COMMUNITY BASED & HOME VISITATION STRENGTHEN PROGRAMS

PATIENT NAVIGATION | PRENATAL CARE COORDINATION | HEALTHY FAMILIES

BY: SARAH M. STELZNER,MD

PATRICK L. WOOTEN, MS., HCM - PROGRAM DIRECTOR

Introduction of Speaker
Sarah M. Stelzner, M.D., is the Assistant Clinical
Professor of Pediatrics for Indiana University School of Medicine. She brings her cultural heritage into her work. As a woman of Mexican Nicaraguan heritage who spent part of her childhood in Latin America, her ability to speak Spanish, and understand cultural differences, greatly enhances the trust and communication between her and her patients. Dr. Stelzner has used these skills while training in primary care at the University of California, San Francisco, serving patients in the Mission district at San Francisco General Hospital, and volunteering in the Haight-Ashbury Free Medical Clinic. In 1998 Stelzner joined the Indiana University School of Medicine faculty as a clinical assistant professor of pediatrics. She directs the child advocacy rotation for second-year residents, organizes a yearly multidisciplinary health education project in Calnali, Mexico, and serves a rapidly growing Hispanic community at Wishard Hospital and Eskenazi Health Center, Indianapolis.
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Dr. Sarah M. Stelzner, MD Assistant Clinical Professor of Pediatrics

Program Director
Patrick Lamar Wooten, M.S., is director of Patient
Navigation and Community Health Programs at Wishard Health Services. In this position, he provides leadership in a broad range of patient care activities, including assisting in the improvement of patient relations between staff and patient/families by identifying and eliminating barriers to patient care and access. He also provides directorial oversight of the Wishard-Eskenazi Medical Center Community Health Center Social Workers, Healthy Families, Patient Navigation, and Prenatal Care Coordination Program. Patrick is a board member for the Central Indiana Affiliate of Susan G. Komen. He is also an active affiliate of IU Simon Cancer Center-IUSCC Health Disparities Advisory Committee and serves as a critical link between IUSCC and Wishard. by identifying effective strategies that focus on efforts of reducing cancer risks, early detection, accrual to clinical trials, and enhancing the survivorship and quality of life for cancer patients.
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Patrick L. Wooten, MS., HCM Director, Patient Navigation and Community Health Program

Learning Objectives
Wishard-Eskenazi Health Centers
Primary Care Network

Patient Navigation & Community Health Programs

History of Navigation Wishard-Eskenazi Health Patient Navigation Prenatal Care Coordination Home Visitation Healthy Families Home Visitation

Success Stories & Top Three Lessons Learned

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Wishard Community Health Centers

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Wishard Hospital

Primary Care Network

Eskenazi Health Center (FQHC) Non-FQHC Sites Employee Health Clinics

Midtown Mental Health

Barton Annex

Blackburn

Cottage Corner

Grassy Creek
Primary

North Arlington

38th Street

Eagledale

Pecar

Forest Manor

Westside

Care
Clinic

38th Street

Linwood

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History of Patient Navigation

Harlem New York Established by Dr. Harold Freeman in 1990 to combat cancer disparities with funding from the American Cancer Society
Wishard Health Services Based upon Dr. Freemans model Adapted for use in primary care Includes home-visitation complements

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Wishard-Eskenazi Health Center Patient Navigation

The goal of the Wishard-Eskenazi Health Center Patient Navigation Program is to increase overall patient health outcomes and quality of life by helping patients: Navigate: through the healthcare system and community resources Identify: barriers to care Connect: to programs and services to address those barriers

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Emphasis of Community Health Center Navigators

Primary Care New patients entering primary care Emergency Department patients requiring Primary Care follow-up Hospitalized patients requiring Primary Care follow-up

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Patient Demographic
(2012 - All Locations - All Statuses Report)
Ethnicity American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Count 14 160 5050 2072 47

Two or more races

Unknown White Totals

213
200 3027 10783

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Process Overview
PATIENT NAVIGATION WISHARD AMBULATORY CARE

PN receives notification of new patient scheduled at CHC and ED follow-up patients

PN mails out introductory letter to patient (7 days out)

PN calls to confirm appointment (3-5 days out from appt)

Pt confirms appt.

Yes

No

PN informs patient of what to expect at first visit PN informs patient of items to bring to provide to registrar PN coaches patient on importance of keeping appointments PN instructs patient on use of TeleVox system PN provides patient with PNs contact information/cell number PN offers patient site tour on day of appointment or another day prior

PN offers to reschedule appt. or cancel if unable to attend

TeleVox reminder call (24/ 48 hrs from appt)

No

Yes

PN meets patient for tour (day of or prior to appt)

PN remains available for patient/family for future scheduling or access needs (contact via PN cell number, or if patient presents on no show list in the future)

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Process Overview Urgent Clinics

PATIENT NAVIGATION WISHARD AMBULATORY CARE

Walk-in patient seeking urgent MED/ PED services at Wishard CHC

Patient is triaged, roomed, and provided medical service from NP/physician

Navigator enters room & conducts urgent care survey/primary care needs assessment

Patient has established PCP?

Yes

No

Schedule return appointment via PHS and/or by contacting the CHC Schedule specialty visits/referrals designated by NP (if applicable) Provide patient with an appointment itinerary

Link patient to PCP based on resident geographic Schedule new MED/PEDS appointment via PHS and/or by contacting CHC Schedule specialty visits/referrals designated by NP (if applicable)

PN mails out introductory letter to patient (7 days out)

PN calls to confirm appointment (3/5 days out from appt)

Patient confirms appt.

Yes

No

PN offers to reschedule appt. or cancel if unable to attend

PN informs patient of what to expect at first visit PN informs patient of items to bring to provide to registrar PN coaches patient on importance of keeping appointments PN instructs patient on use of TeleVox system PN provides patient with PNs contact information/cell number PN offers patient site tour on day of appointment or another day prior

TeleVox reminder call (24/48 hrs from appt)

PN meets patient for tour (day of appt)

PN remains available for patient/family for future scheduling or access needs (contact via PN cell number, or if patient presents on no show list in the future)

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Return on Investment
Wishard-Eskenazi Health Patient Navigation ROI Link: http://connect.iu.edu/p64u2s4h89k/?launcher=false&fcsConte nt=true&pbMode=normal ROI for Patient Navigation the benefit (return) of the program is divided by its cost the result is expressed as a percentage or a ratio

ROI =

(Gain from Patient Navigation Cost of Patient Navigation ) Patient Navigation

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Patient Navigation Community Health Programs Consortium

Patient Navigation Healthy Families Prenatal Care Coordination

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Prenatal Care Coordination Home Visitation Service

Home-based services/education to help pregnant WishardEskenazi Health Center patients get the right resources Individualized support and coordination of services to maximize healthy pregnancy outcomes and decrease infant mortality and morbidity Prenatal care and childbirth classes provide information on:
Breastfeeding Danger signs of pregnancy Healthy eating How your baby grows Labor and delivery
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Organization Chart
Director, Patient Navigation/Community Health Programs Office Coordinator East Office 1-FTE Bilingual Referral Specialist East Office 1-FTE RN, Team Leader - West Office .90-FTE Care Coordinator, BSW 1-FTE MSW, Team Leader- West Office 1-FTE Bilingual Care Coordinator, BSW 1-FTE Bilingual Community Health Worker 1-FTE RN, Team Leader- East Office 1-FTE Bilingual Care Coordinator, BSW 1-FTE Bilingual Community Health Worker 1-FTE MSW, Team Leader - East Office 1-FTE Community Health Worker 1-FTE Community Health Worker 1-FTE Bilingual Community Health Worker 1-FTE Community Health Worker 1-FTE

Prenatal Care Program Staff Office Coordinator: 1-FTEs Care Coordinators; 3-FTEs Referral Specialist: 1-FTE RN Team Leads: 1.90-FTEs MSW Team Leads: 2-FTEs Community Health Works:6-FTEs Total Program FTEs: 14.9

9 out of 14 staff are Bilingual

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Patient Strengthening Programs

Coordination Client Summary

(2012 Clients Enrolled)
Race Black Hispanic Count 327 369 % 40% 45%

Other
White Grand Total

51
71 818

6%
9%

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Healthy Families
History Intensive home visitation demonstration project initiated in Hawaii in 1985 Healthy Families America developed in 1992 by Prevent Child Abuse America Located in over 430 communities in 35 states Indiana has 49 sites providing services in all 92 counties 1 site designated for Wishard-Eskenazi Health patients

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Wishard-Eskenazi Health Healthy Families Program

Voluntary home visitation program providing child development information, access to health care and community resources and parent education Designed to strengthen families and promote healthy childhood growth and development Help reduce child abuse and neglect, childhood health problems and juvenile delinquency Intervention starts at the 3rd trimester of pregnancy (for mom) and last until 3 years of age for the child

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Success Stories

Open for Dr. Stelzner

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Three Top Lessons Learned

1.
2.

Eskenazi Health Center is a unique FQHC model called a public entity coapplicant model. The goal of the Wishard-Eskenazi Health Center Patient Navigation Program is to increase overall patient health outcomes and quality of life by helping patients:
Navigate: through the healthcare system and community resources Identify: barriers to care Connect: to programs and services to address those barriers

3.

Wishard Patient Navigation Program is

Based upon Dr. Freemans model Adapted for use in primary care Includes home-visitation complements

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Contact Information
Dr. Sarah M. Stelzner, MD Assistant Clinical Professor of Pediatric Indiana University School of Medicine Office (317) 278-3411 | Fax (317) 692-2372 sstelzne@iupui.edu

Patrick L. Wooten, MS., HCM Director, Patient Navigation & Community Health Programs CHC Social Workers | Healthy Families | Patient Navigation | Prenatal Care Coordination

Wishard-Eskenazi Health Center - Ambulatory Care 1001 W 10th Street, BA 403 | Indianapolis, IN 46201 Office (317) 630-6143 | Blackberry (317) 945-9392 | Fax (317) 287-3045 patrick.wooten@wishard.edu
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References
DC Cancer Consortium. (2012). Retrieved November 7, 2012 from http://dcpnavigatorrp.wikispaces.com/Patient+Navigation+History
Healthy Families America (2013). Retrieved February 14, 2013 from http://www.healthyfamiliesamerica.org/home/index.shtml Health and Hospital Corporation of Marion County DataMart. (2002). Retrieved October 7, 2012 from http://www.hhcorp.org/ Wishard Health Services. (2011). In About Us. Retrieved November 7, 2012 from: http://wishard.edu/about-us.html Wishard Health Services. (2013). In Patient Navigation. Retrieved February 10, 2013 from: http://wishard.edu/PatientNavigation.html
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Patient Strengthening Programs

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