Accessing Primary Care –
A Partnership Success Story
MN Community Health Worker Alliance Statewide Conference
| June 5, 2014
Today’s Presentation
2
Community Health Worker (CHW) intervention developed
in partnership with WellShare International focuses on
emergency room use by Somali immigrants.
Presentation Objectives
 Show how CHWs can improve the health of the community.



Describe partnerships between community agencies and
communities and the innovative model of care using CHWs.
Present outcome data showing how the CHW initiative improves
access, changes utilization of services and reduces costs.
Provide hands on examples and stories of a CHW’s field work.
UCare Mission
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UCare will improve the health of our
members through innovative services
and partnerships across communities.
Member Demographics
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UCare serves a culturally diverse
mix of over 400,000 members.
State Public Programs
SPP enrollment
316,000
White
51%
African origin
23%
Asian origin
11%
Hispanic (all origins)
7%
Native American
2%
Other
5%
UCare’s Approach to Member Care
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
Program flexibility and support services tailored
to individual needs.

40% consumer representation on Board of Directors;
three member advisory councils.

Expertise in cooperative work with federal, state, and
local governments, and community partners.

Innovative risk and service partnerships
with care systems and providers.
Customer & Clinical Services –
Targeted Approaches
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 Health risk assessments, provider listening sessions and health
promotion materials in Somali.
 Somali Customer Services representatives.
 24-hour access to East African interpreters speaking languages from:
Djibouti, Ethiopia (Amharic), Kenya, Malawi, Somalia, and Tanzania.
 Welcome calls to new members in their primary language.
 Bilingual complaints, grievances and appeals process.
 Language line available to all staff and providers, including
transportation.
 Programs for child & teen checkups and pregnant mothers – prenatal
and post partum.
UCare Programs to Address Health Disparities
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 Pill boxes and sport shoes for Somali elders.
 Health risk assessments in multiple languages,
including Somali.
 Culture Care Connection website – a UCare/
Stratis Health partnership to advance culturally
competent care and clinical training statewide.
 Health Commons – UCare Foundation Grant
(2011-12, 2012-13) to support health of local East
African community.
Community Health Worker Intervention – Background
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 The data shows utilization patterns.
 Chronic conditions (diabetes, hypertension)
and medication management
 Emergency Room utilization trends
 Care management
 Look for innovative solutions.
 CHW intervention and education approach
Caafimaadkaaga “Your Health” Program
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 A WellShare partnership program.
 Began as a pilot in 2012 to address the needs of our
Somali and East African populations around access
to urgent and emergency health care services.
Pilot Program Process
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 Voluntary participation.
 Initiated in Hennepin and Ramsey Counties.
 Members targeted were families with young children.
 One-on-one health education at a location predetermined
by the member (home, primary care clinic or hospital).
 Member is given the tools to ensure that the education
received can be practiced at home.
Role of Community Health Workers
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 Provide education about western health care system
through one-on-one health consultations.
 Primary care
 Urgent care
 Emergency Room care
 Teach thermometer use.
 Practice making calls to primary medical clinic or
UCare nurse.
Community Health Worker Visits
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• 140 home visits in 2012.
• More than 200 home visits in 2013.
• Expansion for 2014.
Participant: “I like that I can call my
doctor to be seen instead of waiting in
the hospital waiting room for four
hours.”
Somalis in Minnesota
5,000+ community health workers
Caafimaadkaaga
Your Health
Scheduling a visit….
Reminder calls are important!
Home visit education
Incentives
Home visit – Additional activities
Reporting and follow up
CHW NAME
HOME VISIT
DATE
URGENT
CARE
CHOSEN
CLINIC
CHOSEN
ADDRESS/
PHONE
NUMBER
UPDATE
OTHER
NOTES
Zahra
5/2/2014
Gargar clinic
Gargar clinic
New phone: Assisted
612-xxx-xxxx member
with….
Emergency Room Education Outcomes
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ED VISITS PER 1,000
PMPM DIFFERENCE
$700.00
43% decrease
350.00
$600.00
52% decrease
300.00
$500.00
250.00
$400.00
Pre-Period
$300.00
Post-Period
200.00
150.00
$200.00
100.00
$100.00
50.00
$0.00
0.00
PARTICIPANTS
NON-PARTICIPANTS
PARTICIPANTS
NON-PARTICIPANTS
Based on 2011-2012 claims. WellShare participants compared to general membership.
Other UCare CHW efforts
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•
Roselawn and Center for Victims of Torture
o
o
o
o
•
Improve adherence with antidepressant medication for Southeast Asian
population.
Expand staffing model to include a CHW for case management.
CHW completes follow up referrals for patients with depression and
prescribes psychotropic medication.
Customer satisfaction results are impressive.
Southlake Pediatrics Model
o
o
o
New care model that embeds a CHW within the primary care setting.
Two populations: children with special needs and immigrants.
Uses onsite visits and telephonic outreach to assist care coordination,
education of child/parent handoffs, education of families in accessing
appropriate levels of care for emergencies and preventive care such as
well child checkups, immunizations and lead screenings.
Next Steps
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 Program has expanded to additional counties through
a statewide telephonic outreach initiative.
For More Information
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Jeri Peters
Vice President, Chief Nursing Officer
UCare
500 Stinson Blvd NE, Minneapolis, MN 55413
[email protected] | 612-676-6500
Laura Ehrlich
International Program Director
WellShare International
122 W Franklin Ave #510, Minneapolis, MN 55404
[email protected] | 612-871-3759
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