- Email: [email protected]
Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults
Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
Contents lists available at ScienceDirect
Journal of Clinical Gerontology & Geriatrics journal homepage: www.e-jcgg.com
Brief communication
Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults Maria A. Han, MD, MSHPM a, *, Ivy Kwon, MPH b, Carmen E. Reyes c, d, e, f, Laura Trejo, MSG, MPA g, June Simmons h, Catherine Sarkisian, MD, MSPH b, i a
David Geffen School of Medicine at UCLA, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA, USA David Geffen School of Medicine at UCLA, Department of Medicine, Division of Geriatrics, Los Angeles, CA, USA California Commission on Aging, Sacramento, CA, USA d Patient-Centered Outcomes Research Institute (PCORI), Washington, D.C., WA, USA e Los Angeles Aging Advocacy Coalition, Los Angeles, CA, USA f American Association of Retired Persons (AARP) California, CA, USA g City of Los Angeles Department of Aging, Los Angeles, CA, USA h Partners in Care Foundation, San Fernando, CA, USA i VA Greater Los Angeles Healthcare System, Geriatric Research Education Clinical Center (GRECC), Los Angeles, CA, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 March 2015 Received in revised form 5 June 2015 Accepted 9 June 2015 Available online xxx
To effectively manage the health of older high-risk patients, health care organizations need to adopt strategies that go beyond the doctor's office and into patients' homes and communities. Communitybased organizations (CBOs) are important underutilized partners in activating and providing the resources necessary to deliver coordinated, culturally-tailored services to older individuals. This paper describes the process and preliminary results of creating and implementing a “Wellness Pathway” to improve the health of older individuals by coordinating care between health care providers and CBOs, such as senior centers. The Wellness Pathway provides a mechanism whereby health care providers refer patients to programs at the senior center, and senior center staff members refer patients for urgent or primary care services at the health care provider organization. The aim of the project was to determine whether the creation of the Wellness Pathway through the health care provider and CBO education and engagement is feasible and to identify challenges in scalability. During the 6 month study period, 25 patients were referred through the Wellness Pathway, and six patients acted on the referral. Stakeholders at both organizations were interviewed to obtain detailed information regarding their experiences with, and perceptions of, the Wellness Pathway. Patients and providers who participated in the pilot believe that it has the potential to positively impact the health of older patients and is worth continuing. The primary challenges that arose in the implementation of the Wellness Pathway resulted from inadequate levels of health care provider and staff engagement and from lagging patient recruitment. Copyright © 2015, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: accountable care community-based organization patient engagement
1. Introduction New models of health care delivery, such as the Accountable Care Organization (ACO), reflect a changing ideology towards “population-based” health care which incentivizes providers to maximize outcomes instead of volume.1 This paradigm shift
* Corresponding author. University of California Los Angeles, Department of Medicine, Division of General Medicine, Robert Wood Johnson Clinical Scholars Program, 10940 Wilshire Boulevard, Los Angeles, CA 90024, USA. E-mail address: [email protected] (M.A. Han).
requires the development of innovative strategies to coordinate care, address social determinants of health, and encourage patient engagement in health. This is particularly true for vulnerable patient populations, such as frail elderly with multiple comorbidities, who tend to be the highest and most costly utilizers of care.2 Community-based organizations (CBOs) can be important partners in activating and providing the resources necessary to deliver coordinated, culturally-tailored services to older individuals. Given their accessibility, affordability, and familiarity, CBOs (such as senior centers) provide a unique platform for reaching and engaging seniors. Unfortunately, in most
http://dx.doi.org/10.1016/j.jcgg.2015.06.004 2210-8335/Copyright © 2015, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
2
M.A. Han et al. / Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
communities, CBOs are not optimally integrated into the health care delivery system. Barriers to meaningful providerecommunity partnerships include lack of provider awareness of community resources, reimbursement challenges, and ill-defined relationships between providers and CBOs. Consequently, health care providers infrequently refer patients to CBOs, despite the resources that may be available to help patients manage chronic conditions and experience healthy aging in their communities.3 Similarly, most CBOs provide aging and social services without strategically coordinating with health care providers, failing to capture an opportunity to link vulnerable seniors with providers who may play a critical role in improving health and quality of life. In an effort to bridge the gap between health care providers and CBOs, we organized the development of a bidirectional referral pathway between a community health center (provider organization) and a senior center (CBO), which focused on improving the health and wellness of community-dwelling seniors. The objective of the project was to determine whether the creation of a “Wellness Pathway” through the health care provider and CBO education and engagement was feasible and to identify challenges in implementation. 2. Methods The study was designed as a feasibility study using semistructured interviews of stakeholders and participation data to assess the success of implementation. Feasibility studies are relied on to produce a set of findings that help determine whether an intervention should be recommended for efficacy testing.4 In this study, feasibility refers to whether this program will be accepted, demanded, adapted, integrated, and expanded by stakeholders. We assessed this in terms of number of patients referred/enrolled in services and stakeholder perception of barriers to implementation and expansion. The primary outcomes of the study were number of patients referred, number of patients enrolled in services, and number of patients receiving services or completing the evidencebased program (EBP). 2.1. Description of the program The Wellness Pathway is a bidirectional referral pathway implemented between one senior center and one health center in the greater Los Angeles area. Through the Wellness Pathway, senior center staff members were encouraged to refer patients for urgent care or primary care at the health center, and health care providers at the health center were encouraged to refer patients to the senior center to participate in health-promoting EBPs. We considered a referral to be made when a senior center staff member suggested to a senior at the multipurpose senior center that he/she seek care at the health center or when a health center staff member suggested (either in-person or via a mailed flier) that a patient at the health center attend an EBP at the senior center. Patients decided independently whether to seek the recommended services. In order to be eligible for participation in the Wellness Pathway, patients had to be over the age of 60 years and have at least two chronic medical conditions. EBPs are health promotion workshops that have been shown to improve patient outcomes such as quality of life, decreased hospitalizations, and reduced health care expenditures.5,6 EBPs promote patient engagement on an ongoing basis by teaching patients disease self-management tools, improving self-efficacy, and providing social support. The EBP that patients in this pilot were referred to was entitled “Tomando Control de Su Salud” (Take Control of Your Health) created by the Stanford Patient Education Research Center, which is a workshop that is taught in Spanish
(without a translator) for 2.5 hours weekly for 6 weeks. Spanishspeaking people with different chronic health problems attend classes together. Classes cover the following topics: (1) healthy eating; (2) appropriate exercise for maintaining and improving strength, flexibility, and endurance; (3) managing depression; (4) appropriate use of medications; (5) communicating effectively with family, friends, and health professionals; (6) relaxation techniques; (7) appropriate use of the health care system; (8) how to evaluate new treatments; and (9) better breathing.7 2.2. Organizational context The need for the Wellness Pathway was conceived of by the Los Angeles Community Academic Partnership for Research in Aging (L.A. CAPRA) team. L.A. CAPRA is a collaboration between the University of California Los Angeles (UCLA), the City of Los Angeles Department of Aging (DOA), Partners in Care Foundation, L.A. County Community and Senior Services, and a diverse group of CBOs. For this project, L.A. CAPRA partnered with two organizations, specifically St. Barnabas Senior Services (SBSS) and Queens Care Health Centers (QCHC). SBSS is a nonprofit organization dedicated to promoting healthy aging, prolonging independence, and enhancing dignity for older adults. It serves > 8000 seniors each year in multiethnic, low-income, and densely-populated areas in Los Angeles. QCHC is an independent nonprofit corporation, consisting of six health centers spread across Los Angeles County. QCHC is focused on serving a growing number of medicallyuninsured, Medi-Cal (the term for Medicaid in California), and Medicare patients regardless of their ability to pay for services. The QCHC Hollywood site was targeted in this pilot, and this location is approximately 3 miles (a 15 minute drive in typical traffic) from the SBSS senior center. 2.3. Implementation and assessment The Wellness Pathway was opened to referrals in January 2014. L.A. CAPRA supplied referral and tracking forms to both sites to facilitate documentation of patient demographics, insurance status (private, Medicare, Medi-Cal or uninsured), date of referral, time of enrollment in EBP or time of health care provider encounter. Six months following implementation of the Wellness Pathway, L.A. CAPRA interviewed seven key stakeholders at both organizations to obtain detailed information regarding their experiences with and perceptions of the Wellness Pathway. Interviewees and their roles within their respective organizations are shown in Figure 1. Each interviewee received a $25 gift card and written informed consent was waived. Interviews were conducted by a primary research investigator. Interviews were semistructured and lasted 30e45 minutes. Interviewees were asked to describe the following: the process of implementation and execution; facilitators and barriers to implementing and sustaining the program; the relationship between the organizations; and patient and provider perceptions of the Pathway. The questions were open-ended and designed to reveal what is most important to understand about the Wellness Pathway. Interview transcripts were reviewed and common themes were identified using the five step method of interview analysis developed by McCracken for long interviews.8 This method involves reading the interview transcripts and identifying finite ideas presented by the interviewee, organizing the ideas into descriptive categories, identifying connections between categories, and identifying underlying themes that encompass the categories. This project was approved by the Institutional Review Board (University of California-Los Angeles) at our associated institution.
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
M.A. Han et al. / Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
3
Figure 1. Organizational structure of St. Barnabas Senior Services and Queens Care Health Centers. Interviewees are designated with dotted boxes. L.A. CAPRA ¼ Los Angeles Community Academic Partnership for Research in Aging. SBSS ¼ St. Barnabas Senior Services.
3. Results 3.1. Programmatic results During the 6 month study period, 25 patients were referred from QCHC to SBSS for an EBP, and six of them enrolled and participated in an EBP course. Across the study population, all participants were Latino, 84% were female, 60% were enrolled in Medi-Cal, and 40% were enrolled in Medicare. Among the six patients who completed EBPs, patients had an average age of 65.5 years, all were Latino, four were female, four were enrolled only in Medi-Cal, one was dually-enrolled in Medi-Cal and Medicare, and one was uninsured. Due to a lack of willingness on the part of patients to travel to the senior center for the EBP classes, the location of the EBP classes was changed to QCHC. Of those six patients who participated, all of them successfully completed at least four of the six EBP classes. No patients were referred from SBSS to QCHC for health care during the pilot period.
(2) Insufficient investment in training and education for providers and staff. Stakeholders identified that one of the challenges of implementing the Wellness Pathway came in trying to achieve buy-in and engagement from busy providers and staff at the clinic site. Several weeks into the start of the program, some providers in the clinics were still not aware of the program or their role in it. Even following staff education at an all-staff meeting, health care provider engagement in the Wellness Pathway remained inadequate. (3) Need for more robust patient-recruitment techniques. Stakeholders acknowledged that successfully enrolling patients in the Wellness Pathway was challenging. While the first EBP class included six participants, the location of the class had to be changed from the multipurpose senior center to the health center to solicit participation and make it easier for patients to attend while they were at the clinic. In the future, stakeholders felt it would be strategic not only to encourage providers to refer patients into the program, but also to market the program directly to patients.
3.2. Interview results 4. Discussion Twelve months following rollout of the Wellness Pathway, indepth interviews with stakeholders revealed the following themes. (1) Participants engaged in and enjoyed the EBP classes. Class instructors noted that there was strong evidence of patient buy-in of the EBPs; for instance, when patients needed to miss a class, they notified the instructor ahead of their anticipated absence. Patients were pleased that the classes were held at the QCHC clinic because they were familiar with the location and staff and able to coordinate the classes with their regularly-scheduled medical appointments. Patients felt that the program provided motivation for behavioral change and noted that “having to report back to the group at the end of the week provided an extra nudge to complete action plans.”
Though the importance of extending care outside of the physician's office visit is being increasingly recognized by providers, payers, and policymakers, partnerships between providers and CBOs continue to be limited in number and effectiveness.9 The results of this pilot highlight barriers to the coordination of services between health care providers and community-based resources. The primary challenges that arose resulted from inadequate engagement of providers and patients, and strategies to overcome these challenges are discussed below. Both health care providers and CBO staff were slow to utilize the Wellness Pathway, as incentives for participation were not aligned. Aligning incentives is a critical step in promoting behavior change in providers. Value-based payment is one such strategy to incentivize the adoption of health careecommunity collaborations. For
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
4
M.A. Han et al. / Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
example, as health care organizations accept increased financial risk in patient care, the use of low-cost resources available in the community become increasingly important in defraying costs associated with preventable hospitalizations and Emergency Department (ED) visits. However, more immediately, we believe that another solution may involve the creation and implementation of externally-reported quality metrics that measure the existence and extent of community-based linkages. Movement in this direction would express the importance and immediacy of linking health care and community-based resources and would allow barriers to be more swiftly identified and resolved across sites. In addition to obstacles to provider engagement, barriers to patient engagement also need to be addressed. Patient engagement can be promoted by increasing awareness of the Wellness Pathway, highlighting benefits of coordinated and comprehensive care, and reducing barriers to participation. Much of the promotion and education around the Pathway can happen remotely through fliers, patient letters, word of mouth, etc. However, the value of the Wellness Pathway should also be emphasized at points of patient contact with the health care system or the CBO. Specifically, providers and staff should highlight the improved outcomes associated with receiving care across the continuum of health and wellness. It is also necessary to address barriers (child care, parking, etc.) to access and participation. In order to determine whether the Wellness Pathway can help provide accountable and value-based care across a population of patients, it will need to be evaluated further with regard to cost, health outcomes, and patient satisfaction. If it is successful in reducing costs and improving outcomes, this is likely to be a model that can be implemented in communities across the country. Conflicts of interest The authors declare that they have no competing interests.
Acknowledgments This work was supported by the National Institutes of Health and National Institute on Aging UCLA Older Americans Independence Center (P30AG028748), Resource Centers for Minority Aging Research IV/Center for Health Improvement of Minority Elderly III (2P30AG021684-11) and a Midcareer Award in Patient-Oriented Community-Academic Partnered Aging Research (1K24AG047899-01) It was also supported by the American Federation for Aging Research/John A. Hartford Foundation (Grant Number: 20133278). The aforementioned funding sources did not have involvement in designing the study, collecting or interpreting data, writing the report, or submitting the article for publication.
References 1. Services Centers for Medicare and Medicaid. Accountable Care Organizations. Accountable care organ. 2013. p. 1e2. Available at: http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ACO/index.html, [accessed 14.12.14]. 2. Komisar H, Feder J. Transforming care for Medicare beneficiaries with chronic conditions and long-term care needs: coordinating care across all services. 2011. Available at: http://www.thescanfoundation.org/sites/default/files/Georgetown_ Trnsfrming_Care.pdf, [accessed 26.2.15]. 3. Arkin E, Braveman P, Egerter S, Williams D. Time to Act: Investing in the Health of Our Children and Communities. RWJ Comm to Build a Heal Am. 2014. Available at: , http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 [accessed 28.12.14]. 4. Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How we design feasibility studies. Am J Prev Med 2009;36:452e7. 5. Ahn S, Basu R, Smith ML, Jiang L, Lorig K, Whitelaw N, et al. The impact of chronic disease self-management programs: healthcare savings through a communitybased intervention. BMC Public Health 2013;13:1141. 6. Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown Jr BW, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2001;39:1217e23. 7. Center SPER. Tomando Control de su Salud. Stanford Small Gr Programs Spanish. 2015. Available at: http://patienteducation.stanford.edu/ [accessed 01.01.15]. 8. McCracken G. The long interview. Newbury Park, CA: SAGE Publications, Inc.; 1988. 9. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369e402.
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
Contents lists available at ScienceDirect
Journal of Clinical Gerontology & Geriatrics journal homepage: www.e-jcgg.com
Brief communication
Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults Maria A. Han, MD, MSHPM a, *, Ivy Kwon, MPH b, Carmen E. Reyes c, d, e, f, Laura Trejo, MSG, MPA g, June Simmons h, Catherine Sarkisian, MD, MSPH b, i a
David Geffen School of Medicine at UCLA, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA, USA David Geffen School of Medicine at UCLA, Department of Medicine, Division of Geriatrics, Los Angeles, CA, USA California Commission on Aging, Sacramento, CA, USA d Patient-Centered Outcomes Research Institute (PCORI), Washington, D.C., WA, USA e Los Angeles Aging Advocacy Coalition, Los Angeles, CA, USA f American Association of Retired Persons (AARP) California, CA, USA g City of Los Angeles Department of Aging, Los Angeles, CA, USA h Partners in Care Foundation, San Fernando, CA, USA i VA Greater Los Angeles Healthcare System, Geriatric Research Education Clinical Center (GRECC), Los Angeles, CA, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 March 2015 Received in revised form 5 June 2015 Accepted 9 June 2015 Available online xxx
To effectively manage the health of older high-risk patients, health care organizations need to adopt strategies that go beyond the doctor's office and into patients' homes and communities. Communitybased organizations (CBOs) are important underutilized partners in activating and providing the resources necessary to deliver coordinated, culturally-tailored services to older individuals. This paper describes the process and preliminary results of creating and implementing a “Wellness Pathway” to improve the health of older individuals by coordinating care between health care providers and CBOs, such as senior centers. The Wellness Pathway provides a mechanism whereby health care providers refer patients to programs at the senior center, and senior center staff members refer patients for urgent or primary care services at the health care provider organization. The aim of the project was to determine whether the creation of the Wellness Pathway through the health care provider and CBO education and engagement is feasible and to identify challenges in scalability. During the 6 month study period, 25 patients were referred through the Wellness Pathway, and six patients acted on the referral. Stakeholders at both organizations were interviewed to obtain detailed information regarding their experiences with, and perceptions of, the Wellness Pathway. Patients and providers who participated in the pilot believe that it has the potential to positively impact the health of older patients and is worth continuing. The primary challenges that arose in the implementation of the Wellness Pathway resulted from inadequate levels of health care provider and staff engagement and from lagging patient recruitment. Copyright © 2015, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: accountable care community-based organization patient engagement
1. Introduction New models of health care delivery, such as the Accountable Care Organization (ACO), reflect a changing ideology towards “population-based” health care which incentivizes providers to maximize outcomes instead of volume.1 This paradigm shift
* Corresponding author. University of California Los Angeles, Department of Medicine, Division of General Medicine, Robert Wood Johnson Clinical Scholars Program, 10940 Wilshire Boulevard, Los Angeles, CA 90024, USA. E-mail address: [email protected] (M.A. Han).
requires the development of innovative strategies to coordinate care, address social determinants of health, and encourage patient engagement in health. This is particularly true for vulnerable patient populations, such as frail elderly with multiple comorbidities, who tend to be the highest and most costly utilizers of care.2 Community-based organizations (CBOs) can be important partners in activating and providing the resources necessary to deliver coordinated, culturally-tailored services to older individuals. Given their accessibility, affordability, and familiarity, CBOs (such as senior centers) provide a unique platform for reaching and engaging seniors. Unfortunately, in most
http://dx.doi.org/10.1016/j.jcgg.2015.06.004 2210-8335/Copyright © 2015, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
2
M.A. Han et al. / Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
communities, CBOs are not optimally integrated into the health care delivery system. Barriers to meaningful providerecommunity partnerships include lack of provider awareness of community resources, reimbursement challenges, and ill-defined relationships between providers and CBOs. Consequently, health care providers infrequently refer patients to CBOs, despite the resources that may be available to help patients manage chronic conditions and experience healthy aging in their communities.3 Similarly, most CBOs provide aging and social services without strategically coordinating with health care providers, failing to capture an opportunity to link vulnerable seniors with providers who may play a critical role in improving health and quality of life. In an effort to bridge the gap between health care providers and CBOs, we organized the development of a bidirectional referral pathway between a community health center (provider organization) and a senior center (CBO), which focused on improving the health and wellness of community-dwelling seniors. The objective of the project was to determine whether the creation of a “Wellness Pathway” through the health care provider and CBO education and engagement was feasible and to identify challenges in implementation. 2. Methods The study was designed as a feasibility study using semistructured interviews of stakeholders and participation data to assess the success of implementation. Feasibility studies are relied on to produce a set of findings that help determine whether an intervention should be recommended for efficacy testing.4 In this study, feasibility refers to whether this program will be accepted, demanded, adapted, integrated, and expanded by stakeholders. We assessed this in terms of number of patients referred/enrolled in services and stakeholder perception of barriers to implementation and expansion. The primary outcomes of the study were number of patients referred, number of patients enrolled in services, and number of patients receiving services or completing the evidencebased program (EBP). 2.1. Description of the program The Wellness Pathway is a bidirectional referral pathway implemented between one senior center and one health center in the greater Los Angeles area. Through the Wellness Pathway, senior center staff members were encouraged to refer patients for urgent care or primary care at the health center, and health care providers at the health center were encouraged to refer patients to the senior center to participate in health-promoting EBPs. We considered a referral to be made when a senior center staff member suggested to a senior at the multipurpose senior center that he/she seek care at the health center or when a health center staff member suggested (either in-person or via a mailed flier) that a patient at the health center attend an EBP at the senior center. Patients decided independently whether to seek the recommended services. In order to be eligible for participation in the Wellness Pathway, patients had to be over the age of 60 years and have at least two chronic medical conditions. EBPs are health promotion workshops that have been shown to improve patient outcomes such as quality of life, decreased hospitalizations, and reduced health care expenditures.5,6 EBPs promote patient engagement on an ongoing basis by teaching patients disease self-management tools, improving self-efficacy, and providing social support. The EBP that patients in this pilot were referred to was entitled “Tomando Control de Su Salud” (Take Control of Your Health) created by the Stanford Patient Education Research Center, which is a workshop that is taught in Spanish
(without a translator) for 2.5 hours weekly for 6 weeks. Spanishspeaking people with different chronic health problems attend classes together. Classes cover the following topics: (1) healthy eating; (2) appropriate exercise for maintaining and improving strength, flexibility, and endurance; (3) managing depression; (4) appropriate use of medications; (5) communicating effectively with family, friends, and health professionals; (6) relaxation techniques; (7) appropriate use of the health care system; (8) how to evaluate new treatments; and (9) better breathing.7 2.2. Organizational context The need for the Wellness Pathway was conceived of by the Los Angeles Community Academic Partnership for Research in Aging (L.A. CAPRA) team. L.A. CAPRA is a collaboration between the University of California Los Angeles (UCLA), the City of Los Angeles Department of Aging (DOA), Partners in Care Foundation, L.A. County Community and Senior Services, and a diverse group of CBOs. For this project, L.A. CAPRA partnered with two organizations, specifically St. Barnabas Senior Services (SBSS) and Queens Care Health Centers (QCHC). SBSS is a nonprofit organization dedicated to promoting healthy aging, prolonging independence, and enhancing dignity for older adults. It serves > 8000 seniors each year in multiethnic, low-income, and densely-populated areas in Los Angeles. QCHC is an independent nonprofit corporation, consisting of six health centers spread across Los Angeles County. QCHC is focused on serving a growing number of medicallyuninsured, Medi-Cal (the term for Medicaid in California), and Medicare patients regardless of their ability to pay for services. The QCHC Hollywood site was targeted in this pilot, and this location is approximately 3 miles (a 15 minute drive in typical traffic) from the SBSS senior center. 2.3. Implementation and assessment The Wellness Pathway was opened to referrals in January 2014. L.A. CAPRA supplied referral and tracking forms to both sites to facilitate documentation of patient demographics, insurance status (private, Medicare, Medi-Cal or uninsured), date of referral, time of enrollment in EBP or time of health care provider encounter. Six months following implementation of the Wellness Pathway, L.A. CAPRA interviewed seven key stakeholders at both organizations to obtain detailed information regarding their experiences with and perceptions of the Wellness Pathway. Interviewees and their roles within their respective organizations are shown in Figure 1. Each interviewee received a $25 gift card and written informed consent was waived. Interviews were conducted by a primary research investigator. Interviews were semistructured and lasted 30e45 minutes. Interviewees were asked to describe the following: the process of implementation and execution; facilitators and barriers to implementing and sustaining the program; the relationship between the organizations; and patient and provider perceptions of the Pathway. The questions were open-ended and designed to reveal what is most important to understand about the Wellness Pathway. Interview transcripts were reviewed and common themes were identified using the five step method of interview analysis developed by McCracken for long interviews.8 This method involves reading the interview transcripts and identifying finite ideas presented by the interviewee, organizing the ideas into descriptive categories, identifying connections between categories, and identifying underlying themes that encompass the categories. This project was approved by the Institutional Review Board (University of California-Los Angeles) at our associated institution.
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
M.A. Han et al. / Journal of Clinical Gerontology & Geriatrics xxx (2015) 1e4
3
Figure 1. Organizational structure of St. Barnabas Senior Services and Queens Care Health Centers. Interviewees are designated with dotted boxes. L.A. CAPRA ¼ Los Angeles Community Academic Partnership for Research in Aging. SBSS ¼ St. Barnabas Senior Services.
3. Results 3.1. Programmatic results During the 6 month study period, 25 patients were referred from QCHC to SBSS for an EBP, and six of them enrolled and participated in an EBP course. Across the study population, all participants were Latino, 84% were female, 60% were enrolled in Medi-Cal, and 40% were enrolled in Medicare. Among the six patients who completed EBPs, patients had an average age of 65.5 years, all were Latino, four were female, four were enrolled only in Medi-Cal, one was dually-enrolled in Medi-Cal and Medicare, and one was uninsured. Due to a lack of willingness on the part of patients to travel to the senior center for the EBP classes, the location of the EBP classes was changed to QCHC. Of those six patients who participated, all of them successfully completed at least four of the six EBP classes. No patients were referred from SBSS to QCHC for health care during the pilot period.
(2) Insufficient investment in training and education for providers and staff. Stakeholders identified that one of the challenges of implementing the Wellness Pathway came in trying to achieve buy-in and engagement from busy providers and staff at the clinic site. Several weeks into the start of the program, some providers in the clinics were still not aware of the program or their role in it. Even following staff education at an all-staff meeting, health care provider engagement in the Wellness Pathway remained inadequate. (3) Need for more robust patient-recruitment techniques. Stakeholders acknowledged that successfully enrolling patients in the Wellness Pathway was challenging. While the first EBP class included six participants, the location of the class had to be changed from the multipurpose senior center to the health center to solicit participation and make it easier for patients to attend while they were at the clinic. In the future, stakeholders felt it would be strategic not only to encourage providers to refer patients into the program, but also to market the program directly to patients.
3.2. Interview results 4. Discussion Twelve months following rollout of the Wellness Pathway, indepth interviews with stakeholders revealed the following themes. (1) Participants engaged in and enjoyed the EBP classes. Class instructors noted that there was strong evidence of patient buy-in of the EBPs; for instance, when patients needed to miss a class, they notified the instructor ahead of their anticipated absence. Patients were pleased that the classes were held at the QCHC clinic because they were familiar with the location and staff and able to coordinate the classes with their regularly-scheduled medical appointments. Patients felt that the program provided motivation for behavioral change and noted that “having to report back to the group at the end of the week provided an extra nudge to complete action plans.”
Though the importance of extending care outside of the physician's office visit is being increasingly recognized by providers, payers, and policymakers, partnerships between providers and CBOs continue to be limited in number and effectiveness.9 The results of this pilot highlight barriers to the coordination of services between health care providers and community-based resources. The primary challenges that arose resulted from inadequate engagement of providers and patients, and strategies to overcome these challenges are discussed below. Both health care providers and CBO staff were slow to utilize the Wellness Pathway, as incentives for participation were not aligned. Aligning incentives is a critical step in promoting behavior change in providers. Value-based payment is one such strategy to incentivize the adoption of health careecommunity collaborations. For
Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004
4
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example, as health care organizations accept increased financial risk in patient care, the use of low-cost resources available in the community become increasingly important in defraying costs associated with preventable hospitalizations and Emergency Department (ED) visits. However, more immediately, we believe that another solution may involve the creation and implementation of externally-reported quality metrics that measure the existence and extent of community-based linkages. Movement in this direction would express the importance and immediacy of linking health care and community-based resources and would allow barriers to be more swiftly identified and resolved across sites. In addition to obstacles to provider engagement, barriers to patient engagement also need to be addressed. Patient engagement can be promoted by increasing awareness of the Wellness Pathway, highlighting benefits of coordinated and comprehensive care, and reducing barriers to participation. Much of the promotion and education around the Pathway can happen remotely through fliers, patient letters, word of mouth, etc. However, the value of the Wellness Pathway should also be emphasized at points of patient contact with the health care system or the CBO. Specifically, providers and staff should highlight the improved outcomes associated with receiving care across the continuum of health and wellness. It is also necessary to address barriers (child care, parking, etc.) to access and participation. In order to determine whether the Wellness Pathway can help provide accountable and value-based care across a population of patients, it will need to be evaluated further with regard to cost, health outcomes, and patient satisfaction. If it is successful in reducing costs and improving outcomes, this is likely to be a model that can be implemented in communities across the country. Conflicts of interest The authors declare that they have no competing interests.
Acknowledgments This work was supported by the National Institutes of Health and National Institute on Aging UCLA Older Americans Independence Center (P30AG028748), Resource Centers for Minority Aging Research IV/Center for Health Improvement of Minority Elderly III (2P30AG021684-11) and a Midcareer Award in Patient-Oriented Community-Academic Partnered Aging Research (1K24AG047899-01) It was also supported by the American Federation for Aging Research/John A. Hartford Foundation (Grant Number: 20133278). The aforementioned funding sources did not have involvement in designing the study, collecting or interpreting data, writing the report, or submitting the article for publication.
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Please cite this article in press as: Han MA, et al., Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults, Journal of Clinical Gerontology & Geriatrics (2015), http://dx.doi.org/10.1016/ j.jcgg.2015.06.004