Genesys HealthWorks Health Navigator in the Patient Centered Medical Home
Genesys HealthWorks is a unique healthcare delivery model focused on keeping patients healthy rather than just treating diseases. A key to achieving this goal is by promoting continuous healing relationships between patients and their primary care physicians. Genesys HealthWorks focuses on achieving the Triple Aim (Institute for Healthcare Improvement) to:
- Improve health
- Reduce costs
- Improve the experience of healthcare for patients and providers
As a population based care (PBC) model of healthcare, the health system agrees to share responsibility for the health and well-being of the population and also agrees to deliver the care required to maintain or improve the health of the population. With a focus on health rather than disease, the Genesys HealthWorks population based care model addresses the need to prevent disease across the population.
The Genesys HealthWorks model builds on a strong, redesigned primary care infrastructure that has demonstrated significant cost savings. Genesys HealthWorks brings an innovative approach to a self-management support system that focuses on cultivating relationships between the primary care physician, patient, and Health Navigator, to improve health. The unique role of the Health Navigator as part of the primary care practice team serves to:
- Support patients
- Support providers
- Provide links to community resouces
The Health Navigator Role
The Health Navigator serves in three capacities: to support patients, to support practices, and to link to community resources. The Health Navigator enhances the relationship between the patient and their primary care provider to support self management. The addition of the Health Navigator to the primary care practice team supports self management at all risk levels: keeping people healthy, reducing health risks with lifestyle improvements, and improved management of chronic illness. In contrast to other programs, the Health Navigator does not focus solely on the highest risk patients, but places significant emphasis on keeping healthy people healthy.
The Health Navigator encourages the central role of the patient in managing their own care, facilitates individualized goal setting based on the patient’s readiness for change, assists the patient in developing a self management plan, and continues to provide ongoing self management support tailored to the patient’s needs and risks. The Health Navigator reaches out to the patient and their family in their home through telephone and other communications to maintain their relationship and provide ongoing support. In Genesys HealthWorks, the Health Navigator focuses on promoting healthy behaviors to prevent and manage chronic disease with the greatest emphasis on those behaviors with the most impact; physical activity, healthy eating, and tobacco avoidance. Patients are encouraged to set their behavior change plan based on their preferences and interests. In order to expand the available services, the Health Navigator maintains links with other health system and community resources that may assist patients in their behavior change and self management efforts. The Health Navigator can encourage the patient to take advantage of such services while providing an ongoing supportive relationship as part of the primary care practice team.
Patients may enter the self management support intervention generally healthy, with chronic disease, or following an acute episode of illness (such as an emergency room visit or hospitalization). In all cases, the Health Navigator supports the patient in their self management and reinforces provider recommendations that may include adopting healthy lifestyles, taking medications as prescribed, self-monitoring, provider visits, and preventive screening. The Health Navigator provides crucial integration with the Patient-Centered Medical Home to assure continuity of care and smooth transition between the community services and various components of the health system.
The self management support provided by the Health Navigator is built on interventions with proven results. The skill set of the Health Navigator includes motivational interviewing techniques, excellent rapport building skills with patients and providers, a broad understanding of community resources, an ability to ‘meet people where they are’, and a capacity to serve as a key member of the health care team. The background of these individuals can be varied and range from health educators, to social workers, to dieticians, nurses or others in health care related fields. The most important feature of the self management project is the emphasis on supportive relationships as the foundation of health improvement.
Although some may see similarities between the Health Navigator and other existing roles such as a case manager, disease manager, or health coach, the Health Navigator is unique. The Health Navigator alone functions as a member of the practice team and can function to support all patients in a practice from those who are generally healthy to those coping with chronic illness, ultimately regardless of payor source.
The effectiveness of the Health Navigator intervention is dependent upon on positive relationships with patients, providers, and community resources. Information systems (IS) can augment the intervention to enhance the efficiency of follow-up communications and information sharing via the internet or email, and assessment, tracking and reporting functions. Information technology can facilitate several aspects of the intervention, but never replaces the core person-to-person interaction.
Genesys PHO
In partnership with the Genesys Physician Hospital Organization (PHO), Genesys HealthWorks is actively engaged in the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP), which has the potential to create new financial mechanisms for both the transformation process and sustainable payment streams in the form of incentive dollars for physicians and infrastructure, supporting our new model of care. In association with the PGIP program, Genesys HealthWorks and the Genesys PHO have collaborated to implement the first two phases of Genesys PHO practices for PCMH designation by BCBSM. In this pilot project, Genesys PHO practices are utilizing the HealthWorks model for the self management support component of the PCMH. Currently, the HealthWorks model is being applied in more than 33 Genesys PHO practices, serving more than 59,000 patients.
Genesee Health Plan
The Genesys HealthWorks model is also being applied to serve over 25,000 underserved patients in our community through the Genesee Health Plan (GHP), a county health plan in Genesee County, Michigan which is designed to provide well-managed, cost-effective primary and preventive care, prescription drugs and specialty care to uninsured adults through a network of independent physicians, clinics, and hospital systems. Together with GHP, the HealthWorks team has implemented the Health Navigator support system in the context of the PCMH for this underserved population. This initiative has demonstrated results, including achieving a 53% improvement in physical activity, 53% improvement in eating habits; 17% reduction in smoking; 82% improvement in self monitoring for diabetics; and 45% increase in attending formal diabetes education for GHP patients.
Genesys East Flint Campus Family Medicine Residency Clinic:
Implementation of the Genesys HealthWorks model at the Genesys East Flint Campus Family Practice Residency Clinic involves more than 11,000 underserved patients. The model is integrated in the clinic’s Patient Centered Medical Home and Integrated Behavioral Health Services transformation efforts. Implementation of the HealthWorks model at the East Flint Campus Family Medicine Residency Clinic began in 2010.
Funding for program development originally came from several grants. Ongoing funding comes from Genesee Health Plan (which employs several Health Navigators and contracts with Genesys HealthWorks for Health Navigator services delivered to enrollees) and from the Genesys PHO, which also employs several Health Navigators. Blue Cross and Blue Shield of Michigan provides funding for Health Navigators through various initiatives, including a grant from the Blue Cross Blue Shield of Michigan Foundation, the Physician Group Incentive Plan Patient Centered Medical Home Initiative (which helped fund the GPHO practices' conversion to Patient Centered Medical Homes), the Care Coordination Delegation Agreement (which covers the cost of one full-time health navigator), and various pay-for-performance and shared-savings programs.
The Health Navigator Self Management Support System is applied to a population of more than 25,000 uninsured adults, representing 72% of the uninsured adults in Genesee County, through a partnership with GHP. As of April 2010, more than 5,911 new GHP enrollees have been assessed and engaged in the HN intervention model since implementation began in 2003.
Implementation of the Health Navigator Self Management Support model at GHP has shown that Health Navigators are key in engaging people in self management, thus achieving improved health and decreased costs. In addition, prior research findings from projects implemented through Genesys HealthWorks corroborate that Health Navigators are effective in improving health outcomes[1].
For these results, data of GHP patients engaged in the Health Navigator Self Management Support model over a six-year period (August, 2003 - July, 2009) was collected. During this time period, 5,911 GHP patients were engaged in the Health Navigator Self Management Support model. The reporting data focuses on 1,763 of the 5,911 engaged members (or 30%) whom were assessed at both at baseline and 6 months after engagement in HN interventions via telephone survey[2].
Improvements in Healthy Behaviors
Of the proportion of people at risk at baseline, the following improvements were reported at 6 month follow-up:
§ 628/1174 (53%) of people who did not eat adequate amounts of fruits and vegetables, now eat adequate amounts;
§ 500/938 (53%) of people who reported no regular physical activity, now are physically active;
§ 610/781 (78%) of people who were physically active at baseline, maintained their physical activity;
§ 120/713 (17%) of smokers quit smoking;
§ 264/311 (85%) of patients who were not taking their medications regularly, now do take medications at prescribed intervals.
For a subset of 797 patients with diabetes:
§ 320/391 (82%) who did not regularly check their blood sugar, now do check their blood sugar regularly;
§ 232/258 (90%) who did not check their feet regularly, now do regular checks;
§ 217/481 (45%) who had never received formal diabetes education, now have attended Diabetes Self Management Education;
§ 260/497 (52%) who had not had a diabetic eye exam within the past year, received an exam;
§ A sub-analysis of 34 diabetics showed that each self reported health behavior improvement was associated with an average 0.8 improvement in HgbA1c;
For a subset of patients with chronic pain:
§ Of patients reporting poor management of chronic pain, 182/488 (37%) reported improved pain management
For a subset of patients with depression:
§ Of patients screening positive for depression, 260/620 (42%) reported improved symptoms.
In 2009, Health Navigators made 4,534 links to other services based on patient needs were completed.
Program impact is not only measured in numbers, but is also captured through individual HN-patient interactions, which are qualitative measures that illustrate the process:
Patient Story “Mr. D”
Mr. D is a 39-year old male with a six year history of hypertension, who is a member of GHP. Following an admission to the hospital for uncontrolled blood pressure, Mr. D was contacted by a GHP Health Navigator. During their initial telephone call, the Health Navigator engaged Mr. D and listened to his story and concerns. As the Health Navigator assessed his needs, she identified that Mr. D had stopped taking his medications a few years ago due to his lack of insurance. Due to his high blood pressure, Mr. D was unable to pass his employers required physical and was not able to work. Mr. D was also experiencing high stress due to a recent divorce and financial pressures. Mr. D also stated he had been reluctant to go to the hospital due to the cost and was concerned about how he was going to pay the bill for his recent admission.
During their call, the Health Navigator offered support to Mr. D, assuring him that he had access to his primary care physician for follow-up appointments through GHP and encouraged him to build a relationship with his provider. The Health Navigator linked Mr. D with the hospital’s Charity Care Coordinator to assist him in covering the cost of his admission. In addition, the Health Navigator connected Mr. D to the GHP Prescription Assistance Program to help him obtain his medications. The Health Navigator also engaged Mr. D in discussions regarding healthy eating, exercise, and smoking cessation, helped him identify areas he wanted to improve and where he could begin to fit these behavior changes into his lifestyle.
Following their initial conversation, the Health Navigator contacted Mr. D periodically over the next 3 months to support his progress on his identify behavior changes.
During their three-month follow-up call, Mr. D stated he had developed a relationship with his primary care physician and was visiting the office regularly. Mr. D was taking his medications as prescribed, and was back at work driving his truck after passing his physical. Mr. D was also packing fruits and vegetables in his lunch at work for snacks to supplement “Truck Stop Food” and had switched to Mrs. Dash for seasoning instead of salt. Mr. D also reported that he was riding his bike regularly for exercise and had stopped smoking. Mr. D stated that he was “feeling really good” with his new healthy lifestyle.
Improvements in Cost
Patients engaged in HN interventions reported about half the use of Emergency Room and hospital admissions 6 months following engagement in HN interventions compared to baseline, which has resulted in much less expensive care for the patient and to the medical system.
Emergency Room Data for a 3-year period include:
Emergency Room Admissions | ||||||
Year | Patient number | Baseline | 6-month follow up | Percent Change | ||
2006 | 251 | 58/251 | 23% | 26/251 | 10% | 55% decrease |
2007 | 232 | 51/232 | 22% | 26/232 | 11% | 49% decrease |
2008 | 233 | 57/233 | 24% | 24/233 | 10% | 58% decrease |
Hospital Admission Data for a 3-year period include:
Hospital Admissions | ||||||
Year | Patient number | Baseline | 6-month follow up | Percent Change | ||
2006 | 240 | 25/240 | 10% | 14/240 | 6% | 44% decrease |
2007 | 229 | 35/229 | 15% | 13/229 | 6% | 63% decrease |
2008 | 255 | 30/255 | 12% | 9/255 | 4% | 70% decrease |
Improvements in Experience
The focus of the Health Navigator Self Management Support intervention is to support patients, support providers, and link to community resources, in an effort to support health behavior change efforts. Engaging people in positive, supportive relationships and in their own self management is the key to achieving positive patient experience as well as improvements in health and cost outcomes. Comments and feedback from GHP patients regarding their experience with the Health Navigator program detail the high level of satisfaction with the intervention. Overall patient satisfaction of GHP patients shows that in 2003, 2006, and 2007, 98%, 99%, and 99% of members (respectively) would recommend GHP.
In one instance, a GHP patient, who had been diagnosed nine years ago with manic depression, informed the Health Navigator that he had been off his medications for seven years. The member made the following comment after his engagement with Health Navigator, who supported him in self management and provided assistance to meet his needs: “Thank you for taking the time to address all of my health concerns! I have been living an unhealthy lifestyle. I want to be around to see my grandkids and with your help I know I can do it! I didn’t realize the symptoms of my mental health condition had such a negative affect on my life. I did not know my health plan covered so much! I appreciate the call and the support. Thank you for your time.”
Additional comments from GHP patients engaged in the Health Navigator intervention include:
§ “Thanks for calling. I really needed to know someone cared.”
§ “Thank you, it was nice to hear a friendly voice offering support.”
§ “Thank you for all you have done for me today, I appreciate you. Thanks for caring.”
§ “Thank you so much for everything you have done for me. You will be blessed for using your whole heart to help people. I am glad you are on my team.”
[1] 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, Volume 35 , Issue 5 , Pages S365 - S372.
[2] In prior programs, self report telephone data has been corroborated with clinical data such as hgba1c and BMI, and is generally considered reliable in the literature and used in national surveys such as the Behavioral Risk Factor Surveillance Survey (BRFSS) to describe lifestyle habits of the public.
Commonwealth Foundation case study featuring Genesys HealthWorks, "Genesys HealthWorks: Pursuing the Triple Aim Through a Primary Care-Based Delivery System, Integrated Self-Management Support and Community Partnerships": http://www.commonwealthfund.org/Content/Publications/Case-Studies/2010/Jul/Genesys-HealthWorks.aspx
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