Hello everyone. Good Afternoon. Carl Garofolo Jr.Community Relations Specialist with Fidelis Carecgarofol@fideliscare.org or at: 845-891-7127.

Welcome Carl!

was it mentioned how long the engagement is between the navigator and the patient?

The goal is 90 days but clients are often engaged for longer

thank you

How long does it typically take to complete this assessment?

How do you determine when the engagement should be ended? Is it the score on the SSM?

do you ever find that clients want to end prior to the 90 days or do they generally want to stay in the program.

This is great work!

the housing piece is incredibly challenging! This is so well done!

Thanks everyone for the great questions, keep them coming and we will make sure to address them at the end :)

very interested in hearing more about how you coded and reported the qualitative data. I am a manager of a CHW program in Maine and we are struggling with this. We know that our team is doing great work but it's really hard to measure for reporting! Can you speak a bit about that?

Were there any populations least likely to utilize/engage with the navigator program? Do you know which ones and were there any changes to strategy to improve engagement?

Did you look at the Community Pathways Hub model?

Ann--I am familiar with the Pathways model. We actally implemented the Penn Center for CHW IMPaCT model at our health center in CT>

Adriana, thanks; would love to learn more.

The navigator selects the rating on the likert scale for the SSM questions?

Did the CHW's interact with the clients in person or va phone? Who initiates the contact? The clients? Or is it based on a referral from a provider or other source? If the latter, any idea what the engagement rate was for those referrals?

How is this navigator program funded?

We have discussed doing an intake health screening at intake and then again at dischaarge

Measurement: you might be able to look at ED visit or readmission rates in patients who got CHW intervention compared with patients who do not. Also, if you are targeting care transitions, you might use the CTM-3 or CTM-15 (care transition measure) approved by CMS

recognizing that some health data points will not change within 90 days

CMT-3 https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=1700

*CTM-3

We have just received a small (very small) grant to create an assessment for peer-based intervention supported by CHWs to encompass - at a high level - an assessment encompassing mental health, substance use, social determinants and physical health. Can we have a brief follow up discussion with you?

How are you recruiting peer CHW at this point?

Excellent work. Thank you so much.

Excellent Work! Thank you for all that you have brought to our Program. Pat Nadle CEO OCHS

Funding: We are working with local ACOs to pay for CHWs with the goal of decreased hospital utilization. Other payers may be willing to pay, also.

Are the CHWs certified - if yes, what is the specific Mass. certification? In Mass. is there reimbursement from insurance for those services?

This can also be demonstrated in reduction in Total Cost of Care. Of course that takes data form the payer.

Massachusetts Community Health Worker Association: MACHW

Yes, total cost is ideal, but hard to get as Robert points out. I’ve used ED and acute care (hospital) use (encounters, not $) since 1) easier to get especially in rural areas with fewer facilities, and 2) ED/acute care represent a huge % of total cost - so good proxy measure.

there is no certification required in Maine but we do have a stakeholder group that is working on skills and competencies. CHWs are trusted community members who has lived experience of the populations that they serve. This is why they are so effective.

National Association of Community Health Workers: NACHW nachw.org

MA CHW Certification: https://www.mass.gov/community-health-worker-certification

Thanks Georgia!

MaineCare, Maine's Medicaid program does reimburse CHWs through work with Community Care Teams

To Tim's point, there are data at the individual level that can be compelling. We have one Navigator patient who went from 60+ ED visits/year to <5.

Wow! That one patient will pay for the CHW program for a year!!

Thank you ladies! Incredible information.

Thank you - great presentation!

Excellent job.

Great student project - really nice!

great presentation thank you!!

Betty, do you know what section that falls under?

Great information; thank you!

https://nysarg.org/webinar-evaluation/