance) Long-term chronic disease management goal Roadmap goals. Provide details about steps taken towards achieving

goal Ask the team a question that will help you improve your work with the

patient Summarize next steps

8. FOLLOW UP WITH YOUR PATIENT.

Call the patient the day after your first meeting and at least once every week after that. See how they are doing, and use the Follow-up Interview guide. Check up on existing Roadmaps and create new Roadmaps for new issues that the patient tells you about.

Make 3 face-to-face visits within the first month of your relationship with the patient. A strong start is crucial! After the first month, you should make contact every week, with at least 1 home visit per month.

When preparing to do follow-ups, be sure to have:* Follow-Up Interviews * Roadmaps forms you completed together when you met at the clinic* New blank Roadmaps forms* Your calendar* Charged cell phone* The address and phone number of the patient

Each week, ask the patient to measure their progress towards their long-term goal every time you do a follow-up. This means, for example:

* Asking a patient to check their glucose (if their goal is to improve their diabetes HgBA1c)

* Asking a patient to step on a scale (if their goal is to lose weight).* Asking a patient to check their blood pressure (if their goal is to reduce blood

pressure.)* Asking a patient to count how many cigarettes they smoked yesterday (if their goal

is to quit smoking.)

• You should not take the measurements yourself, but ask the patient to do it while you watch. If they don’t know how, call the clinic nurse for help.

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• Try to get these important measures of progress without being a ‘health cop.’ If it’s clear that patients are getting annoyed or stressed out by having to measure themselves, you can stop and focus more on things they want to talk about.

Never give any information about your patient to anyone unless your patient has signed a HIPAA release form. You will need this form if you are asking the patient’s old primary care doctor to transfer files to the new doctor, etc. In other words, if you are handling ANY of the patient’s private information, protect yourself by making sure the patient signs a HIPAA release form.

If you are doing a home visit, take all of the safety precautions discussed in the Safety section.

Update your notes in HOMEBASE within 24 hours of doing any task for a patient or speaking with a patient. Document any action, new problems, or progress on a health goal that the patient reports, as well as any action you have taken as a follow up encounter. Check in with your Manager once to twice a week to run your patient list and talk about any Roadmaps that you are having trouble resolving.

After the first month, talk with your patient and Manager about narrowing down the patient’s Roadmaps to the two best ones. These are the ones that the patient seems most committed to. One of the roadmaps should ideally be related to cultivating a long term support person or joining the support group. For the next five months, focus on these two Roadmaps until you get them done.

If any of the Roadmaps you do with your patient involve eating food, make sure the food you eat with your patient is healthy. The last thing you want to do is feed your patient something bad for them and cause a serious health problem. Do not give any food to your patient without first checking with your Manager.

After three months, send an EMR message to your patient’s care team using the following template:

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Dear team, My name is (Your Name) and I am one of your clinic’s IMPaCT Community Health Workers. My job is to provide high-risk patients with intensive support over a period of six months, in order to help them reach their health goals. For the last three months I have been working with (Patient Name) to help him reach his health goal of (long-term goal). In order to reach this long-term goal he has already achieved the following short term goals: (list Roadmap goals already achieved). He told me that his next steps to reach the long term goal will be: (list unresolved Roadmap goals).

Please do not hesitate to call if you need help in conducting outreach to the patient or have any questions.

Best wishes,(Your Name)

Every time you talk to or think about your patient ask yourself: what have I done for this person to change their life? Don’t dawdle, don’t just talk about things: DO THEM. It’s ok if you fail but it isn’t ok not to try.

9. GET PATIENTS HELP IF A CLINICAL SITUATION ARISES.

• There will be times when an urgent clinical situation (medical, psychiatric, sexual assault, domestic violence, etc) arises. This is ALWAYS the most urgent thing you need to take care of. Drop whatever else you are doing for the moment and focus on resolving this issue.

• Medical situations: Remember, your job is to focus mostly on the life issues of the patient, not on the medical issues. But of course, medical issues will come up. Here are some examples:

* A new symptom that the patient has not discussed with their medical provider* A new medication side effect* Patient is unclear about something in the doctor’s instructions* Out of medication, or unable to get a medication (insurance will not cover it,

pharmacy requires a prior authorization, etc.)* If the patient reports blood sugar over 300 or below 70* If the patient reports blood pressure over 200

• Here is what you should do:* Stay with the patient or keep him/her on the phone. It might be hard to find them if

you leave them.

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* Do not tell the patient what to do (e.g. go to the ER or don’t go to the ER), but offer to support them with whatever they think they should do. Remember, you are not a clinician. However, if you are witnessing something that you believe is a true life-threatening emergency (heart attack, can’t breathe, stroke etc.) call 911.

* Notify your Manager.* Offer to get in touch with a doctor. If you have the direct PCP cell phone or pager,

this is often better than calling the clinic main number. Never give the patient the doctor’s pager or cell phone number, but DO use three-way calls with your patient. Use your SBAR training to explain the situation to the doctor: Situation (who you are, where you are), Background (patient’s name/DOB/major medical conditions), Assessment (what is happening), Request (what you need).

* If you can’t get the doctor, ask your Manager to help you find a medical provider.

• Mental health or substance abuse crisis: If a patient has a psychiatric crisis (suicidal, or other threats of harm to self or others) do the following:

* Stay on the line or with the patient as long as you are safe. If you are on the phone, ask the patient to tell you where they are. Ask them if they would be able to get to a safer location, where they are not alone.

* Make a 3-way call to the Manager.* Call a psychiatric emergency hotline with the patient (your Manager will give you a

recommended hotline number – save it in your work phone when you get it). * Ask the patient if they would be willing to go to a psychiatric emergency evaluation

center or crisis response center (your Manager will give you a list of these locations – keep them on hand).

* If you are in the clinic or hospital, offer to walk the patient to the clinic’s social worker and ensure that they talk to the patient.

* Afterwards, send an EMR message to the primary care doctor and/or clinic social worker with the details so that they can continue to support the patient.

• Domestic violence or sexual assault: If a patient is involved with an escalating domestic violence situation or sexual assault, do the following:

• If you are in the patient’s home, leave immediately and get to a safe place. Consider asking the patient if she/he would like to come with you, but don’t do this if it will put you in harm.

• Once in a safe place, call your Manager. • As soon as you can establish contact with the patient, make the patient feel

heard, supported and in control. It can be helpful to say something like, “I’m so sorry this happened to you. You did not deserve this. What do you think you need to feel safe and get the help you need, and how can I support you?”

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• Do a 3-way call with the domestic violence hotline (your Manager will give you a recommended hotline number – save it in your work phone when you get it).

• Afterwards, send an EMR message to the primary care doctor and/or clinic social worker with the details so that they can continue to support the patient.

• If a patient tells you about a clinical issue and asks that you keep it confidential, remind them that you will have to share it with your Manager and the care team.

• You should NEVER tell a patient their lab results or information from the EMR except for the time/location of any upcoming appointments. This is the job of a clinician. If you do this, you could be terminated because it is a major breach of privacy and your boundaries as a CHW. If you want to congratulate your patient on a clinical change (e.g. you noticed that their blood pressure at the last clinic visit was way lower), first contact the clinic and make sure that the patient has already been informed of the clinical change by a medical provider.

10. COACH PATIENTS TO GET THE MOST OUT OF THEIR DOCTOR’s APPOINTMENT

• On the day before important doctor’s appointments, call your patient and review the Pre-Doctor Coaching Interview. This guide will help you coach the patient for their doctor’s visit and help you remind patients to bring their medications and discharge summary to the doctor’s appointment.

11. ATTEND IMPORTANT DOCTOR APPOINTMENTS WITH THE PATIENT.

• On the morning of an important follow-up appointment, call the patient and arrange to meet them at the doctor’s office. Remind them to bring all medications (or a list of them) and their pillbox. If you are unable to contact the patient via telephone, arrange a home visit with your co-worker CHW.

• You should not sit in on the patient’s appointment with the doctor unless the patient asks you to do so. If you are sitting in with the patient, be a moral support only. Be careful about volunteering clinical information; only the patient should do this.

• Go through the Doctor's Appointment interview guide. At some point during the doctor’s visit, make sure to ask the doctor: “How can (Patient Name) get in touch with you if she is not feeling well? How about if it is after hours? What about the weekend?” This is a MANDATORY part of the Doctor's Appointment interview guide.

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12. RUN GROUP SESSIONS.

• You will take turns with the other IMPaCT CHWs to co-lead, weekly patient groups with your Manager. The group is designed to help patients with chronic illness take charge of their health both during and after the IMPaCT CHW intervention. Chronic illness is difficult for patients to manage on their own; the group creates an environment where patients can share stories and strategies, and support one another.

• When it is your turn to facilitate, your Manager will give you a list of patients who have been enrolled by either you or the other IMPaCT CHWs in the last two months. You will call these patients and remind them about the group session every week.

• You will also work with the Manager to plan group sessions. Refer to the Healthy Living Group Manual for details on helping lead this group.

13. PREPARE FOR GRADUATION.

• In order to graduate from IMPaCT Outpatient, you must work with a member for 6 months. If at any point, you lose touch with your patient, complete a pop-up home visit if they gave you permission to do so. If you cannot get ahold of your patient, continue to try. Sometimes numbers change or patients go through stuff that causes them to disappear, but later are able to reconnect, so don’t give up right away.

• After 3 months, and again after 5 months of working with your patient, remind them when they will be graduating from the program. Tell them that you will help them start getting ready for this transition. Make sure the patient knows how to do things for themselves, such as: making appointments, getting referrals, and calling the nurse if they aren’t feeling well.

• Ask the patient how they would like to use the final month in the program to work toward their health goal.

• Tell them that once they have graduated from IMPaCT, you will no longer be working with them directly, but that you will periodically check in with the clinic nurse to make sure things are going well for them. If a patient is in active crisis (suicidal, newly homeless, etc.), you and your Manager will discuss keeping their case open.

• The patient may feel sad about ending their relationship with you, so make sure to support the patient and give them plenty of warning before they finish the program. Encourage them to attend group as a way to stay in touch with you and other patients in the future.

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14. GRADUATE PATIENTS WHEN THEY HAVE COMPLETED THE INTERVENTION.

• At graduation, the patient will receive a certificate of graduation which honors all their hard work.

• At the 6 month mark, make an appointment for the patient to come into clinic and meet with you, or if the patient comes to group session, make some time during group to celebrate their graduation:

* Ask them to share thoughts on the last 6 months and give feedback on the program. Prepare a short statement honoring this patient. Ask the patient to talk about what they have achieved, as well as the challenges they still face. Their fellow group members can continue to help them with these challenges.

* Present the patient with an IMPaCT graduation certificate.

• Send an EMR message to your patient’s care team summarizing their progress and letting them know that you are closing the case:

Dear team,

My name is (Your Name) and I am one of your clinic’s IMPaCT Community Health Workers. My job is to provide high-risk patients with intensive support over a period of six months, in order to help them reach their health goals.

For the last six months, I have been working with (Patient Name) to help him reach his health goal of (long-term goal). He graduated from the IMPaCT model on DATE. He achieved the following goals: (list Roadmap goals already achieved). In order to continue to progress, he may need (list all ongoing goals or support needed from clinic). Please let me know if I can be of help. My cell phone number is (your phone).

Best wishes,(Your Name)

You are not required to, but are welcome to stay in touch with patients in a professional manner after this point. There are three important things to remember:

* Keep the same CHW boundaries you had when the patient was active.* Make sure your contact with closed patients doesn’t crowd out or affect your

work with active patients.* If you end up helping a closed-out patient make sure you document this in

HOMEBASE, and if you help substantially, tell your Manager so that you are not just flying solo.

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YOUR PRIORITIES

There are times where you will feel like you need to be in two places at once. This is not possible, because you are only human! Whenever possible, ask your co-worker to help cover for you when two things are happening at the same time (e.g. a discharge and a patient appointment). This list will help you order your priorities:

1. Clinical/Psychiatric situation: This is ALWAYS your top priority. Help your patient get assistance as outlined above. Drop what you are doing and handle this first.

2. Meeting new patients: If you delay completing this interview, it will be very difficult to establish a relationship with your patient.

3. Home/community visits: This is very important, because it keeps your work grounded in the community. It is easy to get “sucked in” to the clinic and never leave, but an active presence in the community is what makes your role as a CHW so unique and important.

4. Attend clinic meetings: If you need to miss clinic meetings, let the team know so that they are not waiting for you.

5. Doctor's appointments: You can talk with your patients about what appointments are most important for you to attend. Some patients won’t need you to come to any, while others, such as those who have a hard time communicating with doctors, will appreciate your presence.

On the phone or in person: You will have two additional priorities that can happen either in person or on the phone. These priorities can be scheduled with more flexibility:

1. Run the List to review your patients with your Manager.

2. Work on any unresolved Roadmaps using telephone calls.

SAFETY

The most important principle of IMPaCT is that CHW safety comes first. Below are guidelines for CHW safety:

WHAT TO DO IF YOU FEEL UNSAFE:

• Trust your gut and talk to your Manager: If a patient behaves inappropriately or makes you feel uncomfortable or unsafe, or if you experience any threat to your health (e.g. bedbugs) call your Manager. If you are really scared, call 911.

• Safety huddle: Once you report a safety issue to your Manager, you, your Manager and the Director will have a safety huddle THAT DAY to discuss what to do.

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• After safety huddles, the Director may call a safety meeting to brainstorm our policies and work practices to avoid future safety issues.

SAFETY WHEN PICKING UP AND WORKING WITH PATIENTS

• If CHWs realize early on that they know a patient personally, are related to the patient, or live in the same 1-2 block radius as the patient, they should not work with this patient.

• Never tell a patient where you live.

CHW GUIDELINES FOR HOME VISITS:

WHO: Home visits will be made in teams of two. If you are not familiar with the neighborhood, go with someone who is. If you are not crossing the threshold of the home, you can go alone but text your Manager that you are ‘SOLO’ and strongly consider taking a buddy anyway.

WHAT TO DO BEFORE A HOME VISIT: CHWs should be prepared before leaving for a home visit. Run through this checklist:

• Did you document the time and location of this visit on your calendar? Is the location services device on your phone on? Does someone know where you are?

• Do you have transportation? Do not use your bicycle as this can make you a target.• Do you have clear directions and a contact number for the patient in your phone?• Did you call the patient prior to leaving the office, to make sure that the patient is

expecting you?• Do you have charged cell phones? • Do you have your work ID badge? • Do you have your binders and patient forms/scripts that you need?

WHAT TO DO DURING A HOME VISIT:

• Keep your IDs visible• Always text in and out to your Manager as you cross the threshold of the home. If you

don’t feel safe texting outside, you can wait until you are inside but use the threshold as your cue to remember. Think about ‘loading’ your text in advance so that all you have to do when you cross the threshold is to hit send.

• If you are not entering the home and are alone, text ‘SOLO’ so that your Manager checks on you within 30 minutes instead of one hour.

• Aside from texting in and out, don’t use your phone or computer on the street or on public transportation because this can make you look like a snitch or a target for theft.

• Leave if you feel uncomfortable. Once you feel safe, call the patient and reschedule.• Never enter a patient’s car or give them a ride.• Try not to be totally alone with a patient unless you are in public. This protects you from

harm and accusation.29

• Keep your phone’s location services feature on at all times in the event that we need to locate you in a safety emergency. Your tracking password is kept in a central, secure folder and only used by Managers with Director permission in situations of serious concern for your safety.

WHEN: Home visits should be made in the daytime. The exact times may vary depending on the time of year.

WHERE: CHWs should make every effort to do visits at patients’ homes. However, if they have concerns about visiting a patient’s home, they can use a neutral place nearby instead such as a community center or a church.

If you are out in the community and encounter an unsafe area (i.e. a block with active gunfire etc.) let your Manager know immediately and add this to the patient’s safety note. Your Manager will notify the Director, who will communicate this information to the rest of the team. Use your best judgment when considering future home visits in this area, and don’t go if you don’t feel safe. Home visits to blocks with past safety issues should always be done with caution, and always with a buddy until you assess that the risk has passed.WHY: When done safely, meeting patients in their homes and communities is a crucial part of your job. It makes things easier for patients, and helps the CHWs learn even more about their patients’ lives.

ADDITIONAL NOTES FOR MANAGERS:

• When a CHW texts in to let you know they are on a home visit, set your alarm for 1 hour. If it’s a solo visit (i.e. without a buddy) set an alarm for 30 minutes. If you can’t reach your CHW after your alarm goes off, call the Director. You will try to locate the CHW using the location services device on their phone and may end up calling the police to do a check of wellness.

• If the Director decides to terminate a patient from the program because of a safety threat, Managers must document this clearly at the top of ‘Safety Notes’ section in HOMEBASE. This alerts the Coordinator, who may otherwise end up re-enrolling the patient in the future.

• Make sure your CHWs’ location services login information is up-to-date in the organization’s central, secure repository.

Any violation of the Safety Rules will result in immediate disciplinary action (verbal warning, then a written warning with human resources involvement). CHWs should report any breaches of safety to the Manager or Director.

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INFECTION & INFESTATION PREVENTION:

Well-being is an important aspect of safety. Below you will find some information that can help protect you from bedbugs and MRSA.

Protecting Yourself from Bedbugs

Bed bugs are small, reddish-brown bugs that can grow up to the size of an apple seed. They are usually visible to the eye.

Bed bugs move from place to place in luggage, clothes, boxes, and used furniture – or through small cracks between apartments.

They only come out at night – but leaving a light on won’t stop them from biting. Bites from bed bugs cause large, itchy bumps on some people. Other people don’t have any

reaction to the bites.

When in all patients’ homes, CHWs should:* Place your coat, bag and outer wear in an area clear of patient belongings or clutter. * Avoid sitting on beds or furniture that is upholstered or made of wood.* Wear clothing that can be washed and dried at high temperatures.

If you find out your patient has bed bugs at their home:* Inform your Manager and include this information in the HOMEBASE ‘Safety Note’* We will never require you to do a home visit if you feel unsafe, but it is possible to

do safe home visits to homes with bed bugs if you take the precautions listed above

If you find out your patient has bed bugs in their hospital room:* Inform your Manager and the hospital team

If you think you have been exposed to bed bugs:* As soon as possible, wash all clothing and personal items in very hot water for at

least 15 minutes and dry the items on high heat for at least 30 minutes. * Clothing that cannot be subjected to high temperatures should be soaked in warm

water with lots of detergent for several hours. * Clothing that cannot be laundered may be steam cleaned.

If you are worried you may have brought bedbugs home with you:* Check items you brought into patient’s homes for signs of bedbugs. Items to check

include clothing, tablets, briefcases, rolling bags and backpacks. Check carefully along fabric seams.

* Check yourself for signs of bedbug bites.* Check your bedding and mattress (particularly along seams), upholstered and

wooden furniture, moldings and wall cracks. A flashlight is helpful when examining these items for signs of bedbugs.

* Talk to your Manager if you find a bed bug in your home

Bedbugs can be embarrassing and stressful. If you are working with a patient with bedbugs, be kind. Create Roadmaps to address things they may need or want (ex: talking to their doctor about itchiness and other symptoms; resources for extermination)

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Protecting Yourself from MRSA

MRSA is a type of bacteria that is very common in the community. Lots of people have it just living on their skin and it doesn't cause problems. In some people it can cause boils. Rarely, usually if someone is already sick, it can cause more serious illness like pneumonia.

In the hospital, when someone has MRSA we use gowns/gloves/masks, to decrease the chance that one of us (a healthcare provider) will pass the MRSA to a sick patient who could get ill from it. Outside of the hospital (in clinics and community), gowns/gloves/masks are not recommended.

Outside the hospital, the main tool for preventing MRSA is hand hygiene. Hands should be cleaned thoroughly with soap and water or an alcohol-based hand sanitizer, immediately after touching the skin or any item that has come in direct contact with a draining wound. If you have any wounds that are draining (like a cut or a sore) you should keep it covered with clean, dry bandages. Avoid touching any open wounds that a patient might have without wearing gloves. Don't share personal items that you have used such as towels, clothing, bedding, bar soap, razors, or athletic equipment that touches the skin. Consider changing your clothes each day you get home in the evening after work and taking a shower. You can wash all your work clothes in hot water on the weekend and then they are fine to use again.

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JOB EXPECTATIONS

ATTENDANCE AND PUNCTUALITY: Excellent attendance and punctuality are expectations of this job. If you have an illness or personal emergency, please notify your Manager as soon as possible and ask another IMPaCT CHW to cover you for the day. Make sure whoever is covering has access to your HOMEBASE notes and explain any important things that need to be taken care of.

TIME OFF: You have vacation time and you should use it! Submit vacation requests with at least a week’s notice for a few days off and at least two weeks for more than that. Just like when you’re sick, it is your responsibility to provide coverage for your patients. Your Manager can help you identify the best game plan.

WORK HOURS: Text in (including your location) and out to your Manager when you start and end your day. As a general rule of thumb, you should work between the hours of 8am – 5pm because this is the time that most patients expect you to be available. However, you can flex your schedule as necessary for patient needs (e.g meeting patients for early morning walk-in appointments).

WORK AT WORK: It is important to be focused on work during the work day. The expectation is that you are not taking care of personal things (doctor’s appointment, picking up kids, running personal errands, etc.) while you are at work. If something urgent comes up during the workday, give your Manager a heads up, clock out and make sure your patients are covered.

DOCUMENTATION: Update your notes in HOMEBASE within 24 hours of doing any task for a patient or speaking with a patient. Your notes can be concise, but someone else reading the note should be able to understand what happened. This is a requirement because we are a healthcare organization and is necessary to ensure good care in the event that another CHW is covering for you. Also, put your home visits, on-call days and appointments on your calendar (to help keep you safe and organized).

INTEGRITY: This organization was built and stands on truth and integrity. You are responsible for collecting correct information from patients. If you are found to be making up information (e.g. documenting that a Roadmap is resolved, when it is not, or saying that you spoke with/met a patient when you did not), it is grounds for immediate termination.

PERSONAL INTERACTIONS: You will often deal with difficult people (busy nurses, sick patients, frustrated family members, etc). We support you, and do NOT want you to be subjected to any sort of verbal abuse. We want to know about any people who are giving you a hard time, and will do our best to correct the situation. However, there is never an excuse for you to be unprofessional.

PRIVACY: Patient privacy is protected by law. You will have access to private and sensitive information about patients. Do not discuss patient information with anyone outside of the

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clinical team without the patient’s permission and a signed HIPAA form. Carry the minimum amount of patient information and file/enter into HOMEBASE whenever possible. If you are found to have violated a patient’s privacy in any way (e.g. by talking about patient’s personal information with anyone outside of the clinical team) it is grounds for immediate termination.

DRUG FREE: You are in a very sensitive position and in order to protect our sick patients, we reserve the right to have periodic drug testing.

WORKSPACE: Your job is to spend time with your patients so it is important that you are physically present and not working from home. Since you will be moving around a lot, use your judgment about where to work. Be careful making calls when you are in public spaces because this can violate patient privacy. When you are working in the office, please keep in mind that your co-workers are working around you, so please keep your voice low enough to not disrupt others.

DRESS CODE: It’s important that CHWs strike a balance between looking like they fit in to the community (e.g. not looking too formal or wearing a uniform) but also look respectful. Wear comfortable shoes when you have lots of home- and community-based visits, wear closed-toed shoes when you’re in the hospital. The rest of the time, wear clothes you’d feel comfortable having your grandparents see you in! Keep in mind that you represent not only yourself, but all CHWs and you want people to view us with respect.

Meeting these expectations is important to the work that we do, to reach the high bar we’ve set for patient care and for our role as leaders in the Community Health Worker field. If these expectations are not fulfilled, you will be warned and moved through the disciplinary process. If the violation is serious, you may be immediately terminated.

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SUPERVISION AND SUPPORT

In the IMPaCT model, the CHW does not work alone. You will be directly supervised by the Manager, who will encourage your personal growth and learning. Your Manager is available to help you with any question or problem, big or small. Don’t be shy about approaching them.

You will have lots of support:

You will touch base at the beginning and the end of each day with your Manager. This will be brief, mostly to address any immediate problems or issues you have faced during the day.

You will Run the List once or twice weekly with your Manager to discuss your patients. You will attend weekly team meetings with your Manager and the rest of your CHW

team. This is a great change to vent, laugh, share ideas and support each other.

You will have an evaluation meeting with your Manager every six months. This is a chance for you to give the Manager feedback about how you think they are doing and how you think the program is running overall. You will also hear about your own performance and get to see reports that show how your patients are doing.

Good Luck!

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FORMSIt is important for you to stay organized. You should have all of your forms in a binder. Create a section for each of the following categories:

Your calendar IMPaCT Info Sheets Meet the Patient Interview Goal Card Roadmaps Form Patient Calendars Next Steps Forms Follow-up Interview Pre-Doctor's Appointment Coaching Interview Doctor's Appointment Interview IMPaCT Graduation Diplomas Commonly used forms (e.g. HIPAA forms, medical assistance forms, etc.)

You should also keep in your bag:

• A folder for each active patient and any information you need for them.

IMPaCTTM

COMMUNITY HEALTH WORKER: OUTPATIENT INFORMATION SHEET

I am a certified Community Health Worker. I know it can be hard to stay healthy. I’m here to help.

WHAT I CAN DO:• Be a support person to help you work on the health goal you set with your doctor. We are making a

commitment together to get you to your health goal. I take this very seriously and know you do too. I will be with you side by side over the next six months and stick to this even when it gets hard. I’ll be visiting you at home and will be calling you at least once a week to check-in.

• Support you with whatever you think might help you to improve your health. This can mean being a shoulder to lean on if you have stress, exercising together at the gym, or anything else you think of!

• Help you to keep track of your progress towards your goal (by tracking your weight, sugars, etc.)

• Be with you at doctor’s appointments to help you ask questions and connect you to any clinic services.

• Help you keep track of your medications and make sure you get refills when you need them.

• Check on you at home and make sure you are OK. If you give me permission, I may stop by your home if I don’t hear from you over the phone, just to check up on you.

• Connect you to resources like transportation, childcare, insurance, debt collection, drug and alcohol counseling, food assistance, utilities, and many others.

• Help you schedule appointments with your regular doctor, for tests and specialists.

• Enrollment is this program is completely voluntary. If you choose not to participate or decide to stop working with me, it will not affect your medical care or insurance coverage in any way.

• I want you to know that I discuss my patient’s care with my Manager so that I can have supervision in my work. I also discuss my patient’s care with the medical team so that we can improve your care as much as possible. I can promise to keep everything about you confidential to everyone else, unless I witness a threat of child abuse, or if you present a threat of harm to yourself or others.

WHAT I CAN’T DO:• Pay for any of your medications or services• Give you any medical advice or care

MY CONTACT INFORMATION:Name: Cell Phone number:

Please call me anytime between Monday and Friday, 9am-5pm for the next six months.

Please call me anytime between Monday and Friday, 9am-5pm for the next six months

OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

Today’s Date: Hi my name is __________ and I am your IMPaCT Partner. Is this a good time to talk? Would you like to come with me so that we can talk somewhere more private?

CONTACT INFORMATION Before we get started, do you mind if I get your contact info? I want to warn you, I’m going to get as much contact info as I can so that I don’t lose touch with you.

1. First name:

2. Middle name:

3. Last name

4. What would you like me to call you?

5. Date of birth:

6. Phone number:

7. Address:

8. Directions to address:

9. If this number stops working or if I can’t find you, what's a plan B to get in touch with you?10. Backup phone number:

11. Backup address:

12. Directions to backup address:

13. Emergency contact person/relationship:

14. Emergency contact phone number:

15. Emergency contact address:

16. If I lose track of you, is it okay if I stop by? If I am trying to get in touch with you and someone else answers the phone or door, would it be OK to introduce myself as a Community Health Worker from your doctor’s office? If not, what would you like me to say? I want to make sure to respect your privacy.

Great, now that we got that out of the way, let’s talk.

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OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

PATIENT SUMMARY

Here are some of the things I can help you with, and also some things I want you to know I can’t do. (Hand the patient the IMPaCT Info Sheet)

In order for me to get to know you better, can I ask you a few questions?

17a. Tell me a little about yourself [try to get a sense of their life story]

PROMPTS (ask these if the patient doesn’t mention them)

- Where were you born? - Where did you grow up?- What was it like growing up? - Who all lived in the house with you? - How were those relationships?- How was school? -Then what happened [keep going till you get the timeline of major life events]- What are some of the hardships or struggles you have overcome? How did you do this? - What are some moments in your life that you will always be proud of?- Tell me about your life now. -What is most important to you in life? - Where do you live now?-Who are the important people in your life? -Who is your support system? - How do you spend your time? - What kinds of things do you like to do for fun?

[Reflect your Snapshot along the way]

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OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

17b. Great, thank you for sharing all of that. Now let’s focus on your health. Tell me about your health.

18. Can you show me the health goal that you and your doctor set together today?

19. So in six months you want to (long-term goal)?

20. Why is this goal important to you?

21. How do you think you will feel six months from now when you have accomplished that goal? Who will be proud of you? What will have changed? (Visualize the finish line with patient.)

I want you to know that I am going to be on your side, as a coach and a buddy, over the next 6 months and help you get to this finish line. It will get tough sometimes, but I’m going to help you maintain your commitment to this. Let’s write your goal in this calendar that I want to give you. You can have this calendar and stick it on your fridge, so that you can keep this goal in your mind.

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OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

SHORT-TERM GOALS

22. OK, in order to get to this finish line, we need to figure out our path. Let’s work backwards and try to figure out: What things will you need to do in order to reach your health goal?

23. Tell me more about that (Repeat for each short-term goal)

24. What other steps do you think you’ll need to take? (Repeat until no new short-term goals)

25. How about some of the things that are listed in this goal-card? (Go through each item in the middle column of the goal-card for their health problem.)

PROMPTS (ask these if the patient doesn’t mention them)

26. Many people have told me they need to deal with their stress or depression in order to reach their health goal. How do you think that will be for you?

27. Lots of people realize that in order to reach their health goal, they need to get more help (and have less stress!) from friends or family. How is that for you?

28. A lot of people want to develop a system for remembering to take their medications. How about you?

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OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

SHORT-TERM GOALS

29. Many of the people I’ve talked to need to address specific medical concerns, like chronic pain or shortness of breath in order to be able to reach their health goal. How will that be for you?

30. Some people say that in order to be able to reach their health goal, they will need to find a way to get around more easily, maybe with the help of a physical therapist or by using a cane. How is that for you?

31. Many of the people I’ve talked to need to figure out a way to pay for medications in order to reach their health goal. How will that be for you?

32. People have told me they want to cut down on drugs or alcohol in order to reach their health goal? How will that be for you?

33. OK based on what you’ve told me here’s what I think is the big picture (Summarize what you think is the Snapshot: who is this person, what is important to them (hopes/fears) and what if anything is the root cause of their health problems.)

34. You’ve told me about several possible short term goals (list Roadmap ideas). Which two or three do you think are the most important given the big picture we just talked about?” (Write down list of the major goals below, to summarize.)

Do you agree that these are the most important to you to focus on in the next 6 months?

PAGE 5/6

OUTPATIENT MEET THE PATIENT INTERVIEW PATIENT ID_________

ROADMAP

Great. Let’s make a little Roadmap that will help us get to each of these goals.

[Fill out a Roadmap form with the patient.]

WRAP UP

35. Do you already have a (scale, glucometer, BP cuff at home)? If not, did your doctor give you a prescription for one? (If yes), Can I help you see if we can get that prescription filled?

36. We are making a commitment together to get you to (long term goal). I take this very seriously and know you do too. I will be with at your side and will keep you to this even when it gets hard and you don’t want me to.

37. I am going to come by tomorrow. What time would be good for you?

Date:Time:

I’ll be stopping by a few times in the next couple of weeks, so don’t be surprised when I show up! Thank you so much for talking with me today!

PROFILE

Select the Profile that best fits your patient: A B C D

PAGE 6/6

I want to focus on

my:

To work on this condition, you should do things like:

By 6 months from now I

will:

Smoking

_______ ________

Write down all the reasons why you want to quit Set a quit date Tell your friends, family, and coworkers that you plan to

quit, and ask for their help Use stop-smoking gum, pills, patch, nasal spray, or

lozenge. Get rid of cigarettes from your home, car, and work

Quit Smoking

Blood Pressure

_______ ________

Eat less salt (avoid canned foods and eat out less) Talk to your doctor about starting blood pressure

medication or be stricter about taking your meds Lose weight Exercise at least 30 minutes a day Go on the DASH Diet (lots of fruits and vegetables, less

meat)

Get my Systolic Blood Pressure to:

________

Or□ Maintain

Stop if < 130mmHg

Diabetes

_______ ________

Exercise for at least 150 minutes a week Talk with your doctor about medications or insulin

treatment or be stricter about taking your meds Meet with a nutritionist

Get my Hemoglobin A1C to:

________Or

□ MaintainStop if < 7.0%

Weight

_______ ________

Meet with a nutritionist and plan a low cal diet Keep a food diary Start a program like Weight Watchers Decrease your “Screen Time” Start a weight-loss contest with friends and coworkers Exercise for at least 30-60 minutes per day Weight loss surgery

Get my Weight to:

________

Or□ MaintainStop if > 20lbs

Other:

My doctor has suggested that my

CHW and I do some of these things during our time together:

GOAL CARD

ROADMAP # __________ PATIENT ID_________

ROADMAP SECTION PATIENT INFO

Long Term Health Goal

Short-term goal: Let’s make this really concrete so we know what exactly you want to achieve. What will it look like when you reach your goal?

(Can you measure it?)

Confidence: How confident are you that you’ll be able to reach this goal in the next 3 months?

Resources: What do you think we can use to help you with this goal?

(Supportive people, resources, etc.)

Plan: What exactly do we need to do next?

(Your ‘To-Do’ list with who, what, when, where)

Resolved?

(Mark only when Roadmap Complete)

FOLLOW-UP INTERVIEW PATIENT ID_________

Today’s Date:

1. How are you doing?

2. How is it going with your [long term health goal]?

3. Let’s check your progress:

Weight: # Cigarettes smoked yesterday: Blood pressure: Sugar: (current, or from their log if they have it):

4. How is it going with those Roadmaps we worked on together? Let’s go over them and figure out which ones are working for you and which ones may not be. (Review Roadmaps)

5. (If the patient has missed something or put something off:) I know that you were not able to __________. Tell me about that:

6. What made this difficult to do?

7. Do you think this is the right goal for you, or would you like to change it to make it more realistic?

8. (If patient is making excuses, e.g. it was raining, needed to get my hair done, say:) I care about you so I want to talk about this. Be honest with yourself and be honest with me. What do you think is really holding you back?

PAGE 1/2

FOLLOW-UP INTERVIEW PATIENT ID_________

Go over the roadblock diagram with the patient:

REASONS PEOPLE PUT THINGS OFF:1. Fear of Failure: “I can’t fail if I don’t try”

2. Not being sure of the goal: “I don’t really even want to lose weight.”

3. Not knowing what to do.

No matter the reason, it’s best to solve the problem or adjust the goal instead of just putting things off.

9. Let us remind ourselves why we are reaching for (long-term goal). Close your eyes and imagine that it is six months from now and you have reached (long term goal). How do you feel? Who is proud of you?

10. Is there anything else you want to talk to me about?

11. How is it going with your medications? Do you have all of the ones on your list? Are you going to run out of any of your meds in the next week? (Read through the list of medications on EMR. If any confusion, call your Project Manager/clinical contact.)

12. What would you say are the things you have accomplished on your health goal since we started

working together? (Mention a skill they have shown, like sticking to a goal even when things get hard).

13. When can we visit again?CALL or VISIT

Date:Time: PAGE

2/2

PRE-DOCTOR COACHING INTERVIEW PATIENT ID_________

Today’s Date:

1. Let’s call the clinic to confirm your appointment for tomorrow. (Make three-way call with clinic to confirm appointment time and update info)

2. How are you getting to the doctor’s office tomorrow?

3. Let’s think through and plan for anything else that may make it a problem for you to get to your appointment tomorrow. (Prompt for: Childcare, Work.)

4. What questions do you have for the doctor?

5. Any questions about your medications or side effects?

6. Do you have enough medications to last you at least a month or do you need refills?

7. Any tests results you’re waiting for?

8. Any questions about wound care or any equipment like a wheelchair?

9. Are you going to need referrals to any specialists or services?

10. Have you been in the hospital recently? (If yes, when, where and why?) (If yes, do you have your

discharge instructions?)

11. Can I meet you two hours before your appointment and take transit with you to the doctor’s?

(If no) Don’t forget to bring: medication list or medications insurance card photo ID copay if applicable paper copy of referral if needed discharge summary if recently in hospital

See you tomorrow!

PAGE 1/1

DOCTOR'S APPOINTMENT INTERVIEW PATIENT ID_________

Today’s Date:

(Only go into the exam room with the patient if they want you to.)

Hi Dr.__________, my name is __________, I am a Community Health Worker with IMPaCT.

I have been supporting (Patient Name) with reaching his health goal __________ (read out from Goal Card). We also have worked together to deal with some of the life issues that made it hard for him to stay healthy in the past. They are summarized in this packet (hand doctor the Roadmaps).

During the visit:

Remind your patient to ask the questions they had written down

Give the doctor discharge summary if they have been in the hospital

Ask what signs or symptoms to watch out for and what to do if they happen

Ask when next appointment should be

If the doctor is prescribing new medications, ask how much the patient would have to pay.

Explain any financial issues, and request forms to be filled out if necessary.

Dr. __________, thank you so much. One more thing: a lot of my patients end up back in the emergency room because they have trouble getting through to a clinician when they have a question or don’t feel well. What is the best way for (Patient Name) to get in touch with you or maybe a nurse?

What about if it is after-hours or on the weekend?

(Help the patient to schedule the next follow-up appointment and get any referrals, etc. before leaving.)

PAGE 1/1

NEXT STEPS FORM

PATIENT CALENDAR

IMPaCTTM

CERTIFICATE OF ACHIEVEMENT

Patient NameIN RECOGNITION OF YOUR COMPLETION OF

THE IMPaCT PROJECTAND SIX MONTHS OF HARD WORK

TO TAKE CHARGE OF YOUR HEALTH

NAME, COMMUNITY HEALTH WORKER DATE

NAME, PROGRAM MANAGER DATE

THE PENN CENTER FOR COMMUNITY HEALTH WORKERScan help you to plan, implement and optimize your community health worker program.

Penn Center for Community Health WorkersSuite 200, 3801 Market St. Philadelphia, 19104

http://chw.upenn.edu