Community Health Educator Referral Liaison (CHERL): A Potential New Role for Primary Care Practice (Text Version)

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...

• Of how CHERL was born

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 sustainable^2,3.

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 Like

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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.