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Wellness Navigators to Address Social Determinants of Health

Keywords: SDH, CHWs, Social Determinants of Health

Overview

Use of clinic-based Community Health Workers to address social determinants of health

Innovator

Janina Morrison MD MPH

Editor

Ashley Shaw BA

Location

LA+USC Medical Center Adult Primary Care, Los Angeles, CA

Organizational Context

  • The clinic is a hospital-based primary care clinic at Los Angeles County + USC Medical Center affiliated with the University of Southern California Medical Center and is part of the Los Angeles County network of safety net medical services. 
  •  The Los Angeles County + USC Medical Center is an integrated healthcare system whose services and financial health had improved under the 2010 passage of the Affordable Care Act as its payor sources converted from 75% of its patients being uninsured to 75% Medi-Cal (California’s Medicaid program), leading to an influx of resources dedicated to providing more innovative and coordinated care.
    • Most of these resources went to reforming the clinics themselves with Patient-Centered Medical Home transformations and other quality improvement initiatives.
  •  The Wellness Center at Los Angeles County + USC Medical Center is a community-based organization that serves as an umbrella organization for all the separate community-based organizations that have offices on its premises on the medical center campus. 
    • The Wellness Center opened its doors in 2014 as a one-stop shop where vulnerable patients served by LAC+USC could easily access 17 wraparound social services organizations (clustered by their ability to address themes such as chronic disease, adolescent health, etc.) in one physical location. 
  • The plans for the Wellness Center were first conceived in 2009 and featured a competitive process shepherded by a selection committee for community-based organizations to access office space.
    • Community-based organizations get office space at no cost to them in exchange for having a work plan where they collaborate with the other community organizations. 
    • The Wellness Center mostly serves adults although it does provide some services such as after-school programming for children. 

Project Leadership

  • The author Janina Morrison MD MPH began her tenure in Fall 2014 as Medical Director of LAC+USC Primary Care. She collaborated with the Assistant Medical Director for Primary Care.
  • In this role, Dr. Morrison took an active role for programming within the clinic in collaboration with the Wellness Center. 

Project Research & Planning

  • Dr. Morrison assumed the responsibility of strengthening the channels of communication to facilitate referral pathways between the LAC+USC Medical Center Primary Care clinics and The Wellness Center.  
  • The author also began designing collaborative evidence-based programming that was responsive to the shifting needs of the LAC+USC Primary Care population over time and to evaluate and assess these programs over time. 
  • There are a multitude of interprofessional team members with shifting involvement in team-based and evidence-based programming collaboration with the Wellness Center.
    • For example, an OT & pharmacist assist with chronic disease programming.
    • For example, an administrative assistant and medical assistant work on food insecurity programming.
  • The Wellness Coordinator role was created during this intervention.

Training

  •  Initial training for Wellness Coordinators consists of 16 hours of training and supervision by a Wellness Program Coordinator on topics including:
    • LAC+USC’s Intake System
    •  Introduction to The Wellness Center’s Community-Based Organizations
    •  HIPPAA 
    • Boundary Setting
    • Self-Care
    • Mental Health 101
  • The Wellness Coordinators then work at the front desk of the clinic for 1-2 years before they are eligible for promotion to Wellness Program Coordinator.
  • Wellness Program Coordinators undergo training to teach evidence-based chronic disease programming through different community programs based on the Stanford Model of Disease Program. 

Daily Workflow Steps

  • The Wellness Coordinators are based at the clinic’s front desk in the waiting room during clinic hours.
  • The Wellness Coordinators are fully integrated into the clinic’s interprofessional healthcare team.
  • Once a member of the clinic’s interprofessional healthcare team generates a referral for a patient to The Wellness Center, the Wellness Coordinator physically escorts the patient to The Wellness Center offices and facilitates their intake with the appropriate community-based organization.
  • The Wellness Program Coordinators teach routine evidence-based programs mostly focused on using exercise and physical activity to address chronic disease at the clinic

Budget

~$60,000

  • Annual cost of salary + benefits for one Wellness Navigator is $50,000 - $60,000 
  • $60,000 is annual cost of salary + benefits for Lead Wellness Navigator who dedicates 10% of her time to training new Wellness Navigators
  • There are also startup + monthly licensing fees for SalesForce

Status

  • The intervention is currently ongoing

Outcomes

Data collected for studying changes in patient outcomes and changes in patients’ healthcare utilization are forthcoming in 2018.

Benefits

  • Primary Care Providers feel incredibly lucky to be able to turn to the Wellness Navigators and The Wellness Center when they encounter obstacles patients experience to staying healthy that cannot appropriately be addressed in the clinic setting. 
  • Patients participating in the evidence-based programming experience transformation of their health literacy within weeks to months of participating in this program and their PCPs observe tangible changes in indicators such as HbA1C within 6 months. 
  • This program revealed to the author and her colleagues the extent to which their patients were ill-prepared to succeed in modifying their lifestyles according to their physicians’ recommendations
  • For example, patients stated they did not know how to make a plan or identify a substitute for cutting down on sugary soda. 

Unique Challenges

  • It can take months to years of persistent provider referrals to motivate patients to participate in the evidence-based programming. 
  • There is a high burden of training, for example in privacy, to integrate workers without medical training into the medical system in such a new and innovative role.
  • Determining the appropriate amount of training and supervision that respects and gives the Wellness Navigators enough support has been challenging, even for experienced county program directors who have carried out Community Health Worker training for a long time.

Personnel Challenges

  • There is a high degree of workforce turnover in both the Wellness Navigator workforce and the community-based organization staff. 
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