Outreach workers support members at highest risk
Assistance includes social and medical issues
At CareOregon, community outreach workers focus on reducing waste among the 10% of members who consume 50% of the health plan’s resources by acting as care coordinators, social workers, health coaches and mentors to disadvantaged and disenfranchised Medicaid recipients.
"We do more than help with transitions. We provide holistic support for people who are high-risk and costly and help them get the resources they need," says Rebecca Ramsay, BSN, MPH, director of the Portland-based health plan’s Community Care program.
Services for members in the program are coordinated by community outreach workers who come from a variety of backgrounds including mental health, addiction programs, and health education. About half of them have master’s degrees. All have at least two years of experience working with a disadvantaged high-risk population as well as education in the mental health field. "The outreach workers have good engagement skills and at least two years of experience working in the community. They have been trained in motivational interviewing and to understand the issues their clients face and why they may appear to be nonadherent," Ramsay says.
The Community Care Team is centered around primary care practices but is employed by CareOregon. The community outreach workers work with high-risk patients treated by multiple provider teams. The target is for the community outreach workers to work with 20 engaged members at any given time with 10 more in the outreach phase where the workers are trying to find the members and get them to participate. The goal is that they will enroll 60 unique clients over a year. The outreach workers typically work with clients for three to nine months. "Some need just a short intervention, but others need a long period of time to get stable," she says.
Members eligible for the program are identified through their patterns of utilization. They may have had multiple hospital stays and emergency department visits or recently been discharged from the hospital or emergency department. Others are referred by their providers who believe they need extra support.
In addition to having high-risk medical conditions, many of the people in the program have behavioral health issues including mild to moderate depression, post-traumatic stress responses, anxiety, personality disorders, or severe persistent mental illness. Many have problems with addiction to alcohol, opiates and other street drugs and have unstable housing and food insecurity. "Often we have to deal with all of these issues before we get to the medical conditions," she says.
But the biggest common denominator among participants in the program is a personal history of trauma, Ramsay says.
"This creates a whole set of protective behavior that often makes it difficult for others to work with them. They’ve not been treated well in the past and are distrustful. The outreach workers bring their knowledge to the care team to create compassion and understanding of why the patient appears to be non-compliant and difficult to work with. They also mentor the people in the program about how to act to get what they need," she says.
When members are identified for the program, they are entered into a registry and assigned to a community outreach worker who reviews the electronic medical record and claims data and contacts the patient’s primary care team for confirmation that the patient is a good candidate for the program. They contact the member and set up face-to-face meetings with them when they come into the primary care office whenever possible.
The outreach workers conduct open-ended assessments to find out what is working well and where the barriers to care are, and identify areas where the clients need assistance. They determine what is important to the clients and what goals they want to pursue.
"Our outreach is not prescriptive but is a collaborative process with the goal of keeping the client well connected to their physician, improving their health, and keeping them out of the emergency department and hospital," she says.
The outreach workers try to set up a follow-up appointment to see the clients in the home to determine the living situation and any barriers to care. "By visiting the home, they can be the eyes and ears of the care team and determine any needs, such housing assistance, or help with meals or housekeeping," she says. Some of the clients live in shelters, with friends, or in single-room-occupancy facilities. "Their housing situation is variable and not predictable," she says.
Seeing patients in their home environment on their own terms tends to level the playing field and build rapport, Ramsay says. "We want to get the patients out of the mindset that we are the experts and they are the patient," she says.
The outreach workers make sure that clients are connected with whatever assistance they need. "The community outreach workers understand their unique communities and the resources that are available. Most work in the communities in which they live," she says.
"We do a lot of advocacy. Sometimes people haven’t been able to complete the application for assistance or haven’t had an eligibility screen," she says.
Outreach workers collaborate with pharmacists to teach clients how to better manage their medication. They educate patients on the importance of taking their medicine and set up pill boxes with the guidance of a clinician when needed. They reinforce why the treatment plan was developed, help patients learn to follow it, and teach self-management activities. For instance, they help patients with diabetes or heart failure learn to fill out a diet diary.
The outreach workers have more time to spend with their clients than the members of the clinical team. For instance, they may go grocery shopping with members to help them identify foods that fit into their recommended diet. "Instead of telling them what they need to do, they go shopping with the clients, find out their preferences and help them choose healthy foods. They also invite the caregivers to go along," she says.
The outreach workers help the clients build a relationship with their primary care providers. "We find that because of CareOregon’s work around primary care transformation, most have a regular source of primary care but they are not utilizing it optimally. Many times the patient and the primary team have problems understanding each other. We try to get them working better together," she says.
The community outreach workers go through a two-day workshop on motivational interviewing and additional training on chronic diseases, and working with people who have experienced trauma. They learn the effect of trauma on the brain, how it affects behavior, and how to provide a safe environment. They also attend physician-taught sessions on chronic pain and optimal treatment, addiction issues and resources, palliative care and hospice, and how to handle a loss. "There are a lot of deaths in this population, and the outreach workers get close to their clients. We want to help them cope with their grief," Ramsay says.