The document summarizes the results of interviews conducted with 27 community health workers (CHWs) about their roles and experiences integrating into patient care teams at federally qualified health centers in Michigan. Key findings include:
1) CHWs reported roles like identifying and enrolling patients, providing resources, advocating for patients, and conducting home visits. They felt their unique contributions included building strong relationships with patients and addressing social needs.
2) CHWs described collaborating with care teams by referring patients, communicating at huddles, and following up to improve engagement. However, some faced challenges like lack of support, high turnover, and unclear roles.
3) Integrating CHWs was seen as important because they provide
Clinical Workforce Development NCA Informational WebinarCHC Connecticut
Learn more about training and technical assistance offered through Community Health Center Inc.'s National Cooperative Agreement (NCA) on Clinical Workforce Development. Hear more about FREE Learning Collaboratives opportunities to enhance or implement a model of Team-Based Care at your Health Center, and how to implement a Post-Graduate Residency program for Nurse Practitioners and Post-Doc Clinical Psychologists.
The Structure of a 12-month Residency Program and Stories from Former Residen...CHC Connecticut
The goal of the Postdoctoral Psychology Residency program is to train the next generation of psychologists in the Patient Centered Medical Home model. Through weekly seminars, group and individual supervision and clinical work with diverse, underserved populations, residents will fine-tune assessment and therapy skills.
This FREE learning collaborative opportunity will provide health centers with the support, resources and structure to implement a Postdoctoral Clinical Psychology Residency program at their organization.
Clinical Workforce Development NCA Informational WebinarCHC Connecticut
Learn more about training and technical assistance offered through Community Health Center Inc.'s National Cooperative Agreement (NCA) on Clinical Workforce Development. Hear more about FREE Learning Collaboratives opportunities to enhance or implement a model of Team-Based Care at your Health Center, and how to implement a Post-Graduate Residency program for Nurse Practitioners and Post-Doc Clinical Psychologists.
The Structure of a 12-month Residency Program and Stories from Former Residen...CHC Connecticut
The goal of the Postdoctoral Psychology Residency program is to train the next generation of psychologists in the Patient Centered Medical Home model. Through weekly seminars, group and individual supervision and clinical work with diverse, underserved populations, residents will fine-tune assessment and therapy skills.
This FREE learning collaborative opportunity will provide health centers with the support, resources and structure to implement a Postdoctoral Clinical Psychology Residency program at their organization.
Presented at the 2015 IHI International Forum byThe Royal Melbourne Hospital of Victoria,Australia, this poster,speaks to the power of Shadowing to engage patients and families in decisions of care, specifically the post-discharge planning process.
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive CareCHC Connecticut
Join us as we discuss the core concepts of team-based care and introduce elements of team-based care that builds upon these basics to support your teams in advancing their capability to provide satisfying and effective care to complex patient populations. .
We will be joined by Margaret Flinter, Senior Vice President/Clinical Director for Community Health Center, Inc., and both Thomas Bodenheimer, MD, Physician and Founding Director, and Rachel Willard Grace, Director, from the Center for Excellence in Primary Care.
Maxime Lê is a graduate of health sciences from the University of Ottawa that has worn many hats for many roles. Chief among them is being a patient advisor for The Ottawa Hospital. Having frequently been a patient and having a passion for health and healthcare, he decided to get involved at The Ottawa Hospital to help improve care, research and advocate for patients. Maxime, while sharing his hands-on experience and insights, answered the questions that healthcare providers, researchers, or prospective patient advisors may have, such as: ''What does it mean to be a patient advisor?'', ''Why is it important?'', and ''What impact does it have?''.
The webinar was followed by an interactive question and answer session.
How to make care and support planning a two-way dynamic - presentation from webinar held on 1 October 2014
This relates to the first NHS IQ Long Term Conditions Improvement Programmes Wednesday Lunch & Learn Webinar Series. How to make care and support planning a 2 way dynamic hosted by Dr Alan Nye & Brook Howells from AQuA. This webinar discussed how to encourage patients, carers and the public to work alongside (in equal partnership) with clinicians and managers
Communicating Effectively: Strategies to Ensure the Quality of Communication...TraceByTWSG
Blair Wright (The White Stone Group, Inc.) presenting to Massachusetts Association of Hospital Access Managers (MAHAM) on how the quality of communicating with patients is directly linked to the perceived quality of care.
Presented at the 2015 IHI International Forum byThe Royal Melbourne Hospital of Victoria,Australia, this poster,speaks to the power of Shadowing to engage patients and families in decisions of care, specifically the post-discharge planning process.
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive CareCHC Connecticut
Join us as we discuss the core concepts of team-based care and introduce elements of team-based care that builds upon these basics to support your teams in advancing their capability to provide satisfying and effective care to complex patient populations. .
We will be joined by Margaret Flinter, Senior Vice President/Clinical Director for Community Health Center, Inc., and both Thomas Bodenheimer, MD, Physician and Founding Director, and Rachel Willard Grace, Director, from the Center for Excellence in Primary Care.
Maxime Lê is a graduate of health sciences from the University of Ottawa that has worn many hats for many roles. Chief among them is being a patient advisor for The Ottawa Hospital. Having frequently been a patient and having a passion for health and healthcare, he decided to get involved at The Ottawa Hospital to help improve care, research and advocate for patients. Maxime, while sharing his hands-on experience and insights, answered the questions that healthcare providers, researchers, or prospective patient advisors may have, such as: ''What does it mean to be a patient advisor?'', ''Why is it important?'', and ''What impact does it have?''.
The webinar was followed by an interactive question and answer session.
How to make care and support planning a two-way dynamic - presentation from webinar held on 1 October 2014
This relates to the first NHS IQ Long Term Conditions Improvement Programmes Wednesday Lunch & Learn Webinar Series. How to make care and support planning a 2 way dynamic hosted by Dr Alan Nye & Brook Howells from AQuA. This webinar discussed how to encourage patients, carers and the public to work alongside (in equal partnership) with clinicians and managers
Communicating Effectively: Strategies to Ensure the Quality of Communication...TraceByTWSG
Blair Wright (The White Stone Group, Inc.) presenting to Massachusetts Association of Hospital Access Managers (MAHAM) on how the quality of communicating with patients is directly linked to the perceived quality of care.
Se trata de paciente femenino de 70 años de edad quien sufre caída accidental cuando estaba en el baño, con el lavabo se golpea la región frontal sufriendo una contusión traumática que le produce una herida de unos 5.5 centímetros de largo por un centímetro de profundidad, al incorporarse resbala y se golpea contra la pared produciéndose otra contusión traumática en la parte media de la cabeza de aproximadamente las mismas dimensiones.
Realizamos asepsia y antisepsia con yodopovidona de la región frontal y parte media de la cabeza limpiamos las áreas con agua superoxidada, secamos muy bien con una compresa estéril, colocamos campo hendido sobre la herida de la frente y aplicamos lidocaína al 2% con epinefrina, utilizando una sutura de Nylon 3 (0) se cierra la herida en síes puntos separados.
El procedimiento antes descrito fue llevado a cabo en la parte media de la cabeza.
A los 7 días de haber ocurrido el accidente se retiran los primeros 3 puntos en forma alterna, el día 12 se retiran los otros 3.
A continuación se presentan los resultados gráficos.
Somos una agencia de marketing digital conformada por un grupo de profesionales de diferentes áreas con experiencia en la planeación, ejecución, desarrollo de estrategias y planes de marketing digital para ayudar a las empresas a lograr su objetivos en la web.
Entendemos la necesidad de tener presencia en redes sociales, así como también la situación actual, y es por eso que nuestros paquetes incluyen soluciones de marketing online a un precio muy competitivo.
Proyecto de desarrollo app web y móvil donde los constructores pueden realizar sus pedidos y contratar mano de obra calificada a través de una plataforma que permite comparar precios y contactar con varios proveedores.
Grading CriteriaResearch Study Proposal – Part V Final .docxwhittemorelucilla
Grading Criteria
Research Study Proposal – Part V: Final Research Presentation
Content
60 Percent
Points Earned/Points Available
Student has created a 10- to 15-slide presentation with detailed speaker notes. The Final presentation must summarize the health care problem you selected. Describe your proposed research design for your problem statement including the following:
· Importance/relevance of problem
· Problem statement
· Summary of literature review
· Research question
· Methodology to be used
· Implications of the expected findings
There is Discussion of the rationales for the various methods and decisions that are being made throughout the process.
Correct citations in the speaker’s notes and slides indicate clearly what information is coming from what source(s).
It is acceptable for this paper to be informed by, and even to include pieces from prior Individual Assignments in this class that relate to this topic, provided feedback is being considered to correct any errors in those parts from prior assignments.
/6
Organization/Development
20 Percent
Points Earned/Points Available
· The assignment has 10-15 slides in a PowerPoint presentation
· The slide show and the speaker’s notes are organized clearly, are logical, and flow smoothly.
· Sentence and paragraph structure are clearly organized in the speaker’s notes. The slides should be more visually oriented, with bullets and/or graphs or other images that clearly inform the discussion.
· The introduction provides sufficient background on the topic and previews major points.
· The conclusion is logical, flows, and reviews the major points.
/2
Mechanics
20 Percent
Points Earned/Points Available
· The presentation—including the title page, reference page, tables, and any appendixes—is formatted according to APA guidelines as directed by the facilitator. The presentation is laid out with effective use of headings, font styles, and white space.
· Rules of grammar, usage, and punctuation are followed; spelling is correct, in both the slides AND the speaker’s notes.
/2
Total Points Earned/Points Available
/10
Community Health Nursing
Research Study Proposal–Part V: Final Research Presentation
Name
HCS/542
October 9, 2017
Lane Baggett
*
Introduction Nurses face challenges in practice. They have inadequate support, equipment, time, and funds. It becomes hard for them to cater for patients with emotional, behavioral, and cognitive problems. These patients require participatory care delivery This includes the help of nurses and friends, or family members. Also, nurses lack appropriate skills, education, and knowledge to help such patients. Through the appropriate interventions they can approach the patients and initiate participatory care delivery This project offers a way through which the nurses can get help to overcome those limitations.
Nurses in today’s world face numerous challenges in their work. They strive to deliver excellent care with inadequate suppor ...
Behavioral Health Staff in Integrated Care SettingsCHC Connecticut
Webinar broadcast on Feb 27, 2019 - 3:00PM EST
Delivering behavioral health services as a part of an integrated team is crucial to providing comprehensive primary care services. Focusing on the vital role of behavioral health, experts will share the key elements that maximize the contributions of these team members through structured approaches to screening, the use of “warm hand offs” to ensure connection to primary care, and implementing a robust group of treatment programs to enhance access and improve outcomes. This session will also discuss the day-to-day operation of a behavioral health program and detail the data and clinical dashboard that supports the work of these vital team members. There has been tremendous progress from health centers across the country in the integrating behavioral health, this webinar will share how integrated behavioral health can advance the team’s capability to provide effective and high quality care to complex patient populations.
113DNP Prospectus Comment by Cynthia Fletcher Th.docxherminaprocter
1
13
DNP Prospectus Comment by Cynthia Fletcher: This is a good beginning Ann Marie. There are many areas that we will discuss at our meeting to improve clarity and congruence with a DNP Project.
Educating Inpatient Nurses to use Standardized Care Plans
Anne Marie Wouapet
Doctor of Nursing Practice – Nursing Informatics
A00505587
Prospectus: Educating Inpatient Nurses to use Standardized Care Plans
Problem Statement
Standardized care plans can be described as the pre-determined menu of interventions which are used for different patient situations (Monsen, Swenson & Kerr, 2016). Evidence-based care is the conscientious use of the most recent evidence to make decisions on the care of individual patients or in the delivery of health care services (Murdaugh, Parsons & Pender, 2018). The current best evidence is the most recent information which has been obtained from valid and relevant research about the effects of different types of healthcare, the accuracy of diagnostic tests, the potential for harm from exposure to different agents, or predictive power of prognostic factor (Schmidt & Brown, 2017). Standardized care plans form the main basis for the implementation of evidence-based care directly in practice and for the improvement of patient outcomes (Nussbaum et al., 2015; Yehuda & Hoge, 2016). A health care facility recently transitioned to the use of a new and better electronic health record system. The facility also purchased standardized care plans to increase efficiency in their operations. However, the compliance with using the standardized care plans was only 40 percent among the inpatient nurses. Comment by Cynthia Fletcher: ?Comment by Cynthia Fletcher: Questionable purpose.Comment by Cynthia Fletcher: Was it different for those who were not inpatient nurses?
Accordingly, the facility recently had a visit from the Joint Commission on Accreditation of Healthcare Organizations and received a negative rating because the nurses were not adding care plans based on the patients' primary problem or diagnosis in the patients' charts upon admission. This presents several specific problems in the healthcare facility. There is poor compliance from the nurses concerning the addition of standardized care plans to the charts of patients based on their diagnosis or primary problem(s). The system which the facility invested in was not being used for the improvement of patient outcomes and quality of care delivered. The focus of this project is the failure of inpatient nurses to make use of standardized care plans. The gap in nursing is the failure of delivery of evidence-based practice using the standardized care plans which result in poor patient outcomes and quality of life. One of the areas of knowledge that has not yet been explored is the cause of low rates of adoption of standardized care plans by nurses. Another gap is the lack of studies on nurses’ perception of the standardized care plans and how they affect their use in .
SMART GOAL
Leadership SMART Goal Leadership goal Setting a goal is important since it really gives clarity to a person’s vision. A goal specifies the outcome of what one wants to accomplish (Jay, 2011). Developing a SMART leadership goal ensures that one’s goal is actually focused and offers a clear idea of what one wants to accomplish. In essence, a goal that is SMART makes it simpler for one to come up with pertinent activities, to measure his or her progress towards accomplishing the goal, and know when he or she has met his/her goal (Jay, 2011). For me, setting a SMART goal will make what I want tangible since I am declaring to myself that this is really what I want. Basically, the SMART goal will help me to focus my everyday energy towards making my dreams and wishes come true. My set goal is SMART in the following way: Specific: Haughey (2014) pointed out that a specific goal has to be focused, detailed, and stated clearly. My goal is specific enough; it is to work in interdisciplinary/interprofessional teams by Week 10 (as selected from the Institute of Medicine (IOM)). In these teams, I should be able to work with other professionals to offering the best care available to transplant patients and help the patients before the transplant, during the transplant, and after. To accomplish this goal, I will greet and introduce myself to various health professionals in the Transplant Services Department so familiarize my self with the department and the transplant of patients and cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable. In the future health care system, health professionals will have to understand the advantage of high levels of cooperation, coordination, and standardization to guarantee excellence, continuity, safety, and reliability. In short, they will have to think of themselves as a team working in and contributing to a larger system. As Don Berwick, Institute for Healthcare Improvement, said at the summit, The team members integrate their observations, bodies of expertise, and spheres of decision making. Thus this competency refers to the various disciplines working together to address the needs of patients. Interdisciplinary teams are critical in dealing with the increasing complexity of care, coordinating and responding to multiple patient needs, keeping pace with the demands of new technology, responding to the demands of payors, and delivering care across settings Teams tend to reduce the utilization of redundant or duplicate services, and they also tend to develop more creative solutions to complex problems because of their members’ diverse academic backgrounds and experience. Patients needing chronic care, critical acute care, geriatric care, and care at the end of life require smooth team functioning because of the complexity of their needs. Different means and settings for delivering care, such as managed care, community-based care, rehabilitation centers,.
Improving the Health Outcomes of Both Patients AND PopulationsCHC Connecticut
NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series
Webinar broadcast on: May 23, 2019 | 2 p.m. EST
In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...CHC Connecticut
Expert faculty will discuss the drivers, benefits, and processes of implementing a postgraduate residency training program at your health center. This session will dive deeper into a discussion on the responsibilities of key program staff, preceptors, mentors, and faculty for successful implementation. This webinar will equip participants with a road map to go from planning to implementation and offer an opportunity for coaching support.
Panelists:
• Program Director of the Nurse Practitioner Residency Program, Charise Corsino, MA
• Clinical Program Director of the Nurse Practitioner Residency Program, Nicole Seagriff, DNP, APRN, FNP-BC
Creating value through patient support programsSKIM
How do we become more patient-centered as an organization? How do we ensure the patient/caregiver experience is as optimal as possible?
These are the questions that are being poised to healthcare market researchers in today’s healthcare landscape. And typically healthcare market researchers are turning to methods like “patient journeys” and “patient personas” to help bring that patient-centered understanding to the organization. Problem is … in order to be truly patient-centered, you need to take this charge on from the inside out.
Experience, Design and Innovation departments are springing up in all kinds of healthcare organizations intent on facilitating the organizational shift towards patient-centricity. And, unfortunately, market researchers are intentionally not being invited to the table. If history repeats itself, that will soon change though. These Experience, Design and Innovation departments will need the rigor and breadth of method knowledge that market researchers have in order to succeed in the strategic agendas of their work.
This presentation will give market researcher pointers on which skills, methods and mindsets they’ll likely need to adopt if they are hoping to be perceived as a valued contributor to an Experience, Design or Innovation team. In essence, give attendees a blueprint for how to open up a whole new professional opportunity for themselves, with a simple reframe on whom they are and what they do.
2021-2022 NTTAP Webinar: Building the Case for Implementing Postgraduate NP R...CHC Connecticut
Join us as we discuss the drivers and processes of implementing a postgraduate nurse practitioner residency program at your health center, the benefits of implementing a postgraduate residency program, and the residency tracks for Family, Psychiatric/Mental Health, Pediatric, and Adult-Gerontology Nurse Practitioners.
We will be joined by Charise Corsino, Program Director of the Nurse Practitioner Residency Program, and Nicole Seagriff, Clinical Program Director of the Primary Care Nurse Practitioner Residency Program, from the Community Health Center Inc.
Retention, attrition and motivation of voluntary workers in community-based p...jehill3
Retention, attrition and motivation of voluntary workers in community-based programs
Peter Winch and Anne Palaia, Johns Hopkins Bloomberg School of Public Health
CORE Group Spring Meeting, April 29, 2010
Leveraging Patient Support Programs in Biologic-Biosimilar Competitive LandscapeAlex Xiaoguang Zhu
Biologics are facing intense competition from biosimilars. In this competitive landscape, strategic levers for both branded biologics and biosimilars typically include payor strategy, promotion and new formulation. As patients become more engaged and patient-centricity is on the rise, there is an increased opportunity to leverage patient support programs as additional strategic lever. This presentation will cover five key learnings that we have uncovered while conducting multi-phase patient support program research for both branded biologics and biosimilars.
Primary Health Care Strategy:
Key Directions for the Information Environment. Case study report and composite success model.
Steve Creed & Philip Gander
Assessing Health Center Readiness to Train Health ProfessionalsCHC Connecticut
This webinar discussed how to use the Readiness to Train Assessment Tool (RTAT™), developed by HRSA-funded National Training and Technical Assistance Partners (NTTAP) at Community Health Center, Inc., to support health centers’ strategic workforce planning through the lens of health professions training (HPT).
Panelists:
• Jaclyn Cunningham, MHA, Project Manager, Population Health, Community Health Center, Inc.
• Victoria Malvey, MS, Inter-professional Student Specialist, Community Health Center, Inc.
• Amanda Schiessl, MPP, Deputy Chief Operating Officer, Project Director/Co-Principal Investigator, National Training and Technical Assistance Partnership, Community Health Center, Inc.
Similar to Linkages_Initial Report_CHW Interviews_120415 (20)
Assessing Health Center Readiness to Train Health Professionals
Linkages_Initial Report_CHW Interviews_120415
1. Michigan Community Health Worker Alliance
In coordination with the Curtis Center Program Evaluation Group at
the University of Michigan School of Social Work
Linkages Project Evaluation:
CHW Baseline Interview Results
December 4, 2015
For the Michigan Primary Care Association, with funding from the Michigan Health
Endowment Fund
For questions about this report, please contact MiCHWA Project Director Katie Mitchell
(mitchkl@umich.edu) or Lead Evaluation Staff Abby Anderson (ybbaand@umich.edu).
2. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 2
BACKGROUND
The Michigan Primary Care Association (MPCA) works to promote, support, and develop comprehensive,
accessible, and affordable community-based health care services for everyone in Michigan. Enriching Michigan's
health workforce policies is an ongoing strategic focus of the Association which has led to an integral partnership
with the Michigan Community Health Worker Alliance (MiCHWA). A School of Social Work project, MiCHWA
works to promote and sustain the integration of community health workers (CHWs) into Michigan’s health and
human service systems through coordinated changes in policy and workforce development.
MPCA is the recipient of an award from the Michigan Health Endowment Fund. With this award, MPCA launched
a statewide project called Linking Clinical Care with Community Supports (LC3S, or Linkages). MiCHWA will
evaluate elements of the project, including the sustainability of CHWs and the training and integration of CHWs
into care teams at participating federally qualified health centers in Michigan. Evaluation activities include
conducting pre-post CHW training assessments, conducting post-training interviews with CHWs and employers,
and identifying CHW continuing education needs. MiCHWA will also evaluate the role of CHWs in patient care
planning, assess CHW and non-CHW care team member perspectives on the role of the CHW in patient care, and
identify barriers and strategies for successful CHW integration into the care team. This report focuses on the
integration of the CHW into the patient care team, specifically the perspective of CHW care team members.
Purpose of the Report
Interviews were conducted over the phone with CHWs (n=27) about their experience on the patient care team,
especially regarding their role and integration into the team. This report will provide a summary of the baseline
results captured by these interviews.
Methodology
The Evaluation in Social Work course (SW 683) taught by Sue Ann Savas, Director of the Curtis Center Evaluation
Group, conducted the interviews as part of their coursework. The students, under the supervision of Sue Ann Savas
(professor), Dr. Edie Kieffer (PI) and Katie Mitchell (Project Director), developed a key informant interview
protocol. They used this protocol to conduct key informant interviews to document the integration of CHWs into 16
care teams across Michigan-based health centers, including successful strategies and barriers to integration. The
interviews also included information regarding the interviewees and their health clinics used to track responses. This
information, however, was not tied to the responses in analysis to ensure the confidentiality of the interviewees.
CHWs were emailed a recruitment letter through MPCA and asked to sign up for an interview slot on a shared
Google Doc. A student interviewer and notetaker was then assigned to each CHW who signed up. Confirmation
emails were sent participating CHWs, and student pairs then contacted each individual at the designated interview
time. Interviews were recorded for accuracy with interviewee permission. After each interview was conducted, the
interview responses were added to a shared master document for analysis. This document allowed each interviewer
to enter the pertinent information from each of the questions into one document, along with any additional
comments or insight the interviewer had.
To analyze the data, the students examined all of the responses for each question to identify common themes. These
themes were then recorded into the same master document. The research team looked over the themes and made
needed adjustments and additions. Data and themes from this analysis were verified by a student research assistant
with the Curtis Center Program Evaluation Group, and results are presented below.
3. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 3
RESULTS
Q1 What are the roles and responsibilities of the community health worker on the patient
care team?
Probe: What do you do on the patient care team?
The results below demonstrate the CHWs’ various roles in supporting health clinics and patients in the identified
populations. Identified challenges include lack of clarity in the CHW role and lack of CHW participation on the care
team.
Identify and enroll patients that fit their patient specialty
Provide resources (sometimes community resources)
Act as liaisons between patients and providers, including sharing social
issues/information with patient care team
Act as advocates for the patients
Act as patient point of contact and support: identifying barriers to health care
and encouraging compliance, conducting home visits
Administrative tasks, primarily involving scheduling
Lack of clarity of role
Not participating on team
Q2 What is unique about your role on the patient care team?
a. What do you do with the patient that is different from other team members?
i. Probe: how or why is what you do different?
b. Do you see any overlap among team members and their roles in patient care, including
your role?
The CHW plays an important role in building relationships with patients, enabling then to advocate on patients’
behalf. The CHW also facilitates patient care and connects patients with community resources.
Build a strong relationship and rapport
As a member of community, uses a familiar language
Makes patient feel comfortable
Patient may share information they don't share with provider/nurse
Advocates on patients' behalf
Encourages patient
When role as
CHW known
Challenges
Relationship
with patients
Patient education
and empowerment
4. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 4
Helps with goal setting
Have more time to spend with patients; patient doesn't feel rushed; answers
questions pts don't ask providers; able to visit patients' homes; helps meet non-
medical needs that provider doesn't address; allows medical staff to focus on
medical needs; patient follow-up to engage no show/non-compliant patients
Able to go into community to connect patient with resources
Addresses social needs
Finds out information additional, pertinent patient information
Not allowed to do outreach
Role overlaps, potentially with nurse, care manager, BHS and/or SW
Lack of CHW understanding of unique role in patient care - feels engagement is
slowing patient down
Lack of participation in care team
Q3 We’re really interested in how your team is collaborating. Can you share a brief example
or story of how your team has collaborated in patient care so far? What role did you play?
a. Thinking about your team-based care training, has your team identified any challenges to
address or strategies to overcome challenges?
b. Based on you experience so far, do you as a CHW expect any challenges in your integration into
the patient care team?
CHWs collaborate with the care team to address patient needs, both supporting the engagement of other care team
members and providing non-medical patient care. Barriers to effective CHW engagement occur when there is a lack
of support within the health care clinic and/or patient care team, when there is high incidence of turnover, and when
there is CHW isolation due to few referrals or lack of clarity regarding the CHW’s role.
Huddles
Collaboration to meet non-clinical needs - care team members refer to CHW if
non-clinical needs are identified
Integration naturally occurs – CHW widely accepted on teams
Team members use each other as resources according to their expertise
Communication regarding patient information from all members of team to
inform the other PCT members' work
CHW follows up with patient to ensure information was conveyed well and
understood by patient
CHW reduces no-shows by doing reminder calls and reducing barriers to arriving
Patient care
Collaboration
present
Community
connections
Challenges
5. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 5
Disconnection/lack of support from upper management
Finding time for full huddle participation
Care-team member turnover is a possible challenge as new members do not
have the training
Buy-in/support from other members of patient care team (especially the
provider)
Lack of knowledge regarding the role of the CHW on patient care team
Recognizing that all patient care roles are equally important
Lack of patients/cases where CHW collaboration is requested
Isolation from PCTs and patients
Q4. At this point in time and from your perspective, why is it important to integrate the CHW
into the patient care team?
a. Probe: What, if anything, do you see changing about patient care once you’re fully integrated
into the team?
CHWs are an important asset to the patient care team in that they have access to information about the patients that
other members of the patient care team may not. They are able to support the patient in ways that will in turn
improve the overall wellbeing of the patient.
Patients may provide information to CHW that they do not share with provider
– this is shared with the team to broaden the understanding of all members of
the patient care team
Helps engage patient in their own care
Helps patients feel comfortable
Have knowledge and time to connect patients to resources
to improve their lives
CHWs have time to listen to social needs that affect the medical condition of
patient as well
Contributes this information to the patient care team and in huddle
Challenges to
collaboration
Complements the
patient care team
Social support/
resource referral
Addresses social
determinants of
health
6. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 6
Q5. When addressing patient care, which team members do you, as a CHW, interact with
directly?
CHWs interact with many individuals within the health centers, but most frequently with nurses and providers.
Huddles and other in-person contact are the most frequent reported forms of communication.
Most common interactions are with nurses and providers, followed by medical
assistants.
Additional interactions are with behavioral specialists, care managers, front
desk staff, pharmacists, supervisors, outreach coordinator, social workers, other
CHW's.
Interviewer notes indicated variability in amount of contact between CHWs and
teams.
Primary communication methods are…
- in person/face-to-face
- in huddles
- messaging through the Electronic Health Record
- email
- phone
Huddles seem to be primary method of communication between the various
team members
Q6. What is your health center doing to support your role on the team?
The health centers provide support to CHWs through both interpersonal and material means. The challenges to
health centers’ support vary between sites, but include lack of clarity regarding protocol for CHW engagement, lack
of onsite supervision, and delayed access to necessary software.
Time for training and webinars
Answer questions
Provide access to resources
Provide ideas regarding how to help the patient
Weekly meetings
Generally supportive team – encouragement and excitement regarding CHW
role
Introduce CHW to staff and to patients
Monthly site meetings about different topics
Care management meetings
Providers show support by making referrals
Patient care
team
interactions
Communication
methods
Health centers’
supports
7. Linkages Project Evaluation: CHW KI Interviews Baseline Results | 12/04/15 |Page 7
Delays in hiring
Delay in getting needed software
No onsite supervision
Lack of clarity regarding roles and responsibilities
Lack of knowledge regarding role by Health Center/care team
NEXT STEPS
The MiCHWA evaluation team will meet with the MPCA Linkages team to review results to date and identify next
steps. This will include a review of strategies and barriers to CHW integration. This will also include strategies for
improved evaluation in year two of the Linkages project.
Challenges to
health centers’
support