Presentation on scope and practice of community health nurse

1. Using Community Health
Workers As Health
Navigators
Health Care Delivered Where People Live,
Learn, Work and Play
Dennis Dunmyer, JD, LCSW

2. Community Health Workers: Patient
Engagement
American Public Health Association
• APHA Definition of a CHW:
• A Community Health Worker (CHW) is a frontline public
health worker who is a trusted member of and/or has an
unusually close understanding of the community served.
This trusting relationship enables the CHW to serve as a
liaison/link/intermediary between health/social services
and the community to facilitate access to services and
improve the quality and cultural competence of service
delivery.
• A CHW also builds individual and community capacity by
increasing health knowledge and self-sufficiency through a
range of activities such as outreach, community education,
informal counseling, social support and advocacy.

3. Community Health Workers: Patient
Engagement
Kansas City Definition:
• “Community Health Workers bridge the gap
between healthcare providers and populations in
need of care. CHW’s are a trusted member or
have a close understanding of the community
they serve. They are a link between the patient
and the health or social services agencies, striving
to improve health outcomes. Ultimately, a CHW
improves access to services and quality of care
for patients.”
– Established by MARC Regional CHW Stakeholder Committee.
– Currently under review

4. Community Health Workers: Patient
Engagement
Dula Peer Counselor
Health Promoter
Prevention Outreach
worker
Promotora de salud
Navigator
Health Coach

5. Community Health Workers: Patient
Engagement
History of CHWs
• The history of the CHW can be traced back to the
early 17th century. During a shortage of doctors in
Russia, laypeople known as “feldshers” received
training in the field to provide basic medical care to
military personnel.
• In the 1950’s, CHW’s thrived in Latin America. Their
role was to remedy the unequal distribution of
health resources and bring health care to the poor.

6. Community Health Workers: Patient
Engagement
History of CHWs cont.
• In the 1960’s, CHW’s started emerging in the United
States as part of the Great Society domestic programs.
The Federal Migrant act of 1962 and the Economic
Opportunity Act of 1964 brought formal government
support to community health programs. These
legislations also mandated outreach efforts to low-
income neighborhoods and migrant worker camps.
• The use of CHW’s began to wane in the 1970’s and early
1980’s. In the late 1980’s and early 1990’s programs
began to pop up again in migrant and seasonal farm
working communities.

7. Community Health Workers: Patient
Engagement
CHWs today
• In the 2000’s, CHWs continue to grow:
– CMS recognizes CHWs as reimbursable provider
and between 2001 and 2007 the following states
began using CHW’s: Texas, Ohio, New Mexico,
Massachusetts, and Minnesota.
– In 2010 the Affordable Care Act included language
that encourages the use of CHWs
– Currently HHS, CDC, OASH and state and local
Public Health departments are exploring
increasing the use of CHWs

8. Community Health Workers: Patient
Engagement
Scope of Practice*
1. Bridge the gap between communities and the
health and social service systems
2. Navigate the health and human service systems
3. Advocate for individual and community needs
4. Provide Direct Services
5. Build individual and community capacity
*Minnesota CHW Alliance

9. Community Health Workers: Patient
Engagement
Bridge the Gap
• Enhance the quality and safety of health care by
aiding communication between provider and patient
• Educate community members about how to use the
health care and social service systems
• Educate the health and social service systems about
the community needs and perspectives

10. Community Health Workers: Patient
Engagement
Navigate
• Increase access to Primary Care
– Often will attend medical visit with the client
• Make referrals and coordinate services
• Teach self management skills and tools
• Facilitate continuity of care by providing follow-up
• Enroll clients in health coverage programs
– Ie Medicaid, Medicare, Marketplace
• And educate them on how to use their new coverage
• Link clients to community resources

11. Community Health Workers: Patient
Engagement
Advocate
• Be a spokesperson for clients when they are unable
to speak for themselves
• Involve participants in self and community advocacy

12. Community Health Workers: Patient
Engagement
Direct Services
• Provide culturally appropriate health information
• Educate clients about disease prevention
• Assist clients in self-management of chronic disease
• Assist clients with medication adherence
• Conduct health screenings
• Provide individual and social and health care support
• Organize and facilitate support groups

13. Community Health Workers: Patient
Engagement
Build capacity
• Build individual capacity to achieve wellness
• Build community capacity by addressing social
determinants of health
• Identify individual and community needs
• Mentor other CHWs

14. Community Health Workers: Patient
Engagement
Bob
• ED high utilizer (8 times for alcohol abuse)
• Homeless with no phone
• CHW worked with ED staff so that ED staff contacted
CHW the 9th time Bob came in. CHW worked with
Artist’s Helping the Homeless and together enrolled
Bob in rehab at Salvation Army. Then the CHW
created care plan and worked with Bob to connect
him to Medicaid and housing.

15. Community Health Workers: Patient
Engagement
Bob 2 years later
• Has Medicaid
• Stable housing
• Sober
• Has not been to the ED in over a year
• Attends medical appointments at his new Primary
Care medical home

16. Community Health Workers: Patient
Engagement
Settings for CHWs
• Hospitals
• Physician Clinics
• Health Departments
• Faith Communities
• Community Based Organizations

17. Community Health Workers: Patient
Engagement
Why a CHW?
• Hired from within at-risk communities, CHWs
reflect the values and culture of the community
they work within.
• Peer-to-peer relationship of trust with patients,
rather than provider-patient relationships.
• It is this relationships that allows CHWs to
communicate openly with patients on issues
related to health and ultimately to improve
health care access and outcomes.

18. Community Health Workers: Patient
Engagement
KC CARE CHW program
• Our goal is to improve health of patients as
evidenced by:
1) increased access to medication
2) improved patient self-management
3) high percentage of patients achieving personal
healthcare goals
4) increased engagement with a medical home
5) reduction in ED use
6) a high level of patient satisfaction

19. Community Health Workers: Patient
Engagement
CHWs at the KC CARE Clinic
• Started in 2010 with two CHWs working with
“afterhours” safety net clinics
• Today intervene in a continuum with 8 CHWs
– Hospital EDs
– Safety Net Clinics
– Wellness Center

20. Community Health Workers: Patient
Engagement
Strategies for Patient engagement
• CHWs function as a medical tour guide for patients,
walking side-by-side they teach patients to navigate
the health care system
– Attendance at appointments
– Home/Community visits
• Individualized assessment and treatment plan
• Motivational interviewing techniques
• Self management capacity building
– Ask me three
– Pre-appointment planning
– Post-appointment review

21. Community Health Workers: Patient
Engagement
Self Management Strategies cont
• Note book
– Pre-appointment planning
– Post appointment review
• “Ask me three” (questions to ask provider)
– What is my main problem?
– What do I need to do?
– Why is it important for me to do this?
• Operationalizing care plan
– Home visit or trip to grocery store

22. Community Health Workers: Patient
Engagement
Mary
• Diabetes, Hypertension, COPD
• $200,000 hospital bill because of frequent ED use
• Agoraphobia
• Using ED because leaving the house terrifies her and
so a trip to the doctor was frightening
• CHW met her at her house to travel with her by cab
to the first doctor’s appointment

23. Community Health Workers: Patient
Engagement
Mary after CHW
• Approved for Medicaid and disability
• Attends appointments with primary care doctor
• Diabetes is now controlled
• Attended specialty physician visits
• Currently in MH services for her agoraphobia
• Will now leave the house with her husband
occasionally
• Overall health improvement

24. Community Health Workers: Patient
Engagement
Sustainability/ROI
• Cost savings due to lower ER utilization and hospital
admissions, and access to preventive medicine
– Denver Health found an ROI of $2.38 for every $1
invested
– Arkansas Community Connector realized 23.8 percent
reduction in Medicaid spending for long term care
with use of CHWs
– In Baltimore, MD, CHWs work with diabetes patients
on Medicaid. They realized 38% reduction in ER visits
and 27% drop in Medicaid spending for these
patients. Each CHW is estimated to save $80-90,000

25. Community Health Workers: Patient
Engagement
Questions???
• Dennis Dunmyer
– dennisd@kccareclinic.org