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School-based Integration of Community Health Workers

State: NH Type: Promising Practice Year: 2018

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City of Manchester Health Department 
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School-based Integration of Community Health Workers
The City of Manchester Health Department (MHD) is an innovative local governmental public health agency that works both internally and externally to improve the health of Manchester residents. The City of Manchester, New Hampshire (NH) is the largest urban community in northern New England with a total population of 109,565 residents, which is over 8% of the State's population. It is densely populated and is the most racially and ethnically diverse area within NH. Although Manchester lies in a relatively affluent state, it grapples with poverty and priority populations, including complex disparities that are found in larger cities. According to the American Community Survey, over 35,000 residents of all ages are living below 200% of poverty, which is larger than one entire NH County. Additionally, over the past decade, the City has seen over a 30% increase in the number of children who are enrolled in the Federal Free and Reduced Meals Program (58% in 2016). Moreover, 90% of those enrolled qualify for the Free Meal, at or below 130% of the FPL. In 2012, with health outcomes and socioeconomics trending in the wrong direction, MHD launched an initiative known as the Manchester Community Schools Project (MCSP). The overall goal of the effort was to transform local elementary schools into neighborhood hubs to better connect residents to health and social services and improve neighborhood connectivity. To-date, the MCSP has successfully established two primary community schools with engagement in three additional partner schools. Through the MCSP's initial community-based surveying, which included over 500 responses, neighborhood residents identified barriers to accessing needed health and community services including: lack of knowledge and information about available services (38%), lack of transportation (18%), affordability (22%), limited English proficiency (5%), childcare (25%), and agency/service hours (10%). In response, MHD, in partnership with the community's Federally Qualified Health Center (Manchester Community Health Center) and the School District, established a formal system for community care coordination through a Community Health Worker (CHW) Model. This model successfully connects three primary home environments - school home, medical home, and neighborhood home. Strengthening linkages among these home environments has created a more comprehensive mechanism for prevention that addresses the systemic barriers to accessing preventive services, including the social determinants of health. As employees of the Manchester Community Health Center, CHWs work as an extension of the clinical team, but they are co-located directly into within the community schools and serve all residents in the neighborhood (not just families served by the school). They are also intentionally multicultural/multilingual. Since its full scale implementation in September 2016, 362 families received assistance with navigating health, community/social services within impoverished neighborhoods. Approximately 70% of these families had at least one concern successfully addressed as a result of their assistance from a CHW. These concerns span a broad array of domains beyond traditional health care access to include items such as housing issues, food insecurity, legal assistance, and employment. In regards to medical home linkages and health insurance access, approximately 25% of families successfully received this type of assistance from the CHWs. When considering the return of investment, it is well documented that connections with a medical home and/or health insurance can result in averted health care costs in the Emergency setting in particular, which are more costly ($2000 per visit on average). Assuming that each family who received connections to a medical home and/or health insurance may have accessed the ED for care at least once, it is estimated that the CHW model accounted for $180,000 in cost savings to the health care delivery system. Even after adjusting for expenses to sustain three, full-time CHWs for one year, there is still an estimated return on the investment of $70,000 to the health care delivery system in averted health care costs. Across the country, CHWs have been mostly utilized to support chronic disease management; however, according to the County Health Rankings and Roadmaps approach, 80% of what determines an individual's health status is comprised of healthy behaviors (30%), social and economic factors (40%), and the environment (10%). Given this knowledge, health care agencies should consider employing CHWs to directly integrate into other community settings outside of traditional health care to identify potentially isolated and disconnected populations who are not accessing preventive care, and address concerns related to the social determinants of health, such as employment. By embracing a broader definition of health, it will enable higher level population health gains that are directly rooted in social and economic factors. https://www.rwjf.org/en/library/features/culture-of-health-prize/2016-winner-manchester-nh.html
The Centers for Disease Control and Prevention defines a Community Health Worker (CHW) as a frontline public health worker who is a trusted member or has a particularly good understanding of the community served. A CHW serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery. Across the country, CHWs have been utilized to support patient navigation and case management within a traditional health care delivery system, to include emergency department settings. However, there has been limited use of CHWs who are direct employees of the health care delivery system to work exclusively in alternative settings while addressing social and economic factors of health as their primary role. The County Health Rankings and Roadmaps approach, which was created by the University of Wisconsin with support from the Robert Wood Johnson Foundation, cites that only 20% of an individual's health status is determined by their ability to access quality, clinical health care. The additional 80% of factors are related to healthy behaviors (30%), physical environment (10%), and social and economic factors (40%). In other words, where people live, work, learn, and play greatly impacts a person's health and ability to lead a healthy, productive life. In fact, through sub-geographic analysis, data analysts are now able to predict the life expectancy of a newborn by the zip code they are born. Yet, as a nation, we continue to spend more on health care access than creating systematic approaches to improving social and economic conditions as the root cause of health inequity. Educational achievement, economic wellbeing, family and social support, and community safety are the leading areas that need more attention to make population health gains. In Manchester, eight neighborhoods in are considered Federal Poverty Areas,” defined as having 20% or more of the resident population living below poverty. Three of these neighborhoods have more than 40% of the resident population living below poverty with less than a high school education. Additionally, within these areas of concentrated poverty, five Eastside census tracts have been designated by HRSA as Medically Underserved Areas,” and four Westside census tracts have been designated as Exceptional Medically Underserved Populations.” These designated neighborhoods share significantly higher rates of overall neighborhood deprivation and poor health outcomes, such as higher rates of heart disease mortality, violent crime, expectant mothers with late or no prenatal care, barriers to preventive health care due to cost, lead poisoning, childhood obesity, uncontrolled asthma, and substandard housing. These disadvantaged neighborhoods lacked a systematic approach that strategically aligned and connected the health care delivery system with community and public health resources to increase access to preventive health services and ensure a healthy start for all children and their families. To address these factors locally, the City of Manchester Health Department (MHD), and its partners, established the Manchester Community Schools Project (MCSP). Based on best practice guidelines from the Children's Aid Society and the Coalition for Community Schools, the MCSP has worked to integrate and leverage community partnerships to transform two public schools into community schools. These schools serve as year-round, neighborhood hubs (open afterschool, evening, and weekend hours) for accessing needed resources and programming to foster social capital and connectedness, such as educational opportunities for residents of all ages, linkages to physical and mental health services, and access to social services. From over 500 resident surveys and several key informant interviews, the MCSP identified a need for a more coordinated system of care to decrease barriers to accessing services and supports beyond health care. This system of community care coordination is grounded in the established of a CHW model that integrates workers as employees of the health care system (Manchester Community Health Center – MCHC) into the local education system. This approach allows the MHD and the Manchester Community Health Center to better identify isolated and/or disconnected residents from primary care and address the root causes of poor health as a primary role of the care coordination model; not an indirect benefit. While CHWs are not a novel approach, the utilization of CHW expertise in this capacity outside of the traditional health care setting represents a creative use of an existing practice. The County Health Rankings and Roadmaps best practices database known as What Works for Health cites Some Evidence” as supporting the use of CHW for improving patient knowledge, access to care, healthy behaviors, and preventive care. In addition, The Community Guide recommends the use of CHWs specific to the prevention and management of chronic diseases, such as diabetes and cardiovascular disease.
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The overarching goal of this effort is to utilize a community schools approach to strengthen linkages among the school, home and medical environments to systematically address barriers in accessing preventive health services and ensure a healthy start for all children and their families within Manchester's most impoverished neighborhoods. The strategic objective to achieving this goal is a formalized system of community care coordination to assist residents in navigating healthcare and social services. This model successfully connects three primary home environments - school home, medical home, and neighborhood home. Strengthening linkages among these home environments has created a more comprehensive mechanism for prevention that addresses the systemic barriers to accessing preventive services, including the social determinants of health. Primary objectives to measure success included: - By September 2017, increase the number of families receiving assistance with navigating health, community/social services within the target neighborhoods via CHWs. - By September 2017, increase the proportion of elementary students with a usual primary care provider within the community schools. To achieve these objectives, multilingual/multicultural CHWs were hired by the Manchester Community Health Center (MCHC) to be co-located within the school setting as members of the school's social services team. Currently, three, full-time CHWs are employed to serve five schools. A key distinction in the CHW role is its ability to serve all residents; not only families served by the school. In addition, these positions conduct home visits for families and serve as the bridge to community resources for the school neighborhood through the summer months as well. Traditionally, school staff do make referrals to outside agencies, but the difference in this model, is an actual position dedicated to providing navigation assistance and support to ensure that the family receives the support/services that they need in the community. CHWs provide intensive support for their clients, but do not provide technical/professional services like formal counseling. They primarily act as a skilled problem solver that can navigate a range of issues from housing to employment to food insecurity to domestic violence. They are often a coach and advocate, but mostly an invaluable positive and reliable person within the life of a family in need of support. In addition to community care coordination, CHWs provide health education workshops on key topics, such as cancer prevention and access to health insurance, and assist students and their families in connecting with preventive health care for immunizations and secure follow-up dental treatment through the MHD's school-based dental van program. The Health Leads model established at the Boston Medical Center in Emergency Settings has helped to inform the development of this approach with a focus on adapting it to a non-healthcare setting. As the lead facilitator of the Manchester Community Schools Project (MCSP), in which the CHW approach is housed, MHD's Division Head of Chronic Disease Prevention and Neighborhood Health served as the Project Director. A collaborative partnership structure of three primary leadership bodies was employed to ensure shared decision-making: 1) The Neighborhood Health Improvement Strategy Leadership Team (NHIS-LT) is comprised of the community's senior leadership from major stakeholder organizations and groups; including, the City's Mayor, Police Chief, Superintendent, business and healthcare leaders, residents, and local philanthropists. The NHIS-LT provided policy and resource development capacity to support the long-term sustainability of strategies. 2) Community Schools Leadership Team (CSLT), is comprised of school administration, teachers, social workers, bilingual assistors, counselors, and residents. CSLTs are instrumental in guiding school-specific strategies, such as how to maximize the school-based CHWs. 3) A Project Implementation Team was established to serve as an ongoing mechanism for communication and decision-making and evaluation, and was comprised of the MHD and the Manchester Community Health Center. The MCSP has two primary partners - the Manchester Community Health Center (MCHC) and the Manchester School District. The MCHC serves as the employer of the CHWs and provides clinical oversight and supervision to the positions. The Manchester School District provides physical space for staff integration onsite and supports access to the student population through a formal release of information and informed consent process. The MHD worked closely with the Manchester School District to ensure that this initiative did not become one more item for the schools to manage and worked through staff roles and responsibilities to facilitate integration within the exiting social services team within the community schools. This relationship building is a central role of the MHD in the implementation of this approach. As a neutral convener, the MHD was well positioned to be a broker for community-school partnerships. This is a role that many local health departments across the country have the ability to play. These skills combined with public health training in program development and evaluation can be leveraged to support clinical connections that bolster improved population health outcomes. In 2012, the Robert Wood Johnson Foundation with support from several local foundations (Granite United Way, NH Charitable Foundation, Endowment for Health, and Cogswell Benevolent Trust) provided the initial seed funding to launch the MCSP approach. In 2014, the CHW model for community care coordination received funding through the National Prevention Partnership Awards by the U.S. Assistant Secretary for Health to bring implementation to full scale. Today, the CHW model is supported by the community's local hospitals – Elliot Health System and Catholic Medical Center – as part of community benefits under Charitable Trusts. CHWs are relatively affordable investments, especially when considering their potential return on investment. In Manchester, the average annual salary and benefits for a CHW is $37,500 with an additional $2000 for expenses related to office supplies and technological supports (phone and computer). Additionally, approximately $1000 in training and professional development has been allocated annually.
Success for the CHW approach is defined by two primary objectives: (1) By September 2017, increase the number of families receiving assistance with navigating health, community/social services within the target neighborhoods via CHWs (target 150 families). At the start of this initiative, this type of approach was not in existence; therefore, zero families were receiving navigation assistance via CHWs as an extension of the health care delivery system in an educational setting. The initial target was to reach 150 families. Since full scale implementation in September 2016, 362 families received assistance with navigating health, community/social services within impoverished neighborhoods. Approximately 70% of these families had at least one concern successfully addressed as a result of their assistance from a CHW. These concerns span a broad array of domains beyond traditional health care access to include items such as housing issues, food insecurity, legal assistance, and employment. In regards to medical home linkages and health insurance access, approximately 25% of families successfully received this type of assistance from the CHWs. Moreover, 57 adults and 134 children were referred or reestablished with a medical home for improved access to preventive health services. In addition, the CHWs provided assistance for families in need of dental treatment for their children. The CHWs were able to connect via telephone with 73 of 115 families (64%) referred from the MHD dental van for follow-up dental treatment for their child from the community schools. From this, 40 families (55%) indicated that they had scheduled a dental appointment for their child (at the time of phone contact), and 28 families (38%) received some level of assistance from the CHWs - including phone number information for the appropriate clinic, assistance making the appointment, transportation, and/or assistance with health insurance or charitable care enrollment. (2) By September 2017, increase the proportion of elementary students with a usual primary care provider within the community schools (target 84%). As of school year 2014-2015, 76% of students indicated that they had a usual primary care provider, as determined by school enrollment data within the primary community schools. As of school year 2016-2017, 85% of students had a usual primary care provider. This represents nearly a 12% increase in primary care access by the student population. While it cannot be determined that the CHWs were the only reason for this increase, it can be assumed that this approach greatly contributed to the improvements in medical home access. CHWs utilized a Microsoft Excel spreadsheet to track client connections and outcomes. This spreadsheet included basic contact information, language needs, assistance needed, referrals made, referrals converted, and follow-up results/progress. Data was entered on a daily basis and monitored by the MHD quarterly. All clients of the CHWs completed an informed consent and release of information process that enabled data to be shared between the Manchester Community Health Center, Manchester School District, and the MHD. Other referrals requiring the release of more than just contact information were also specifically named in the release process. Although the use of Microsoft Excel did provide a means for CHW client tracking and outcome measurement, it was determined that a more robust electronic platform would greatly improve the case management abilities of the CHWs. This system would require a centralized database that would serve as an interface to link existing electronic health records and would enable the CHWs to more effectively work with local partners on coordinating care. Given this need, the MHD has secured funding from The Dartmouth Institute to establish an electronic system to support and enhance the CHW model. It is anticipated that this new system will be launched in school year 2018-2019.
The CHWs direct medical home connection within the school home environment has proved to be invaluable. As employees of the community's Federally Qualified Health Center, CHWs are well-positioned to more directly assist residents who are isolated and/or disconnected from health care and social services. Moreover, the CHW greatly increased their outreach capabilities by being integrated within the school setting resulting in a higher level of community trust and ability to reach vulnerable populations. Locally, this effort is a successful example of a population health approach that melds public health and medicine in a non-traditional health care setting. Both the MHD and MCHC are committed to continuing to partner of this worthwhile effort in conjunction with the Manchester School District. When considering the return of investment, it is well documented that connections with a medical home and/or health insurance can result in averted health care costs in the Emergency setting in particular, which are more costly ($2000 per visit on average). Assuming that each family who received connections to a medical home and/or health insurance may have accessed the ED for care at least once, it is estimated that the CHW model accounted for $180,000 in cost savings to the health care delivery system. Even after adjusting for expenses to sustain three, full-time CHWs for one year, there is still an estimated return on the investment of $70,000 to the health care delivery system in averted health care costs. One limiting factor in the financial sustainability of the approach is a lack of opportunity for adequate reimbursement from federal sources, such as Medicaid, for CHW services that focus on addressing the social determinants of health. As previously mentioned, some CHW models utilized the positions to assist with chronic disease management, and some States have successfully expanded Medicaid to support these services. However, CHW services targeting issues of social and economic factors are typically not considered reimbursable services and some legislation goes as far as banning this type of work as part of a reimbursable visit. However, alternative sources for financial support include exploring the use of community benefits funding that is obligated by a community's Charitable Trusts, like public hospitals. These entities have a legal responsibility to provide a certain level of support back to the community in order to maintain their tax-exempt status as a not-for-profit entity. Locally in Manchester, the two hospitals have pledged to fund the CHW model through August 2019, as part of their charitable giving for community benefits.
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