By the Playbook staff
Tony Reed is Chief Administrative Officer of Keystone Accountable Care Organization (ACO) and Associate Vice President for Accountable Care Initiatives at the Geisinger Health System. The Keystone ACO is a partnership between Geisinger, Evangelical Community Hospital, Wayne Memorial Hospital, and the Wright Center for Graduate Medical Education. It serves 73,000 Medicare beneficiaries in the Medicare Shared Savings Program (MSSP). Keystone ACO entered the MSSP in 2013 and in 2018 joined MSSP Track 1+, where it is responsible for sharing losses if it fails to meet the MSSP spending targets. Keystone ACO’s beneficiaries include residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland.
Health care systems and ACOs have become interested in better serving economically disadvantaged and culturally diverse communities through use of community health workers (CHWs); lay persons with a deep understanding of the communities and populations they serve. The CHWs serve as a liaison between health care providers, social service agencies and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
Rob Mechanic, Executive Director of the Institute for Accountable Care and Senior Fellow at Brandeis University, recently spoke to Mr. Reed for the Playbook.
Q: Why did the Geisinger Health system decide to start a community health assistant initiative?
A: We were looking for a better way to connect patients with social service agencies that were already available in their area. We realized that we can see patients in our offices, write them a script, and do tests, but if we send them out the door with no way to pay for their prescription, no food in the house or even no home to go to, what good have we really done?
So, we put together a pilot program with community health workers designed to introduce patients to available service providers and actually help them sign up for services. We wanted to see how we could better close those gaps, and what impact it would have on the health of our population. We started a three-year pilot where we hired community health assistants and a few social workers to work with communities in five counties to develop a program that would connect patients who were at risk for social determinants of health to the resources that would help them the most.
Q: Was the pilot successful?
A: Yes. We were able to assist 16,000 individuals and closed 24,000 “care gaps” in three years. We liked the result so much that we made it part of our Proven Health Navigator medical home model. So, we went from five community health assistants in the pilot to 36 covering a much wider geography today.
Q: How are the community health assistants organized and what do they actually do and how do they interact with the care team?
A: They're set up to be mobile. We do have offices in some of our primary care practices that they can use if they need to, but their job is really in the community, getting out to the patients’ homes, assessing the patient’s living environment and coordinating access to health care and social services. They have cell phones, laptops, mobile printers and wireless hotspots; everything they need to work from the road.
They report up to our case management team. Within our medical home, we have physicians, nurses, all the normal parts of a medical practice, but we also have social workers and pharmacists. We added the community health assistants to expand the reach of our medical home model. So, they report to the case manager for the area that they cover. But they’re the part of the care team that gets us out into the communities our patients live in and into their homes.
Q: How do you identify patients who could benefit from a CHA?
A: We take referrals from our primary care physicians and case managers. We also take referrals from community organizations. They call our practices and say they have someone they believe has social or health-related needs that could benefit from outreach and assistance. They don't necessarily have to be a Geisinger patient. We'll work with them, assess their needs, and then set them up with the appropriate care.
Q: So, instead of using analytics as many health systems do to identify high-risk patients, you rely on referrals.
A: We are starting to develop data analytics, to identify what we call the rising risk population, but today its mostly referral-driven. Once we identify a need, we send a CHA to the patient’s home to do an assessment, identify the specific needs, and get the patients connected to available services. One thing I think that’s different about our program is that our CHAs actually help people fill out the paperwork and submit it. We actually follow through and make sure that that the organizations that run the programs they applied to actually get back to that particular person and make the connection.
Q: What’s the case load of a typical CHA and do they do in a typical day?
A: The caseloads vary, but normally, they’re seeing up to 50 or 60 different patients in a month’s time.
A typical day all depends on what they’re facing with a particular patient. The core activities are assessing the patient’s needs and closing the gaps with services that best fit the patient’s needs at that time. This could be as simple as arranging transportation for the patient’s next medical appointment, helping them complete an application for medical assistance or getting them signed up for Meals on Wheels. A subgroup of our CHAs are trained to fit patients with a heart failure monitoring vest called a ReDS vest, where it allows us to monitor their lung fluid when they come out of the hospital after a heart failure exacerbation. We send CHAs out to their house twice a week to get these readings with these vests. Then they call those readings back in to the case manager and the care team can then adjust the patient’s medication.
Q: Do CHAs provide temporary support or work with patients over a longer period?
A: We have a small cohort of patients that continue to have difficulty even after we’ve set everything up so we continue to monitor them. But for the most part, once we get our patients set up with community programs and well-connected with their health care providers, our community health assistants move on to the next patient. Our case management team and social workers will follow them long-term.
Q: What kind of people tend to succeed as CHAs and how do you recruit them?
A: When we first put this role together, we wanted it to be a layperson; somebody who is empathetic and can put themselves in another person’s shoes. We require a high school diploma and prefer some health care experience but it isn’t necessary. They need to drive and have their own vehicle. They need to be resourceful and be able to help people fill out applications and follow through with their physicians. They have to be very personable. They can’t be afraid to get out in the community and to go to other people’s homes.
What ended up happening is that we got applicants with associate, bachelor’s and even master’s-level trained people applying because they wanted to help people in their communities. We were thinking this would be a lower-level position, and we actually ended up getting much more qualified people than we had ever dreamed of. The biggest challenge we’ve had recruiting is that some people like the role until they realize they’ve got to go into somebody else’s home. But that’s an integral part of this position, getting into the patient’s home and seeing the living conditions so we can really understand what kind of help they need.
Q: What kind of training do you provide?
A: We have an eight-week program that includes instructor-led training from our case management department. It includes training on chronic conditions and how to spot signs of an exacerbation. We train them on common medications and the importance of medication adherence. We train them on how to safely enter someone else’s home. The goal is to get that person comfortable with going out to people’s homes, figure out their needs and taking steps to meet those needs.
Q: What does it cost to put together a program like this and can a small ACO do this without breaking the bank?
A: We were lucky to get a grant from the Weinberg Foundation to help us get started, but it really is not that expensive. We started out small with five community health assistants and a couple of social workers. We ran the three- year program for less than a million dollars. Now we fund it through our medical home program, and it’s quite affordable. One thing we discovered is that we ended up paying an awful lot in mileage. If you're in a rural marketplace one of the bigger expenses that folks need to plan for is the travel.
Q: What about salaries?
A: Our average salary for community health assistants is about $29,000 a year; much less than what it would cost to put an LPN or an RN in that type of a role.
Q: Have you been able to actually calculate a return on investment for the program?
A: We don’t look at it in terms of dollars and cents. We look at it in terms of care gaps closed, so those would be things that the person needs in order to live a healthy life. So, it could be are we helping the patient get access to the medications that they need? We help them apply for the Program of All-inclusive Care for the Elderly (PACE) program here in Pennsylvania. We help them fill out forms to get discounts on their medications. One huge care gap for us is when patients have difficulty getting in for medical appointments. Transportation’s a huge issue in our service area because it’s so rural, so we actually work with the different county transportation offices to get people plugged into their system so that they can get a ride to the doctor, and then get back home. Addressing those types of gaps leads to better care for the patient, and thus better outcomes. We believe it’s reducing our overall cost of care but haven't been able to quantify it yet.
Q: What have been your biggest challenges running this program?
A: At first, it was getting the clinicians to accept the CHAs as part of the team. They’re not licensed medical people. So, getting the providers to understand how they could help took a little bit of time. But now they get along fabulously. The physicians and mid-levels look at them as a great way to extend services out into the communities. The challenge is the rural nature of our area requires a lot of travel and a lot of driving. That can make it harder to fill the positions.
But overall, I think that they’ve been very well-accepted into our primary care practices, and as part of our care team, and the patients really like it. They really develop a good relationship with these patients, and those patients know to reach out to these community health assistants directly when they need something that's non-health care related.
Q: What practical advice would you give to an organization like that, that wants to build up a program like this?
A: I would start small. We took our time, three years, to get this up and running, trying different approaches and understanding what fits in the communities that we were serving. Each community is a little different. Some have housing problems, others have shortages of medical providers. So taking the time to understand the needs of each community and tailoring your efforts is very important.
Q: And developing partnerships with agencies that might not be used to working with health care systems?
A: When we started, we went out to 140 different community agencies in those five counties and told them what we were looking to do, how we were looking to do it, how we’re funded, and asked how we could best work with them. It didn’t happen all at once. But they started to realize, “Hey, I can get this person all kinds of other resources besides the one that we provide by calling this group and getting them involved.” It takes some time but community organizations will get behind you after you start working with them and they see you’re there to help.
Q: It sounds like it’s been a real home run from your perspective.
A: We've been very, very happy with the results. Our community health assistants have freed up our case managers to focus in on the clinical aspects of case management, and not worry as much about the social aspects, because they have somebody out there who’s working on that already. When our CHAs do an assessment, they share it with the case manager who works on what we need to do for the patient medically while the CHA and the social workers will work on the social side. So, you really have a range of people trying to give the full continuum of services that a patient needs, rather than one person trying to do it all.
I’ll tell you the “feel good” stories were numerous. Story after story of how we helped this person pay an electric bill, helped this person find a job, helped someone else find a better place to live. And that’s what gets the communities to rally around you, when you start having those wins that you can share with the organization.