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44006688161744April 17, 20184000020000April 17, 2018-944880-117856000Reproductions of this manual are not permitted without express written permission of:Dr. Shreya Kangovi, Penn Center for Community Health Workers, 423 Guardian Drive, 13th Fl. Blockley Hall, Philadelphia, PA 19104Cite as: Kangovi, S. K., Chanton, C., Feldstein, J. (2018). IMPaCT (Individualized Management for Patient-Centered Targets) Manager Manual. Our Purpose Community Health Workers The IMPaCT Model IMPaCT Theory: the Arc, Goal-setting, IBM and Profiles IMPaCT Work practices CHW Functions Structure of an IMPaCT Team Structure of the IMPaCT Program: Inpatient Outpatient Selecting PatientsYour Role Tips for Successfully Managing a Team of IMPaCT CHWs Overview of Responsibilities Detailed Responsibilities Evaluating Your Success SafetyGeneral Information Job Expectations SupervisionForms Supervisor Call Script Inpatient Next Steps Form Inpatient Next Steps Form Example Outpatient Next Steps Form Outpatient Next Steps Form Example Progress Report Community Health Worker Evaluation FormOVERVIEWOUR PURPOSEEvery day in hospitals and doctor’s offices across the country, healthcare providers do their best to help patients get healthy. But patients often struggle because of real-life challenges: job pressures, trouble paying for medications, hunger, trauma, lack of insurance...the list goes on. These problems occur more often in lower-income communities.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 who come from the communities they serve. They are described as “natural helpers.”As Manager, you will use the IMPaCT model to supervise CHWs across both inpatient and outpatient settings. The purpose of IMPaCT Inpatient is to help inpatients address the root causes of their illness so they can stay healthy after hospital discharge. The purpose of IMPaCT Outpatient is to help outpatients achieve long-term health goals. For the purposes of this manual, we will assume that IMPaCT Outpatient CHWs mostly work within primary care practices and target patients with chronic diseases like diabetes, hypertension, smoking or weight. However, the Penn Center for CHWs can help you adapt this model to other outpatient care settings, e.g. OB/GYN practices, dialysis centers, etc.In order to get the most out of this manual, you should read through the CHW Inpatient and Outpatient manuals first. COMMUNITY HEALTH WORKERSWHO IS A COMMUNITY HEALTH WORKER?Community Health Workers (CHWs) are trained laypeople who share life circumstances (race, income, language, health conditions, etc.) with the patients they serve.1 Yet they are more than just demographic mirrors.2 The sociology literature describes CHWs as “natural helpers.”3 They are the kind of people who will bring soup to a sick neighbor or care for an aging parent. CHWs work with patients in their homes and communities to address the underlying determinants of health. They do things that nurses, doctors, and social workers do not. They sit with patients on the front porch and talk about the struggles of daily life: the grief of losing children to violence; the embarrassment of not being able to pay bills; the confusion of coordinating complex medical care. CHWs provide both emotional and instrumental support—hands-on support that goes beyond just giving out information or referrals. For example, CHWs can go with patients to community centers and smoking cessation classes, read through insurance forms, or exercise together at the local gym.WHO IS NOT NECESSARILY A CHW?Navigators, health coaches, advocates, care coordinators, and case managers are terms that are often confused with CHWs. The difference is simple: these terms describe functions (things that people do), whereas a CHW is an identity. CHWs can perform the functions of navigator or coach, but so can nurses, student volunteers, or family members.WHY ARE SPECIFIC QUALITIES OF A CHW IMPORTANT?If anyone can perform the functions of a CHW, why choose a CHW? Can’t a nurse or college student just call or visit high-risk patients and support them in health behavior change?The social psychology and health disparities literature explain that the combination of shared life experiences and innate empathy gives CHWs the potential to be more effective than other personnel. The Penn Center for Community Health Workers conducted in-depth qualitative research with hundreds of high-risk patients. These patients confirmed that they felt a sense of disconnect and often mistrust with traditional healthcare personnel who did not share their background. These patients wished for non-judgmental support from someone more relatable.WHAT CAN CHWS DO?CHWs have the potential to address many challenges that both healthcare organizations and vulnerable communities share. They can: Navigate patients from the hospital setting to accessible preventive and primary care.7Reach beyond the clinic walls to address root causes of poorly controlled chronic disease.8-10Gain patients’ trust and improve their experiences of careStrengthen social capital and build capacity within communitiesPerform important non-clinical tasks better and more cost effectively than expensive clinically-trained personnel.HELPING YOUR TEAM UNDERSTAND THE ROLE OF THE COMMUNITY HEALTH WORKERCHW programs are growing increasingly common in the United States, but there is still wide variation in who is considered a CHW and what they do with and for patients. As the Manager of IMPaCT CHWs, you are taking on an important role in shaping the field of community health work. This is exciting, but it also means that some patients and clinic staff will be confused about the role of the CHWs. Medical professionals in your own clinic or hospital will need your help understanding the role of the CHW and the skills that they can bring to the patient care team. Ensure that the CHW has a clearly defined role in your clinic by:Using a structured community health worker intervention, as outlined here.Scheduling an introductory meeting where the CHW has an opportunity to explain his or her role to the whole team.Establish regular (i.e. biweekly or monthly) meetings with CHWs and other members of the care team. THE IMPaCT MODELThe Penn Center for Community Health Workers designed the IMPaCT model to address these five critical areas. The model, which we’ve refined and tested for nearly a decade, was designed based on hundreds of in-depth qualitative interviews,8-11 and over 1,000 surveys12 conducted with high-risk patients. We used these studies to build the IMPaCT model, which includes protocols for several key areas:RECRUITING AND HIRING CHWS:Patients we spoke to wanted support from someone to whom they could relate: “I need to share with somebody that can share with me, like I’ve been there.” They suggested that CHWs should have a non-judgmental nature, the ability to “take time and listen,” to “work with people and have patience.” Patients emphasized the need for CHWs to “win their confidence and become part of their life. It’s not a fly by night thing. It has to be sincere from your heart that I’m going to be here for you no matter what you go through.”IMPaCT has developed human resources guidelines and hiring algorithms, including behavioral questionnaires and case scenarios for job applicants, which help recruit and hire individuals who possess the qualities that high-risk patients seek.TRAINING AND CERTIFICATION:Patients explained that most issues that made it hard for them to stay healthy were not really medical issues and were not specific to any one condition like diabetes or hypertension. Instead, they were “real-life issues” that fell into the following categories: psychosocial, health system navigation, resources, neighborhood, and healthy behaviors.IMPaCT has developed college-accredited training that teaches CHWs how to effectively work with patients in the healthcare setting, community and home. It teaches CHWs to address the issues (psychosocial, navigation, etc.) which patients described as health barriers and provides certification checkpoints to ensure new CHWs have mastered core elements of the job.STANDARDIZED CHW CARE:Patients wanted care that was tailored to their needs and goals. In the IMPaCT system, CHWs provide patient-centered care in three stages:SET GOALS: IMPaCT CHWs work with patients and their providers to set a health goal that is important and achievable. Then, they help patients create tailored action plans, or Roadmaps, towards reaching their goal.SUPPORT: CHWs provide hands-on support to help patients achieve their goals: coaching, supporting, and navigating to social and medical resources. Their tasks could include anything from helping patients make appointments, to understanding discharge summaries, and getting medications. But they also provide support by calling, texting, sitting on the porch, working out together at the local gym, going to the grocery store, or organizing a support group. CHWs are experts in using novel and non-traditional approaches for patient care and do whatever it takes to get patients to the finish line. The main types of support that CHWs provide are:Emotional support – actions to make patients feel cared for, such as listening to patients’ hopes and fears and validating their experiences and feelings Instrumental, or hands-on, support – doing something with or for patients, such as going to the grocery store together or dropping off a benefit application form to the local welfare office Informational support – actions to provide patients with information, such as how to cook low-salt recipesAppraisal support – actions to provide patients with accurate assessments of their current situation, such as motivational interviewing CONNECT: The hardest part of any intensive support model is the end. Patients often lose ground after an intervention ends due to the voltage drop in support. IMPaCT CHWs work to transition patients to a soft landing. For recently hospitalized patients, this means getting them into a primary care practice that can meet their needs. IMPaCT CHWs can also transition patients to weekly support groups that they facilitate. These groups are a powerful way for patients to support each other and solidify the health gains they have made for the long-term. This standardized care also includes program infrastructure in critical areas such as team structures, caseloads, duration, and HOMEBASETM an electronic, secure documentation and reporting system.SUPERVISION AND INTEGRATION:Community health workers don’t work in isolation. We have created manuals for:Directors: these are the people who want to take the lead in running a CHW program at their institution. This manual provides guidance on important topics like calculating return on investment, hiring and training, and maintaining quality.Managers: these are typically social workers who will be directly supervising CHWs. This manual, which you are reading now, provides guidance on topics like day-to-day supervision practices, on-going training, avoiding burnout, and integration with healthcare munity Health Workers: these are the natural helpers you have hired to work directly with patients. These manuals, one for inpatient and one for outpatient CHWs, provide guidance on topics like daily work with patients, responding to patient emergencies, and how to stay safe in the field.Coordinators: these are the individuals who identify and, in some cases, enroll eligible patients in IMPaCT and who collect data to evaluate the program. The Penn Center for CHWs can help you customize the Coordinator manual for your local setting. HIGH-QUALITY RESEARCH AND EVIDENCE:IMPaCT has been tested among high-risk patients in three randomized controlled trials. The model has been proven to:Help with weight loss, diabetes control and smoking cessation Improve mental healthImprove discharge communication and the quality of primary care Increase access to post-hospital primary care by 12%Lower hospitalization rates by 30%IMPaCT THEORY GOAL-SETTING:IMPaCT 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, and if 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.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: CHWs then 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, CHWs 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 the patient how confident they are that they’ll be able to reach that goal by using this picture:21“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 get to 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.The IBMSometimes people have a hard time reaching their goals. The Integrated Behavioral Model13 (IBM) is a sort of checklist to think about why a patient may be struggling to change his/her behavior and to reach goals. BELIEFS: Does the patient have beliefs about the short-term goal that are preventing progress? For example: “Eating is the best way to enjoy life.” Beliefs are hard to change, so CHWs might need to work around them: in this example, instead of encouraging the patient to diet, a CHW could go produce shopping with the patient as a way to enjoy healthy food. ATTITUDES: How does the patient feel about the behavior? What do they think are the pros and cons? CHWs can try to find out using motivational interviewing. Sometimes just getting the patient to understand their attitudes towards a behavior helps to move them along.OTHERS’ BEHAVIORS: Can you use social norms to encourage change? CHWs are a built-in social norm. They should be practicing good health behaviors with the patient (going for walks, eating healthy foods, etc.)OTHERS’ EXPECTATIONS: Is there someone whose opinion this patient cares about? Can this person keep the patient accountable to their goal?CONTROL/SELF-EFFICACY: If the person “just can’t” seem to stick to the plan and get to the short-term goal, try breaking it down into even smaller steps and getting things done. Small successes make patients feel more confident in taking the next step. EXTERNAL BARRIERS: Even when patients are very motivated to reach their goals, they often face external obstacles: lack of transportation, competing issues like homelessness, etc. CHWs can help address these external constraints so that patients can reach their health goals.KNOWLEDGE: Does the patient know the information they need to reach the short-term goal? If you’re not sure, test them with a teach-back: for example, does the patient know how to give himself insulin? Have them show the nurse/pharmacist in the clinic or by using a CHW phone video recorder.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 use this knowledge to tailor their support to patients over the course of the IMPaCT program. Of course, not all patients fall neatly into one of these Profiles, but they provide a useful framework to help CHWs assess patients and tailor their support. See the Profile chart on the next 2 pages.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 the 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 groupTHE ARCA CHW-patient relationship should ideally progress through four stages. This is how we explain the Arc to CHWs. Listen. You should listen INTENTLY to the patient and also talk to caregivers and the 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. It may not always be crystal clear at first and can evolve with time. 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, share 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 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 for each goal using the Roadmaps form. Do it now! For each Roadmap, 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 CHWs follow these stages, they will have a better chance of spending their time wisely and doing work that really makes a difference for patients. If not, they may spin their wheels with busy work that doesn’t link back to the patient’s core needs.IMPaCT WORK PRACTICESCHW FUNCTIONSCHWs provide intensive support for their patients. They will perform the following roles, depending on patient need:Help patients deal with the psychosocial issues (e.g. stress, domestic violence, addiction, depression) that are keeping them from staying healthyCoach patients on health behaviors (e.g. quitting smoking or finding time to exercise) that are required for patients to meet their own health goalsHelp patients get access to the daily life resources they need to be healthy (housing, food, transportation, etc.)Help patients with navigating the health care system and accessing medical care (e.g. arranging appointments, filling medication prescriptions)Advocate for community-level change so that low-income neighborhoods can foster health (e.g. organizing community meetings to deal with violence, etc.)The specific tasks of a community-health worker might include the following:Help patients set goals for their own healthVisit patients at home and in the communityProvide emotional support by using active listening and empathy to understand the root causes of poor healthPerform health behaviors with the patient as a buddy: e.g. work out at the gym together, go grocery shopping together, accompany patients to smoking cessation class, etc.Help patients collect and sort their medical documentsHelp patients find a food bank or senior center in their areaAccompany patients to their medical appointments and help the patient ask questions to better understand the doctor’s instructionsHelp patients locate the documents they need to apply for or renew their Medicaid, food stamps and other public benefitsSenior Community Health Workers have additional duties including helping hire and train new CHWsWHAT COMMUNITY-HEALTH WORKERS DON’T DO:Provide blood pressure checks or any other medical careGive clinical advice to patientsFile papers and other office work outside of what is required for a patient’s careSTRUCTURE OF AN IMPaCT TEAMA single IMPaCT Team is composed of one Manager, a half-time Coordinator, and up to eight CHWs. Because IMPaCT is not disease or setting-specific, CHWs on the same team can be spread across different practices or settings.STRUCTURE OF IMPaCT PROGRAMSIMPaCT programs follow a standard basic structure:SET GOALS: IMPaCT CHWs work with patients and their providers to set a health goal that is important and achievable. They then help patients to create tailored action plans towards reaching their goal.SUPPORT: IMPaCT CHWs provide hands-on support towards helping patients achieve their goals.CONNECT: IMPaCT CHWs 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.This core model has been adapted for inpatient and outpatient settings. INPATIENTThe purpose of IMPaCT Inpatient is to help patients who have been cared for at the hospital stay healthy after discharge. Inpatient CHWs enroll new patients in a hospital setting, support them through hospital discharge, work with them to address the root causes of their poor health, and identify a long-term support person who can help them after the program ends. 2522220176784000294132119691350MEET THE PATIENT: Inpatient CHWs are embedded on inpatient care teams. They receive a list of patients assigned to them (this list is generated by the Coordinator). CHWs conduct the Meet the Patient interview on the day of hospital admission. They use this interview to set goals and identify Roadmaps patients think will lead them to staying healthy after discharge. CHWs start working on these Roadmaps while patients are still in the hospital. CHWs also communicate with the medical team after they pick-up a patient. This interaction strengthens patient care by offering a more complete view of the patient to the full care team, and gives the patient and CHW valuable information about the patients’ health. It also has the benefit of “closing the loop” for inpatient team members, who often lose sight of patients after discharge.HOSPITAL DISCHARGE: Inpatient CHWs use the Discharge Interview to help patients understand discharge instructions, obtain a copy of the discharge summary, connect patients to home care, if necessary, and fill discharge prescriptions. RETURN TO THE COMMUNITY: Inpatient CHWs work with patients in their homes and communities on their Roadmap goals, addressing the underlying determinants of health. IMPaCT CHWs provide emotional and instrumental support, e.g. going with patients to community centers and smoking cessation classes, helping them read through insurance forms and helping to arrange childcare during doctor’s visits.CONNECT TO PRIMARY CARE: Inpatient CHWs help patients select a primary care doctor, schedule appointments, and accompany patients to these appointments. CHWs coach patients before their appointment, including reminding them to bring discharge summaries and pillboxes, and planning questions for the doctor. They also go with patients to their appointment. There, they explain outstanding social issues to clinic staff, enabling the clinic to continue to address social determinants of their patients’ health after the program ends.DURATION AND CASELOAD: The program lasts 3 months. Inpatient CHWs have an active caseload of 18-20 patients, which means they work with 75 patients each year. At the end of the 3 months, patients are transitioned to a long-term support person who is identified and cultivated throughout the program.MEASURES OF SUCCESS: Key measures of success for IMPaCT Inpatient (reflected in Progress Reports and/or quarterly scorecards) include:Reach: CHWs have provided care to 75 patients per yearQuality of Communication: CHWs were present at discharge and improved patient-provider communication (as measured by HCAPHS score)Access to medications: Patients received their discharge medicationsAccess to primary care: Patients completed a primary care appointment within 14 days of dischargeAchieving patient-centered goals: Proportion of Roadmap goals achievedPreventable hospitalizations: 30-day hospital readmissionsPatient satisfaction with IMPaCT: Patients are likely to recommend IMPaCT (as measured by Net Promoter Score) Connection with long-term support OUTPATIENT The purpose of IMPaCT Outpatient is to help low-income patients of primary care practices achieve a long-term health goal they set with their provider.MEETING THE PATIENT: IMPaCT Outpatient CHWs are embedded in outpatient care teams. First, Coordinators enroll new patients in the program and help patients set a long-term health goal with their doctor. Then CHWs conduct the Meet the Patient interview immediately after patients’ examination. They use this interview to identify Roadmaps patients think will help them reach their long-term health goals.WEEKLY FOLLOW-UP: Outpatient CHWs work with patients in their homes and communities on their Roadmap goals to address the underlying determinants of health. They connect with the patient face-to-face at least once a month, and speak by phone with the patient at least once a week. IMPaCT CHWs provide emotional and instrumental support, e.g. going with patients to community centers and smoking cessation classes, helping them read through insurance forms, and helping to arrange childcare during doctor’s visits. If patients go into the hospital, CHWs should perform similar functions as Inpatient CHWs during and after hospitalization (visiting the patient, helping the patient to communicate with the care team, getting a copy of discharge summaries, and helping patients set up post-hospital care). CONNECTION TO SUPPORT GROUP: Outpatient CHWs and the Manager together facilitate weekly support groups for patients. These groups are a way to foster social support ties between patients and for patients to share important lessons about health promotion and chronic disease management with peers. They begin to attend these groups during the six-month CHW program. After they “graduate” from the intensive phase, patients are encouraged to continue group sessions in order to maintain connections with their peers and get a lower “dose” of support from the CHW and Manager. These groups are explained in greater detail in a Healthy Living Group Manual. DURATION AND CASELOAD: IMPaCT Outpatient is a 6-month long program. Outpatient CHWs have an active caseload of 25-30 patients, serving each patient for 6 months. Outpatient CHWs can carry about 50-60 patients annually. They spend approximately 40 hours with each patient in total. At the end of 6 months, patients are transitioned to group visits.MEASURES OF SUCCESS: Key measures of success for IMPaCT Outpatient (reflected in Progress Reports and/or quarterly scorecards) include:Reach: Have CHWs provided care to our target number of patientsImproving health outcomes: Proportion of patients who are maintaining or improving control of their selected chronic disease Quality of outpatient care: Have CHWs helped patients to feel good about the care they receive at their clinic (as measured by CAPHS PCMH) Achieving patient-centered goals: Proportion of goals achievedPreventable hospitalizations: Hospital admissionsPatient satisfaction with IMPaCT: How likely are patients to recommend IMPaCT (as measured by Net Promoter Score) SELECTING PATIENTSYour organization’s Director will provide you with guidelines for which patients will be assigned CHWs. In general, CHWs work with patients who have:1. PSYCHO-SOCIOECONOMIC RISK. For example, patients who live in a geographic region characterized by high rates of poverty AND are uninsured or insured by Medicaid.and2. MEDICAL RISK. For example, patients who have multiple chronic conditions (asthma/COPD with tobacco dependence, obesity, hypertension, diabetes).While Coordinators do take referrals, we do not recommend relying purely on a referral-based approach (e.g. CHWs only work with patients referred by the clinical teams). Providers tend to under-refer, or only refer Profile A patients. For example, Profile B patients often are overlooked by providers, even though they often have significant needs. It is important (to prevent burnout and achieve results) that CHWs’ caseloads are balanced across Profiles. As Manager, you will need to work with clinical teams to make sure they understand the reasons for keeping CHW caseloads balanced.YOUR ROLEIn order to be an effective Manager, you will need to be genuine and committed to the cause of helping vulnerable patients. CHWs should want to work for you. You should gain their commitment by demonstrating that you are hard-working and humble enough to support them however you can. This can mean doing less glamorous tasks like expediting appointments or buying notepads. You will need to keep CHWs motivated through a very difficult job. You will need to pick your battles, listen and be flexible. You should recognize individual CHWs strengths and provide praise. You will also need to be comfortable providing direct feedback - your CHWs can’t grow if you don’t help them see where they can improve. There will be inevitable problems. While trouble-shooting, stay calm and learn how to analyze a situation objectively, even when it involves people and personalities.A crucial piece of your job is CHW oversight. You are responsible for providing real-time oversight for your team via phone and text, and meeting with CHWs individually 1-2 times per week to review their caseloads (Running the List). This is very important; a lack of sufficient supervision can lead to adverse patient outcomes. You are also responsible for helping CHWs facilitate support groups for patients.You are responsible for creating a healthy team atmosphere, particularly by running weekly meetings with all the CHWs on your team. These meetings are crucial. In many other CHW models, CHWs are inadequately supported. This leads to burn-out, because the CHW job can be incredibly intense and emotionally draining. Weekly meetings with CHWs and the Manager not only provide a forum for ongoing training, they are also a place for debriefing difficult patients, and redesigning and improving operations. TIPS FOR SUCCESSFULLY MANAGING AN IMPaCT CHW1. MAINTAIN CHW CASELOADS: For Outpatient: 25 – 30 active patients max and no more than two new patients per week. For Inpatient: 20 active patients max and no more than 1-2 new patients per week. It is equally important to make sure CHWs enroll enough patients as it is to prevent CHWs from picking up too many patients. Make sure CHWs reach the weekly targets for their caseload. You also need to manage patient close outs, i.e. ensuring CHWs are completing tasks quickly and efficiently so cases close on time.2. RESPECT THE ROLE OF CHWS: Ensure that your CHWs aren’t assigned tasks that are outside the scope of their work (i.e. filing, making coffee, or doing blood pressure checks). Since IMPaCT CHWs are integrated into the health system and are embedded on care teams, they may face a pull to become increasingly medical and institutional. Resist the urge to make CHWs medical case managers (clinic or hospital-based and focused mostly on making appointments and providing referrals). If you are not careful, CHWs can get trapped in the medical hamster wheel and lose their unique ability to address underlying social determinants of health. Make sure they are getting out into the field, doing home visits and providing instrumental and emotional support. Your job is to ensure they perform functions that are distinct from medical case management and leverage their unique skills and position as empathic members of the community.3. ENSURE SAFETY: Require a buddy system for home visits. Keep track of CHWs while they are on home visits. Terminate patients who make threats or act abusively from the program. (See the Safety section later in this manual.)4. INTEGRATE CHWS WITH CARE TEAMS: Arrange an introductory meeting in the clinic or with the inpatient team after new CHWs come on board. Set up biweekly/monthly team meetings so that nurses, doctors, social workers, and CHWs can discuss IMPaCT patients.5. CREATE SPACE: Make sure CHWs have a private space to meet with patients and access the electronic medical record (EMR).6. KNOW HOW TO PRIORITIZE: There are times when you will feel like you need to be in two places at once. This is not possible because you are only human! This list will help you order your priorities as an IMPaCT Manager:CHW safety: The most important principle of IMPaCT is that CHW safety comes first. Any CHW-related safety issue is always your highest priority.Patient clinical situations: The IMPaCT clinical protocol requires CHWs to notify their Managers of any patient clinical situation. Helping CHWs resolve clinical situations is second on your list.Providing effective supervision: Each week, Managers meet one-on-one with their CHWs to Run the List (provide individual supervision for patient care). Running the List helps CHWs prioritize cases, clarify their priorities for the week, and get things done in the moment (e.g. call patients and doctors, research resources).Completing weekly reports: Each week, Managers produce a report that provides a snapshot of CHW performance. Taken together, these reports provide a 360-degree view of how your CHWs are performing and help you identify areas where CHWs may be struggling. As an IMPaCT Manager, it is important you set aside time each week to complete, analyze and provide necessary follow up/coaching to CHWs based on your performance reports.7. KNOW WHEN TO ESCALATE TO YOUR DIRECTOR: Managers need to know what issues need to be escalated to their Director. There is no simple formula for this and it requires good inherent judgment, practice and supervision. Examples of types of issues that might warrant escalation can range from CHW concerns (e.g. CHWs concerned about co-workers doing personal stuff during the work day), relationships with clinical partners (e.g. physician who was previously a champion feeling annoyed about CHWs taking too much touchdown space), advocacy (e.g. CHWs realizing that multiple patients live in an unlicensed and neglectful boarding home), clinical situations (e.g. a patient feeling suicidal and the CHW doesn’t have a great plan) and safety (e.g. a CHW feeling unsafe). Of the examples above, safety situations always warrant escalation (See ‘Safety’ section of the manual.) 8. ALWAYS BE CLEAR ON NEXT STEPS: It is important for Managers to be able to turn chaos into order! They are often part of conversations that are unstructured and contain a lot of information. The Manager should practice the skill of reflecting (“here’s what I am hearing so far…”) throughout conversations. At the end of conversations, the Manager should summarize key points and action items out loud which should also include who is doing what by when. Ideally, the Manager also puts these action items into writing. OVERVIEW OF RESPONSIBILITIESRecruiting and hiring CHWsTraining and certifying CHWsIntegrating CHWs with care teamsSupporting CHWs in their work with patients Making sure CHWs are doing a good job Providing team leadershipThe next section reviews each of these responsibilities in more detail. DETAILED RESPONSIBILITIESAs Manager, your responsibilities are:1. RECRUITING AND HIRING CHWsYou will work with your Director to finalize CHW job descriptions.You will work with current CHWs to advertise the job descriptions by circulating them among community groups and making presentations at local community meetings. In order to perform this step, you will need to develop good relationships with a network of community organizations.You will work with the Director and your Human Resources department to select the top applicants for interviews. In order to do this, you will need to read through (probably a large volume of) applications, run Meet and Greet sessions to screen applicants, call references and conduct interviews. You’ll use the CHW hiring guidelines described in the Director manual to select the most qualified applicants. You will need to strike a balance between exercising objectivity and following your instincts without second-guessing yourself.* DELIVERABLES: Meet and Greets, reference checks, interview evaluations for new CHWs2. TRAINING AND CERTIFYING CHWsYou will work with the Penn Center for CHWs, your Director and current CHWs to plan CHW training. Initial training: You will invite appropriate guest speakers to provide local expertise (e.g. local clinic staff or legal aid organization). In order to do this, you will need knowledge of community resources and organizations who can provide guest trainers.You will be responsible for organizing the logistics for the training (food, space, supplies).Once the training begins, you should attend all training sessions.You will collect feedback from CHWs after each training session and use this to make changes.On-the-Job Training, Sign Off, and Certification: After initial training is complete, CHWs undergo on-the-job training. You’ll work with the Penn Center for CHWs to set this up and ensure your CHWs meet learning benchmarks during this training. These benchmarks are to:Successfully complete the IMPaCT On the Job online training and learning assessment.Learn how to stay organized. You’ll check their binders to make sure things are in order. You’ll make sure CHWs are keeping themselves organized with to-do-lists and appointment calendars. Pass quizzes that you give them to make sure they’ve read and understood their manual. Explain their role to other members of the care team. Pay close attention to safety protocols and remember to text in/out during home visits at least three times in a row. A senior CHW will observe each new CHW doing his/her work for a full day. The senior will follow along with their manual and make sure the new CHW is getting things right. After the senior CHW has signed off on a full day of observation, you’ll do the same. Finally, the Director will observe each new CHW for one full day and make sure they are following the manual. After a CHW completes these benchmarks, he/she can be signed off. The IMPaCT online training and certification system helps you keep track of these benchmarks. Once all these benchmarks have been met, the Penn Center for CHWs will certify individual CHWs. Ongoing training: After the initial and on-the-job trainings are over, training is by no means complete. You’ll work with other Managers and the Director to coordinate ongoing training that will occur during monthly team meetings. Check in with CHWs to see what topics they want to be trained on as they progress in their work and also schedule refreshers on core content (e.g. the Arc). * DELIVERABLES: Feedback forms from training participants, CHW certification benchmarks, ongoing training during monthly team meetings3. INTEGRATING CHWs WITH CARE TEAMS Your job is to integrate CHWs into existing care teams, while preserving their unique identities and work practices. Regular communication with the care team will help you fulfill your role of ensuring that CHWs:Do not get assigned more than their caseload limitsAre assigned a mix of Profile A, B, C and D patients to balance their caseloadsDo not get pulled too far in a medical directionCan quickly and easily communicate with other members of the care team to resolve patient emergences, share information and ‘close the loop’ on patient careWork with the Coordinator to create and advertise a system for accepting referrals from care teams. Make sure your CHWs have access to the EMR. Ensure that care teams know in real time which patients are enrolled in IMPaCT, through an EMR flag/message sent by you or the CHW.When you first integrate into a new clinical setting, meet with the care team to help them understand and appreciate CHWs unique role, including what they can and cannot do with patients. Agree upon communication practices (ex: daily huddles, EMR messages) that work best for that team’s workflow. Attend interdisciplinary meetings in your hospital or clinic. If these do not already occur, you can help organize such meetings so that CHWs are well integrated with other members of the care team. There is a lot of variation in the structure and timing of interdisciplinary meetings. However, one good way to structure these meetings is a weekly huddle including the CHW or Manager, social work, a nurse or chronic care manager, and physicians. As a group, go through a list of patients that the practice has flagged as “high risk.” Discuss each patient and their needs and decide which patients are best suited for IMPaCT. Refer these patients using the referral hotline.Provide updates on existing patients. Below is a sample script to help CHWs prepare for provider meetings. This should take 1-2 minutes:Patient nameOne-line description of who she is (ex: Ms. Smith is a 56-year-old woman with depression and controlled diabetes who loves to dance)Long-term health goalRoadmap goals. Provide details about steps taken towards achieving goalAsk the doctor a question that you think will improve your work with the patientSummarize next steps Regularly meet with colleagues across all settings where CHWs are embedded, to get feedback and suggestions about CHW integration and communication.4. SUPPORTING CHWs IN THEIR WORK WITH PATIENTSYour most important function is to help CHWs support patients. There are a number of key ways you can do this, including:a. Maintaining caseloads b. Reviewing cases and prioritizing action steps (“Running the List”)c. Providing real time oversight for ongoing issuesd. Ensuring CHW safety e. Facilitating healthy living support group Below, we review each of these in detail: a. MAINTAINING CASELOADS Every CHW program should have yearly targets for the number of patients to enroll. Your Director will set this number, and help you break it down into quarterly and weekly enrollment targets for each CHW on your team. If CHWs keep pace with their enrollment targets and graduate patients at the appropriate time, their caseloads will always be nice and steady. For example, an Inpatient CHW might enroll 2 patients a week and graduate 2 patients per week so that her total caseload remains constant. Your job is to make sure that CHWs keep pace with their weekly enrollment targets. There are four strategies for doing this:On-call schedule Dealing with absencesTracking enrollmentCorrecting courseOn-call schedule:You’ll need to assign each CHW on your team on-call days. On an ‘on-call’ day, CHWs meet and enroll new patients. Make sure that each CHW has enough ‘on-call’ days to meet their enrollment targets. Also try and make sure there’s always at least one CHW on-call every day at each clinical site, so that they can enroll new patients who show up. The HOMEBASE calendar (sample below) can help you keep this straight. The Coordinator will also use this calendar to know which CHW will be picking up newly enrolled patients each day. 13970011303000Dealing with absences:If a CHW has an absence, they should ask another CHW to take care of their patients and cover their on-call days. Ultimately, it is the Manager’s responsibility to make sure this gets done. Managers also need to update the HOMEBASE calendar with any changes to the on-call schedule in real-time so that the Coordinator knows who to assign patients to.Tracking enrollment:At the end of each day, review the Target List of patients assigned to each CHW. Make sure the CHW has marked down which patients they enrolled, which patients were not enrolled, and why not. Knowing why patients are not being enrolled can be really important: for instance, if you see that a particular CHW has a high number of patients who refuse services, you can coach him on making patients feel more comfortable during the initial meeting. Correcting course: It’s helpful to have monthly meetings with the Coordinator and Director to get updates on patients enrolled to date and adjust enrollment targets for the rest of the quarter. If you notice that CHWs are falling short of their targets, you can troubleshoot the issue. Maybe you’ll need to assign CHWs more on-call days, or the Coordinator will have to think about whether enrollment is lagging and why. *DELIVERABLE: Enrollment targets b. RUNNING THE LIST Once-to-twice each week you will meet with your CHW to review their cases. We call this Running the List! The goal of Running the List is to help CHWs prioritize cases, focus in on the most important action steps, and clarify the best way to spend their time for that week. Before you Run the List: Figure out which patients you’d like to discuss. Use your performance reports (explained in more detail later in this section) to prioritize patients who aren’t doing well. You should make time to discuss new patients or patients about to graduate. Make sure that you’re discussing each patient on your CHW’s caseload every 2-3 weeks. HOMEBASE can help you stay on top of this by sorting patients by the date of last review. Read charts of patients you’re planning to discuss in advance.When you sit down to Run the ListTake a minute to check in with your CHW and see how they’re doing.Jump in and start discussing patients. In many ways each patient discussion should follow the same pattern as the Arc:LISTEN: Since you’ve read the case notes in advance, you can sit back away from the computer and face your CHW. Have them start by giving you their summary, or Snapshot, of the patient. Remember, these should not be just medical summaries, but human summaries. In other words, they should not be: “55-year-old man with hypertension and diabetes.” Rather, they should be along the lines of: “55-year-old man who lives with his wife and cats in a bad part of town and stays up all night worrying about how to pay his rent.” Stay on this part until you feel like you have a good understanding of who the patient is. Some questions to help you get a good understanding of the patient are:Help me picture this person – tell me about them so I could pick them out in a subwayTell me a quick version of their life story What is their purpose in life?What would be the best way to change the course of this person’s life?What do you think will mess this patient up?SNAPSHOT: Agree on the patient’s 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. You may not be correct, but start with something. Continue to revisit and develop the Snapshot for patients each time you Run the List. ROADMAPS: Review the patient’s Roadmaps. Make sure that Roadmaps make sense given the patient’s Snapshot and Profile (A, B, C or D). Remember, the best Roadmaps are personalized and creative. If patients seem stuck with a particular Roadmap, use the Integrated Behavioral Model to troubleshoot. Abandon Roadmaps that don’t seem to be useful so CHWs can focus on the most important ones. Help CHWs create a Next Steps List (See: Forms) to organize the most important information they need for their patients. HOMEBASE auto-populates this list, automatically compiling this information for each active patient into one easy-to-read form. DO IT NOW: Confirm the next steps for each patient. Make sure they are specific and have deadlines. You can model the importance of this by completing at least one to-do item while you are Running the List (for example, call a patient and invite them to the support group). Every time you review a patient, ask yourself: what have we done to help this person change their course? Don’t dawdle, and don’t just talk about things: DO THEM. It’s ok if you fail but it isn’t ok not to try.Close patient cases: You may mark a patient case as closed if they have met the following criteria: Inpatient: Had at least 3 months of care, identified a long-term support person/group, and completed a Roadmap addressing the root cause of their health problem. You can also close out an inpatient if your CHW has had four unsuccessful attempts at contacting them (including a home visit) over a two-month period of time.Outpatient: Had at least 6 months of care. You can also close out an outpatient if your CHW has had ten unsuccessful attempts to contacting them (including a home visit) over a six-month period of time. Here are other things to ask your CHW before you close out a patient:Does the patient know that their care with you is ending? Who should they call now if they need help? (This is why it is important to identify a long-term support person early on)Look at roadmaps and see:If they have been resolved: that there is some documentation in the follow up notes about when/how they got resolved.If they’re not resolved: that you have some sense of why they didn’t happen (patient decided they weren’t interested, senior group became less of a priority with their kids getting more involved, etc.) The expectation is not that 100% of roadmaps get resolved (we aim for 60%) but you want to feel like you have a handle on what happened and why.Make sure key forms (e.g. discharge day info including provider discharge summary and doctor’s appointments) are filled out.Remind CHWs to let the care team know whenever a case is being closed*DELIVERABLES: Review each patient every 2-3 weeks, updated Next Steps List for CHWsc. PROVIDING REAL-TIME SUPPORT WHEN CHWS NEED HELP DECIDING HOW TO PROCEED Be available via phone or text from 9-5 to provide real-time support to your CHWs. You will need to be prepared to help CHWs problem-solve on the spot, which means being familiar with the safety protocol and how to handle clinical, mental health, domestic violence, and other urgent situations. You will need to be prepared as a Manager to intervene if a CHW is having trouble getting patients the care they need. This may include escalating the concern to a higher level, including outreach to a clinic practice manager. You will need to be vigilant and always have your phone charged and on. You’ll take turns with the other Managers to be available to support CHWs for after-hours and weekend patient emergencies. d. ENSURING CHW SAFETYThis is the most important part of your job. You should memorize the Safety section of this manual. Stay vigilant about having CHWs text in/text out to you during home visits. * DELIVERABLE: Text-in/out safety checkse. HEALTHY LIVING SUPPORT GROUPThe Healthy Living Support Group is a very important part of the IMPaCT model because it helps patients build social support ties with each other. It is open to all patients who have ever been enrolled in IMPaCT (even after their case is closed). Therefore, it provides a “step-down” from intensive CHW support.The support group is facilitated by you and a CHW. The support group may be a group visit that your clinic or hospital can bill for through insurance. A facilitation manual for the Healthy Living Support Group is available through the Penn Center for CHWs.5. MAKING SURE CHWs ARE DOING A GOOD JOB AND DELIVERING OUR DESIRED OUTCOMESEveryone thinks they’re doing a good job. The only way to really know for sure is to have a system for monitoring performance. The first part of doing a good job is showing up! Every day, you’ll track CHW attendance. Then, for every week of the month, you’ll drill down and assess your CHWs performance in a different way: Week 1: Contact Reports Week 2: Progress ReportsWeek 3: Supervisor CallsWeek 4: Chart Reviews Once a month, you’ll also spend some time directly observing your CHWs in action. Each of these performance assessment strategies is explained in detail below. a. CHW ATTENDANCE Check-in with each CHW at 9am and check-out with each CHW at 5pm. Enter any lateness into a daily log along with any days off. If one of your CHWs calls in sick, make sure they find another CHW to cover and communicate important patient information. Have them put their patient appointments on a calendar they share with you, so you know where your CHWs are and that they’re being productive even when they’re not on site. * DELIVERABLE: Timesheetsb. CONTACT REPORTSRun a report to see how often CHWs are contacting their patients. Each CHW should make contact with each patient at least once per week.* DELIVERABLE: Contact Reports for each CHW (weekly)c. PROGRESS REPORTSCreate a Progress Report once a month for each CHW on your team (See: Forms). This document is a high-level overview of outcomes for each patient on your CHWs’ caseloads. This can be automatically generated as a report in HOMEBASE.* DELIVERABLE: Progress Reports for each CHW (monthly)d. SUPERVISOR CALLSCall one active patient for each CHW on your team once a month. Use the Supervisor Call Script Form (See: Forms) to collect feedback from patients on individual CHWs and the program as a whole. This is easy to skip, but crucial for assessing CHW performance and program effectiveness. * DELIVERABLE: Supervisor Call for each CHW (monthly)e. CHART REVIEWSRead the charts of patients you’re planning to discuss in your weekly Running the List reviews. As you’re reading, make notes on the quality of the work. Use the Arc as a guideline:*Listen: Has the CHW really gotten to know the patient? Is the summary complete and thorough?*Snapshot: Does the Snapshot feel right and specific to the person? Or is it just filled with vague jargon (e.g. patient who has had trauma)* Roadmaps: Do Roadmaps make sense given the Snapshot and Profile, and is there one that addresses the root cause of their poor health? * Do it Now!Is the CHW getting things resolved quickly and efficiently?Is there the right type and frequency of contact (example: a call after discharge if the CHW wasn’t present to ensure they got their medication? A face-to-face visit soon after they met an Outpatient? At least weekly contact in all programs?)Are the CHWs doing what they say they will do? (example: If a note says a home visit is scheduled for August 1, is there documentation that this home visit happened?) Is documentation accurate and up-to-date? (example: Are all fields filled in? If a Roadmap is marked as resolved, is there documentation on what the CHW did/when?)Discuss these notes with your CHW when you’re Running the List. Afterward, share your notes so they have your feedback in writing. *DELIVERABLE: Chart reviews for each CHW (monthly)f. DIRECT OBSERVATIONSObserve each CHW doing their job at least once every month: listen to a phone call, join them on a home visit, or watch a new patient meeting. Take notes in the CHW manual on things you see that deviate from the manual, and discuss your notes afterward with your CHW so they know what to correct moving forward. * DELIVERABLE: Notes on manual fidelity for each CHW g. BIANNUAL EVALUATIONSSynthesize all of the different parts of CHW performance (attendance, contact reports, progress reports, supervisor calls, chart reviews and direct observation). Use this to provide a formal evaluation for each CHW once every six months (See: CHW Evaluation Form). HOMEBASE can automatically synthesize performance reports into a 360 view for each CHW. 842645-52895500During these evaluations, also check that their binders and work-flow systems are organized, as this is a critical and often difficult aspect of the job for CHWs. * DELIVERABLE: Evaluation for each CHW (every six months)6. PROVIDING TEAM LEADERSHIP Your job as a team leader is to create a culture that promotes excellence and troubleshoots problems. Here are three strategies to achieve those goals:a. RUNNING TEAM MEETINGSAt least 2-3 times a month, you will convene all the CHWs on your team. The most important purposes of these meetings are to: Build team relationshipsGive public recognition for hard workOffer mutual support to relieve stressShare informationProvide ongoing trainingStart the meeting with an opening question that allows everyone to speak. Allow time for CHWs to share stories about patients. Patient stories provide CHWs with an opportunity to vent, share successes and receive public recognition for hard work, and get help with difficult cases. You can also use team meeting as a place to elicit suggestions for improvement and provide ongoing training. These meetings should also be a time to reinforce program fidelity. Ask the team a question from the CHW manuals each time you meet. Ask each CHW to write down the answer and hand it in. Then go over the correct answer and explain the rationale. * DELIVERABLES: Team meetings, manual quizzesb. MAINTAINING INVENTORY AND BASIC ACCOUNTINGMaintain inventory of items your CHWs use every day (phones, laptops, public transportation passes) and deal with malfunctions that arise in a timely manner. Document all purchases and submit receipts.c. MEET WEEKLY WITH YOUR DIRECTOR TO REVIEW DELIVERABLES AND ASSESS PROGRESS:You will meet weekly with your Director. To help you stay organized and to ensure you’re in alignment on priorities, you will track your responsibilities and deadlines in a workplan agenda you update each week. You’ll also review and discuss each of the deliverables detailed above. EVALUATING YOUR SUCCESSAt the end of each year, you will know that you have succeeded in your role as Manager if:Goal #1: You understand the IMPaCT program and your role. Measured by:You can deliver an ‘elevator pitch’ explaining your CHW program You know the CHW and Manager manuals cover to cover. This will be measured by your Director who might ask you quiz questions from the manuals and observe you doing your job Goal #2: Community Health Workers consistently achieve the following results:Annual caseloads of 50 patients (Outpatient), 75 patients (Inpatient)60% Roadmaps resolved; overall Roadmaps are creative, personalized and make sense given the patient’s Snapshot and Profile90% of patients get their discharge medications35% of the time, Inpatient CHWs are present at discharge so that they can support their patient 60% of patients working with an Inpatient CHW make it to a primary care provider appointment within two weeks of hospital discharge 55% of patients working with an Outpatient CHW achieve the long-term health goal they set with their primary care providerCHWs contact all of their patients each weekCHW documentation is up to date CHWs answer 75% of manual quiz questions correctlyGoal #3: Effective integration of CHWs into care teams You’ve cultivated at least one strong clinical champion at each hospital or clinic where your CHWs workYou’ve established a standard meeting schedule with other members of the care team (physicians, social workers etc.)Members of the care team know you and your CHWs by nameMembers of the care team strongly recommend the programGoal #4: CHWs are hired carefully and feel supported and engaged in the jobAnnual turnover rate <3%SAFETYThe most important principle of IMPaCT is that CHW safety comes first. These are the guidelines for safety included in the CHW manual: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 services device 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.?GENERAL INFORMATIONJOB EXPECTATIONSATTENDANCE AND PUNCTUALITYExcellent attendance and punctuality are expectations of this job. If you have an illness or personal emergency, please notify your Director as soon as possible.PRIVACYIn this job, you will deal with private and sensitive information. If you are found to have violated a patient’s privacy in any way (e.g. by talking about the patient’s personal information with anyone outside of the care team), you will be immediately terminated. INTEGRITYYou will also be responsible for collecting correct information from patients. If you are found to be making up data or lying in any way, you will be immediately terminated.PROFESSIONALISMYou will often deal with stressed out people. 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 we will do our best to correct the situation. However, there is never an excuse for you to act unprofessionally.SAFETYYou are expected to have all required immunizations for your own safety and patient safety. You are required to comply with our safety protocols and make sure that your team does the same.DRUG FREE: You are in a very sensitive position. In order to protect our sick patients, we reserve the right to have periodic drug testing.If these expectations are not fulfilled, you will be warned and placed on probation. If there is a serious safety violation, immediate disciplinary action will occur.SUPERVISIONYou will be directly supervised by your Director. This position is meant to encourage personal growth and learning. The Director is available to help you with ANY question or problem, big or small. Don’t be shy! You will have two-way feedback sessions weekly to review your role and your deliverable.FORMSSupervisor Call ScriptInpatient Next Steps FormOutpatient Next Steps FormInpatient Progress ReportOutpatient Progress ReportCommunity Health Worker Evaluation Form-19050-130175SUPERVISOR CALL SCRIPTHello, may I speak to _____________________________?My name is _______________________________ and I am a Manager for the CHW program at (health care organization). I am calling as part of our quality monitoring to make sure that everything went OK with your experience with your Community Health Worker, _______________________.1. Can you tell me your thoughts about the program?2. When was the last time you spoke with or saw your CHW?3. Your CHW is supposed to help you deal with life issues that can get in the way of being healthy. Was there anything that you think he/she could have done differently?4. Can you describe a time when your CHW said they would do something and didn't?5. How likely is it that you would recommend this program to a friend or family member on a scale of 1-10 (10 is the best)?6. Tell me more about your reason for giving the program that score. What would you change about the program to make it better?0SUPERVISOR CALL SCRIPTHello, may I speak to _____________________________?My name is _______________________________ and I am a Manager for the CHW program at (health care organization). I am calling as part of our quality monitoring to make sure that everything went OK with your experience with your Community Health Worker, _______________________.1. Can you tell me your thoughts about the program?2. When was the last time you spoke with or saw your CHW?3. Your CHW is supposed to help you deal with life issues that can get in the way of being healthy. Was there anything that you think he/she could have done differently?4. Can you describe a time when your CHW said they would do something and didn't?5. How likely is it that you would recommend this program to a friend or family member on a scale of 1-10 (10 is the best)?6. Tell me more about your reason for giving the program that score. What would you change about the program to make it better?INPATIENT NEXT STEPS FORM-8572515684500OUTPATIENT NEXT STEPS FORM-9652012763500INPATIENT PROGRESS REPORT -3238510668000OUTPATIENT PROGRESS REPORT -10668012763500-19050-139700COMMUNITY HEALTH WORKER EVALUATION FORMPAGE 1/2Employee’s Name: Today’s Date:Hire Date:Evaluation Period:Evaluator(s):RELIABILITY: (Always does what he/she says they will do, on time and consistently?)Excellent Very Good Good Fair PoorComments:ATTENDANCE AND PUNCTUALITY: (Present and on time for work, appointments and meetings)Excellent Very Good Good Fair PoorComments:JOB KNOWLEDGE AND SKILLS: (Keeps up with community resources, can explain the CHW role and is skilled at his/her job)Excellent Very Good Good Fair PoorComments:SENSITIVITY AND COMPASSION: (Patients report that CHW is non-judgmental, empathetic, supportive and possesses excellent listening skills)Excellent Very Good Good Fair PoorComments:PRODUCTIVITY AND QUALITY OF WORK: (CHW works hard and does not waste time at work. CHW resolves >60% of Roadmaps and gets perfect satisfaction ratings from >90% of clients)Excellent Very Good Good Fair PoorComments:INITIATIVE AND DECISION MAKING: (CHW has a consistent drive for excellence, is able to perform duties with minimal supervision, makes appropriate and timely decisions and possesses effective problem-solving skills?)Excellent Very Good Good Fair PoorComments:0COMMUNITY HEALTH WORKER EVALUATION FORMPAGE 1/2Employee’s Name: Today’s Date:Hire Date:Evaluation Period:Evaluator(s):RELIABILITY: (Always does what he/she says they will do, on time and consistently?)Excellent Very Good Good Fair PoorComments:ATTENDANCE AND PUNCTUALITY: (Present and on time for work, appointments and meetings)Excellent Very Good Good Fair PoorComments:JOB KNOWLEDGE AND SKILLS: (Keeps up with community resources, can explain the CHW role and is skilled at his/her job)Excellent Very Good Good Fair PoorComments:SENSITIVITY AND COMPASSION: (Patients report that CHW is non-judgmental, empathetic, supportive and possesses excellent listening skills)Excellent Very Good Good Fair PoorComments:PRODUCTIVITY AND QUALITY OF WORK: (CHW works hard and does not waste time at work. CHW resolves >60% of Roadmaps and gets perfect satisfaction ratings from >90% of clients)Excellent Very Good Good Fair PoorComments:INITIATIVE AND DECISION MAKING: (CHW has a consistent drive for excellence, is able to perform duties with minimal supervision, makes appropriate and timely decisions and possesses effective problem-solving skills?)Excellent Very Good Good Fair PoorComments:0-120650COMMUNITY HEALTH WORKER EVALUATION FORMPAGE 2/2DOCUMENTATION AND ORGANIZATIONAL SKILLS: (Documentation occurs within 24 hours of patient encounter)Excellent Very Good Good Fair PoorComments:COMMUNICATION SKILLS: (CHW is literate, well-spoken, easy to get along with, can resolve conflicts, and has receives positive feedback from care teams)Excellent Very Good Good Fair PoorComments:ADVOCACY AND SUPPORT SKILLS: (CHW’s ability to interact with external providers, organizations and agencies)Excellent Very Good Good Fair PoorComments:CALM/PROFESSIONALISM: (Has a sense of calm, maintains professionalism and does not let personal issues interfere with work)Excellent Very Good Good Fair PoorComments:TRUSTWORTHINESS/CONFIDENTIALITY/PRIVACY: (Trusted with sensitive information and adheres to confidentiality and HIPAA policies)Excellent Very Good Good Fair PoorComments:SUPERVISION AND WEEKLY TEAM MEETINGS: (CHW is responsive and is able to incorporate feedback)Excellent Very Good Good Fair PoorComments:ADDITIONAL COMMENTS:Employee Signature:Manager Signature:Director Signature:0COMMUNITY HEALTH WORKER EVALUATION FORMPAGE 2/2DOCUMENTATION AND ORGANIZATIONAL SKILLS: (Documentation occurs within 24 hours of patient encounter)Excellent Very Good Good Fair PoorComments:COMMUNICATION SKILLS: (CHW is literate, well-spoken, easy to get along with, can resolve conflicts, and has receives positive feedback from care teams)Excellent Very Good Good Fair PoorComments:ADVOCACY AND SUPPORT SKILLS: (CHW’s ability to interact with external providers, organizations and agencies)Excellent Very Good Good Fair PoorComments:CALM/PROFESSIONALISM: (Has a sense of calm, maintains professionalism and does not let personal issues interfere with work)Excellent Very Good Good Fair PoorComments:TRUSTWORTHINESS/CONFIDENTIALITY/PRIVACY: (Trusted with sensitive information and adheres to confidentiality and HIPAA policies)Excellent Very Good Good Fair PoorComments:SUPERVISION AND WEEKLY TEAM MEETINGS: (CHW is responsive and is able to incorporate feedback)Excellent Very Good Good Fair PoorComments:ADDITIONAL COMMENTS:Employee Signature:Manager Signature:Director Signature:NOTESDHHS. Community Health Worker National Workforce Study In: U.S. Department of Health and Human Services Health Resources and Services Administration BoHP, ed. Washington, D.C. March 2007. Balcazar H, Rosenthal EL, Brownstein JN, Rush CH, Matos S, Hernandez L. Community health workers can be a public health force for change in the United States: three actions for a new paradigm. Am J Public Health. Dec 2011;101(12):2199-2203. Thoits PA. Stress, coping, and social support processes: where are we? What next? J Health Soc Behav. 1995;Spec No:53-79. Bone LR, Mamon J, Levine DM, et al. Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers. Am J Emerg Med. Jan 1989;7(1):16-20. Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. May 2007;32(5):435-447. Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med. Mar 20 2012;156(6):416-424. Adair R, Christianson J, Wholey DR, et al. Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease. J Ambul Care Manage. Jan-Mar 2012;35(1):27-37. Kangovi S, Barg FK, Carter T, et al. Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition. J Gen Intern Med. Aug 6 2013. Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over outpatient care. Health Aff (Millwood). Jul 2013;32(7):1196-1203. Kangovi SG, D.; Carter, T.; Barg, F.; Rogers, M.; Glanz, K.; Shannon, R.; Long, J.A. . The use of participatory action research to design a patient-centered community health worker care transitions intervention Kangovi SL, K.; Barg.F; Carter, C.; Long, J.A.; Grande, D. Post-hospital syndrome among older adults of low socioeconomic status J Health Care Poor Underserved. 2013;Pending. Kangovi S, Grande D, Meehan P, Mitra N, Shannon R, Long JA. Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. Nov-Dec 2012;7(9):709-712. Rimer, K. & Brewer, N. (2014) Introduction to health behavior theories that focus on Individuals. In Health Behavior: Theory, Research, and Practice, edited by Karen Glanz, et al., Wiley, 2014. ProQuest Ebook Central, . Downloarded from upenn-ebooks on 2018-01-04 09:59:40.THE PENN CENTER FOR COMMUNITY HEALTH WORKERSis available for consultation to aid you with implementation, work practices, and evaluation of your Community Health Worker program.Penn Center for Community Health WorkersSuite 200, 3801 Market St. Philadelphia, 19104 ................
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