Slide Presentation from the AHRQ 2009 Annual Conference
On September 14, 2009, Jodi Summers Holtrop made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.8 KB) (Plugin Software Help).
Slide 1
Community Health Educator Referral Liaison (CHERL): A Potential New Role for Primary Care Practice
Jodi Summers Holtrop PhD
Michigan State University Department of Family Medicine
Great Lakes Research Into Practice Network (GRIN)
Slide 2
Our Story...
Slide 3
5 A's Clinical Practice Guidelines for Health Behaviors1
- Assess
- Advise
- Agree
- Assist
- Arrange
Slide 4
Practices were having trouble getting past the first two A's (assess/ask and advise)
- Assess, Advise
- Tobacco—pretty good; diet/physical activity—some; alcohol - poor.
- Agree, Assist, Arrange
- Mostly not happening.
- Some studies MADE it happen—not sustainable2,3.
Slide 5
At the same time...
- Holtrop, et al., qualitative study of clinician referral to a smoking cessation quit line—why do they NOT refer?
- Overwhelmed and gave up.
- Black hole phenomenon 4
- "... I have a lot going on with the patients ... other than smoking. If there's a program in place that can actually track whether or not the patient is successful in quitting really is what I'm most interested in... " - clinician.
Slide 6
Their Idea
"… it's wonderful to have a single referral source that I can simply refer people to, and it make the job infinitely simpler. And it actually makes it possible in my mind. It's almost impossible if within the context of our office we have to look up and see what the health plan is, and then try to match that against the appropriate referral capabilities." - Clinician.
Slide 7
We Need a Bridge!
Patients in primary care.
Health behavior change resources.
"CHERL"
Slide 8
What is a CHERL?
- Community.
- Health.
- Educator.
- Referral.
- Liaison.
Pronounced like CHERYL or SHARYL.
Slide 9
CHERL—What we Proposed
- Problem: Patients in primary care with poor health.
- Behaviors don't get effectively connected with services
- Behaviors not identified.
- Patients not referred to services.
- When referred, patients don't follow through.
- Solution: CHERL coordinates the referral
- Practice identifies behaviors, refers to CHERL.
- CHERL contacts patients, coordinates referral, provides feedback to practice.
Slide 10
Intervention - Practice
- 15 Practices in Three Communities:
- Identify health risks (diet, physical activity, tobacco, alcohol).
- Refer to CHERL (fax).
- Review feedback letters.
- Perspective of Practices...
- Research project.
- Totally NEW role.
- NO money.
- Don't send us too many (only one 70-80% CHERL per community).
Slide 11
Intervention—CHERL
- CHERL:
- Develop relationship with community resources and maintain resource guide.
- Develop, together with the practice, a plan for identification and referral of eligible patients.
- Accept patient referrals from practices.
- Contact patients (all telephone) and refer them to resources. Provide behavior change counseling if needed.
- Reassess patients at 3 and 6 months.
- Send clinician patient-specific feedback letter (initial, 3, 6 months).
Slide 12
Our Results
Slide 13
Diversity of Patients
- Mean age 48 (SD=13).
- Female 70%
- African American 18%; White 78%
- High school education or less 39%
- Less than $15,000 income 25%
- Positive depression screen 42%
- One or more chronic diseases 88%
- No health insurance, Medicaid
- Or local health plan 28%
Slide 14
Most Practices Referred Patients to CHERL
- Most practices found at least some patients with health risks and referred to the CHERL.
- One liked the idea so well, they hired their own "CHERL" type person (nurse practitioner).
Slide 15
Practice Referral to CHERL
[Image of referrals to CHERL]
Slide 16
Patients Reported Improved Health Behaviors
- Once engaged, able to change regardless of age, race, gender or SES.
Slide 17
Patients Health Behaviors Pre-Post5
[Image of patients health behaviors]
Slide 18
What we Really Learned
Slide 19
We Need a Bridge!
Patients in primary care.
Health behavior change resources.
"CHERL"
Slide 20
What the Bridge was Really Like6
Patients in primary care.
Health behavior change resources.
"CHERL"
Slide 21
Patient Referrals
[Image of patient referrals]
Slide 22
So Why Don't We Just Have Practices Refer to Resources?
Slide 23
Practices Need Support
- Demands to see more patients in less time.
- Focus on doctor visit for payment.
- Lack of personnel to support prevention.
- Change can be difficult.
Slide 24
CHERL Offered "One Stop Shopping" Health Behavior Referral
Easy for the practices to refer patients to the CHERL.
Slide 25
Patients Needed to be Supported Not Just "Connected"
- Patients needed more just a pass-off to another resource. Follow-through important.
- "If it weren't for you, I would not have done this (quit smoking)."—Patient.
Slide 26
CHERL Facilitated Use of Unused Existing Resources
- "The diabetic educator comes to the clinic 1 day a week for 4 hours every Wednesday. Did you (the clinical staff) forget that she's there? Did you forget that [diabetes] is their overall major problem, and you/no one referred the patient to this wonderful community resource we have that's covered by insurance for the most part?" - CHERL.
Slide 27
CHERL Facilitated Relationships with Community Resources to Get Patients Engaged in Using Them
Slide 28
CHERL Filled in Gaps where There Was a Lack of Resources Offering Behavior Change Support
"Then somebody has to reinforce [behavior change] long-term. So follow-up is real important until people ingrain those behavioral changes into them and it's just something that they do." - Clinician.
Slide 29
CHERL Facilitated Motivation Not Just Dispensed Information
- CHERL used motivational focus rather than education focus.
- Need for understanding on how to make change.
- "I needed someone to be held accountable to other than myself." - Patient.
Slide 30
CHERL Addressed Other Patient Issues
- Majority had chronic disease.
- Almost half screened positive for depression; co-morbid mental health an issue.
- Low-income and lack of money to pay for services.
Slide 31
As a Result... the Resource Guide Changed
- FROM—Alcohol, Diet.
- Physical Activity, Tobacco.
- TO - Diabetes education.
- Mental Health, Food Pantry.
- Referral helpline (211).
- Financial Assistance.
Slide 32
CHERL Supported Practices by Assisting with Difficult/Complex Patients
Slide 33
CHERL Supported the Patient-Physician Relationship
Slide 34
CHERLs had Different Training, but all Were Successful
Slide 35
What is Unique about the CHERL Role?
Slide 36
CHERL is Many Roles...
- Health care team member.
- QI facilitator.
- Health behavior change counselor/coach.
- Referral coordinator/resource guide manager.
- Relationship-builder (practice/patient/community).
- Data collector (C-base).
Slide 37
CHERL Implementation Challenges and Questions
- Difficult to reach people via telephone
- Is it better to combine in-person and telephone counseling?
- Limited scope of CHERL's role
- Does CHERL only do health behavior or chronic disease self-management (or other) also?
- Managing the patient contacts and data
- What systems support patient identification and referral?
- What systems assist CHERLs in counseling and referral to resources?
- What data gets reported to clinicians/practices?
- Overwhelmed by patient load
- What is a reasonable/cost effective patient load?
- Lack of follow-through - both patients and practices
- How to improve reach to patients?
Slide 38
CHERL Sustainability
Funding at the practice level is key. Opportunities include:
- Insured patients—
- Pay for performance/PCMH initiatives.
- Direct billing for care management for patients with chronic disease.
- Group visits.
- Documentation improvement/billing for more comprehensive care.
- Care management "delegation."
- Other ideas—
- Employer/community resource contracting.
- Out of pocket payment.
Slide 39
Further Information
www.aboutcherl.org
Jodi Summers Holtrop, PhD
Department Family Medicine
Michigan State University
B105 Clinical Center
East Lansing MI 48824
(517) 884-0432
Jodi.holtrop@hc.msu.edu
Slide 40
References
- Whitlock E, Olreans C, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-283.
- Woolf SH, Glasgow RE, Krist A, Bartz C, Flocke SA, Holtrop JS, Rothemich SF, Wald ER. Putting it together: finding success in behavior change through integration of services. Annals of Family Medicine. 2005;3(S2):S20-27.
- Dosh S, Holtrop J Summers , Torres T, White L, Baumann J, Arnold A. Changing organizational constructs into functional tools: an assessment of the five A's in primary care practices. Annals of Family Medicine. 2005;3(S2):S50-52.
- Holtrop J Summers, Malouin R, Weismantel D, Wadland W. Clinician perceptions of factors influencing referrals to a smoking cessation program. Biomed Central Family Practice. 2008;9:18.
- Holtrop J Summers, Dosh SA, Torres T, Thum YM. The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors. American Journal of Preventive Medicine. 2008;35(5S):S365-72.
- Etz R, Cohen D, Stange K, Holtrop J Summers, Olson A, Donahue K, Woolf S, Ferrer R, Hickner J. Linking primary care practices and communities. American Journal of Preventive Medicine. 2008;35(5S):S390-7.
Current as of December 2009
Internet Citation:
Community Health Educator Referral Liaison (CHERL): A Potential New Role for Primary Care Practice. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/holtrop.htm