Community benefit program embeds community health workers with social service agencies, medical settings
By NANCY FRAZIER O'BRIEN
Hillery Ross-Furse never knows what challenges she will encounter as she begins work each day as a community health worker for Mercy Health Muskegon's Pathways to a Healthy Pregnancy program.
It might be a mother so desperate for money that she is selling her breast milk. It might be a woman with a drug dependency disorder whose pregnancy is threatened by her return to jail. It might be a pregnant teenager who simply needs help navigating the maze of paperwork necessary for her to get the government assistance for which she and her child are eligible.
Dalton Cheshire and Britney Johnson learn how to interact with a newborn during a Baby 101 class organized by the Health Project, a Mercy Health Muskegon program.
The key, Ross-Furse said, is to "understand the true life and nature of the people we are able to reach so that we can move them and motivate them" toward healthier lives for themselves and their babies.
Bonds that last
Tressa Crosby, lead community health worker for the program, recalls one of her first patients — a pregnant woman abusing drugs who lost her child to miscarriage. "But she knew she could call me if she ever needed anything," and when the woman became pregnant again, she called to say, "I want to do this right; I want to keep this baby," Crosby said.
Through Pathways to a Healthy Pregnancy, the woman was able to enter a drug treatment program, get the medication and other assistance she needed and give birth to a healthy baby girl.
"Those are the types of connections we are able to make," Crosby said. "When things go wrong, they still have the trust and confidence in us to say, 'This is what is going on with my life.'"
The expectant and new mothers "are very grateful to have someone they can call and talk to," said Crosby. "I have patients from three years ago that will email me. They're thankful that I am always there to help with lots of emotional support."
Pathways to a Healthy Pregnancy is just one program that makes up the Health Project, the community benefit ministry of Mercy Health Muskegon in Michigan, part of Trinity Health. Since it came under the Mercy Health Muskegon umbrella in 2009, the Health Project has responded in a multitude of ways to problems uncovered through Mercy Health Muskegon's community health needs assessment process.
Its services include the Mercy Health Physician Partners food truck; the Wheels of Mercy mobile health van; Lungs at Work, an in-school anti-smoking program for preschoolers through high schoolers; KnowSmoke, which educates the community about the dangers of vaping; Eyes of Hope, a mobile vision care clinic; Muskegon Prescribes Food for Health, a 12-week program that teaches participants how to cook healthy meals; the Pharmaceutical Access Program; and Pathways to Re-Entry, which helps recent parolees connect to a medical home and social services.
Hub and spokes
The Health Project operates through a "hub" that serves as a clearinghouse matching patients with the community agencies and health workers most suited to their needs.
"We serve as a traffic cop for all the referrals that come in and deploy community health workers based on their expertise," said Judy Kell, hub operations manager, who has been associated with the Health Project as an employee or contractor for the past 15 years.
Community health workers are embedded with a variety of community agencies — homeless shelters, ob-gyn practices, a domestic violence shelter, emergency rooms, senior high-rise communities, infectious disease clinics and other sites. The Health Project also has formed and works with a number of community coalitions addressing specific social influences on health, such as tobacco use and substance abuse.
Kell has seen a shift in community health priorities since she started. "One thing that has been very successful is that when the drug-free coalition started, binge drinking was very high in our community," she said. "But that has changed over time as we get more and more prevention work."
The project also has seen "some very significant changes" in use of emergency rooms by patients with chronic diseases when they have received assistance in meeting other needs, such as housing, transportation to medical visits with their primary care physicians and consistent use of medications, she added.
Measures of success
A study by Grand Valley State University showed the effects of the Pathways to a Healthy Pregnancy program in terms of dollars and cents. With program costs ranging from about $300 to $390 per patient, the study found that $2,431 in medical costs was avoided for each mother with delivery of a healthy birth-weight baby.
Patients enter the program "at high risk in terms of social needs and medical needs," including high blood pressure, cancer, obesity, domestic violence, homelessness and poverty, Crosby said. The study found, however, that "for patients enrolled in their first (or early second) trimester, birth outcomes exceeded their Medicaid peers and were brought to the same level as that of commercial insurance patients."
Reaching vulnerable seniors
The project's Senior Transitions program showed even greater success in return on investment. Assisted by a brief questionnaire that measured risk through an evidence-based algorithm, community health workers provided education and care coordination to seniors leaving hospitals and nursing homes.
With a cost of $246,732, the program saved more than $1 million in the patients' first 30 days after discharge, with a median participant savings of more than $18,500.
"We are also seeing more and more need for services" for seniors, Kell said. Through the project's Senior Navigator program, community health workers go to sites frequented by seniors to help link them to other needed services, she added.
The most recent community assessment identified child care availability and affordability, substance abuse, the cost and availability of nutritious foods, education and employment issues, sexually transmitted diseases and advance directives as the top concerns influencing health in the Muskegon area.
"One of the beauties of the pathways program is it is not limited" to one or two types of assistance, Kell said. "We also assist people in returning to school and in connecting with our Michigan Works! Association," which provides support and services for the state's workforce development system.
"It's a nice approach in terms of being able to address any of the issues a patient might have in terms of social determinants" of health, she added.
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