Empowering a Community to Health

By: Michelle Lansing

 

Flor C. puts her hand gently on Eddie Polanco’s shoulder. Looking directly into his eyes, her voice begins to crack as she speaks to him in her native Spanish. Eddie bows his head and smiles. As she finishes, she wipes the tears from her eyes and reaches out to him for a hug. Emotional, Eddie looks back to the camera and clears his throat before speaking. “I mean, she loves me. She loves me like I’m one of her own children, one of her own sons.” Flor beams as Eddie translates what she has said; she is proud of the person he has become.

Eddie Polanco moved to Schenectady, New York when he was 15 years old. After struggling with addiction for over a decade, Eddie has spent nearly seven years in recovery. Now 36, the father of six is grateful for the support and trust Flor gave to him during his darkest times. “I’ve said thank you to her a million times, but now I’m actually able to be there for her and thank her back the same way she did to me.”

But Eddie isn’t helping Flor with addiction. He’s helping this much-beloved, mother figure improve her health. A selfless woman with a caring heart, Flor put the welfare of countless others ahead of her own well-being. But now as a health ambassador for Empower Health, a collaboration between The City Mission of Schenectady and Alliance for Better Health, Eddie encourages Flor to make her own health a priority.

Understanding DSRIP

Alliance for Better Health is one of 25 Performing Provider Systems (PPSs) selected by New York State to implement its five-year Delivery System Reform Incentive Payment (DSRIP) program. Seeking to reshape the way health providers and systems serve those in the community who are covered by Medicaid, the DSRIP program is designed to shift the focus from “caring for the sick” to promoting better health.

By giving individual PPSs, like Alliance, flexibility and funding, the State looks to these groups to find innovative and effective ways to collaborate with both providers and the community. These partnerships develop sustainable health programs that overcome barriers keeping the people they serve from seeking primary and preventive medical care. The ultimate goal of these collaborations is to achieve a 25 percent reduction in avoidable hospital use over the five-year span of the DSRIP program.

Led by CEO Jacob Reider, M.D., Alliance is working to redefine how health is achieved across a six-county area in upstate New York that includes the underserved markets of Albany, Schenectady, Rensselaer, Saratoga, Fulton, and Montgomery counties. Comprised of 2,000 diverse partners that represent every facet of health care and social services, including hospital systems, private practice, and Community-Based Organizations (CBO), Alliance for Better Health is committed to establishing health equity across its service area.

“Health equity is a guiding principal of our organization, and it means that no matter who you are, regardless of your employment, your ability to pay, how much you make, your race, your gender — you are entitled to health in the community,” Reider said in a recent interview. “When we say health equity, it’s not just about access to health care, it’s about access to health.”

Jacob Reider, MD

Jacob Reider, MD

CEO / Alliance for Better Health

“Health equity is a guiding principal of our organization, and it means that no matter who you are, regardless of your employment, your ability to pay, how much you make, your race, your gender — you are entitled to health in the community.”

How will communities achieve health equity? Alliance and its partners believe Community-Based Organizations are key. Recognizing and addressing the social determinants of health, CBOs are able to better connect people to non-medical services and resources that may impede their ascent to a healthier life.

“Community-Based Organizations really understand the populations that they’re serving; they’re really on the ground with them on a day-to-day basis,” said Erin Simao, Empower Health program manager. “The healthcare system, while they’re serving this population, does not know them to the same degree, typically.”

“The goal of DSRIP is how do we reach the most at risk, the highest-need populations, and get them engaged in healthcare in a new and meaningful way,” Simao said. “Through this funding and the ability to be innovative, we have been able to take those chances, to do those pilot projects to see what works.”

The Health Ambassador Program

Eddie Polanco

Eddie Polanco

Health Embassador / Empower Health, City Mission of Schenectady

“How can you tell someone what’s good for them, or what can be good for them, if you don’t know what they’re struggling with or what their challenges are? Building those relationships with the clients, with the folks in the community, is so important on so many levels.”

And what they’re finding is that Empower Health and Alliance’s collaborative Health Ambassador program seems to be working quite well. Launched in November 2016, the program relies on the “lived experience” of its ambassadors to connect with the underserved in the community. Once engaged, the ambassadors are able to discern the social determinants that need to be addressed before an individual can become engaged in their health, maintain a primary care relationship, and understand appropriate (and inappropriate) use of the emergency room.

The program’s first health ambassador, Eddie Polanco was immediately on board with the idea. “How can you tell someone what’s good for them, or what can be good for them, if you don’t know what they’re struggling with or what their challenges are?” Eddie questioned. “Building those relationships with the clients, with the folks in the community, is so important on so many levels.”

To start building that rapport, Eddie says it’s important for him and his counterparts to engage clients where they are, whether it’s at a bus stop, in a shelter, or on the street. Ambassadors wear no uniform to announce their role, instead they perform their responsibilities in regular street clothes. For Eddie, this almost always means sneakers and a baseball hat that accentuate his large metal ear plugs and complement his numerous tattoos.

Being part of the community and having been through his own struggles, Eddie easily relates to others and understands the barriers that prevent good health and health maintenance. “When you’re living in that tyranny of the moment, when you’re living in survival mode, you’re living minute-by-minute, second-by-second, hour-by-hour,” Eddie stressed.

For many this means waiting until an emergency, or only going to the doctor outside of a set survival schedule so not to miss a hot meal or a place to sleep. In these situations, the emergency department offers a warm environment that is available 24 hours a day. Eddie says changing this mindset is a matter of making additional resources available, and that’s where Empower Health can help.

“Health care is having a roof over your head, having food in your stomach, you know, clothes on your back, having support systems … all these things that will make a person healthy.” By providing additional resources to meet these needs, Eddie believes clients will start looking to Empower Health to fill the gap between survival mode and healthy living.

Making clients comfortable with the healthcare system outside of the emergency department is a big part of changing this mindset, and Empower Health is doing whatever it takes to get them there. Health ambassadors are trained to coach, prepare, and support clients through any barriers, whether it’s filling out an application, arranging transportation, or even accompanying the client to an appointment.

Health ambassadors are trained to connect with the community by being part of the community. Ambassador Wendy Alvira finds that many times lending an ear is the best way reach out to someone. “A lot of people are having a crappy day and all they need is someone to talk to. So I ask them, ‘How is your day? What’s going on in your life? Is everything okay? How is the children? How is the spouse?’” Their answers, Wendy says, tend to open the door to a great conversation and lasting professional relationships.

 

Once the client is comfortable, the health ambassador asks if they would be willing to answer a few questions regarding their health care. If willing, and most are, a Patient Activation Measure (PAM) survey is quickly administered via an iPad. PAM is an assessment tool that measures patient behavior, knowledge, and engagement in individual decisions related to health.

All PPSs must implement PAM for non-utilizing (NU) and low-utilizing (LU) Medicaid members.

Results from the PAM tool allow Empower Health and Alliance to see how engaged the patient is in their own health care; it also helps them determine the best way to support the individual.

After completing the survey, the client is given a business card with contact information for the health ambassador and a health coach. Serving as a health liaison, the health coach can provide the client with additional resources to manage the social determinants of health, including housing, food, clothing, transportation, and literacy.

Since every client may not be ready to receive help at the time of the survey, the health ambassador encourages them to hold on to the card and call when needed. As a show of good faith and as a thank you for their participation, the health ambassador gives the client a one-day bus pass. It’s a small gesture, but one that can make a lasting connection.

Using Patient Activation Measure as a Tool

The results of the PAM surveys are fed into a growing state-wide database accessed by Alliance. Since the program’s start, more than 4,000 surveys have been administered to the target audience, an audience that has historically been difficult for health organizations to reach. For the partners within Alliance, this new information is gold.

Neha Pirwani is the practice transformation manager at Hometown Health Centers, a primary and preventative care provider in Alliance. She says that both the health ambassadors and PAM surveys have been critical to reaching and connecting with their patient population. Because physicians often don’t realize the barriers that prevent a patient from keeping an appointment or maintaining their health, Empower Health fills a gap.

“Empower Health helps us engage with our patients, understand what social issues they’re going through, what needs, apart from health care, that they have that prevent them from accessing health care,” Pirwani said.

Additionally, the trust built between the patient and health ambassador provides an interface that Hometown Health can then use to develop their own affective relationship. Pirwani adds, You don’t need everyone in healthcare to be clinically minded, but what you need is trust with the patient to return them to the clinically minded appropriate preventative care setting.”

Where Empower Health is the “high touch” side of the partnership, Alliance is the analytical arm. In addition to providing its partners with PAM survey results, Alliance also identifies where its partners are providing services to the same clients. This client overlap information helps providers and Community-Based Organizations identify where there is opportunity to work together to coordinate care. This, in turn, breaks down the health care silos that have kept many patients from receiving holistic care.

Moving Toward Value-Based Payments

Jacob Reider, MD

Jacob Reider, MD

CEO / Alliance for Better Health

“Historically, healthcare providers have been paid fee-for-service — each test, each visit, each procedure, equals payment. Whereas, Community-Based Organizations have been paid on a rate basis or through grant-based funding. Now, we want to invest more money in Community-Based Organizations focused on upstream activities like providing housing, food, and connection to substance-use programs, in order to prevent folks from falling down stream. We need to think about the services that we provide differently, and ask how they can directly improve outcomes for those we serve while generating savings for New York State Medicaid.”

This crucial information is gleaned thanks to another essential component of the DSRIP program, changing the way health care providers are paid. Currently, providers are paid for services delivered, but moving forward, the medical model will change to value-based payment (VBP).

“The value that people are talking about when they say value-based payment is the investments in the community, the improvement of health quality, and ideally care quality, when care has to be provided,” Reider said. “Historically, healthcare providers have been paid fee-for-service — each test, each visit, each procedure, equals payment. Whereas, Community-Based Organizations have been paid on a rate basis or through grant-based funding.”

Reider continued, “Now, we want to invest more money in Community-Based Organizations focused on upstream activities like providing housing, food, and connection to substance-use programs, in order to prevent folks from falling down stream. We need to think about the services that we provide differently, and ask how they can directly improve outcomes for those we serve while generating savings for New York State Medicaid.”

“Thinking” is exactly what Alliance is doing for its partners. The information gleaned from the PAM surveys, as well as the Medicaid client lists that Community-Based Organization partners submit, is being compiled and aggregated with clinical analytics. Provided by the Alliance’s Data Analytics team, these targeted health analytics help CBOs better understand the clinical profile of their population, determine where there is the greatest opportunity for client engagement, and where they can significantly impact care delivery.  Sharing these analytics is also preparing CBOs for the forthcoming value-based payments, an additional, sustainable revenue stream available for CBOs to demonstrate their value proposition.

In other words, Alliance is actively using the information supplied through these once-unlikely partnerships to develop plans for a system that collaborates and coordinates care and to shift the way that care is paid for. It is a seemingly essential role for an entity with a defined lifespan, and it has many wondering what happens when DSRIP’s time comes to an end in 2020.

Moving Forward

“DSRIP is a five-year program, and constantly I have to ask myself, ‘Is five years enough?’” Pirwani said. Hers is a valid question, but many, like Pirwani herself, see value in continuing with Alliance.

“For us moving forward, Alliance is going to play an integral role in helping us to prove our value and to assist with our sustainability,” said Empower Health’s Simao. “Their connection with the managed-care agencies and other organizations that we may be able to partner with in the future as we look to value-based payment can be really beneficial.”

Alliance and Empower Health symbiosis can’t be denied. One provides an essential connection to a hard-to-reach population, along with access to much-needed support and resources. The other paves the way for sustainability and continued movement toward health equity. Together, they are a powerful partnership.

And they both agree that their efforts would be in vein if not for their front line. The health ambassadors are Empower Health,” Simao reflected. Without them, we would not be able to do the work that we’re doing. They are what makes this so effective and successful.”

For these individuals, working for this program is both a personal and a professional success. Three years ago, Wendy could never imagine herself in a position of helping others. “To see me make a difference in people is really, really rewarding,” Wendy said, her eyes filling with tears. “To know my family is proud of me, is even more of a reward.”

And thanks to the resources and support shown him, Eddie went from survival mode to building a life he loves —one that supports his family, his community, and of course, Flor. “…higher education, being a father of my kids, career, job, like, that’s for other people. That wasn’t in my world, in my mentality, that wasn’t possible for me.” He pauses and smiles. “But here I am.”

And thanks to Alliance and its partners, we are all on a path toward better health.

 

 

 

For more information on Alliance for Better Health the Empower Health Program, or Hometown Health, please contact Brooke McConnell at 857.636.8562 or brooke.mcconnell@abhealth.us.

 

Video Production credit: Rogue FX