By Melinda Young

EXECUTIVE SUMMARY

The CHECK program teams community health workers with licensed behavioral health staff to address patients’ social determinants of health and improve health outcomes.

  • The program uses resources efficiently, with one licensed professional per 1,000 patients.
  • Community health workers represented the neighborhoods they served.
  • The CHECK team helped patients with transportation, home environmental issues, and other obstacles to health management.

A program created to help children and young people, from birth to age 25 years, with chronic illnesses has evolved into a way to prevent emergency department (ED) visits and rehospitalizations for any population, including at-risk, older adults.

The CHECK program was designed to address social determinants of health, including cost, school attendance, and patient engagement, among a Medicaid population in Cook County, IL, says Michael Gerges, LCPC, executive director of the CHECK program at the University of Illinois at Chicago and UI Health.

CHECK, initially called the Coordinated Healthcare for Complex Kids, began as a four-year grant to help Medicaid families with children with one of four conditions/criteria: asthma, sickle cell anemia, diabetes, or premature birth. (See story about CHECK and prevention focus in this issue.)

“Originally, it was a three-year grant, but we got an extension to run it for four years,” Gerges says.

It is a relatively low-cost care management model, composed of community health workers supervised by licensed providers. The ration is one community health worker per 200 patients and one licensed provider per 1,000 patients. They are supported by care management software, texting outreach programs, a community-based medical neighborhood of organizations, online health education, and a robust early intervention model for mental disorders, says Benjamin W. Van Voorhees, MD, MPH, head of the department of pediatrics at the University of Illinois Chicago and CHECK project director. The goal was to reduce ED visits and medical costs.

Investigators found the program’s healthcare usage and costs declined over the first year, but the control group’s healthcare utilization and costs also fell in the same period. “However, during the same time CHECK was implemented, Illinois transitioned its Medicaid program to managed Medicaid private sector companies,” Van Voorhees says. “These companies also implemented cost control models at the same time. Consequently, even though healthcare utilization and costs fell in the CHECK intervention group, they also fell to a comparable extent in the control group.”

Researchers are analyzing data from the second and third years of CHECK implementation. This information might help clarify group differences, if they exist, he adds.

“Generally, we saw a reduction in hospital days, so patients who were going to the hospital were not staying as long as they had before,” Gerges says. “We saw some reduction in ED costs and an overall reduction in patient costs. We saw some reduction in school absenteeism, where patients were better able to remain in school.”

For example, CHECK community health workers created care plans for families, including ways to help them establish 504 plans or individualized education programs. They also linked parents, schools, and medical teams to improve communication.1

CHECK also facilitated asthma support to children at Chicago Public Schools using in-service training and support of school nurses. From 2016-17, the CHECK asthma medical director gave an introductory course to all the school nurses in the district. The program formed a work group of school nursing coordinators and CHECK physician leadership to meet monthly to determine ways to improve asthma management in schools.2

The CHECK program was implemented concurrently with the value-based, population health benefits of the Affordable Care Act, Gerges notes.

“The readmission numbers went down across the board, and that made it tricky to know whether our numbers were going down because of what we were doing, or whether they would be going down if we hadn’t done anything,” he adds.

Increased Efficiency, Lower Costs

CHECK used a tiered screening model focused on mental health and social determinants of health — a somewhat unique aspect of the project, Van Voorhees says. The project was efficient, using nonlicensed community health workers to assist with care plans that were reviewed, approved, and monitored by licensed supervisors. “In this manner, one licensed professional can supervise 1,000 patients rather than 100 or less,” Van Voorhees says.

“We had a team of 30 community health workers,” Gerges adds.

CHECK also created a behavioral health team of licensed professionals who could perform a biopsychosocial assessment of patients. “We addressed the needs of patients and their family members together,” Gerges says.

Referrals of study participants, including those in the control group, came through the Centers for Medicare & Medicaid Services and insurance plans.

“Perhaps the most important aspect was the use of middle-skill workers like community health workers — combined with technology and automation — to create a potentially lower cost and, thus, a more feasible method to implement the chronic care model,” Gerges explains. “Future studies may further examine the potential cost-effectiveness of the CHECK model.”

The community health workers were hired to represent the neighborhoods they would be serving. “We had some folks who had more like nursing home experience, but not hospital or clinic-based experience,” Gerges says. “This proved to be really helpful.”

For example, the CHECK team met weekly for clinical rounds to discuss challenging cases. One community health worker had visited a patient’s home and found the family did not have adequate bedding, Gerges recalls. The worker wanted to help the family find an affordable mattress. Another person on the team, who lived in the area, mentioned a nearby store that did not advertise online, but offered mattresses at affordable prices.

“It was amazing to watch when someone actually knows the neighborhood and knows how to find resources that the rest of us wouldn’t know was there,” Gerges notes.

Community health workers also provided coaching to families to encourage adaptive behavior in managing the patient’s disease. For instance, they worked with sickle cell disease patients to help them overcome barriers, such as provider access issues, patient frustration, disorganized medications, inadequate hydration or nutrition, family stress, and household chaos.3

Behavioral health staff address the needs of patients who have not been diagnosed with a behavioral or mental health condition, but might be experiencing anxiety or some other issue. “They could use quick skills with patients and families. Our hope was it would prevent them from having a situation that worsens,” Gerges says.

Alternative Approach for Chronic Care

CHECK should be considered an alternative and lower-cost approach to delivering a chronic care model for children and young adults, Van Voorhees notes.

“While the development of databases, care management software, texting outreach, and online health education technology was complex and proved difficult to operate in tandem, it did enable the reasonably efficient delivery of more than 120,000 services to more than 6,000 patients,” he says. “Further studies are being proposed to examine the health impacts of different components of the CHECK model.”

Once the grant ended, the CHECK program evolved to work with at-risk adults. Initially, an insurance company agreed to continue the program for its clients. Later, it evolved into a program for a specific health plan’s Medicare population, Gerges says.

“We’re looking out for new opportunities to utilize this model to provide services,” he adds. “We really want care coordination in the system to be a flow-through process. As time goes on and more research is done, we hope we can demonstrate long-term outcomes.”

REFERENCES

  1. Minier M, Hirschfield L, Ramahi R, et al. Schools and health: An essential partnership for the effective care of children with chronic conditions. J Sch Health 2018;88:699-703.
  2. Pappalardo AA, Glassgow AE, Kumar HV, et al. CHECK: A multi-level program to improve outcomes for urban children and youth with asthma. J Asthma 2020;57:911-913.
  3. Hsu LL, Green NS, Ivy ED, et al. Community health workers as support for sickle cell care. Am J Prev Med 2016;51:S87-S98.