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May 2021 NYSARH/NERHA Webinar: The Impact of Navigators on Community-Specific Social Determinants of Health through Novel Interventions Tailored to the Outer Cape Cod Community - Shared screen with speaker view
Carl Garofolo Jr.
20:27
Hello everyone. Good Afternoon. Carl Garofolo Jr.Community Relations Specialist with Fidelis Carecgarofol@fideliscare.org or at: 845-891-7127.
Ann Day
20:50
Welcome Carl!
adriana rojas
29:43
was it mentioned how long the engagement is between the navigator and the patient?
Aisling Ryan
30:24
The goal is 90 days but clients are often engaged for longer
adriana rojas
31:05
thank you
Ann Day
32:48
How long does it typically take to complete this assessment?
Robert Cawley
33:29
How do you determine when the engagement should be ended? Is it the score on the SSM?
Betty St. Hilaire
34:04
do you ever find that clients want to end prior to the 90 days or do they generally want to stay in the program.
Ann Turner
35:20
This is great work!
Adriana Rojas, CHCI (she/her/hers)
35:46
the housing piece is incredibly challenging! This is so well done!
Ann Day
36:08
Thanks everyone for the great questions, keep them coming and we will make sure to address them at the end :)
Betty St. Hilaire
38:08
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?
Georgia Simpson, HHS Region 1
41:36
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?
Ann Turner
42:06
Did you look at the Community Pathways Hub model?
Adriana Rojas, CHCI (she/her/hers)
42:32
Ann--I am familiar with the Pathways model. We actally implemented the Penn Center for CHW IMPaCT model at our health center in CT>
Ann Turner
43:45
Adriana, thanks; would love to learn more.
Robert Cawley
45:46
The navigator selects the rating on the likert scale for the SSM questions?
Robert Cawley
48:25
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?
Tyler DuBois
51:17
How is this navigator program funded?
Adriana Rojas, CHCI (she/her/hers)
51:17
We have discussed doing an intake health screening at intake and then again at dischaarge
Tim Burdick
51:19
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
Adriana Rojas, CHCI (she/her/hers)
51:31
recognizing that some health data points will not change within 90 days
Tim Burdick
53:32
CMT-3 https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=1700
Tim Burdick
53:51
*CTM-3
Robert Cawley
54:23
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?
Tyler DuBois
56:22
How are you recruiting peer CHW at this point?
Georgia Simpson, HHS Region 1
56:59
Excellent work. Thank you so much.
Patricia Nadle
58:18
Excellent Work! Thank you for all that you have brought to our Program. Pat Nadle CEO OCHS
Tim Burdick
01:01:27
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.
Julie Scharnberg (she/her)
01:02:12
Are the CHWs certified - if yes, what is the specific Mass. certification? In Mass. is there reimbursement from insurance for those services?
Robert Cawley
01:02:45
This can also be demonstrated in reduction in Total Cost of Care. Of course that takes data form the payer.
Georgia Simpson, HHS Region 1
01:05:27
Massachusetts Community Health Worker Association: MACHW
Tim Burdick
01:05:50
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.
Betty St. Hilaire
01:06:06
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.
Georgia Simpson, HHS Region 1
01:07:00
National Association of Community Health Workers: NACHW nachw.org
Georgia Simpson, HHS Region 1
01:07:15
MA CHW Certification: https://www.mass.gov/community-health-worker-certification
Ann Day
01:07:28
Thanks Georgia!
Betty St. Hilaire
01:07:54
MaineCare, Maine's Medicaid program does reimburse CHWs through work with Community Care Teams
Andy Lowe
01:08:07
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.
Tim Burdick
01:08:41
Wow! That one patient will pay for the CHW program for a year!!
Tina Cobb
01:08:44
Thank you ladies! Incredible information.
Lori Fedewa
01:08:46
Thank you - great presentation!
Robert Cawley
01:08:56
Excellent job.
Tim Burdick
01:09:04
Great student project - really nice!
Betty St. Hilaire
01:09:06
great presentation thank you!!
Tyler DuBois
01:09:11
Betty, do you know what section that falls under?
Ann Turner
01:09:13
Great information; thank you!
NERHA Admin - Kiera Hight
01:09:22
https://nysarg.org/webinar-evaluation/