Keynote Panel #1 Melissa Freel, WCHAP José Reyna, Spectrum Health Jane Sills, Saginaw Pathways

ANNUAL MEETING

October 8, 2014 | Lansing Community College West Michigan Community Health Worker Alliance

Funded By The Kresge and W. K. Kellogg Foundations

Wayne Children’s Healthcare Access Program WCHAP, Inc.

A Private-Public Community Health Collaborative

*Increasing Access , Equity and Quality

*Improving Child Health and Wellness *Reducing Costs *Advancing Systems Change for Medicaid Enrolled Children and Families

WCHAP Mission Statement

WCHAP strives to improve quality, access and health outcomes for

children eligible for Medicaid by promoting the Medical Home Model

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MI-CHAP Now 10 Counties!

2 in Implementation

2 Partial Funding for 2013

6 Planning Stage - unfunded

Collaborators – CHAP Teams MI American Academy of

Pediatricians MI Dept. Community Health Public Health, Health Plans Hospitals, Federal Clinics Office of Great Starts Parents, Family Advocates Education, Policy Makers, Mental Health,

Kent and Wayne CHAP are leading the way in this statewide collaborative

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Macomb

WCHAP Primary Care Practices and Child/Family Agencies

1. ADVANTAGE HEALTH CENTERS 2. BOSTFORD PEDIATRIC 3. CHILDREN’S HOSPITAL OF MI 4. COVENANT COMMUNITY CARE (2 CLINICS ) 5. DETROIT COMMUNITY HEALTH CONNECTIONS (3 CLINICS) 6. DETROIT RIVERVIEW PEDIATRICS 7. MORANG CHESTER CLINIC 8. NEW CENTER COMMUNITY 9. NORTHEAST GUIDANCE CENTER 10. WESTERN WAYNE FAMILY HEALTH CENTERS (3 CLINICS) 11. WAYNE STATE UNIVERSITY PHYSICIANS GROUP 12. SCHOOL BASED HEALTH CENTERS HENRY FORD HEALTH SYSTEMS COVENANT –NEWTON CENTER

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MI Chapter American Academy of Pediatrics

Great Start Collaborative

Wayne

Michigan Dept. of Community Health, MDCH

Institute for Population

Health

Detroit Wayne County Community Mental Health

Authority

Detroit Public Schools

Detroit Department Health and Wellness Promotions

School-Community Health

Alliance of Michigan

Wayne Regional Educational Services

Agency, WRESA

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Children Die from

Asthma, a Manageable

and Often Preventable

Disease.

African American Children

Die at 3-4 times the Rate of

Caucasian Children

More than a Disparity… Asthma is an Issue of Social, Economic and

Health Equity

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Obesity

Evidence Based – Acute Child-Family Interventions

and Clinic Education

• Fit Kids360! • Coming! FK 360 for Toddler/Pre-

Schoolers and Teen • FK At your Location!

Continuum of Obesity Interventions and Education in Clinic and Community Settings

• Families Moving in the D • Yoga & Fitness 4 Health • Food, Nutrition and Fitness

Partnerships

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William - Before and After

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WCHAP Highlights: Our Family and Physician Voices

• “I don’t know what you guys are doing, but I have never seen anything like it. Our patients love it and the results have been great!”-Dr. Treece (DRP)

• “Fit Kids really changed his attitude and made him look at things differently. He is so proud! Dr. Mosby kept yelling, “Where is William?” around the office because he couldn’t believe the difference in him in his last checkup.”-LaTonya Peterson (Mom of William)

• “I thank Fit Kids, I just need someone to believe in me and give me a push”.

• “This program has changed my life for the better.” Melvin Hall

• “This program has done for Melvin what four doctors were not able to do in the last few years!”- Belinda Williams (Melvin’s Mom)

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WCHAP Advisory Council....Advancing Family Centered Medical Home Partnerships

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Celebrating Community Health Worker Month with MiCHWA’s Katie Mitchell, Coordinator and

WCHAP Awesome Community Health Workers!

Reducing Infant Hearing Loss – Presentation by Deanna Basha, EHDI and WCHAP Early Intervention Specialist

José Reyna Spectrum Health Healthier Communities

ANNUAL MEETING

October 8, 2014 | Lansing Community College West Michigan Community Health Worker Alliance

Saginaw Pathways to Better Health

MiCHWA Annual Meeting

October 8, 2014

3-yr $14M CMS Innovations Grant Awarded to MPHI: July 1, 2012 – June 30, 2015 o The funding was used for the implementation of the Pathways

Community HUB model in Michigan o Three sites were chosen:

• Ingham • Muskegon • Saginaw

Adults (18 years of age and older) 2 or more chronic health conditions Eligible or Enrolled in Medicare and/or

Medicaid or Saginaw Health Plan Residents of Saginaw & adjacent counties “At Risk”- high utilizers, frequent

rehospitalizations, under resourced, socially isolated

•Psycho/social issues huge determinant of health/outcomes •Positive health outcomes can be achieved via education, awareness, support, personal responsibility and empowerment •Health is a general measure of everything else going on in society

Pathways to Better Health Premise

SCCMHA: Lead Agency/Fiduciary, HUB MiHIA & Alignment Saginaw: Co-conveners Coordinating Care Agencies (CCAs)

o Health Delivery, Inc. o Covenant/VNSS o St, Mary’s of Michigan/Center of HOPE o Saginaw County Department of Public Health

Core Leadership Team – key community stakeholders

Saginaw County Community Mental Health Authority (SCCMHA) Hub is a central registration and quality improvement center It receives referrals, screens clients, makes assignments to

CCAs, assures two-way communication with referral entities Serves as a data information clearinghouse and fiduciary Monitors project activity for quality Reports outcomes to the community

Recruit, hire, supervise, and deploy Community Health Workers (CHWs)

Accept assignments from the HUB and assign CHWs to clients

Document care coordination provided by CHWs using Pathways templates/MiPathways database

Transmit data from CHWs and their supervisors to the HUB Outreach and collaboration

Trained in an evidence-based curriculum with goals: o Improve clients’ health o Increase clients’ utilization of primary care services o Decrease cost of clients’ health care by decreasing utilization of ER and

hospitalizations Help clients understand their chronic diseases and how to manage them CHWs track client progress to complete Pathways sequences and reach

milestones Help clients make positive lifestyle choices to promote health and well-being Help clients with navigating health and human services systems to get them

connected to resources to improve their health and reduce the cost of care

Better health Better care Lower cost

Triple Aim: Make the Numbers

Year 1 CHW’s: 12

Clients enrolled: 522

Year 2 CHW’s: 20

Clients enrolled: 1740

Year 3 CHW’s: 25

Clients enrolled: 2175

Food Housing Clothing Schizophrenia Parkinson's Disease

Alzheimer's Disease

Cancer Primary Care

Transportation Child Care Health Insurance Finances

Obesity Arthritis Diabetes Hypertension Asthma Hearing Aids

Employment Education/Job Training Diet Specialty Care Exercise Smoking

Depression Substance Abuse

Domestic Violence Legal Problems Utilities Prenatal

Care

CVD Stroke COPD Amputation Bipolar Disorder Medications

Health insurance Cessation of tobacco use/smoking Medication assessment Medication management Education about health conditions and prevention Medical home Medical referral Social Services Pregnancy Postpartum Family planning

Target Population - Find those at greatest risk 1 – Find

2 – Treat

Confirm connection to evidence-based care

3 – Measure

Measure the results

saginawhub.org

MIECHV/Home Visiting

The project described was supported by Funding Opportunity Number 1C1CMS331025 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation.

The contents of these materials are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Questions Melissa Freel, WCHAP José Reyna, Spectrum Health Jane Sills, Saginaw Pathways

ANNUAL MEETING

October 8, 2014 | Lansing Community College West Michigan Community Health Worker Alliance