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43868217911465April 17, 20184000020000April 17, 2018-944880-154178000Reproductions of this manual are not permitted without express written permission of:Dr. Shreya Kangovi, Penn Center for Community Health Workers, 423 Guardian Drive, 12th Fl., Blockley Hall, Philadelphia, PA 19104Cite as: Kangovi, S. K., Chanton, C., Feldstein, J. (2018). IMPaCT (Individualized Management for Patient-Centered Targets) CHW Inpatient Manual. Our Purpose IMPaCT goal-settingProfilesThe ArcTips for SuccessYour Role Structure of IMPaCT Overview of Steps Step by Step Guide Your Priorities Safety Job Expectations Supervision and SupportForms IMPaCT Info Sheets Patient Calendar Meet the Patient Interview Roadmaps Next Steps Discharge Interview Follow-up Interview Pre-Doctor’s Appointment Coaching Doctor’s Appointment InterviewOVERVIEWOUR PURPOSEEvery day, hospitals care for sick patients. They try their best to make them feel better so that they can go back to their normal lives. However, hospitals are not great at addressing the things that may have made patients sick to begin with: stress, lack of food, trauma, mental illness, substance abuse, homelessness, etc. These stressors weigh heavily on low-socioeconomic status (SES) patients who have limited resources, and can cause them to get sick over and over again. We believe that the people who can best understand what patients are going through and help them get through these challenges are Community Health Workers (CHWs). CHWs are people like you who come from the communities they serve and who are “natural helpers.”IMPaCT CHWs provide structured support for patients and help them reach their health goals. You will be working in the IMPaCT Inpatient program. The purpose of the IMPaCT Inpatient program is to help low-SES hospital patients stay healthy after discharge.As an IMPaCT Inpatient CHW, you will start by getting to know patients and understanding what patients need to stay healthy after discharge. You will work with patients to set goals and achieve those goals. You’ll also help with some important things that all patients need after hospitalization, such as arranging follow-up care and getting medication. IMPaCT GOAL-SETTINGIMPaCT is built on the science of goal-setting. Most people are better at reaching goals if they are broken down into baby steps, or short-term goals, so they have a clear path to follow. IMPaCT CHWs help patients work backwards from a long-term health goal and create a Roadmap for reaching that goal.ROADMAPS are plans that use a patient’s resources to achieve short-term goals that patients feel confident about achieving. These short-term goals will eventually lead to the long-term health goal. Example:1. LONG-TERM GOAL: Patients start by choosing a long-term health goal that is clear and measurable. This is something that patients can do with the help of their health care provider. For instance: “I want to stay out of the hospital for the next 6 months” or “I want to get my blood pressure to 140/90.”2. SHORT-TERM GOALS: You will ask the patient what they think they will need to do to reach this long-term goal. These are the patient’s short-term goals.3. ROADMAP: After helping the patient identify short-term goals, you will help patients create action plans, or Roadmaps, for each short-term goal. Roadmaps have five components. See the Roadmap chart on the next page.IMPaCT ROADMAPSROADMAP SECTIONDESCRIPTIONSPECIFIC EXAMPLESHORT-TERM GOAL STATEMENTCHWs work with patients to create a specific, measurable goal, so that they will know when they have accomplished it.“In order to lower my blood pressure, I need to learn how to cook a low-salt recipe.”CONFIDENCEIMPaCT CHWs ask patients how confident they are that they’ll be able to reach that goal by using this picture“How confident are you that you can cook a low-salt recipe?”Patients score their confidence using a scale of 1-10. If patients score below 7, the CHW should go back and ask them to pick a slightly easier goal.RESOURCESThe things, people, or ideas that the patient thinks might help them achieve their goals.“My sister and I like to cook together and she’s interested in low-salt recipes as well.”CHW has a copy of a low-salt recipe book.PLANThe concrete next steps that need to get done to make sure the goal is reached. The Plan gets updated every time the CHW talks to the patient. CHWs make sure each plan has a ‘who, what, when, where.’CHW to help patient find low-salt recipes by Monday.CHW to cook low-salt meal with patient and his family by next Friday.RESOLVED?Has the patient achieved their short term goal? CHWs make goals specific and measurable from the beginning, so they know when they’ve been achieved.When patients can demonstrate that they have reached a goal, the Roadmap is resolved.PROFILESThrough our research, we have found that there are generally four types of patients, which we call Profiles A, B, C and D. During the Meet the Patient interview, CHWs get a sense of which profile fits their patient, and uses this knowledge to tailor their support to the patient over the course of the IMPaCT program. PROFILEDESCRIPTIONCHW SUPPORT FOCUSPROFILE ATraumatic experiences (jail, sexual assault, murder, etc.)Social/family dysfunctionMental illnessSubstance abuseHousing instabilityDisabledAlready uses resources like disability check, Parole Officer, case worker, es to the hospital a lot (more than 5 times in 6 months)Not very motivated to work on Roadmaps Emotional Support:CHWs should listen to these patients and get to know them. They should not force them to make short-term goals they are not ready to make.CHWs should focus on providing emotional support, helping them to find meaning in life, and connecting them to supportive people to help them when the IMPaCT program is over.PROFILE BSupportive familyCaregiver burden: lots of friends/family are also sick or have problems. The patient cares for them, often more than they care for themselvesJob stress: patients have to get back to work which makes it hard to recover when they are sickCan’t afford medications or medical careVery motivated to work on Roadmaps but struggles to find timeInstrumental Support:CHWs should connect these patients with community resources, insurance, etc.CHWs should help them get things done and reach their short-term goals.PROFILE CMedically complex, frail and often elderlyTerminal condition like end-stage cancerGoing back and forth to the hospital often for severe illnesses that are not just due to social issuesEnd of Life Support:CHWs should talk to the care team with the patient to understand their prognosisCHWs should help the patient to think about the end of life, and talk about it with their family or friendsCHWs should connect patient to support for the end of life, including home nursing or hospice. PROFILE DIndependentRelatively healthy and may not have a deeply rooted cause of their health problemsInform and Empower:CHWs should respect that this patient may not need or want much support. Provide whatever information or support they ask for, but otherwise back off!Don’t talk down to these patients. Do the opposite: ask them to be a role model for other patients or share their strategies at groupOf course, not all patients fall neatly into one of these Profiles. The idea is to run through these and make sure you have a sense of what type of support might best fit your patient.The ARCA CHW-patient relationship should ideally progress through four stages. -Listen. You should Listen INTENTLY to the patient. Talk to caregivers and the medical team. Try to get a ‘Snapshot’: a sense of who is this person, what is important to them (hopes/fears) and what, if anything, is the root cause of their health problems. -Snapshot. As you listen, reflect and ask questions, you will develop your Snapshot. It may not always be crystal clear at first and can evolve with time. Ideally the Snapshot is something you develop with the patient, reflects both strengths and challenges, and continues to be refined over time. As you do the Meet the Patient Interview, and throughout your relationship, talk about your Snapshot out loud to see if the patient agrees: “Ms. Jones it seems to me that you are a strong, caring mama-bear. You’ve lost your son recently and that’s been so hard that you picked up smoking again. Now you’re looking for a quick, convenient stress release to replace the cigarettes.” -Roadmaps. List the goals that you and your patient set for your time together. Prioritize the goals that make sense given their Snapshot and best address the root cause of their health troubles. Map out a Roadmap to each goal using the Roadmaps form. -Do it now! For each Roadmap, try to get as much done as you can right there in the moment. Make calls, look things up on the internet, get busy. Putting things off takes the wind out of everyone’s sails. If you follow these stages, you’ll have a better chance of spending your time wisely and doing work that really make a difference for your patient. If not, you may spin your wheels with busy work that doesn’t link back to your patient’s core needs.TIPS for SUCCESS To be a good CHW, you need to be good at motivating people. Here are some big picture tips:Don’t forget the Arc: Listen, get a Snapshot, create Roadmaps that make sense given the Snapshot and Do it now! Get started on a Roadmap DURING your first meeting with the patient. Call a housing program, start a food diary, schedule a nutrition appointment etc. Early victories will jumpstart the patient’s motivation! Complete a WHOLE Roadmap in your first week together. Then praise the patient for their success! This feels like a reward and also gets them confident to make changes in their life! Be a fun person who the patient loves to talk to. When you call the patient, connect with them as a person and joke around for a few minutes before you get down to business. Bring them a silly picture or article you clipped out of a magazine! Do a fun activity together! Send them a card! Be creative. If you bring fun into the relationship the patient will stay motivated to work with you. Never lecture a patient or act disappointed that they didn’t do the things they planned to do. This can feel like punishment and may make patients avoid you. Instead, when the patient tells you they didn’t do something they said they’d do, praise them for being honest! It’s hard to admit you messed up! Ask the patient what made it hard to do.Ask the patient what they learned from not being able to get it done. This could help them succeed next time. Ask the patient what they plan to do next.Depression, anxiety, substance use, chronic pain and lack of sleep are frequent roadblocks to success on health goalsAsk the patient if they ever feel stressed or depressed. Ask if they have ever considered talking to someone about it. Be direct about discussing mental health with your patient. It is crucial to get comfortable talking about substance use. Be direct but not disapproving or judgmental. If a patient has chronic pain or can’t sleep, ask their doctor for help or a referral. Motivational Interviewing is an important skill to help patients reach their health goals. If a patient is thinking about changing a habit (e.g. quitting smoking) but hasn’t done it yet, help them to list the pros and cons of the habit. For example, a pro of smoking: “it’s fun to take smoking breaks at work with my friends.” A con: “I hate the taste in my mouth.” Then, in a very non-judgmental way, help them to start to focus a little more on the cons, especially any physical sensations they may not like.YOUR ROLESTRUCTURE OF IMPaCTIMPaCT programs follow a standard basic structure:SET GOALS: As an IMPaCT CHW, you will work with patients and their providers to set health goals that are important and achievable. Then you will help patients create tailored action plans that will lead to their goals.SUPPORT: Throughout the program, you will provide hands-on support towards helping patients achieve their goals.CONNECT: You will also work to connect patients to a source of long-term support in order to prevent the voltage drop that often occurs after an intensive program.You are working in the Inpatient program, the IMPaCT program targeted towards hospitalized patients. You will meet new patients in the hospital, support them through hospital discharge and return to the community, and help them transition to a primary care clinic. You will also work with your patient to identify a long-term support person who can help them after the program ends. Throughout the program, you’ll work with them to address the root causes of their poor health. 342709530130750037510504961Support Person0Support PersonOVERVIEW OF STEPSThis list will give you the basic idea of your workflow, which will be described in the next section in more detail.9315456350First thing every morning: check in with your Manager and log onto HOMEBASE, IMPaCT’s secure computer program for CHWs, and determine if it will be an On-Call day or a Home Visit Day.00First thing every morning: check in with your Manager and log onto HOMEBASE, IMPaCT’s secure computer program for CHWs, and determine if it will be an On-Call day or a Home Visit Day.922020125674Gather the interview guides and forms for your day.00Gather the interview guides and forms for your day.922020128961If it is an On-Call day, go to the hospital with your Target List.00If it is an On-Call day, go to the hospital with your Target List.922020130754Introduce yourself to the patient and explain IMPaCT.00Introduce yourself to the patient and explain IMPaCT.92202040584Conduct the Meet the Patient Interview and fill out the patient calendar.00Conduct the Meet the Patient Interview and fill out the patient calendar.92202040584After a new patient interview, enter notes into HOMEBASE. Run the List: talk about your patients with your Manager.00After a new patient interview, enter notes into HOMEBASE. Run the List: talk about your patients with your Manager.92202038156If the new patient is uninsured, contact the hospital business office about insurance/ help with the hospital bill. 00If the new patient is uninsured, contact the hospital business office about insurance/ help with the hospital bill. 915670394268.Conduct the Discharge Interview.008.Conduct the Discharge Interview.915670438719.If the patient needs discharge prescriptions, help them with prescriptions from the pharmacy.009.If the patient needs discharge prescriptions, help them with prescriptions from the pharmacy.9156703942610.Encourage patients to schedule a follow-up primary care doctor’s appointment.0010.Encourage patients to schedule a follow-up primary care doctor’s appointment.91567011562611.Coach patients to get the most out of their doctor’s appointments.0011.Coach patients to get the most out of their doctor’s appointments.91567013646912.Attend the follow-up doctor’s appointments with the patient.0012.Attend the follow-up doctor’s appointments with the patient.91593714323813.Follow up with all of your patients at least once a week.0013.Follow up with all of your patients at least once a week.91567015361414.Get patients help if clinical issues arise from home.0014.Get patients help if clinical issues arise from home.9213019413615.Support patients if they are readmitted. 0015.Support patients if they are readmitted. 91567015150116.Prepare for graduation and find long-term supports.0016.Prepare for graduation and find long-term supports.91567080301117.Graduate patients when they have completed the program.0017.Graduate patients when they have completed the program.STEP-BY-STEP GUIDE1. FIRST THING EVERY MORNING: CHECK IN WITH YOUR MANAGER AND LOG ONTO HOMEBASE AND DETERMINE IF IT WILL BE AN ON-CALL DAY OR HOME VISIT DAY.Each morning (~ 9 am), you should call or text your Manager to check-in. Then log onto HOMEBASE, IMPaCT’s secure computer program designed for CHWs.Check the calendar to see if this is an On-Call day for you. An On-Call day is a day when you are assigned new patients to enroll at the hospital. If it is not an On-Call day, you will be visiting your other patients who are still in the hospital, doing home visits, attending primary care appointments, making phone calls, and/or entering documentation.If it is an On-Call day for you, at 9:15 am click on your Target List and print it out. Look to see which patients are assigned to you. These are the patients you will meet with at the hospital. 2. GET ORGANIZED AND GATHER THE INTERVIEW GUIDES AND FORMS FOR YOUR DAY.Here is our system for organizing your time:Start your day by printing your online calendar. Throughout the day, when you say ‘I will do that…’ make a [] on your calendar so that you can keep track of what you’ve committed to doing. If you say you will do something at a specific time, check your calendar to be sure you are available. At the end of the day, review your checklist to make sure you got everything done. Transfer new appointments to your online calendar. You can also do all of this directly on your phone or tablet, as long as you have it with you at all times. Here is our system for organizing your stuff:Your Manager should have a team binder at your clinical site. This should have a copy of this manual and multiple blank copies of each form.You should carry a ?” thick binder which should include a Table of Contents and 1-2 blank copies of each form. This binder shouldn’t contain any identifiable patient information.Keep separate folders for each patient. Try to minimize the amount of identifiable information you carry. Upload documents into HOMEBASE and shred as soon as you can.Make sure you have all your interview guides and other things you need including:Target ListBinderPillboxYour calendarCell phoneLaptop In order to get started with a patient’s Roadmaps ASAP, you will want to have key resources on hand. Your Manager will make sure you have links for common resources in your area such as:Programs that help pay for prescription medicationsLow-cost medication formularies for local pharmaciesHealth centers that serve low-income and uninsured patientsPublic benefits officeArea agency on agingLow-income cellular phone program3. IF IT IS AN ON-CALL DAY, GO TO THE HOSPITAL WITH YOUR TARGET LIST.When you arrive on the floor where your patient is located, introduce yourself to the Unit Secretary. It pays to be as friendly to everyone as you can! If anyone gives you a hard time, call your Manager or Director. Also, make sure to introduce yourself using this brief introduction to EVERYONE who is new to you:Hello, my name is ______ and I am an IMPaCT Community Health Worker. My job is to provide social support to patients from the community during hospitalization, discharge and recovery.(Give them an IMPaCT Info Sheet if they have more questions, and use this to walk them through what you do.)If any team member asks you to enroll a patient, let them know that the fastest way to refer a patient is to call the IMPaCT Referral Hotline. The Coordinator will screen the patient to see if they are eligible for IMPaCT. Here are some things to know about the Target List: You’ll enroll about 2 patients each time you’re on call but your Manager will give you an exact enrollment goal each Monday. Sometimes there will be more than 2 names on the Target List for any given day. Start with the patients at the top (Referred patients who were admitted most recently) and work your way down the list. Starting with referred patients helps us build good relationships with clinicians and prioritizing patients who were most recently admitted will give you more time to work with the patient in the hospital before they are discharged.After you have gotten 2 patients to agree to work with you, call your Manager. Together you will decide what to do with any remaining patients assigned to you on your Target List. Mark which patients you enrolled, which ones you didn’t enroll and why. Sometimes, you might enroll a patient who has been in IMPaCT before. Read any old notes and think about:What were the Roadmaps? Were they accomplished? If not, why?What went well working with this patient? What were some of the challenges?How might the patient or their situation have changed since the last time they had IMPaCT?Pay attention to safety concerns from old notes. Remember the Target List contains confidential patient information, so make sure to keep it in a secure place and shred it each day.Introduce yourself to the nurse of the patient you are targeting and tell her that you are an IMPaCT CHW who is there to meet with the patient. You should be enrolling patients by no later than 9:30 am. If you arrive later than that, you could miss the patient if they get discharged.4. INTRODUCE YOURSELF TO THE PATIENT AND EXPLAIN IMPaCTYou’ve found your patient! This is the time to use your natural instincts for being a caring, friendly person to make this person feel comfortable.Give them their pillbox and Patient Calendar (people like gifts)! Explain your role using the IMPaCT Information Sheet and ask the patient if they would be interested in the program. When talking about your role, make sure to explain that you are not a clinical provider. Also explain that you will keep their information confidential except for discussions with your Manager and the clinical team, or if you witness child or elder abuse, or if the patient seems like they are a threat to themselves or others.If the patient would like to work with you, ask for permission to talk about their case with others (family members, outside doctor’s office, etc.) and if so, ask them to sign a HIPAA form. Finally, make sure they know that you will be providing support for 3 months. This will make it a bit easier to say goodbye once the program ends.If at any point a patient behaves inappropriately or is threatening to you, please report it to your Manager or Director (See ‘Safety section’). Their case may be terminated. There may also be patients who are not “with it” and too confused to talk to you. If that happens, ask the nurse for contact information for the patient’s designated family member or caregiver and go through the IMPaCT process with that person. The most important thing for these patients is to make sure you have contact information for designated family/caregivers and also know how to get in touch with the patient once they are discharged.If you realize early on (before or soon after the Meet the Patient interview) that you know the patient personally, are related to the patient, or live in the same 1-2 block radius as the patient, PLEASE DO NOT ACCEPT THIS PATIENT. This has a small chance of threatening the patient’s privacy and/ or your safety. Instead, explain to the patient that because you know them outside of the hospital, it will be better for another CHW to accept their case and remain objective. Let your Manager know and arrange to re-assign the patient to another CHW.Sometimes, you will be assigned a patient who is a family member of another patient who is already in your care. There are two options for this situation:1. Sit down with each patient individually and ask their permission to care for both in a family-centered way. The family approach can be really powerful. But in order for this to work, both patients need to be comfortable with sharing their personal information with each other and need to sign a HIPAA waiver. It will just be too difficult for you to keep their privacy if you are working with two people in the same family.2. Assign the newer patient to another CHW. This makes it easier to maintain privacy.5. CONDUCT THE MEET THE PATIENT INTERVIEW AND FILL OUT THE PATIENT CALENDAR.Once you have identified and met the new patient, conduct the Meet the Patient Interview. The goals of this interview are:Listen. You should listen INTENTLY to the patient. Talk to their caregivers and medical team. Try and get a ‘Snapshot’: a sense of who is this person, what is important to them (hopes/fears) and what, if anything, is the root cause of their health problems. Snapshot. As you listen, reflect, and ask questions you will develop your Snapshot. We call this a Snapshot because it’s a quick image of your patient as a person. The Snapshot may not always be crystal clear at first and can evolve with time. Ideally the Snapshot is something you develop with the patient, reflects both strengths and challenges, and continues to be refined over time. As you do the Meet the Patient Interview, and throughout your relationship, talk about your Snapshot out loud to see if the patient agrees: “Ms. Jones it seems to me that you are a strong, caring mama-bear. You’ve always wanted to see your kids graduate and worry about the streets getting ahold of them. You’ve lost your son recently and that’s been so hard. Now you need a quick, convenient stress release to replace the cigarettes that have helped you to deal with stress for so long.” Be concise, honest and positive. Reflecting the Snapshot out loud with your patient:Helps you to understand what your patient is sayingAllows your patient to feel heard, which builds trustConfirms what’s important in the patient’s life, which will shape the goals you create togetherRoadmaps. You should choose the top few goals that your patient has told you about during the interview. Prioritize the goals that make sense given their Snapshot and best address the root cause of their health troubles. Map out a Roadmap to each goal using the Roadmaps form. Do it now! For each Roadmap, try to get as many Next Steps done as you can right there in the moment. Make calls, look things up on the internet, get busy. Putting things off takes the wind out of everyone’s sails. Take notes as you conduct the interview. Most CHWs prefer to do this on paper rather than typing so that they can keep eye contact with their patients. Make sure to collect multiple sets of contact information. When you get their primary phone number, tell them that you are going to call it now so that you have it in your phone. Make sure it works, and that the voicemail is set up. If not, politely ask them if they would set up the voicemail with you, so that you can reach them.Show the patient their calendar and help them fill it out with their upcoming appointments (also involve the nurse). Also fill in the date that they will graduate from IMPaCT. If you’d like, make a copy of the patient calendar for your records. When you are done, tell the patient and nurse you will come visit the patient again in the hospital to work on their goals, and you will try to be there on the day they are discharged. After meeting with the patient, take a look at their chart in the electronic medical record (EMR), focusing on the diagnosis list and discharge document. Make sure you aren't missing anything important like mental health or substance use issues. If you learn new information in the EMR that did not come up in the interview, add a Roadmap to explore this with the patient.Then, text the doctor right away but do not include any confidential information about your patient: Hi Dr. ___, this is ___, an IMPaCT Community Health Worker. My role is to provide social support, advocacy and navigation to patients in the transition from hospital to home. I just met with one of your patients and would like to talk with you to get some advice. Could you please call me? Thank you! When you talk to the doctor on the phone, include the following: Explain your role and how long you will be working with the patient. Give a 1-2 sentence Snapshot of the patient. Ask the doctor:What do you think I should know about this patient?What concerns do you have? What do you think we should be working on? Don’t wait too long to talk to the doctor. If completing the Meet the Patient Interview is delayed, you may need to talk to the doctor before you have a chance to complete it. 6. AFTER A NEW PATIENT INTERVIEW, ENTER NOTES INTO HOMEBASE. RUN THE LIST: TALK ABOUT YOUR PATIENTS WITH YOUR MANAGER.Find a quiet spot to enter your notes into HOMEBASE. Destroy paper notes with any patient identifiers (names, room number, contact info, etc.). Run the List with your Manager: discuss each of your patients. This is crucial, so make time for this. But don’t wait on this to get going: when you meet with your Manager to run the list, you should already have tried to complete some Roadmaps with the patient. Your Manager is there to hear about your patients and to support you. Your Manager will help you create a Next Steps list, which is a to-do list based on the plans for each of your patients. This is a great tool to help you organize what you need to do. Always keep it with you in your binder.Some patients may be in the hospital for several days or weeks. In these cases, work closely with the patient to reach as many of their goals as possible while they are in the hospital. Come with your computer and any resources you may need. Together you can call organizations, fill out applications, and work towards the patient’s goals. This time can be very productive for reaching goals since it can be easier to coordinate with the patient and meet with them.7. IF THE NEW PATIENT IS UNINSURED: CONTACT THE HOSPITAL BUSINESS OFFICE ABOUT INSURANCE / HELP WITH THE HOSPITAL BILL. If your patient is uninsured, you can coordinate with the hospital business office to make sure that an application for health insurance or payment assistance for the hospital bill is completed. Send a SECURE email to the business office, stating the following:Dear Colleagues at the Business Office, I hope you are well! I am an IMPaCT Community Health Worker who provides social support, advocacy and navigation to patients of the health system in the transition from hospital to home. I have just completed an intake with the following uninsured patient: (Name, Date of Birth, Medical Record Number). I may be coming to the business office to obtain a list of the items this patient needs to submit or to drop off items to complete this patient’s health insurance/payment assistance application. Please feel free to contact me at: (Your cell phone #).Sincerely,(Your Name)Or you can go to the business office and introduce yourself using the following statement:Hello, my name is ______ and I am an IMPaCT Community Health Worker. My job is to provide social support to patients from the community during hospitalization, discharge and recovery.(Give them an IMPaCT Information Sheet, including your contact information.)I am supporting an uninsured patient (Name, Date of Birth) and I would like to help him/her complete an application for health insurance with the business office. May I have a list of the items this patient still needs to submit? Is there a specific benefits counselor assigned to this patient? May I have his or her contact information?? Use the checklist from the business office to help the patient complete his or her application for medical insurance. However, never change any of the patient’s information in the hospital business office records without the patient’s permission. If you notice that the records are wrong (e.g. patient is listed as homeless when you know they aren’t) tell the patient and ask him if he wants to update the information. Sometimes patients don’t give the billing office their correct contact information because they are afraid of hospital bills. Do not interfere with this.8. CONDUCT THE DISCHARGE INTERVIEW.It’s very important for CHWs to be at their patient’s discharge since this is when the patient’s care can “fall through the cracks,” especially with getting the medication the patient needs. You can use the Discharge interview to help patients ask important questions to make sure that they have everything they need when they leave the hospital. Go straight to the hospital every morning if you have a patient who has not yet been discharged. Discharge is unpredictable. If the patient tells you at any point that they may be discharged, come back to the hospital as soon as possible. If you miss a discharge (e.g. if it happens at night or over the weekend), schedule a call/home visit with the patient for the next day to make sure that they filled their prescription from the pharmacy and received their discharge instructions.When you meet a patient to be discharged, be sure to have:Discharge InterviewPatient CalendarYour calendarIf the patient requests it, you can be present while the nurse gives discharge instructions. Remember, this doesn’t mean that you can give clinical advice later! This can simply help you to advocate for the patient. Use ‘Teach-Back’ to make sure that you and the patient understand the instructions that the nurse is giving. If you don’t: ask the nurse.Pay special attention on the discharge instructions to whether the patient is supposed to get home care. If so, call the home care agency right away and schedule an appointment time with the patient. You should mark this on your and the patient’s calendar. You will need to give them a telephone/home visit reminder for the home care appointment.Help the patient ask the nurse for a copy of the discharge summary to give to their primary care doctor.Help the patient put appointments and relevant information onto their patient calendar. Also put all of the scheduled follow up dates on your calendar so that you can remember to give patients reminders the day before. Even if a patient is uninsured, DO NOT wait to make appointments or get medications! This should be done prior to discharge. Think about low-cost formularies and low-cost clinics where the patient can go. It can take a long time for insurance to come through and a sick patient can’t wait on that for follow-up appointments or mediations. Get the prescriptions from the nurse. (See next section regarding pharmacy and prescriptions.)Ask the patient when you can call/visit them next to check up on them. Make sure that you have a copy of your calendar in front of you when you are doing this so that you don’t offer dates or times when you or your CHW co-worker is unavailable. If you schedule a visit, tell the patient that your co-worker CHW will come along.Again, once your patient leaves the hospital, transfer all your notes from the Discharge Interview into HOMEBASE and destroy any written notes that could identify your patients. Make sure to put any home visits on the calendar, including the patient addresses and phone number. Upload paper discharge summaries onto HOMEBASE until you need them for the primary care doctor’s appointment.9. IF THE PATIENT NEEDS DISCHARGE PRESCRIPTIONS, HELP THEM WITH PRESCRIPTIONS FROM THE PHARMACY.Prior to discharge, ask the patient if they would like you to help get the discharge prescriptions filled immediately at the hospital’s outpatient pharmacy.Make sure you tell patients that they will still need to pay for the prescriptions, and that all you are doing is dropping off the prescriptions and finding out how much the co-pay will be.Get the prescriptions from the nurse. Ask the nurse to please wait to discharge the patient until you have had a chance to drop off the prescriptions and find out what the co-pay is.Drop prescriptions off at the hospital’s pharmacy. (If your hospital does not have an outpatient pharmacy or if the patient does not want to use this, you can ask the nurse to fax prescriptions to the patient’s pharmacy.) Ask the pharmacy how much the co-pay is. You may need to provide the patient’s date of birth to get this information. Return to the patient room and alert them of the amount. If they tell you they can’t afford to pay, let the nurse know that this is a problem.After the patient is discharged, accompany them to the pharmacy so that they can pick up their pills on their way out of the hospital. DO NOT PICK UP MEDICATIONS FOR THE PATIENT. This puts you in a bad position if the pills are found to be missing or incorrect. Remind the patient to bring all of their medications and the pillbox to the primary care appointment.If for any reason you are not able to help the patient pick up their medications at the time of discharge, getting discharge medications becomes a high alert Roadmap. It is a priority to make sure that the patient is able to fill their medications by the next day at the latest. If you cannot verify that pick-up has happened, notify your Manager immediately.10. ENCOURAGE THE PATIENT TO SCHEDULE A FOLLOW-UP PRIMARY CARE DOCTOR APPOINTMENT.Call the patient the day after discharge and, if you haven’t already done this in the hospital, encourage them to schedule a doctor’s appointment within two weeks of discharge. Help them arrange this appointment and feel free to recommend doctors you and other patients like. Document the plan for the primary care doctor and home care appointments on the ‘Doctors Appointment’ form in HOMEBASE. Write the appointment information on your and the patient’s calendar. Plan to do a home visit on the day of the doctor’s appointment and make sure your CHW coworker is available at that time.11. COACH PATIENTS TO GET THE MOST OUT OF THEIR DOCTOR’S APPOINTMENTS.On the day before the first post-hospital doctor’s appointment, call your patient and go over the Pre-Doctor Interview. This guide will help you coach the patient for their primary care doctor’s visit and help remind you to tell patients to bring their medications and discharge summary to their appointment. If you are unable to contact the patient on the phone before their first post-hospital doctor’s appointment, notify your Manager and arrange a home visit with your CHW coworker.12. ATTEND THE FOLLOW-UP DOCTOR’S APPOINTMENT WITH THE PATIENT.On the morning of the doctor’s appointment, call the patient and arrange to meet them at the doctor’s office. Remind them to bring all medications (or a list of them) and their pillbox. If you are unable to contact the patient via telephone, arrange a home visit with your CHW coworker so that you can make sure your patient makes it to the doctor. Make sure to bring:Patient’s discharge summaryPrinted copy of the patient’s RoadmapsAt the doctor’s office, make sure the patient has a copy of the discharge summary to give to the doctor.You should not sit in on the patient’s appointment with the doctor unless the patient asks you to do so. If you are sitting in with the patient, act as moral support only. Be careful about volunteering clinical information; the discharge summary will provide this.Go through the Doctor’s Appointment Interview guide. At some point during the doctor’s visit, make sure to ask the doctor, “How can this patient get in touch with you if he/she is not feeling well? How about if it is after hours? What about the weekend?” If there is a case manager/social worker present, ask to speak with this person. Give this person a copy of your Roadmaps forms and point out any Roadmaps that still need to be resolved. If there is no case manager/social worker, give the Roadmaps to the doctor.Make sure that you tell the doctor that you will be working with this patient for the next three months and that you would like to work closely with them during this time. Ask for a contact phone number for a nurse/social worker that will help to coordinate care. 13. FOLLOW UP WITH ALL OF YOUR PATIENTS AT LEAST ONCE A WEEK.Call the patient at least once every week. See how they are doing, and use the Follow-up Interview guide. Check up on existing Roadmaps and create new Roadmaps for new issues that the patient reports. Make three face-to-face visits within the first month of your relationship with the patient. A strong start is crucial! After the first month, you should make contact every week, with at least one home visit per month.When preparing to do follow-ups, be sure to have:Follow-Up Interviews Roadmaps forms you completed together in the hospitalNew blank Roadmaps formsYour calendarCharged cell phoneThe address and phone number of the patientNever give any information about your patient to anyone unless your patient has signed a HIPAA release form. You will need this form if you are asking the patient’s old primary care doctor to transfer files to the new doctor, etc. In other words, if you are handling ANY of the patient’s private information, protect yourself by making sure the patient signs a HIPAA release form. If you are doing a home visit, take all of the safety precautions discussed in the Safety section. Update your notes in HOMEBASE within 24 hours of doing any task for a patient or speaking with a patient. Document any action, new problems, or progress on a health goal that the patient reports, as well as any action you have taken as a follow up encounter. Check in with your Manager once to twice a week to run your patient list and talk about any Roadmaps that you are having trouble resolving.After the first month, talk with your patient and Manager about narrowing down the patient’s Roadmaps to the two best ones. These are the ones that the patient seems most committed to. One of the roadmaps should ideally be related to cultivating a long term support person. For the next two months, just focus on these two Roadmaps until you get them done. If any of the Roadmaps you do with your patient involve eating food, make sure the food you eat with your patient is healthy. The last thing you want to do is feed your patient something bad for them and cause a serious health problem. Do not give any food to your patient without first checking with your Manager. Every time you talk to or think about your patient ask yourself: what have I done for this person to change their life? Don’t dawdle, don’t just talk about things: DO THEM. It’s ok if you fail but it isn’t ok not to try.11. GET PATIENTS HELP IF A CLINICAL SITUATION ARISES.There will be times when an urgent clinical situation (medical, psychiatric, sexual assault, domestic violence, etc.) arises. This is ALWAYS the most urgent thing you need to take care of. Drop whatever else you are doing for the moment and focus on resolving this issue. Medical situations: Remember, your job is to focus mostly on the life issues of the patient, not on the medical issues. But of course, medical issues will come up. Here are some examples:A new symptom that the patient has not discussed with their medical providerA new medication side effectPatient is unclear about something in the doctor’s instructionsOut of medication, or unable to get a medication (insurance will not cover it, pharmacy requires a prior authorization, etc.)If the patient reports blood sugar over 300 or below 70If the patient reports blood pressure over 200Here is what you should do:Stay with the patient or keep him/her on the phone. It might be hard to find them if you leave them. Do not tell the patient what to do (e.g. go to the ER or don’t go to the ER), but offer to support them with whatever they think they should do. Remember, you are not a clinician. However, if you are witnessing something that you believe is a true life-threatening emergency (heart attack, can’t breathe, stroke etc.) call 911.Notify your Manager.Offer to get in touch with a doctor. Never give the patient the doctor’s pager or cell phone number, but DO use three-way calls with your patient. Use your SBAR training to explain the situation to the doctor: Situation (who you are, where you are), Background (patient’s name/DOB/major medical conditions), Assessment (what is happening), Request (what you need). There are two possibilities when you have to contact a doctor:If the patient has not made it to their primary care doctor’s appointment yet, you will call/page the attending doctor who discharged the patient from the hospital.If the patient has made it to their primary care doctor’s appointment, you will call the primary care doctor. If you have the primary care doctor’s direct cell phone or pager, this is often better than calling the clinic main number.If you can’t reach either of these doctors, call your Manager who will help you find a medical provider.Mental health or substance abuse crisis: If a patient has a psychiatric crisis (suicidal, or other threats of harm to self or others) do the following:Stay on the line or with the patient as long as you are safe. If you are on the phone, ask the patient to tell you where they are. Ask them if they would be able to get to a safer location, where they are not alone.Make a 3-way call to the Manager.Call a psychiatric emergency hotline with the patient (your Manager will give you a recommended hotline number – save it in your work phone when you get it). Ask the patient if they would be willing to go to a psychiatric emergency evaluation center or crisis response center (your Manager will give you a list of these locations – keep them on hand).If you are in the clinic or hospital, offer to walk the patient to the clinic’s social worker and ensure that they talk to the patient.Afterwards, send an EMR message to the primary care doctor and/or clinic social worker with the details so that they can continue to support the patient.Domestic violence or sexual assault: If a patient is involved with an escalating domestic violence situation or sexual assault, do the following:If you are in the patient’s home, leave immediately and get to a safe place. Consider asking the patient if she/he would like to come with you, but don’t do this if it will put you in harm. Once in a safe place, call your Manager. As soon as you can establish contact with the patient, make the patient feel heard, supported and in control. It can be helpful to say something like, “I’m so sorry this happened to you. You did not deserve this. What do you think you need to feel safe and get the help you need, and how can I support you?” Do a 3-way call with the domestic violence hotline (your Manager will give you a recommended hotline number – save it in your work phone when you get it). Afterwards, send an EMR message to the primary care doctor and/or clinic social worker with the details so that they can continue to support the patient.If a patient tells you about a clinical issue and asks that you keep it confidential, remind them that you will have to share it with your Manager and the care team. You should NEVER tell a patient their lab results or information from the EMR except for the time/location of any upcoming appointments. THIS IS THE JOB OF A CLINICIAN AND IF YOU DO THIS, YOU COULD BE TERMINATED BECAUSE IT IS A MAJOR BREACH OF PRIVACY AND YOUR BOUNDARIES AS A CHW. If you want to congratulate your patient on a clinical change (e.g. you noticed that their blood pressure at the last clinic visit was way lower), first contact the clinic and make sure that the patient has already been informed of the clinical change by a medical provider. 15. SUPPORT PATIENTS IF THEY ARE READMITTED IMPaCT patients are at pretty high risk for returning to the emergency room or hospital. You will receive text message and email alerts when your patient has visited your healthcare system’s emergency department or hospital. If you receive an alert, make a plan for visiting the patient in the hospital, being present for discharge if possible and helping patients get discharge medications, primary care appointments and home care. If your patient is readmitted to the hospital, remember to complete the readmission section of the Discharge form in HOMEBASE Most importantly: think about why the readmission happened. Could we have helped to prevent the patient from getting sick again? But remember, never feel like your job is to ‘keep patients out of the hospital’ because sometimes that is the safest place for a sick patient to be.16. PREPARE FOR GRADUATION AND FIND A SUPPORT PERSON.In order to graduate from IMPaCT Inpatient, you must work with a patient for 3 months after their discharge. The patient must: Receive discharge medication and any medical equipmentComplete primary care doctor’s appointmentConfirm home care visit completed if applicableIdentify a long term support person If at any point, you lose touch with your patient, complete a pop-up home visit if they gave you permission to do so. If you cannot get ahold of your patient, continue to try. Sometimes numbers change or patients go through stuff that causes them to disappear, but later are able to reconnect. Don’t give up right away. If you do a pop up home visit and at least two months of weekly phone calls to try and reach the patient, you will have to close the case and mark the patient as lost to follow up.After you’ve been working with a patient for two months, remind them that they’ll be graduating in a month and that you will help them to get ready for this transition. By this time, you should have identified a support person who will be able to look out for your patient even after the program ends (family member, friend, support group, church, etc.). Spend time solidifying the relationship between your patient and the support person. Also by this time, make sure the patient knows how to do things for themselves, such as making appointments, getting referrals, and calling the nurse if they aren’t feeling well.Ask the patient how they would like to use the final month in the program. Tell the patient that once they have graduated from IMPaCT, you will no longer be working with them directly, but that you will periodically check in with the clinic nurse to make sure things are going well for them. Obviously, if a patient is in active crisis (suicidal, newly homeless, etc.), you and your Manager will discuss keeping their case open. But in general, you have to learn to say goodbye in order to focus on your next patient and help them during their very difficult time.The patient may feel sad about ending their relationship with you, so make sure to support the patient and give them plenty of warning before they finish the program. Encourage them to attend IMPaCT group sessions as a way to stay in touch with CHWs and other patients in the future.17. GRADUATE PATIENTS WHEN THEY HAVE COMPLETED THE PROGRAM.At Graduation, the patient will receive a certificate of graduation that honors all of their hard work.At the three-month mark, make an appointment for a face-to-face meeting or, if the patient comes to a group session, make some time during the group to celebrate their graduation:Ask them to share their thoughts on the last three months and to give some feedback on the program. Prepare a short statement honoring this patient. Ask the patient to talk about what they have achieved, as well as the challenges they still face. Their fellow group members can continue to help them with these challenges.Present the patient with an IMPaCT Graduation Certificate.Send a secure email to your patient’s primary care doctor summarizing their progress in the IMPaCT program, letting them know that you are closing the case:Dear (Clinician),My name is (Your Name) and I am an IMPaCT Community Health Workers. My job is to provide high-risk patients with intensive support over a period of three months in order to help them reach their health goals. For the last three months, I have been working with (Patient Name). He(/she) graduated from the IMPaCT program on (Date). He(/she) achieved the following short term goals: (list Roadmaps goals already achieved). In order to continue to progress, he(/she) may need (list all ongoing goals or support needed from clinic). Please let me know if I can be of help. My cell phone number is (your phone).Best wishes,(Your Name)You are not required to, but are welcome to stay in touch with patients in a professional manner after this point. There are three important things to remember: Keep the same CHW boundaries you had when the patient was active.Make sure your contact with closed patients doesn’t crowd out or affect your work with active patients.If you end up helping a closed-out patient make sure you document this in HOMEBASE, and if you help substantially, tell your Manager so that you are not just flying solo.YOUR PRIORITIESThere are times where you will feel like you need to be in two places at once. This is not possible because you are only human! Whenever possible, ask your CHW coworker to help cover for you when two things are happening at the same time (e.g., a discharge and a patient appointment). This list will help you order your priorities:1. Clinical/Psychiatric/Domestic violence situation: This is ALWAYS your top priority. Help your patient get assistance as outlined above. Drop what you are doing and handle this first.2. Meeting new patients: If you delay completing the interview in the hospital, it will be very difficult to establish a good relationship with your patient.3. Doctor’s appointments: If you can’t stay for the entire appointment, try to make sure that patients get to their appointment and get checked-in. Provide them with a copy of their discharge summary and Roadmaps.4. Discharges: If you need to miss a discharge, try to visit the patient in the hospital before the discharge occurs and tell them that you can’t be there at the actual time of discharge. Advise the patient to get a copy of the discharge summary and fill prescriptions on the day of discharge at the outpatient pharmacy. Call the patient as soon as they get home to make sure that discharge went smoothly.5. Home visits: Home visits are very important but can be a little more flexible when you are in a pinch. Because this is the lowest on the priority list, always tell patients that you will always be on time and keep your commitments to them, EXCEPT when you have another patient emergency. That way, they are not disappointed if you have to reschedule.On the phone or in person: You will have two additional priorities that can happen either in person or on the phone. These priorities can be scheduled with more flexibility:1. Run the List to review your patients with your Manager.2. Work on any unresolved Roadmaps with patients.SAFETYThe most important principle of IMPaCT is that CHW safety comes first. Below are guidelines for CHW safety:WHAT TO DO IF YOU FEEL UNSAFE:Trust your gut and talk to your Manager: If a patient behaves inappropriately or makes you feel uncomfortable or unsafe, or if you experience any threat to your health (e.g. bedbugs) call your Manager. If you are really scared, call 911. Safety huddle: Once you report a safety issue to your Manager, you, your Manager and the Director will have a safety huddle THAT DAY to discuss what to do.After safety huddles, the Director may call a safety meeting to brainstorm our policies and work practices to avoid future safety issues. SAFETY WHEN PICKING UP AND WORKING WITH PATIENTS If CHWs realize early on that they know a patient personally, are related to the patient, or live in the same 1-2 block radius as the patient, they should not work with this patient.Never tell a patient where you live.CHW GUIDELINES FOR HOME VISITS:WHO: Home visits will be made in teams of two. If you are not familiar with the neighborhood, go with someone who is. If you are not crossing the threshold of the home, you can go alone but text your Manager that you are ‘SOLO’ and strongly consider taking a buddy anyway.WHAT TO DO BEFORE A HOME VISIT: CHWs should be prepared before leaving for a home visit. Run through this checklist:Did you document the time and location of this visit on your calendar? Is the location service on your phone on? Does someone know where you are? Do you have transportation? Do not use your bicycle as this can make you a target.Do you have clear directions and a contact number for the patient in your phone?Did you call the patient prior to leaving the office, to make sure that the patient is expecting you?Do you have charged cell phones? Do you have your work ID badge? Do you have your binders and patient forms/scripts that you need?WHAT TO DO DURING A HOME VISIT: Keep your IDs visibleAlways text in and out to your Manager as you cross the threshold of the home. If you don’t feel safe texting outside, you can wait until you are inside but use the threshold as your cue to remember. Think about ‘loading’ your text in advance so that all you have to do when you cross the threshold is to hit send.If you are not entering the home and are alone, text ‘SOLO’ so that your Manager checks on you within 30 minutes instead of one hour. Aside from texting in and out, don’t use your phone or computer on the street or on public transportation because this can make you look like a snitch or a target for theft.Leave if you feel uncomfortable. Once you feel safe, call the patient and reschedule.Never enter a patient’s car or give them a ride.Try not to be totally alone with a patient unless you are in public. This protects you from harm and accusation.Keep your phone’s location services feature on at all times in the event that we need to locate you in a safety emergency. Your tracking password is kept in a central, secure folder and only used by Managers with Director permission in situations of serious concern for your safety. WHEN: Home visits should be made in the daytime. The exact times may vary depending on the time of year.WHERE: CHWs should make every effort to do visits at patients’ homes. However, if they have concerns about visiting a patient’s home, they can use a neutral place nearby instead such as a community center or a church.If you are out in the community and encounter an unsafe area (i.e. a block with active gunfire etc.) let your Manager know immediately and add this to the patient’s safety note. Your Manager will notify the Director, who will communicate this information to the rest of the team. Use your best judgment when considering future home visits in this area, and don’t go if you don’t feel safe. Home visits to blocks with past safety issues should always be done with caution, and always with a buddy until you assess that the risk has passed.WHY: When done safely, meeting patients in their homes and communities is a crucial part of your job. It makes things easier for patients, and helps the CHWs learn even more about their patients’ lives.ADDITIONAL NOTES FOR MANAGERS:When a CHW texts in to let you know they are on a home visit, set your alarm for 1 hour. If it’s a solo visit (i.e. without a buddy) set an alarm for 30 minutes. If you can’t reach your CHW after your alarm goes off, call the Director. You will try to locate the CHW using the location services device on their phone and may end up calling the police to do a check of wellness. If the Director decides to terminate a patient from the program because of a safety threat, Managers must document this clearly at the top of ‘Safety Notes’ section in HOMEBASE. This alerts the Coordinator, who may otherwise end up re-enrolling the patient in the future. Make sure your CHWs’ location services login information is up-to-date in the organization’s central, secure repository. Any violation of the Safety Rules will result in immediate disciplinary action (verbal warning, then a written warning with human resources involvement). CHWs should report any breaches of safety to the Manager or Director.INFECTION & INFESTATION PREVENTION:Well-being is an important aspect of safety. Below you will find some information that can help protect you from bedbugs and MRSA. Protecting Yourself from Bedbugs Bed bugs are small, reddish-brown bugs that can grow up to the size of an apple seed. They are usually visible to the eye.Bed bugs move from place to place in luggage, clothes, boxes, and used furniture – or through small cracks between apartments.They only come out at night – but leaving a light on won’t stop them from biting.Bites from bed bugs cause large, itchy bumps on some people. Other people don’t have any reaction to the bites.When in all patients’ homes, CHWs should:Place your coat, bag and outer wear in an area clear of patient belongings or clutter. Avoid sitting on beds or furniture that is upholstered or made of wood.Wear clothing that can be washed and dried at high temperatures.If you find out your patient has bed bugs at their home:Inform your Manager and include this information in the HOMEBASE ‘Safety Note’We will never require you to do a home visit if you feel unsafe, but it is possible to do safe home visits to homes with bed bugs if you take the precautions listed above If you find out your patient has bed bugs in their hospital room:Inform your Manager and the hospital team If you think you have been exposed to bed bugs:As soon as possible, wash all clothing and personal items in very hot water for at least 15 minutes and dry the items on high heat for at least 30 minutes. Clothing that cannot be subjected to high temperatures should be soaked in warm water with lots of detergent for several hours. Clothing that cannot be laundered may be steam cleaned.If you are worried you may have brought bedbugs home with you:Check items you brought into patient’s homes for signs of bedbugs. Items to check include clothing, tablets, briefcases, rolling bags and backpacks. Check carefully along fabric seams.Check yourself for signs of bedbug bites.Check your bedding and mattress (particularly along seams), upholstered and wooden furniture, moldings and wall cracks. A flashlight is helpful when examining these items for signs of bedbugs.Talk to your Manager if you find a bed bug in your homeBedbugs can be embarrassing and stressful. If you are working with a patient with bedbugs, be kind. Create Roadmaps to address things they may need or want (ex: talking to their doctor about itchiness and other symptoms; resources for extermination)Protecting Yourself from MRSAMRSA is a type of bacteria that is very common in the community. Lots of people have it just living on their skin and it doesn't cause problems. In some people it can cause boils. Rarely, usually if someone is already sick, it can cause more serious illness like pneumonia.?In the hospital, when someone has MRSA we use gowns/gloves/masks, to decrease the chance that one of us (a healthcare provider) will pass the MRSA to a sick patient who could get ill from it. Outside of the hospital (in clinics and community), gowns/gloves/masks are not recommended.?Outside the hospital, the main tool for preventing MRSA is hand hygiene. Hands should be cleaned thoroughly with soap and water or an alcohol-based hand sanitizer, immediately after touching the skin or any item that has come in direct contact with a draining wound. If you have any wounds that are draining (like a cut or a sore) you should keep it covered with clean, dry bandages. Avoid touching any open wounds that a patient might have without wearing gloves. Don't share personal items that you have used such as towels, clothing, bedding, bar soap, razors, or athletic equipment that touches the skin. Consider changing your clothes each day you get home in the evening after work and taking a shower. You can wash all your work clothes in hot water on the weekend and then they are fine to use again.?JOB EXPECTATIONSATTENDANCE AND PUNCTUALITY: Excellent attendance and punctuality are expectations of this job. If you have an illness or personal emergency, please notify your Manager as soon as possible and ask another IMPaCT CHW to cover you for the day. Make sure whoever is covering has access to your HOMEBASE notes and explain any important things that need to be taken care of. TIME OFF: You have vacation time and you should use it! Submit vacation requests with at least a week’s notice for a few days off and at least two weeks for more than that. Just like when you’re sick, it is your responsibility to provide coverage for your patients. Your Manager can help you identify the best game plan.WORK HOURS: Text in (including your location) and out to your Manager when you start and end your day. As a general rule of thumb, you should work between the hours of 8am – 5pm because this is the time that most patients expect you to be available. However, you can flex your schedule as necessary for patient needs (e.g meeting patients for early morning walk-in appointments). WORK AT WORK: It is important to be focused on work during the work day. The expectation is that you are not taking care of personal things (doctor’s appointment, picking up kids, running personal errands, etc.) while you are at work. If something urgent comes up during the workday, give your Manager a heads up, clock out and make sure your patients are covered. DOCUMENTATION: Update your notes in HOMEBASE within 24 hours of doing any task for a patient or speaking with a patient. Your notes can be concise, but someone else reading the note should be able to understand what happened. This is a requirement because we are a healthcare organization and is necessary to ensure good care in the event that another CHW is covering for you. Also, put your home visits, on-call days and appointments on your calendar (to help keep you safe and organized). INTEGRITY: This organization was built and stands on truth and integrity. You are responsible for collecting correct information from patients. If you are found to be making up information (e.g. documenting that a Roadmap is resolved, when it is not, or saying that you spoke with/met a patient when you did not), it is grounds for immediate termination. PERSONAL INTERACTIONS: You will often deal with difficult people (busy nurses, sick patients, frustrated family members, etc.). We support you, and do NOT want you to be subjected to any sort of verbal abuse. We want to know about any people who are giving you a hard time, and will do our best to correct the situation. However, there is never an excuse for you to be unprofessional.PRIVACY: Patient privacy is protected by law. You will have access to private and sensitive information about patients. Do not discuss patient information with anyone outside of the clinical team without the patient’s permission and a signed HIPAA form. Carry the minimum amount of patient information and file/enter into HOMEBASE whenever possible. If you are found to have violated a patient’s privacy in any way (e.g. by talking about patient’s personal information with anyone outside of the clinical team) it is grounds for immediate termination. DRUG FREE: You are in a very sensitive position and in order to protect our sick patients, we reserve the right to have periodic drug testing.WORKSPACE: Your job is to spend time with your patients so it is important that you are physically present and not working from home. Since you will be moving around a lot, use your judgment about where to work. Be careful making calls when you are in public spaces because this can violate patient privacy. When you are working in the office, please keep in mind that your co-workers are working around you, so please keep your voice low enough to not disrupt others.DRESS CODE: It’s important that CHWs strike a balance between looking like they fit in to the community (e.g. not looking too formal or wearing a uniform) but also look respectful. Wear comfortable shoes when you have lots of home- and community-based visits; wear closed-toed shoes when you’re in the hospital. The rest of the time, wear clothes you’d feel comfortable having your grandparents see you in! Keep in mind that you represent not only yourself, but all CHWs and you want people to view us with respect. Meeting these expectations is important to the work that we do, to reach the high bar we’ve set for patient care and for our role as leaders in the Community Health Worker field. If these expectations are not fulfilled, you will be warned and moved through the disciplinary process. If the violation is serious, you may be immediately terminated.SUPERVISION AND SUPPORTIn the IMPaCT model, the CHW does not work alone. You will be directly supervised by the Manager, who will encourage your personal growth and learning. Your Manager is available to help you with any question or problem, big or small. Don’t be shy about approaching them.You will have lots of support:You will touch base at the beginning and the end of each day with your Manager. This will be brief, mostly to address any immediate problems or issues you have faced during the day.You will Run the List once or twice weekly with your Manager to discuss your patients.You will attend weekly team meetings with your Manager and the rest of your CHW team. This is a great chance to vent, laugh, share ideas and support each other.You will have an evaluation meeting with your Manager every six months. This is a chance for you to give the Manager feedback about how you think they are doing and how you think the program is running overall. You will also hear about your own performance and get to see reports that show how your patients are doing.Good Luck! FORMSIt is important for you to stay organized. You should have all of your forms in a binder. Create a section for each of the following categories:Your calendar IMPaCT Info SheetsMeet the Patient InterviewRoadmaps FormDischarge InterviewPatient CalendarsNext Steps FormsFollow-up InterviewPre-Doctor's Appointment Coaching InterviewDoctor's Appointment InterviewIMPaCT Graduation DiplomasCommonly used forms (e.g. HIPAA forms, medical assistance forms, etc.)You should also keep in your bag:A folder for each active patient and any information you need for them.-497205-589915IMPaCTTMCOMMUNITY HEALTH WORKER: INPATIENTINFORMATION SHEETI am a certified Community Health Worker. I know it can be difficult to be discharged from the hospital, get back on your feet, and stay healthy. I’m here to help.WHAT I CAN DO:Be a support person who will help you get through this hospitalization and reach your own health goals over the next 3 months. I take this very seriously and know you do too. I will be with you side by side and stick with this even when it gets hard. I’ll be calling and visiting with you at least once a week to check in.Be with you when you get your discharge instructions and help you ask questions to make sure that it is all clear. Help you get your prescriptions filled at the hospital pharmacy on the day you are discharged so that you can have them as you walk out the door. This way, we will try to make sure you can afford the co-pays and ask the doctors to try and adjust things if you cannot. . Make sure that you get to your regular doctor so that they know what happened in the hospital. I can also go with you to doctor’s appointments to help make sure your doctor gets all the hospital paperwork, and to connect you to any services that you need at the clinic. Check on you once you are home and make sure you are OK. If you give me permission, I may stop by your home if I don’t hear from you over the phone, just to check up on you. Connect you to resources like transportation, childcare, insurance, debt collection, food assistance, utilities, drug and alcohol counseling, and many others. Enrollment in this program is completely voluntary. If you choose not to participate or elect to stop working with me, it will not affect your medical care or insurance coverage in any wayI want you to know that I discuss your care with my Manager so that I can have supervision in my work. I also discuss your care with the medical team so that we can improve your care as much as possible. I can promise to keep everything about you confidential to everyone else, unless I witness a threat of child abuse or if you present a threat of harm to yourself or others.WHAT I CAN’T DO:Pay for any of your medications or services.Give you any medical advice or care. MY CONTACT INFORMATION:Name:Cell Phone number:Please call me anytime between Monday and Friday, 9 am-5 pm for the next three months.00IMPaCTTMCOMMUNITY HEALTH WORKER: INPATIENTINFORMATION SHEETI am a certified Community Health Worker. I know it can be difficult to be discharged from the hospital, get back on your feet, and stay healthy. I’m here to help.WHAT I CAN DO:Be a support person who will help you get through this hospitalization and reach your own health goals over the next 3 months. I take this very seriously and know you do too. I will be with you side by side and stick with this even when it gets hard. I’ll be calling and visiting with you at least once a week to check in.Be with you when you get your discharge instructions and help you ask questions to make sure that it is all clear. Help you get your prescriptions filled at the hospital pharmacy on the day you are discharged so that you can have them as you walk out the door. This way, we will try to make sure you can afford the co-pays and ask the doctors to try and adjust things if you cannot. . Make sure that you get to your regular doctor so that they know what happened in the hospital. I can also go with you to doctor’s appointments to help make sure your doctor gets all the hospital paperwork, and to connect you to any services that you need at the clinic. Check on you once you are home and make sure you are OK. If you give me permission, I may stop by your home if I don’t hear from you over the phone, just to check up on you. Connect you to resources like transportation, childcare, insurance, debt collection, food assistance, utilities, drug and alcohol counseling, and many others. Enrollment in this program is completely voluntary. If you choose not to participate or elect to stop working with me, it will not affect your medical care or insurance coverage in any wayI want you to know that I discuss your care with my Manager so that I can have supervision in my work. I also discuss your care with the medical team so that we can improve your care as much as possible. I can promise to keep everything about you confidential to everyone else, unless I witness a threat of child abuse or if you present a threat of harm to yourself or others.WHAT I CAN’T DO:Pay for any of your medications or services.Give you any medical advice or care. MY CONTACT INFORMATION:Name:Cell Phone number:Please call me anytime between Monday and Friday, 9 am-5 pm for the next three months.-510540-575945INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________Today’s Date: Hi my name is __________ and I am an IMPaCT Community Health Worker. Is this a good time to talk? I know a lot of people have been in and out of your room today! We know that a lot of people need help in order to stay healthy after they get discharged from the hospital. I am here to support you through this time, and help you deal with any issues that come up so that you can focus on staying healthy.CONTACT INFORMATIONBefore we get started, do you mind if I get your contact info? I want to warn you, I’m going to get as much contact info as I can so that I don’t lose touch with you.1. First name: 2. Middle name:3. Last name:4. What would you like me to call you?5. Date of birth: 6. Phone number: 7. Address: 8. Directions to address:9. If this number stops working or if I can’t find you, what's a plan B to get in touch with you?10. Backup phone number: 11. Backup address: 12. Directions to backup address:13. Emergency contact person/relationship: [HIPAA]14. Emergency contact phone number: 15. Emergency contact address:16. If I lose track of you, is it okay if I stop by? If I am trying to get in touch with you and someone else answers the phone or door, would it be OK to introduce myself as a Community Health Worker from your doctor’s office? If not, what would you like me to say? I want to make sure to respect your privacy. [Sign any HIPAA FORMS]PAGE 1/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________Today’s Date: Hi my name is __________ and I am an IMPaCT Community Health Worker. Is this a good time to talk? I know a lot of people have been in and out of your room today! We know that a lot of people need help in order to stay healthy after they get discharged from the hospital. I am here to support you through this time, and help you deal with any issues that come up so that you can focus on staying healthy.CONTACT INFORMATIONBefore we get started, do you mind if I get your contact info? I want to warn you, I’m going to get as much contact info as I can so that I don’t lose touch with you.1. First name: 2. Middle name:3. Last name:4. What would you like me to call you?5. Date of birth: 6. Phone number: 7. Address: 8. Directions to address:9. If this number stops working or if I can’t find you, what's a plan B to get in touch with you?10. Backup phone number: 11. Backup address: 12. Directions to backup address:13. Emergency contact person/relationship: [HIPAA]14. Emergency contact phone number: 15. Emergency contact address:16. If I lose track of you, is it okay if I stop by? If I am trying to get in touch with you and someone else answers the phone or door, would it be OK to introduce myself as a Community Health Worker from your doctor’s office? If not, what would you like me to say? I want to make sure to respect your privacy. [Sign any HIPAA FORMS]PAGE 1/8-483235-562610INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________PATIENT SUMMARYGreat, now that we got that out of the way, let’s talk. Like I said, I’m here to work alongside you in meeting your health goals, and in order to do this, I want to take the time to get to know you as a person. So:17a. Tell me a little about yourself [try to get a sense of their life story]PROMPTS (ask these if the patient doesn’t mention them)- Where were you born? - Where did you grow up?- What was it like growing up? - Who all lived in the house with you? - How were those relationships?- How was school? -Then what happened [keep going till you get the timeline of major life events]- What are some of the hardships or struggles you have overcome? How did you do this? - What are some moments in your life that you will always be proud of?- Tell me about your life now. -What is most important to you in life? - Where do you live now?-Who are the important people in your life? -Who is your support system? - How do you spend your time? - What kinds of things do you like to do for fun?[Reflect the patient’s Snapshot along the way]PAGE 2/8PAGE 2/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________PATIENT SUMMARYGreat, now that we got that out of the way, let’s talk. Like I said, I’m here to work alongside you in meeting your health goals, and in order to do this, I want to take the time to get to know you as a person. So:17a. Tell me a little about yourself [try to get a sense of their life story]PROMPTS (ask these if the patient doesn’t mention them)- Where were you born? - Where did you grow up?- What was it like growing up? - Who all lived in the house with you? - How were those relationships?- How was school? -Then what happened [keep going till you get the timeline of major life events]- What are some of the hardships or struggles you have overcome? How did you do this? - What are some moments in your life that you will always be proud of?- Tell me about your life now. -What is most important to you in life? - Where do you live now?-Who are the important people in your life? -Who is your support system? - How do you spend your time? - What kinds of things do you like to do for fun?[Reflect the patient’s Snapshot along the way]PAGE 2/8PAGE 2/8-333375-535305INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________PATIENT SUMMARY17b. Great, thank you for sharing all of that. Now let’s focus on your health. Tell me about your health.18. Do you have a regular doctor?Doctor Name:Doctor Phone:Doctor Facility:19. How many times in the last 6 months have you been to the Emergency Room at any hospital?20. Do you have insurance? I can try to help you figure this out if you don’t.YESNOIf yes, what coverage:PAGE 3/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________PATIENT SUMMARY17b. Great, thank you for sharing all of that. Now let’s focus on your health. Tell me about your health.18. Do you have a regular doctor?Doctor Name:Doctor Phone:Doctor Facility:19. How many times in the last 6 months have you been to the Emergency Room at any hospital?20. Do you have insurance? I can try to help you figure this out if you don’t.YESNOIf yes, what coverage:PAGE 3/8-469900-466725INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________SHORT-TERM GOALS21. I know that your goal is to stay healthy after you get out of the hospital. What things will you need to do over the next three months that will help you to stay healthy? I’m not just talking about medical things, but all kinds of life issues like dealing with shut-off notices, housing issues, etc.22. Tell me more about that. (Repeat for each short-term goal.)23. What other steps do you think you’ll need to take? (Repeat until no new short-term goals.)PROMPTS 24. Many people have told me they need to deal with their stress or depression in order to improve their health. How do you think that will be for you?25. Lots of people realize that in order to be healthy, they need to get more help (and have less stress!) from friends or family. How is that for you?PAGE 4/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________SHORT-TERM GOALS21. I know that your goal is to stay healthy after you get out of the hospital. What things will you need to do over the next three months that will help you to stay healthy? I’m not just talking about medical things, but all kinds of life issues like dealing with shut-off notices, housing issues, etc.22. Tell me more about that. (Repeat for each short-term goal.)23. What other steps do you think you’ll need to take? (Repeat until no new short-term goals.)PROMPTS 24. Many people have told me they need to deal with their stress or depression in order to improve their health. How do you think that will be for you?25. Lots of people realize that in order to be healthy, they need to get more help (and have less stress!) from friends or family. How is that for you?PAGE 4/8-477520-460375INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________26. Many of the people I’ve talked to need to continue to work on medical issues, like chronic pain or shortness of breath. How will that be for you?27. Some people want to find a way get around more easily, maybe with the help of a physical therapist or by using a cane. How is that for you?28. Lots of people say they want to get insurance in order to stay healthy after discharge. How about you?29. Many of the people I’ve talked to need to figure out a way to pay for medications in order to reach their health goal. How will that be for you?30. An important part of staying healthy is seeing your regular doctor. Are there any steps you think you’ll need to take in order to see your doctor for a follow-up appointment after you get out of the hospital?How do you like your current doctor?How is it to get an appointment with your regular doctor?How easy is it to travel to your doctor’s office?How do you feel about everything else about your clinic?Are there long waits?Rude staff?Expensive copay?Are there any reasons you would choose to go to the emergency room for your care rather than going to a primary care doctor?31. Some people have told me they need to find help with reading the medical information they got from the doctor, like discharge instructions. How do you think that will be for you?PAGE 5/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________26. Many of the people I’ve talked to need to continue to work on medical issues, like chronic pain or shortness of breath. How will that be for you?27. Some people want to find a way get around more easily, maybe with the help of a physical therapist or by using a cane. How is that for you?28. Lots of people say they want to get insurance in order to stay healthy after discharge. How about you?29. Many of the people I’ve talked to need to figure out a way to pay for medications in order to reach their health goal. How will that be for you?30. An important part of staying healthy is seeing your regular doctor. Are there any steps you think you’ll need to take in order to see your doctor for a follow-up appointment after you get out of the hospital?How do you like your current doctor?How is it to get an appointment with your regular doctor?How easy is it to travel to your doctor’s office?How do you feel about everything else about your clinic?Are there long waits?Rude staff?Expensive copay?Are there any reasons you would choose to go to the emergency room for your care rather than going to a primary care doctor?31. Some people have told me they need to find help with reading the medical information they got from the doctor, like discharge instructions. How do you think that will be for you?PAGE 5/8-480695-460375INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________32. People have told me they want to cut down on drugs or alcohol in order to stay healthy after they are discharged? How will that be for you?33. Some people think that getting involved in their community (like becoming a block captain or doing neighborhood cleanups) might help them feel happier and healthier. How about you?34. Some people need to figure out how to deal with pressures from work while they recover after discharge? How will that be for you?35. How about dealing with any housing issues?36. Lots of people have told me they need a plan for dealing with bills after discharge? How is that for you?37. Lots of people need help getting childcare in order to go do doctor’s appointments after discharge. How is that for you?38. People have told me they need help with transportation to the doctor or the pharmacy? How will that be for you?39. People have said they need to take steps to get a regular phone number once they get out of the hospital. How will that be for you?PAGE 6/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________32. People have told me they want to cut down on drugs or alcohol in order to stay healthy after they are discharged? How will that be for you?33. Some people think that getting involved in their community (like becoming a block captain or doing neighborhood cleanups) might help them feel happier and healthier. How about you?34. Some people need to figure out how to deal with pressures from work while they recover after discharge? How will that be for you?35. How about dealing with any housing issues?36. Lots of people have told me they need a plan for dealing with bills after discharge? How is that for you?37. Lots of people need help getting childcare in order to go do doctor’s appointments after discharge. How is that for you?38. People have told me they need help with transportation to the doctor or the pharmacy? How will that be for you?39. People have said they need to take steps to get a regular phone number once they get out of the hospital. How will that be for you?PAGE 6/8-483235-508000INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________40. Some people feel like they need a boost getting motivated to do the things their doctors tells them to do after they get out of the hospital. How will that be for you?41. Lots of people want to develop a system for remembering to take their medications. How about you?42. Many people think that cutting down on smoking will help them to stay healthy after discharge. How about you?43. Many people think that starting to exercise will help them to stay healthy after discharge. How about you?44. Some people need a plan for getting enough food, getting the right types of food or preparing food after discharge? How do you think that will be for you?45. Lots of people want to make some changes in what they eat, like cutting out salt or eating more fiber, in order to stay healthy after discharge. How about you?46. OK based on what you’ve told me here’s what I think is the big picture (Summarize what you think is the Snapshot: who is this person, what is important to them (hopes/fears) and what if anything is the root cause of their health problems.)47. You’ve told be about several possible short term goals (list Roadmap ideas). Which two or three do you think are the most important given the big picture we just talked about?” (Write down list of the major goals below, to summarize.) Do you agree that these are the most important to you to focus on in the next 3 months?PAGE 7/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________40. Some people feel like they need a boost getting motivated to do the things their doctors tells them to do after they get out of the hospital. How will that be for you?41. Lots of people want to develop a system for remembering to take their medications. How about you?42. Many people think that cutting down on smoking will help them to stay healthy after discharge. How about you?43. Many people think that starting to exercise will help them to stay healthy after discharge. How about you?44. Some people need a plan for getting enough food, getting the right types of food or preparing food after discharge? How do you think that will be for you?45. Lots of people want to make some changes in what they eat, like cutting out salt or eating more fiber, in order to stay healthy after discharge. How about you?46. OK based on what you’ve told me here’s what I think is the big picture (Summarize what you think is the Snapshot: who is this person, what is important to them (hopes/fears) and what if anything is the root cause of their health problems.)47. You’ve told be about several possible short term goals (list Roadmap ideas). Which two or three do you think are the most important given the big picture we just talked about?” (Write down list of the major goals below, to summarize.) Do you agree that these are the most important to you to focus on in the next 3 months?PAGE 7/8-527685-471805INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________ROADMAPSGreat. Let’s make a little Roadmap that will help us get to each of these goals. [Fill out a Roadmap form with the patient.] WRAP UP & PLANNING FOR DISCHARGEI know we’ve talked a lot today, and you’re probably tired. I would like to come back on the day you are discharged so that I can help you get everything you need. It is hard to predict when a patient is discharged, and in order for me to help you, I want to be there with enough time to get your prescriptions filled and also make sure you are good with the discharge instructions. In order to do this, I’ll need some advance notice.Do you mind calling me and letting me know as soon as one of your doctors or nurses mentions the word “discharge” to you? I will also be checking with your nurse each morning.Would it be OK if I also check in with the social worker and doctor to see if they can help us with any of the things we talked about today?Thank you so much for talking with me today!PROFILESelect the Profile that best fits your patient: A B C DPAGE 8/800INPATIENT MEET THE PATIENT INTERVIEWPATIENT ID_________ROADMAPSGreat. Let’s make a little Roadmap that will help us get to each of these goals. [Fill out a Roadmap form with the patient.] WRAP UP & PLANNING FOR DISCHARGEI know we’ve talked a lot today, and you’re probably tired. I would like to come back on the day you are discharged so that I can help you get everything you need. It is hard to predict when a patient is discharged, and in order for me to help you, I want to be there with enough time to get your prescriptions filled and also make sure you are good with the discharge instructions. In order to do this, I’ll need some advance notice.Do you mind calling me and letting me know as soon as one of your doctors or nurses mentions the word “discharge” to you? I will also be checking with your nurse each morning.Would it be OK if I also check in with the social worker and doctor to see if they can help us with any of the things we talked about today?Thank you so much for talking with me today!PROFILESelect the Profile that best fits your patient: A B C DPAGE 8/8-469900-494030ROADMAP # __________PATIENT ID_________ROADMAP SECTIONPATIENT INFOShort-term goal:Let’s make this really concrete so we know what exactly you want to achieve. What will it look like when you reach your goal?(Can you measure it?)Confidence: How confident are you that you’ll be able to reach this goal in the next 3 months? Resources: What do you think we can use to help you with this goal?(Supportive people, resources, etc.) Plan: What exactly do we need to do next?(Your to-do list with who, what, when, where) Resolved?(Mark only when Roadmap Complete) 00ROADMAP # __________PATIENT ID_________ROADMAP SECTIONPATIENT INFOShort-term goal:Let’s make this really concrete so we know what exactly you want to achieve. What will it look like when you reach your goal?(Can you measure it?)Confidence: How confident are you that you’ll be able to reach this goal in the next 3 months? Resources: What do you think we can use to help you with this goal?(Supportive people, resources, etc.) Plan: What exactly do we need to do next?(Your to-do list with who, what, when, where) Resolved?(Mark only when Roadmap Complete) -469900-480695INPATIENT DISCHARGE INTERVIEWPATIENT ID_________Today’s Date:1. How are you doing today?2. Could think about any questions you have for the doctor or nurse? 3. Do you have all your discharge paperwork? Let’s go over it and make sure that you can do it all.(If Home Care ordered) It looks like you are supposed to have a visit from a home care nurse, which is really helpful. They can help sort out your medications and check up on your medical issues. They should come out in the next day or two, if they don’t please let me know [CHW to make a note of home care and follow up in 1-2 days after discharge to make sure this occurred]. 4. Do you have any questions for the doctor before you leave?5. Would you like me to drop off your prescriptions at the pharmacy here so that you can pick them up before you leave? Also, that way, if the co-pay is too expensive we can let the doctor know right away.6. Do you have any other issues besides what we talked about already?PAGE 1/200INPATIENT DISCHARGE INTERVIEWPATIENT ID_________Today’s Date:1. How are you doing today?2. Could think about any questions you have for the doctor or nurse? 3. Do you have all your discharge paperwork? Let’s go over it and make sure that you can do it all.(If Home Care ordered) It looks like you are supposed to have a visit from a home care nurse, which is really helpful. They can help sort out your medications and check up on your medical issues. They should come out in the next day or two, if they don’t please let me know [CHW to make a note of home care and follow up in 1-2 days after discharge to make sure this occurred]. 4. Do you have any questions for the doctor before you leave?5. Would you like me to drop off your prescriptions at the pharmacy here so that you can pick them up before you leave? Also, that way, if the co-pay is too expensive we can let the doctor know right away.6. Do you have any other issues besides what we talked about already?PAGE 1/2-537845-494030INPATIENT DISCHARGE INTERVIEWPATIENT ID_________7. Once you get home and settled, I would like to call you or come out and visit you. Would that be OK with you? Great, let’s make a date when I can check up on you.CALL or VISITDate:Time:8. How do you feel about going home and working on the goals that we made together? (Refer to their Roadmaps)Tell me more: OK, talk to you soon!PAGE 2/200INPATIENT DISCHARGE INTERVIEWPATIENT ID_________7. Once you get home and settled, I would like to call you or come out and visit you. Would that be OK with you? Great, let’s make a date when I can check up on you.CALL or VISITDate:Time:8. How do you feel about going home and working on the goals that we made together? (Refer to their Roadmaps)Tell me more: OK, talk to you soon!PAGE 2/2-483235-480695INPATIENT FOLLOW-UP INTERVIEWPATIENT ID_________Spend most of your time on questions 1 and 2.1. How are you doing?2. How is it going with those goals that we set while you were in the hospital? (You should have the Roadmaps in front of you while you talk. Do it Now and work on these with the patient!.) 3. How is it going with your medications? Do you have everything that’s on your list? (Readthrough the list of medications in the discharge summary. If the patient has any confusion, callyour Manager and get in touch with the doctor.)4. Do you understand which of your old and new medications to take? (If the patient has anyconfusion, call your Manager and get in touch with the doctor.)5. Were you expecting a home care nurse to come out? [If yes,] how did that go?6. Were you expecting any medical supplies? (If yes) Did you receive them? Do you knowhow to use them?7. (If they haven’t already been to the doctor after discharge) How is it going with getting a follow-up appointment with a regular doctor?Doctor Name:Facility/Address:Appointment Date:Appointment Time:8. Would it be all right if I came out and rode along with you to your appointment just tomake sure you don’t need any help with transportation or with co-pays?PAGE 1/200INPATIENT FOLLOW-UP INTERVIEWPATIENT ID_________Spend most of your time on questions 1 and 2.1. How are you doing?2. How is it going with those goals that we set while you were in the hospital? (You should have the Roadmaps in front of you while you talk. Do it Now and work on these with the patient!.) 3. How is it going with your medications? Do you have everything that’s on your list? (Readthrough the list of medications in the discharge summary. If the patient has any confusion, callyour Manager and get in touch with the doctor.)4. Do you understand which of your old and new medications to take? (If the patient has anyconfusion, call your Manager and get in touch with the doctor.)5. Were you expecting a home care nurse to come out? [If yes,] how did that go?6. Were you expecting any medical supplies? (If yes) Did you receive them? Do you knowhow to use them?7. (If they haven’t already been to the doctor after discharge) How is it going with getting a follow-up appointment with a regular doctor?Doctor Name:Facility/Address:Appointment Date:Appointment Time:8. Would it be all right if I came out and rode along with you to your appointment just tomake sure you don’t need any help with transportation or with co-pays?PAGE 1/2-524510-508000INPATIENT FOLLOW-UP INTERVIEWPATIENT ID_________9. (If they haven’t made an appointment) Can I help you with setting up an appointment?Here are some of the doctor’s offices in your neighborhood that might be able to see you(Use Provider Profile) Do any of these sound like a good option?10. Did you want to come to our Healthy Living Support Group this week? I can try and meet you there if you want.11. When can I check up with you again?CALL or VISITDate:Time:PAGE 2/200INPATIENT FOLLOW-UP INTERVIEWPATIENT ID_________9. (If they haven’t made an appointment) Can I help you with setting up an appointment?Here are some of the doctor’s offices in your neighborhood that might be able to see you(Use Provider Profile) Do any of these sound like a good option?10. Did you want to come to our Healthy Living Support Group this week? I can try and meet you there if you want.11. When can I check up with you again?CALL or VISITDate:Time:PAGE 2/2-455930-494030INPATIENT PRE-DOCTOR’S APPOINTMENT COACHINGPATIENT ID_________Today’s Date:1. Let’s call the clinic to confirm your appointment for tomorrow. (Make three-way call with clinic to confirm appointment time and update info)2. How are you getting to the doctor’s office tomorrow?3. Let’s think through and plan for anything else that may make it a problem for you to get to your appointment tomorrow. (Prompt for: Childcare, Work.)4. What questions do you have for the doctor?5. Any questions about your medications or side effects?6. Do you have enough medications to last you at least a month or do you need refills?7. Any tests results you’re waiting for?8. Any questions about wound care or any equipment like a wheelchair?9. Are you going to need referrals to any specialists or services?10. Have you been in the hospital recently? (If yes, when, where and why?) (If yes, do you have your discharge instructions?)11. Can I meet you two hours before your appointment and take transit with you to the doctor’s? (If no) Don’t forget to bring:medication list or medicationsinsurance cardphoto IDcopay if applicablepaper copy of referral if neededdischarge summary if recently in hospitalSee you tomorrow!PAGE 1/100INPATIENT PRE-DOCTOR’S APPOINTMENT COACHINGPATIENT ID_________Today’s Date:1. Let’s call the clinic to confirm your appointment for tomorrow. (Make three-way call with clinic to confirm appointment time and update info)2. How are you getting to the doctor’s office tomorrow?3. Let’s think through and plan for anything else that may make it a problem for you to get to your appointment tomorrow. (Prompt for: Childcare, Work.)4. What questions do you have for the doctor?5. Any questions about your medications or side effects?6. Do you have enough medications to last you at least a month or do you need refills?7. Any tests results you’re waiting for?8. Any questions about wound care or any equipment like a wheelchair?9. Are you going to need referrals to any specialists or services?10. Have you been in the hospital recently? (If yes, when, where and why?) (If yes, do you have your discharge instructions?)11. Can I meet you two hours before your appointment and take transit with you to the doctor’s? (If no) Don’t forget to bring:medication list or medicationsinsurance cardphoto IDcopay if applicablepaper copy of referral if neededdischarge summary if recently in hospitalSee you tomorrow!PAGE 1/1-469900-494030DOCTOR'S APPOINTMENT INTERVIEWPATIENT ID_________Today’s Date:(Only go into the exam room with the patient if they want you to.)Hi Dr.__________, my name is __________, I am a Community Health Worker with IMPaCT.I have been supporting (Patient Name) with staying healthy after his/her hospitalization and will be working with him/her for 3 months. We also have worked together to deal with some of the life issues that made it hard for him to stay healthy in the past. They are summarized in this packet (hand doctor the Roadmaps).During the visit:Remind your patient to ask the questions they had written downGive the doctor any discharge summaries Ask what signs or symptoms to watch out for and what to do if they happenAsk when next appointment should beIf the doctor is prescribing new medications, ask how much the patient would have to pay. Explain any financial issues, and request any forms to be filled out if necessary.Dr. __________, thank you so much. One more thing: a lot of my patients end up back in the emergency room because they have trouble getting through to a clinician when they have a question or don’t feel well. What is the best way for (Patient Name) to get in touch with you or maybe a nurse?What about if it is after-hours or on the weekend?(Help the patient to schedule the next follow-up appointment and get any referrals, etc. before leaving.)PAGE 1/100DOCTOR'S APPOINTMENT INTERVIEWPATIENT ID_________Today’s Date:(Only go into the exam room with the patient if they want you to.)Hi Dr.__________, my name is __________, I am a Community Health Worker with IMPaCT.I have been supporting (Patient Name) with staying healthy after his/her hospitalization and will be working with him/her for 3 months. We also have worked together to deal with some of the life issues that made it hard for him to stay healthy in the past. They are summarized in this packet (hand doctor the Roadmaps).During the visit:Remind your patient to ask the questions they had written downGive the doctor any discharge summaries Ask what signs or symptoms to watch out for and what to do if they happenAsk when next appointment should beIf the doctor is prescribing new medications, ask how much the patient would have to pay. Explain any financial issues, and request any forms to be filled out if necessary.Dr. __________, thank you so much. One more thing: a lot of my patients end up back in the emergency room because they have trouble getting through to a clinician when they have a question or don’t feel well. What is the best way for (Patient Name) to get in touch with you or maybe a nurse?What about if it is after-hours or on the weekend?(Help the patient to schedule the next follow-up appointment and get any referrals, etc. before leaving.)PAGE 1/191440023812500965835-463550NEXT STEPS FORM 00NEXT STEPS FORM 1-377825PATIENT CALENDAR 00PATIENT CALENDAR 44005505461000004400550546100000219075-384175IMPaCTTMCERTIFICATE OF ACHIEVEMENTPatient NameIN RECOGNITION OF YOUR COMPLETION OFTHE IMPaCT PROJECTAND THREE MONTHS OF HARD WORKTO TAKE CHARGE OF YOUR HEALTHNAME, COMMUNITY HEALTH WORKERDATENAME, PROGRAM MANAGERDATE00IMPaCTTMCERTIFICATE OF ACHIEVEMENTPatient NameIN RECOGNITION OF YOUR COMPLETION OFTHE IMPaCT PROJECTAND THREE MONTHS OF HARD WORKTO TAKE CHARGE OF YOUR HEALTHNAME, COMMUNITY HEALTH WORKERDATENAME, PROGRAM MANAGERDATETHE PENN CENTER FOR COMMUNITY HEALTH WORKERScan help you to plan, implement and optimize your community health worker program.Penn Center for Community Health WorkersSuite 200, 3801 Market St. Philadelphia, 19104 ................
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