CHW Employers GRID Organization and Contact Information CHW Services what context and for whom Training/education Requirements and Performance Standards for CHWs Provider Training/Preparation to Integrate CHWs Funding Mechanism that Supports CHWs Plan for Sustainability Primary Care Practices Colbert Family Health and Wellness Raeven Smith, CHW Patients are referred to CHWs by physician using the CHW Script to address SDH, and connect patients to community based health and social services resources. CHWs develop Patient Support Plan to track interventions with patients. CHWs be high school graduates and completed Ohio Board of Nursing approved CHW curriculum within the first year of employment. Practice Team competes a four hour orientation which reviews roles and responsibilities of CHWs, goals for improved clinical and quality outcomes and ROI, and documentation procedures for CHW. MEDTAPP HCA CHW grant Demonstrate improved clinical outcomes and ROI so practice hires CHW after grant ends Pediatrics PriMed Wright Dunbar Raeven Smith, CHW Patients are referred to CHWs by physician using the CHW Script to address SDH, and connect patients to community based health and social services resources. CHWs develop Patient Support Plan to track interventions with patients. CHWs be high school graduates and completed Ohio Board of Nursing approved CHW curriculum within the first year of employment. Practice Team competes a four hour orientation which reviews roles and responsibilities of CHWs, goals for improved clinical and quality outcomes and ROI, and documentation procedures for CHW. MEDTAPP HCA CHW grant Demonstrate improved clinical outcomes and ROI so practice hires CHW after grant ends Wright State Physicians, Family Medicine Clinic Michelle Nelson, CHW Patients are referred to CHWs using a warm hand-off in the office, and through an in-box in the practice EHR to address chronic disease CHWs be high school graduates and completed Ohio Board of Nursing approved CHW curriculum Practice Team competes a four hour orientation which reviews roles and responsibilities of CHWs, goals for MEDTAPP HCA CHW grant Demonstrate improved clinical outcomes and ROI so practice hires CHW after grant ends
management, prevention services and SDH while also connecting patients to community based health and social services resources. CHW chart interventions with patients in the practice HER. within the first year of employment. improved clinical and quality outcomes and ROI, and documentation procedures for CHW. Wright State Physicians Geriatric Practice Pam Macha, CHW Patients are referred to CHWs using a warm hand-off in the office, and through an in-box in the practice EHR to address chronic disease management, advanced directives, and SDH while also connecting patients to community based health and social services resources. CHW chart interventions with patients in the practice HER. CHWs be high school graduates and completed Ohio Board of Nursing approved CHW curriculum within the first year of employment. Practice Team competes a four hour orientation which reviews roles and responsibilities of CHWs, goals for improved clinical and quality outcomes and ROI, and documentation procedures for CHW. MEDTAPP HCA CHW grant Demonstrate improved clinical outcomes and ROI so practice hires CHW after grant ends Hospitals Dayton Children’s Hospital Asthma Clinic Tiffany Huber, CHW CHWs work with a team that includes a Regional Air Pollution Control Agency representative, a respiratory therapist, and a physician, conducting home assessments and follow-up to assist families with accessing needed resources. CHWs be high school graduates and completed Ohio Board of Nursing approved CHW curriculum within the first year of employment. Practice Team competes a four hour orientation which reviews roles and responsibilities of CHWs, goals for improved clinical and quality outcomes and ROI, and documentation procedures for CHW MEDTAPP HCA CHW grant Demonstrate improved clinical outcomes and ROI so practice hires CHW after grant ends
Pathways, Enhancing the Talent Pipeline Program incumbent and/or prospective employees are assessed, identified and trained as certified CHWs at TriHealth. Medicaid Managed Care Buckeye Health Plan Michael Craun, MSA, CRT Manager, Member Connections 866-246-4356 x24248 419.764-3705 CHWs primarily work one to one with our member population (i.e. Medicaid plan members) by providing ongoing support thru face-to-face in home visits, gathering health assessment information, HEDIS gap closure, and social service resource assistance. By assisting members to access doctors and other resources that address social determinants of health to improve health outcomes while increasing quality of care and reducing overall cost of care. CHWs also plan and lead member and community events and programs such as Baby Showers, Diaper Days, health fairs, Adopt-A-School, Homeless CHWs must have completed Ohio Board of Nursing approved CHW training program or complete the program within the first year of hire; and comply with Ohio State Board of Nursing standards and guidelines as it pertains to CHWs. Care Management staff (i.e. RN, LPN, LSW) are educated on the role of the CHW and how they fit into the integrated care team. CHW training is paid by Buckeye Health Plan if candidate does not have certification upon hire. CHWs are integrated into our overall care management model and are a vital part of assisting our intensive and high risk members. Centene Corp. is working to adopt this model for all Centene health plans throughout the U.S.
Pathways HUBS Hospital Council of Northwest Ohio The Northwest Ohio Pathways HUB 3231 Central Park West Toledo, OH 43617 Barbara Gunning, Performance Manager, 419-842-0800 The Northwest Ohio Pathways HUB does not directly hire CHWs; however, we contract with agencies for CHWs. The agencies that we contract with include: ProMedica Mercy Health University of Toledo Senior Independence Neighborhood Health Association Dental Center of Northwest Ohio East Toledo Family Center Economic Opportunity Planning Association (EOPA)/Pathway Sandusky County Emergency Medical Services 10. University Church 11. Toledo/Lucas County CareNet 12. Heart Beat/Your First Look 13. Toledo-Lucas County Health Department 14. Adelante 15. Baby University All CHW are certified through the Ohio Board of Nursing. We also accept CHW students currently enrolled in the training program and individuals who are prepared to attend the next program that is offered. Generally, there are Spring and Fall training programs offered through the University of Toledo AHEC program funded by MedTAPP. All CHW supervisors are required to attend an initial training session and they are asked to attend monthly meetings as well. In addition, a Pathways HUB staff member will meet with supervisors and have telephone conversations with them to problem solve or for planning purposes. Pathways HUB staff also communicate with new, potential CHW employers and referral sites. This communication can occur via email, telephone but almost always this is followed by a meeting or presentation. Grants and contracts fund the work of CHWs working through the certified Pathways HUB. The Medicaid Managed Care Plans provide funding through negotiated contracts for outcomes. The plans are billed only for agreed upon positive client outcomes. By requesting funding only for positive client outcomes, funding agencies are willing to provide funding for the work of CHWs. It is necessary for the Pathways HUB to document all CHW activity and continually strive to improve client outcomes. This results in a win/win situation for the client (improves health), the CHW (maintains employment), the funding agency (obtains required outcomes) and the HUB (sustains and further develops the model of care). Mahoning County Pathways HUB, The HUB contracts with local care coordination CHWs complete certification training All care coordination agencies employ CHWs are employed by care Local care coordination
Michelle Edison-HUB Coordinator 330-270-2855 ext. 136 agencies that employ CHWs in order to connect women to healthy pregnancies by ensuring that they receive the services and support available to promote positive birth outcomes. The CHWs directly engage clients through home visits, face-to-face meetings, and other communication strategies. through the Ohio Board of Nursing within 6 months of hire. They must follow the appropriate performance standards as determined by the state and by their respective agencies. The HUB also employs quality improvement strategies that directly involve CHWs that are assigned to the HUB. supervisors that are competent professionals who work within the scope of their license to oversee and support CHWs. The care coordination agencies have specific policies and procedures, curricula, and protocols for their programs. coordination agencies which receive funding through public and private sources. agencies have provided needed services for at-risk populations for years. With the implementation of the HUB, other agencies that provide services and support to targeted populations may also see the benefit of employing CHWs in order to engage in care coordination. Public Health Departments Clark County Public Health Carlisa Parker 937 207 7299 CHWs work with pregnant women, young children and families providing per-natal education, and the Healthy Family Curriculum. Clark County serves as a placement site for CHWs completing training through North Central State Community College on a path toward certification. Clark County Health Department staff supervise CHW students so are knowledgeable about how to use CHWs. CHWs are funded through an OMRI program grant and an MCH grant. Continued grant funding for the present. Summit County Public Health Heather Pierce, Director of Administrative Services (330) 926-5605 Summit County Public Health is one of several Care Coordination Agencies (CCAs) providing services through the Summit County Pathways HUB. The HUB has contracts with CCAs to provide community based services to at-risk pregnant women utilizing CHWs must be Certified through Ohio Board of Nursing approved CHW training program. Community Agencies interested in providing Care Coordination Services through the Summit County Pathways HUB receive information on CHW certification programs, scholarship CHWs employed by Summit County Public Health are funded through a contract with the Summit County Department of Job and Family Services. Overall funding for the Pathways HUB The HUB is negotiating contracts with the 5 Medicaid MCOs in Ohio to establish outcome based payment for services provided by CHWs
Community Health Workers and the “Pathways” model. The Pathways model is a standardized process that identifies, defines, and resolves an at-risk individual’s needs through one system that tracks outcomes. information, HUB software training and ongoing technical assistance. initiative in Summit County is provided by the Ohio Commission on Minority Health and Ohio Medicaid. Social Services Organizations Columbus Cancer Clinic – a program of LifeCare Alliance Christin Brown, Director 614-437-2840 The CHW’s primary role is to assist in community outreach to underserved populations. The CWH provides education and care coordination to increase access to cancer screening and prevention services. We are working to develop a care pathway for best practice. Our CHW works both in the community and with our Nurse Practitioner in our clinic. Our Community Health Worker went through the OSU School of Nursing CHW training with certification provided by the Ohio Board of Nursing. Performance standards for CHW’s are defined by the Ohio Revised Code section 4723. This is a work in progress for us. We are working in conjunction with Komen to develop a care pathway for best practice. Komen and agency funding through LifeCare Alliance. Research funding opportunities for certification and implementation of care pathways to improve outcomes. The Division of Cancer Prevention and Control’s (DCPC’s) National Comprehensive Cancer Control Program (NCCCP) provides funds to help states, tribes/tribal organizations, and territories establish coalitions, assess the burden of cancer, determine priorities, and develop and implement comprehensive
Gwen Cooper, CHW and ROI, and documentation procedures for CHW. Wellbridge Health, Rachel Hersh, Program Point of Contact, 412-508-2502 This is a 6 month project dubbed REACH, (Role in improving member Experience, Access/Utilization and Cost) exploring preventative care access and utilization outcomes when using (licensed and unlicensed) CHWs. CHWs will assess the health care needs of a select cohort of Health plan members between the ages of 18 and 64 who have been identified as having challenges in obtaining medical care and is focused on 4 predetermined urban neighborhoods to access resources and minimize barriers of social determinants and improve access to preventative services and improve health outcomes. CHWs have received compliance training and REACH Program training by the Health plan. Wellbridge Health has provided HIPAA, Safety, Motivational Interviewing and Mandated Reporter Training. Performance standards and expectations have been defined by the Health Plan and Wellbridge Health. N/A Wellbridge Health bills the Health plan for CHW service time and Point of Contact management hours. After completion of this program, its impact will be evaluated, looking at indicators such as whether participating members had an increase in recommended preventive healthcare visits, appropriate access to acute care, utilization of social and community services, reduction in overall healthcare costs, etc. Program outcomes will inform decisions about continuation and/or expansion of the program. The following organizations have advertised Community Health Worker positions in the last six months: