With temperatures dropping quickly, she’s been worried about one of her clients–someone who’s been in and out of the ER a lot lately–who can no longer fit into his winter coat. After a series of calls, she’s found one that will fit and clearly can’t wait to get it to him.
As a community health worker with the Livingston-Washtenaw Community Health Innovation Region (CHIR), Ebony is part of a diverse coalition of caregivers at 11 local organizations that are working together to serve hundreds of residents who are struggling with the kind of complex health and social issues that can land them in the ER repeatedly.
On the health side, many of their clients have multiple chronic medical conditions–things like heart problems, breathing disorders, diabetes, chronic pain, mental health challenges, substance use addictions, and more. On the social side, their clients have housing challenges, food shortages, transportation needs, financial concerns–the list goes on.
“Usually you go to them and they tell you one problem and you help them with that,” says Ebony, who works at the Washtenaw Health Plan. “You keep going to them and you find out there’s more, much more, like layers of an onion.”
Dr. Paul Valenstein, an Integrated Health Associates physician who co-chairs the community-wide care coordination effort for the Washtenaw Health Initiative, says the CHIR’s average client “makes 12 trips to the emergency department a year, is admitted to the hospital two or three times annually, and is more likely than not to suffer from mental illness or substance abuse.”
The initiative hopes to improve the health and quality of life of these clients while demonstrating that true patient-centered care–care that addresses people’s health, mental health, and social needs in concert–can reduce the need for costly emergency department services.
Brent Williams, director of the Complex Care Management Program at Michigan Medicine, says comprehensive care management is a relatively recent phenomenon, but one that has grown of necessity. “One care manager works with a client for health needs, social service needs, mental health needs. Wherever the needs go, that’s where the care coordinator goes with the patient,” Williams explains.
The design of the current community-wide care coordination initiative incorporated learnings from previous local initiatives, like Avalon Housing’s FUSE program, which provided housing and support services to high-cost utilizers of the health system. What’s new about the SIM is that those care coordinators talk to each other across organizations, share information about what their clients need, and work together to meet those needs.
“And not only are they talking to each other, they also have access to community health workers—intensely patient-facing partners who cross all the boundaries,” says Williams. “The patients love them. The care managers love them. They go anywhere they’re needed and they take a client’s perspective, rather than an institutional perspective, and that’s crucial.”
“Sign paperwork, go here, go there”
That kind of all-encompassing care is unusual, and patients aren’t always ready for it when it’s offered. “You’re asking patients to open up their whole life to you, and they don’t know you from a can of paint,” says Curry. “They have to sign paperwork, go here, go there, meet this person, then that person, then share all of their information again.”
Community health workers, like Curry and her colleagues Renato Quelhas and Maria Pomo Castillo at the Washtenaw Health Plan, build trust by showing patients they’ll be there for them, and often in ways that traditional care coordinators can’t be. They call patients when they haven’t heard from them in a bit, help with the patient’s priorities—even if they aren’t necessarily the most imminent medical priorities—and always follow through.
For these reasons and more, community health workers are a precious shared resource across the initiative, a uniting force between care coordinators at a diverse coalition of Livingston and Washtenaw County agencies that focus on health, mental health substance use, food, housing, and other needs. Of the 200-plus patients currently enrolled in the initiative, 82 have a community health worker on their care team.
Heat, hot water, and other health needs
What do community health workers do? What do they contribute to these care teams? First and foremost, they help patients access health care—helping them get and keep health insurance, locate a primary care physician, schedule appointments with medical specialists, secure prescriptions and necessary medical equipment, and successfully navigate a complex health system.
Second, and particularly important for the patients enrolled in this initiative—64 percent of whom report food insecurity; 37 percent of whom report housing insecurity—community health workers help patients address the social determinants of health, the human needs that, when unmet, can play an outsized role in health outcomes.
“Our health system is fragmented and difficult to navigate,” says Jeremy Lapedis, the project manager housed at the initiative’s backbone organization, the Center for Health and Research Transformation (CHRT).
“Patients with chronic conditions are expected to coordinate multiple appointments, plan months in advance, take medications on an exacting schedule. This can be hard for anyone, but it’s a lot harder when you have to worry about whether you will have cell phone minutes to last you through the month, will be able to get a ride to the doctor’s office, or will have heat when winter sets in.”
Renato Quelhas, another community health worker, recently helped a client in a mobile home do just that. She had diabetes and hypertension, but also a sparsely populated pantry, limited financial resources, poor access to transportation, and few community connections. In addition to helping her navigate appointments, doctor’s orders, and medications, Quelhas worked with care coordinators across the initiative to secure home food delivery, rides to church and the local senior center, heat and hot water, and more.
“Instead of printing out the food pantry list, we’ll take them to the food pantry, make sure they know how to access it, and carry in the groceries,” says Katie Wolfe, a care coordinator at Home of New Vision, which also works with the initiative. “We’re trying to go above and beyond, to get patients to a different spot.”
That kind of assistance–not medical, but just as necessary—makes it much easier for patients to focus on their health.
“Someone who can”
Though community health workers have worked in Livingston and Washtenaw Counties for years, this initiative employs them in a novel way—as a shared resource and bridge between health, mental health, and social service providers.
For Renato Quelhas, who recently earned his master’s in public health from the University of Toledo, helping people access the day-to-day services they need both aligned with his values and seemed like a good way to get to know the real-world challenges people face on the ground.
For Ebony Curry, who earned her bachelor’s degree in psychology and criminal justice at Eastern Michigan University, the job was something of a calling. While growing up, Ebony moved around a lot, throughout western Wayne County and Detroit, and understands how difficult it can be to open up to a series of strangers.
“[Our clients] are trying to manage chronic diseases on limited income, and they’re caught in a system and may not be able to navigate it to get the services they’re eligible for,” says Ebony. “People forget, or may not know or understand, that in the midst of our everyday rat race, that there are people that need assistance. If you can’t help them, send them to someone who can.”
While federal funding for this initiative ends in November of 2019, the Washtenaw Health Initiative is hopeful that it can sustain this community-wide care coordination effort going forward.