Under the big sky of the Eastern Plains, the Southeast Health Group (SHG) is helping residents of Prowers County gain access to behavioral and primary health care through the initiative TIPPING POINT: Total Integration, Patient Navigation and Provider Training Project. The three-year project estimates a savings of over $1.8 million and is aiming to help chronic disease patients better manage their health.
In 2012 SHG received a three-year $1.4 million award from the Centers for Medicare and Medicaid Innovation to advance Tipping Point through their Health Care Innovation Challenge. The goal of a healthier population through cross-system care coordination led SHG to collaborate with the Prowers Medical Center, Prowers County Public Health, High Plains Community Health Center, and Otero Junior College. This team is now working to teach residents with a history of high utilization of health care how to manage and control their chronic conditions.
Foundational to the program are Health Navigators who identify high-risk patients and work to empower and educate them regarding their health situation. Nancy Harris King, Development Director for SHG, explains that each Navigator has “carte blanche to use whatever means are available to assist individuals in accessing routine health care and managing chronic disease.” After understanding patient concerns using Motivational Interviewing techniques, the Navigators focus on the social determinants of health such as income status, employment, housing, healthy foods, transportation, and personal social support systems. Navigators help with things like picking up prescriptions and finding transportation options for medical appointments. They also conduct ’Healthier Living’ classes which are based on the Stanford Model of Chronic Disease Self-Management and help train patients with conditions like diabetes to establish health goals and effectively manage their health.
To date, eight residents with chronic conditions have completed the Stanford Model of Chronic Disease Self- Management and Tipping Point’s Health Navigators have helped 713 individuals. One life that stands as a testament to the effectiveness of the program is a 40-year-old homeless woman with diabetes who was frequenting the emergency room for care. By working with a Health Navigator, it was determined that she had been exhausting her supplies by over-testing her blood sugar levels. The Navigator was able to facilitate conversations with her primary care doctor to help her understand the necessary frequency of testing and now she is able to better manage her own health situation. Using information gleaned in weekly care coordination meetings, the Health Navigator has reported that this patient is improving and is now invested in self-care – and that she may be interested in pursuing employment in the area.
The Health Navigator workforce is supported through a partnership between SHG and Otero Junior College where they now offer both a one-year Community Health Worker Certificate and a two-year Associates of Applied Science. Both programs are accessible and affordable with on-ground and online classes being offered. Thus far, 28 Health Navigators have been trained at Otero Junior College.
Ms. King indicates that SHG is on track to meeting its $1.875 million goal in public health savings. They have overcome the challenges of attempting disruptive innovation in public health that will touch both residents and providers by “offering scholarships to dozens of incumbent health care workers to take an overview course in Health Navigation so they would understand the role of the Health Navigator and know when to refer people for care.”
The Tipping Point team embodies the pioneer spirit of the frontier region of Colorado and by tailoring their initiative and messaging toward the unique residents of Prowers County, they are poised to effect real change and innovation of health care delivery systems in one of the Centennial State’s rural counties.
Tipping Point is supported by Funding Opportunity Number CMS 1C1-12-001 from the Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
For more information, contact Nancy King, Develompent Director at email@example.com or 719-980-0914.