Concepts of Teamwork and Collaboration Applied to the Community Health Workers as Part of the Primary Care Team

Cathy Franklin, DNP, RN, FNP-CEast Boston Neighborhood Health CenterEast Boston, MA.

© Copyright Cathy Franklin, 2015

Disclosures

Objectives

Review the history and evidence related to patient outcomes regarding:

◦ Primary care

◦ The community health worker (CHW) movement

Review concepts related to teamwork and collaboration

Apply concepts of collaboration and teamwork to a model that describes CHWs as members of the primary care team

1920 1960’s 1967 1978 1996

Concept of

Primary Care

Coined in the

Dawson Report

Credentialing for a new specialty of

family practice

conceived

Declaration of

Alma- Ata

IOM Report: Primary

Care: America’s Health in a New Era

AAP introduces

the concept of “Medical Home”

Time Line…

History of Primary Care

History of Primary Care:

2002 2007 2008 2010 2012

The Future

of Family

Medicine

Project

Joint Principle

s of PCMH

released

Safety Net

Medical Home

Initiative

Patient Protection

and Affordable Care Act

passes

IOM Report: Primary Care

and Public Health:

Exploring Integration to

Improve Population

Health

Time Line

Outcomes in Primary Care2005: Major systematic review

demonstrates that primary care improves the health of individuals and communities, reduces health disparities, and lowers total costs of health (Starfield, Shi, Macinko, 2005)

2012 : Patient Centered Primary Care Collaborative Report

Largest report to date on outcomes of PCMH projects across the United States demonstrating reduced costs and improved outcomes: Reduced ED visits and hospitalizations

Improved management of chronic illness

Improved patient experience (Nielsen, Grundy, Nace, 2012)

Community Health Workers “…frontline public health workers who are trusted members

of and/or have an unusually close understanding of the community served… “

Serve as a liaison, link, or intermediary between health/social services and the community to:

◦ facilitate access to services and

◦ improve the quality and cultural competence of service delivery

Building 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

◦ AdvocacyAPHA, 2009

National Call for CHWsImprove the Nation’s Health

IOM (2010): Recommended CHWs as part of their strategic plan to prevent, control, and reduce the impact of hypertension

PPACA (2010): Identified the need to encourage CHW engagement in health promotion and improving health outcomes for the medically underserved

CDC (2011): Policy Brief: Addressing Chronic Disease through CHW’s

CHWSPredominantly reflects the ethnic background

- live in the communities they serve

Over 85,000 paid and volunteer CHWs in the United States

Titles include:

◦ Lay health workers

◦ Volunteer health workers

◦ Community health agents

◦ Promotora de salud

◦ Care Coordinators

Outcomes of CHW Interventions Vulnerable and Underserved Populations

Improved health promotion and prevention such as:

◦ Vaccination compliance

◦ Maternal child health

◦ Cancer screenings

Improved management of chronic illnesses such as:

◦ Asthma

◦ Diabetes

◦ Heart disease

Cost savings

Viswanathan, 2009; NE CEPAC, 2013

17th Century

1950’s 1966Mid

70’s-80’s 1990’s

First Evidenc

e

Village health

volunteers reported in Thailand &

Latin America

Earliest note of CHW in

US as an interventi

on to address poverty

Private grants fund

special health

promotion & access

National conversatio

n about standardized training for CHW’s;

various state bills

unsuccessfully passed

HistoryCommunity Health Workers:

Time Line…

HistoryCommunity Health Workers:

2001 2006 2008 2010 2014

Texas becomes

1st state to require

HHS agencies

to use CHWs and

require training & certificatio

n

Massachusetts CHWs

assist over 200,000

residents to enroll in

state’s first universal

healthcare plan & gain access to

primary care

Minnesota CHWs

granted reimburse-ment for

broad spectrum

of interventio

ns

Patient Protectio

n and Affordabl

e Care Act

passes

States with CHW Organizations:Arizona, Colorado

District of Columbia Florida,

IndianaKentucky, Maine

Maryland Massachusetts

Michigan, MinnesotaMontana, Nebraska,

New Mexico New York

North CarolinaOregon

Rhode IslandTennessee, Utah

Virginia, WashingtonWisconsin

Time Line

CHW National Workforce Study

Five Models of Health Care Delivery:

1. Member of the care delivery team

2. Navigator

3. Screening and health educator provider

4. Outreach-enrolling-informing agent

5. Organizer

HRSA, 2007

CHW ActivitiesDefined by 2007 Workforce Study

Six key areas of CHW activity identified as follows:

1. Creating linkages between communities and the healthcare system

2. Providing health education and information,

3. Assisting and advocating for underserved to receive appropriate services

4. Providing informal counseling

5. Directly addressing basic needs

6. Building community capacity in addressing health issues

HRSA, 2007

CHW Workforce Profile

Approximately 67% of the CHW workforce are paid and employed by a variety of organizations

◦ Approximately 27% of which can be categorized as ambulatory health care organizations

Approximately 33% are volunteers deployed by:

◦ Grassroots community

◦ Faith based

◦ Advocacy organizationsHRSA, 2007

States with CHWTraining/Certification Standards

Astho, 2015

States Implementing CHW Strategies

CDC sponsoring program in 50 states to reduce the risk factors associated with childhood and adult obesity, diabetes, heart disease, and stroke with focus on healthy environments in workplaces, schools, and in the community.

◦ 23 of the states are using CHWs to reduce health disparities in chronic illness through the provision of:

Training in health coaching for chronic disease self management

Development of core competencies and certification

Access to electronic health record (EHR) systems to facilitate follow-up with patients, communication with providers on the care team, and the referral of patients to community resources.

Exploration of financing mechanisms to sustain programs

HRSA Office of Rural Health Policy published its CHW Evidence-Based Models Toolbox for CHW program models and training

CDC, 2014; HRSA, 2011

National Call Teamwork and Collaboration

IOM (2001) in Crossing the Quality ChasmIncreased development of interdisciplinary teamwork and team training as part of the redesign of the health care system

WHO (2010) in Framework for Action on Interprofessional Education & Collaborative Practice

Put forth an action agenda, described as an “urgent challenge,” to integrate interprofessional education and collaborative practice into service, education, and health policy globally in order to strengthen health systems based on primary care.

Interprofessional Education Collaborative (IEC) (2011)Introduced core competencies for interprofessional collaborative practice

IOM (2012) Primary Care and Public Health: Exploring Integration to Improve Population Health

Call for establishment of community based interprofessional teams to support primary care providers in PCMHs

Outcomes of Interprofessional Teamwork and Collaboration

Improves patient outcomes

Improves access to healthcare.

Healthcare workers who serve as part of a team have higher job satisfaction than those who do not

Archer et al., 2012; Davenport, et al., 2007, Raab et al., 2013; Zatzick, et al., 2014

Terminology…Team: “a group of people working together to achieve

common purpose for which they hold themselves mutually accountable” (Scholtes , et al., 2003)

Interprofessionality: “…a cohesive practice between professionals from different disciplines. It is the process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population”

Contrasted with:

Multidisciplinarity: a process whereby multiple disciplines work on the same project in an independent and parallel fashion reflecting a lower degree of collaboration on the spectrum (D’Amour and Oandasan, 2005)

Terminology

Teamwork creates the environment that supports collaboration

Collaboration: exchange between professionals “which values the expertise and contributions that various healthcare professionals bring to patient care”

Collaboration requires two constant and key elements:

1. Construction of collective action that addresses the complexity of client needs and

2. Construction of a team life that integrates the perspectives of each professional where each member experiences respect and trust

D’Amour and Oandasan, 2005

Assumptions of Effective Teamwork

Shared understanding of roles, norms, values, and goals of the team; shared responsibility and commitment

Cooperation: Working together that recognizes and respects involvement and contributions of all members

Interdependence/Egalitarianism: All members contribute to the relationship

Synergy

Outcomes achieved are greater than the effect of any one team member aloneGage,1998; Rice, 2000; Scholtes et

al.,2003

Integrating CHWs into the PCMH: Lessons learned in promoting teamwork from the literatureShared understanding of roles, norms, values, and goals of the team Clarification of role and scope of practice

Recruitment of CHWs for leadership & communication skills

Education of all team members re: role expectations

CHW training in skills & PCMH

Agreed upon protocols/workflow maps

Administrative Support:

◦ Organizational champions

◦ Technology and other resources

◦ Infrastructure supportCDC, 2014; Franklin et al., 2015; Matiz et al., 2014; Salant, et al., 2014;

Wennerstrom et al., 2015

Integrating CHWs into the PCMH: Lessons learned in promoting teamwork from the literatureCooperation/

Interdependence/

Egalitarianism: CHWs part of planning

Co-location

Systems for ongoing Communication

◦ Team huddles

◦ Team meetings

◦ Team building exercises

◦ EHR accessCDC, 2014; Franklin et al., 2015; Matiz et al., 2014; Salant, et al., 2014;

Wennerstrom et al., 2015

Commonalities of ModelsAll Assumptions for Effective Teamwork identified

CHWs were part of the primary care team

Patients who were recipients of CHW interventions were members of either a community health center, public health clinics, or academic center primary care clinic

CHW interventions included the management of a chronic disease — Type II diabetes and asthma

Franklin et al., 2015

CHW as Part of Healthcare Teams Studies from Literature that Exemplify Teamwork

Nurse

Physician

Dietitian

Social worker

Psychologist

Nursing Director

Medical Assistant

Project coordinator

Franklin et al., 2015; Wennerstrom, 2015

Teams were comprised of a CHW and one or more of the following:

East Boston Neighborhood Health Center Care Navigator

2011

Community HealthCorps Member: (Division of AmeriCorps)

Serve as Volunteers for 11 months full time (1700 hours)

Often a gap year prior to grad school

9 Care Navigators integrated into each primary care/health center team at the health center

Clear role: May not perform employee duties or fill in for an absent employee

Receive an Education Award ◦ $5645

Receive a living allowance◦ $14,000 1st year

◦ $20,000 2nd year

Loan Forbearance while serving

East Boston Neighborhood Health Center Care Navigator: Role

Assistance and guidance in navigation of the health care system for high risk populations:

◦ Immigrant

◦ Illiterate

◦ Disabled

◦ Veterans

Advocacy, empowerment, and care coordination for patients with medical & non-medical needs

Information about community resources, e.g. :

◦ Housing & Shelter

◦ Heating

◦ Child care

◦ Exercise, Food

◦ Heating

◦ Legal Services

◦ Substance Abuse

◦ Rape Crisis

Provide escort for patients to appointments

Tutoring

Summary and Conclusions…

Primary Care will be at the hub of access within PCMHs

CHW interventions have demonstrated important significant clinical outcomes, reduced health disparities, and reduced costs

Patient care can no longer be delivered in silos. Effective teamwork and collaboration are essential for all healthcare team members

The integration of interprofessional teamwork and collaboration with primary care workforce redesign that integrates CHWs sits on the brink of bridging the gap between primary care and public health

Summary and Conclusions

Integrating CHWs into Primary Care teams presents an opportunity to: Improve access

Reduce health disparities

Increase cultural competence of the primary care team

Improve cost savings

Improve patient satisfaction

Improve primary care team job satisfaction

Improve management of chronic illnesses

Promote the overall health of individuals, families, and communities thereby strengthening of the healthcare system overall

Cathy Franklin can be contacted at East Boston Neighborhood Center franklic@ebnhc.org

References Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety

problems. Cochrane Database Syst Rev. 2012;10: 1-277. Association of State and Territorial Health Officials (Astho). Community health workers.

2015. Available at http://www.astho.org/community-health-workers/ Center for Disease Control and Prevention. Addressing chronic disease through

community health workers: A policy and systems-level approach. 2011. Available at http://www.cdc.gov/dhdsp/docs/chw_brief.pdf.

Centers for Disease Control and Prevention. Community health workers/promotores de salud: Critical connections in communities. 2003. Available at http://www.cdc.gov/diabetes/projects/pdfs/comm.pdf

Centers for Disease Control and Prevention. States implementing community health worker strategies. 2014. Available at http://www.cdc.gov/dhdsp/programs/spha/docs/1305_ta_guide_chws.pdf

D'amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care. 2005; 19(S1): 8-20.

Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer Jr RM. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg. 2007; 205(6): 778-784.

Franklin, CM, Bernhardt, JM, Lopez, RP, Long-Middleton, ER, Davis, S. Interprofessional teamwork and collaboration between community health workers and healthcare teams: An integrative review. Health Services Research and Managerial Epidemiology. March 16, 2015; 1-9. doi: 10.1177/2333392815573312. Available at http://hme.sagepub.com/content/2/2333392815573312.full.pdf+html

Institute of Medicine. A population-based policy and systems change approach  to prevent and control hypertension. The National Academies Press. Released February 22, 2010. Available at http://www.iom.edu/Reports/2010/A-Population-Based-Policy-and-Systems-Change-Approach-to-Prevent-and-Control-Hypertension.aspx

Gage M. From independence to interdependence: Creating synergistic healthcare teams. J Nurs Adm. 1998; 28(4): 17-26.

.

References Institute of Medicine. Committee on Quality of Health Care in America. Crossing the

quality chasm: A new health system for the 21st century. National Academies Press; 2001. Available at http://www.nap.edu/catalog.php?record_id=10027

Institute of Medicine. Primary care and public health: Exploring integration to improve population health. National Academies Press, 2012. Available at http://www.nap.edu/download.php?record_id=13381#

Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. 2011. Available at http://www.aacn.nche.edu/education-resources/ipecreport.pdf

Matiz LA, Pereyz, PJ, Jacotin, PG, Cruz, C, Ramirez-Diaz, E, Nieto, AR. The impact of integrating community health workers into patient-centered medical home. J Prim Care Community Health. 2014; 5(4): 271-274. doi:10.1177/2150131914540694

Nielsen, M, Langner, B, Zema, C, Hacker, T, Grundy, P. Benefits of implementing the primary care patient-centered medical home: A review of cost and quality. 2012. Patient Centered Primary Care Collaborative. Avaialble at https://www.pcpcc.org/guide/benefits-implementing-primary-care-medical-home

Raab CA, Will SEB, Richards SL, O'Mara E. The effect of collaboration on obstetric patient safety in three academic facilities. J Obstet Gynecol Neonatal Nurs. 2013; 42(5): 606-616.

Rice AH. Interdisciplinary collaboration in health care: Education, practice, and research. National Academies of Practice Forum. 2000; 2(1): 59-73.

Salant, T., Slavin, S., Baumrin, E., et al. Lessons in translation: Insights from a collaboration integrating community health workers into diabetes care. J Ambulatory Care Manage. 2013; 36(2): 156-165. doi: 10.1097/JAC.0b013e31827fb325

Scholtes, PR, Joiner, BL, Streibel, B.J. The Team Handbook. 3rd ed. Madison, WI: Oriel; 2003.

Starfield, B, Shi, L., Macinko, J. Contribution of primary care to health systems and health. 2005. Milbank Quarterly, 83(3), 457-502.

References The New England Comparative Effectiveness Public Advisory Council. Community

health workers: A review of program evolution, evidence on effectiveness and value, and status of workforce development in New England:  Final report—July 2013. The Institute for Clinical and Economic Review. Available at: http://cepac.icer-review.org/wp-content/uploads/2011/04/CHW-Final-Report-07-26-MASTER1.pdf.

U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Profession. Community health workers evidence-based models toolbox:  HRSA office of rural health policy. 2011. Available at http://www.hrsa.gov/ruralhealth/pdf/chwtoolkit.pdf.

U.S. Department of Health and Human Services Bureau of Health Professions. Community health worker national workforce study. 2007. Available at http://bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf

Viswanathan M, Kraschnewski J, Nishikawa B, et.al. Outcomes of community health worker interventions. Evid Rep Technol Assess.Assessment No. 181. AHRQ Publication No. 09-E014.Rockville, MD: Agency for Healthcare Research and Quality. June 2009

Wennerstrom A, Bui T, Harden-Barrios J, Price-Haywood EG. Integrating community health workers into a patient-centered medical home to support disease self management among Vietnamese American: Lessons learned. Health Promot Pract. 2015; 6(1): 72-83. doi: 10.1177/1524839914547760

Zatzick D, Russo J, Lord SP, et al. Collaborative care intervention targeting violence risk behaviors, substance us, and posttraumatic stress and depressive symptoms in injured adolescents: A randomized clinical trial. JAMA Pediatrics. 2014; 168(8): 532-539.

Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009; 3(CD000072): 1-30