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Case Study: Spectrum Health’s Community-based Chronic-Disease Management Program

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Since 1997, Spectrum Health in Grand Rapids, Mich., has provided community-based care through its Healthier Communities initiative. Developed through the merger of two previous programs, Core Health was added in 2008 to provide in-home education on general wellness, including weight and stress control, for patients with early-stage chronic conditions, such as diabetes, heart failure and chronic obstructive pulmonary disease.

Eventually, it became evident that Core Health, as originally designed, was not serving some of the communities’ neediest members, those with more advanced disease, some of whom also had cognitive and behavioral challenges that made it difficult to benefit from the home-education curriculum.

“We realized that, wow, we’re saying, ‘No’ to a cohort of people who don’t have anywhere else to go,” says Core Health Program Supervisor Bethany Swartz.

Accomodating advanced disease

“We were challenged to shift the program to be able to serve those folks who were a little more clinically complex, a sicker population, those not so much in early-disease state,” Swartz says, “and also those who cognitively didn’t have the same capacity for learning and might have behavioral health issues that impede their ability to focus on their health first.”

Like its predecessors, Core Health employs community health workers, or CHWs, who make home visits to at-risk populations in Spectrum’s Grand Rapids and Greenville, Mich., markets. The program has been instrumental in improving patient health and reducing hospitalizations and emergency department visits among its participants.

Supporting article: Spectrum’s Award-winning Community Health Approach

Core Health tailored its services to the needs of its clients by adding a bilingual, licensed social worker and behavioral health screens for depression and anxiety. Core Health staff also developed a health risk assessment to better identify how social factors, such as housing, transportation, finances, food access, education, immigration status and relationship status, affect a client’s health.

The original Core Health curriculum was modified to reflect clients’ cognitive abilities and pace of learning. As in the original program, the Core Health curriculum includes lessons on healthy eating, stress management and portion control. However, the order and topics are determined by client goals and not by a pre-designed curriculum, Swartz says.

While the original was a yearlong program, in its new iteration, there is no defined timetable. The program is deemed successful when clients demonstrate necessary self-care management skills.

“We changed how we define success,” Swartz says.

How it works

Core Health is staffed by six CHWs, three full-time-equivalent registered nurses who function as care managers, and a full-time licensed social worker, in addition to Swartz. The CHWs visit three to four clients in their homes each day, spending about an hour with each, Swartz says, which allows them to see each of its approximately 300 clients about once a month.

During the visit, the CHW monitors the client’s condition and helps to set goals, such as eating more healthfully or exercising more.

In addition, a care manager performs medication reconciliation with each client about every three months.

The CHWs maintain contact with a client’s care manager and primary care physician. For example, if a client’s blood pressure is higher than a certain level or blood sugars are too high or too low, the CHW will call either the care manager or the PCP for further instruction. “Our ultimate goal is to get the client to a place where they’re using their primary care doctor to make their health decisions,” Swartz says.

The CHW also documents the visit as part of the client’s care plan in Spectrum’s electronic health record, which is then routed to a Core Health care manager, who must approve the plan within 24 hours after it’s sent.

CHWs are selected for their ability to relate to community members. They are intimately familiar with the barriers and struggles of the target population, says Mark Lubberts, R.N., manager of community health education for Spectrum Health’s Healthier Communities outreach program. “You’re not looking for the person with the master’s degree in public education,” he says. “You want somebody who has lived the life of many of our clients.”

Once selected, CHWs undergo rigorous training in a certification program developed jointly by Spectrum Health’s Healthier Communities and the Grand Rapids Community College to provide the Michigan Community Health Worker Alliance standardized curriculum. Upon completion, the student will receive a certificate from GRCC. To become certified for the Core Health program, CHWs are tested in eight competencies, including advocacy and outreach; community and personal strategies; legal and ethical responsibilities; teaching and capacity building; communication skills and cultural competencies; coordination, documentation and reporting; healthy lifestyles; and mental health. The eight-week onboard training includes classroom work, scenario precepting, job shadowing and peer mentoring, after which CHWs understand the nature of diabetes, heart failure and COPD, as well as the resources to manage them.

Newly minted CHWs also undergo Spectrum’s systems, department and program orientations.

Swartz notes that CHWs are being used more frequently by hospitals these days, and that it has become a coveted career in the region. Often, there are more applicants than job openings. “I think that is in part due to the training and certification and the amount of attention that this position is getting at local, state and national levels,” she says.

Outcomes to date

In 2016, Core Health had the following results in client engagement and health and cost efficiency:

• Success for the client is measured using a patient activation measure, or PAM, score, which assesss a client’s competence and readiness to manage his or her condition and engagement with primary care. In 2016, 70 percent of clients had a mean increase in their PAM scores of 26 percent. The client satisfaction rate was 97 percent.

• Objective measures of patient health indicate an improvement as well; more than 52 percent of diabetes clients decreased their A1c levels by an average of 17.2 percent during the period they participated in Core Health.

• Clients reduced the number of hospital stays and visits to the emergency department, which dramatically reduced Spectrum’s costs to care for these patients.

Lessons learned

The major takeaway, Swartz says, is the extent to which factors other than physical health affect the client’s ability to manage a chronic condition. “Looking back at the original design of Core Health, the behavioral and social health needs of our clients were probably underestimated,” she says.

Core Health staff have come to appreciate the complexity of chronic conditions, especially for the program’s target clientele. The acuity level of the clients’ conditions and the number of community members who were not receiving appropriate care services were unexpected, Swartz says.

Modeling the program around the client’s needs and capabilities is also much more productive than trying to mold clients into a certain approach, she says. This means that work with the clients is more intense, but often not as long.

“Our caseloads might be smaller, but we’re discharging clients more successfully at a faster rate so we can open that slot to somebody new,” Swartz says.

Next steps

One future objective is to incorporate technology into home visits. Swartz perceives a great need for pharmacy services, especially medication reconciliation for clients who are seeing providers from multiple health systems. Managing medication prescribed from non-Spectrum providers is often challenging, she says.

The solution most likely involves virtual visits, Swartz says. Spectrum has a new online platform called MedNow that enables patient visits with a primary care physician or advance practice provider via online access. Pharmacy visits might one day be offered through MedNow, as well. Virtual nurse visits would allow care managers to “visit” more patients, expanding the effective client base of the program.

Whatever the approach, the goal is to keep evolving. “I think we can get creative,” Swartz says.

“This has been an incredibly exciting program over the years,” says Lubberts.

“It has impacted a lot of outcomes,” she says, “but still the most impactful elements within this program were the times when I would receive phone messages from clients describing how a community health worker made all the difference in their lives.” 

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