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AHA NOVA Award winner uses community health workers to reach underserved chronically ill at home

November 22, 2013

“Community Connections” spotlights the many ways in which hospitals serve their communities. AHA members can learn more by visiting  www.ahacommunityconnections.org.


Managing a chronic illness is daunting enough on its own, but when you factor in barriers like being unable to afford your medication or read the directions on your medication because of low English proficiency, it can be near impossible.

After seeing many of its most vulnerable patients struggling with these kinds of barriers, Spectrum Health, a not-forprofit health system based in Grand Rapids, MI, developed the Core Health Program of Healthier Communities. The program was implemented in 2009 to provide a continuum of
care for community members with diabetes or heart failure – chronic diseases that have reached epidemic proportions, particularly among the underserved. A primary care physician, registered nurse (RN) and community health worker (CHW) team up to help patients improve clinical and behavioral outcomes through motivational interviewing, disease management and cultural sensitivity.

The comprehensive program earned Spectrum Health a 2013 AHA NOVA Award, which honors hospital-led collaborative programs that help build healthier communities.

“We knew that these individuals needed additional support, so we went back to the old way of doing things,” says Erin Inman, Spectrum Health’s director of Healthier Communities. “We began meeting people in their homes and making house calls to provide support, intervention and care to help them manage their diseases and feel empowered to navigate the health care system.”

Participants in the free, voluntary program typically work with their individualized care teams for 12 months. Once a month, CHWs, often accompanied by RNs, visit patients in their homes to help them better manage their diseases by teaching them chronic disease self-management skills, connecting them with community resources, and helping them overcome obstacles to care related to trust, culture and language issues. The CHWs play an integral role in the program’s success.

“People don’t care what you know until they know that you care,” says RoShawnda Thompson, a community health worker in the program. “Community health workers bridge the gap between the social world and the health world. We keep our boundaries, but let patients know that we do care about them.”

In addition to monitoring patients’ blood pressure, measuring their body mass index, and ensuring that patients are adhering to their medication regimens, these visits provide an opportunity for the Core Health team
to establish trust in the medical community, improve patients’ mental and physical health, and address other issues in the patients’ environments that may be precluding them from managing their diseases.

“I once had a patient with diabetes who I knew was being evicted and didn’t have a refrigerator – my message about diabetes wasn’t going over well,” says Thompson. “Once we ensured that she had the housing and the food that she needed, she began to measure her blood sugar levels. She was able to free her mind and focus on her health.”

Since its inception, the Core Health Program has enrolled 871 uninsured or underserved patients with either heart failure, diabetes or both. After the first year of the program, emergency department use dropped by more than 85%
for heart failure patients, and hospital admissions dropped nearly 90%, with significant drops in those categories for patients with diabetes. These reductions have achieved $4.3 million in net savings for the health system.

Spectrum Health attributes a great deal of the program’s success to its partners, which include federally qualified health centers, insurers, community centers, food pantries and primary care providers.

“As health care has evolved, we recognize that the care of the patient is a continuum of care – it also takes place in their communities and in their homes,” says Inman. “Now, we look at the holistic care of the individual and not episodic care. We use a very integrated approach to provide services based on the individual’s entire set of needs.”

“The best part is finding resiliency in a person and meeting them where they are,” adds Thompson. “A patient recently thanked me and said, ‘I’m the pilot and you’re the co-pilot,’ and I thought, wow, that’s really true.”

Interested in applying for a 2014 AHA NOVA Award? The deadline to apply is Dec. 6. Learn more by visiting
www.aha.org/nova.

Watch this video on Spectrum Health’s program. Tune in here.

 

By Meg Figley