The Sedgwick County Health Department serves all 489,365 residents of Sedgwick County. The target population for this practice was uninsured residents. Recent data from the Small Area Health Insurance Estimates (SAHIE) show that among Sedgwick County residents, under the age of sixty-five, 14.7% (approximately 63,063) are uninsured. The public health issue addressed through this practice is Essential Public Health Service 7, linking people to need personal health services. In 2009, the Institute of Medicine issued a report America’s Uninsured Crisis: Consequences for Health and Health Care that describes many of the harmful effects of uninsurance, which often leads to lack of access to care. The report found that compared to insured adults, adults without insurance were more likely to be diagnosed at an advanced stage of cancer, were at greater risk of death from congestive heart failure, heart attack and stroke, and were less likely to be aware of hypertension. Further, the report explored the fact that this problem not only affects the individual, but neighbors, friends, family members, businesses, and the entire health care system.
The goals of the Community Health Navigator Project are to:
• Recruit, train, and deploy prepared volunteers to take information and materials to their peer groups and organizations.
• Educate residents on the importance of having a medical home for seeking primary care and preventative care.
• Provide health access education information and materials to community residents through one-on-one conversations or group settings.
• Collect demographic data for evaluation purposes of the Health Access Projects.
• Collaborate with county residents, public and private agencies, non-profits, and academic institutions to improve health status, healthcare access, and reduce health disparities.• Increase the proportion of persons who have a medical home.
This project began in March of 2009, and it has achieved several milestones. To-date, 52 navigators have been recruited and they have reached nearly 4,000 residents (far exceeding initial goals of 500) with health care information and materials. Initially, Health Access Educational Kits which contained a self-care and kid care booklet, a brochure called “How to Use the Emergency Room” (aimed at appropriate utilization), Sedgwick County prescription discount card, a directory of safety net resources including Federally Qualified Health Centers, and a 2-1-1 magnet were distributed. The kit contents were also available on the Sedgwick County Health Department’s website in English and Spanish. In an effort to contain costs and to provide a more relevant mode of sharing information, volunteers now provide the Sedgwick County prescription discount cards and ink pens with retractable banners that list the county’s six safety net clinics’ contact information and services (health/dental) provided, the United Ways’ 2-1-1 Call Center (available twenty-four hour/seven days a week), a “How to help your doctor help you” message, and the website addresses of Sedgwick County and United Way of the Plains. The budget for this project included $10,000 for meeting costs, materials and incentives for navigators; $4,000 for staff training, travel, and office supplies, .5 FTE for a public health project manager and significant in-kind support for office space, computers, supervision and fiscal management. Lessons learned from the practice have included three key things. First tracking the recipients of these materials was a significant challenge as they are often transitory. Second, originally, the project has hoped that the community health clinics (including the Federally Qualified Health Centers) would help track where clients had heard about their services, but this proved to be beyond current capacities. Third, the navigators were able to reach audiences that Health Department staff would not have had access to, and their outreach efforts allowed this program to triple its reach in the community.
Disparities exist in access to primary health care in certain subgroups among Sedgwick County residents. Access to preventive services may play a role in helping to reduce disparities in the communities’ health outcomes. There are few resources available discussing the benefits of having a medical home, where to find local options for affordable medical homes, and how to use a medical home, appropriately. Barriers exist for vulnerable populations who try to access medical and dental care. Vulnerable populations consist of those who are uninsured or under-insured, lack adequate transportation, do not speak or read English, may not trust accessible providers of health care, and may not understand the system. The 2009 Small Area Health Insurance Estimate (SAHIE) shows that among the 489,365 Sedgwick County residents, under the age of sixty-five, 14.7% (approximately 63,063) are uninsured. Behavioral Risk Factor Surveillance System (BRFSS) data from 2009 reports that 11.8% of Sedgwick County citizens surveyed indicated they did not see a doctor in the past 12 months because of cost. Over 11% reported not having a doctor or medical home at all. Households earning < $35,000 annually were 25.8% more likely to forego seeing a doctor due to cost and 25.5% reported having a no health care provider. African Americans (26.2%) and Hispanics (11.3%) were more likely than Whites (10.5) to report not seeing a doctor due of costs. African Americans (26.7%) and Hispanics (36.2) also reported not having a personal doctor or provider at all. Citizens, living with a disability (17.0%), reported not seeing a doctor due to cost versus the 10.1% living without a disability. Lack of health insurance and residents reporting not seeing a doctor due to costs were both public health issues that this Community Health Navigators project addressed
In 2004, Sedgwick County, with the help of the Hugo Wall School of Urban and Public Affairs at Wichita State University (WSU), assembled more than 140 citizens to explore and examine the issue of public health through the Sedgwick County Assembly: Prescription for Healthy Citizens (Assembly). With assistance from WSU and community-minded businesses and organizations, Sedgwick County facilitated various community focus groups as well as the distribution of 25,000 health-focused surveys to registered voters throughout the county. The Assembly and survey created the foundation for work on health care access. Communities across the United States are feeling the direct impact of rising health care costs and the increased societal burden to take care of those under- or uninsured citizens. Those without access to primary medical health care have a significant impact on the medical care system, employment market and economic growth, and other social and community assistance programs. After the 2004 assembly, further research was done to assess where and how people sought care. People without insurance sought care from the seven safety-net clinics and two residency programs in Sedgwick County, while others sought care directly from hospital emergency rooms. In other situations, people did not seek care, resulting in exacerbated medical conditions. June 7, 2007, approximately 90 community members representing the health care industry, nonprofit sector, business community, consumers, labor unions, and local and state governments came together for the Sedgwick County Summit on Health Care Access. Three work groups were created to explore solutions to three main barriers that emerged: coverage, system coordination and system navigation. The Community Health Navigators program was designed as a direct response to the concerns about system navigation. Further, the Community Health Priorities-Setting process in 2010 narrowed the public health priorities to five; and again, access was included as a community priority, as well as reducing health disparities. The new Community Health Improvement Plan is focused on action and calls for new ways of working together to accomplish improved health. The action steps center on convening, catalyzing and collaborating—and these are all directly supported by the Community Health Navigators program.
The Community Health Navigators Program addresses health care system navigation issues experienced by residents. By taking health clinic information and materials about when and how to speak with one’s healthcare provider to the community--to family, neighbors, and co-workers--navigators helped link residents to health care services. Monthly 101 Community Health Navigators Academies and quarterly newsletters were employed to further educate volunteers about the health care options available to citizens. SCHD staff recruited, trained and deployed diverse groups of volunteers. Navigators were African, African Americans, Caucasians, Mexicans, Latinos, Pacific Islanders, and Vietnamese. On an as needed basis, volunteers could address audiences in English, French, Portuguese, Spanish and Vietnamese. Some volunteers helped share health information at special events, and others presented information at regularly scheduled trainings and natural catchments for potentially uninsured residents. Some volunteers worked full time jobs as social workers, home daycare providers and business owners providing information and materials to their clients. Still other volunteers shared information with audiences comprised of juvenile and adult offenders who were reentering society and at-risk families with small children. Navigators presented in a wide variety of venues such as the monthly Laid-Off Workers Center events, Food Handlers’ Licensure Classes, Child Care Licensure Classes, Sedgwick County sponsored health fairs, cultural health fairs, and faith-based health fairs. Because of the diversity among the volunteers, outreach extended past the county boundaries to communities near and far as 200 miles away.
No, this practice has not yet been uploaded to the toolbox. Further a review of “access to care” resources in the toolbox all appear to be tied to specific disease or age categories. This Community Health Navigator program is unique in that it focuses on the larger essential service of linking people to personal health services. The Sedgwick County Health Department has been actively using the MAPP process to assess the community, develop priorities, and create a health improvement plan. This practice is central to the action phase of our MAPP process, as access to health care through community health clinics has been identified as a priority.
According to the CDC’s Community Health Workers Sourcebook, “CHWs are trusted, respected members of the community who serve as a bridge between their community members and professionals in the field of health and human services…. As community advocates, CHWs help people get the services and follow-up care they need. CHWs serve as patient and community advocates, as “coaches” for disease management, and as patient “navigators,” guiding patients through the health care system. They also strengthen their community’s understanding and acceptance of medical care.” This Community Health Navigator program is led by a Community Health Worker who triples her outreach capacity by training Community Health Navigators who serve as lay health advocates who are members of diverse communities and provide social support to individuals who may find navigating the health system difficult. One indication that this practice is an inventive use of volunteers is the fact that the toolbox had no other programs similar to this one. Further, when the issue of system navigation was identified as a priority issue in 2007, this program did not exist and has been created to fill this gap.
A number of approaches are being used in this community to improve access to personal health services. Primarily, efforts have focused in three areas. First, the United Way provides workers to help recruit families to enroll in the State Children’s Health Insurance Program. Second, a program called Project Access helps connect uninsured residents with donated specialty care by physicians in the community. Third, in the past few years, this community has expanded services through the Federally Qualified Health Centers, growing one center to three with several satellite offices. These approaches seek to improve insurance status or free/reduced-cost care. However, none of these efforts helps educate communities who often lack access to health services by helping them understand the system of care and helping them navigate that system.
A review of NACCHO’s Model Practices Database using the key word search of “access to care” revealed several programs that were focused on serving the needs of special populations. This Community Health Navigator program is unique in its use of volunteers and reaching out to populations at risk for lack of access regardless of age, race, ethnicity, economic status, employment status, or life station.
The primary stakeholders were the uninsured and underinsured populations of Sedgwick County, those without knowledge of or access to affordable health care options. Other stakeholders included the Sedgwick County Health Department, healthcare providers, community health clinics, leaders of nonprofit agencies, business leaders, community advocates, insurance providers, academia and local and state government officials and leaders.
Role of Stakeholders/Partners
The Community Health Navigators program received support and guidance from the Health Access Project Oversight Committee. This Committee was led by the Board of Health and members included representatives from stakeholders listed above. Several partners/stakeholders serve among our fifty-two Community Health Navigators.
The Sedgwick County Health Department developed this program in response to needs discovered through a variety of community engagement and assessment activities. LHD staff supervise, recruit, train, and deploy volunteers. LHD staff develop and manage materials for distribution and work closely with community clinic partners for up-to-date information. LHD staff provide regular updates about access events to Navigators (like Give Kids a Smile dental events or special opportunities for vision exams). LHD staff conduct the evaluation for this project and develop quality improvement strategies to improve outcomes. Funding for volunteer incentives is provided by LHD.
The Sedgwick County Health Department recently did an assessment among all staff asking about their work with community coalitions. This inquiry generated a list of more than forty community coalitions that staff regularly work with on a variety of health issues. Further, as is already documented in this application, the Health Department has been involved in large, formal community engagement efforts in 2004, 2007 and 2010, all of which identified access to health care services as a community need. A Sedgwick County Commissioner, the Health Department Director, the Child and Family Health Director, CHN Project Manager and SCHD staff sit on the Health Access Project Oversight Committee, which is comprised of multiple private and public agency partners. SC Health Department Director, the Child and Family Health Director and SCHD staff convene monthly meetings with the Coalition of Community Health Clinics (including FQHCs and Project Access). The MAPP process is managed through a large community collaborative effort called Visioneering Wichita. The health improvement plan is monitored by the Visioneering Wichita Health Alliance, which is co-chaired by Sedgwick County Health Department staff. The process to develop the health improvement plan involved more than 150 community health, business, education, nonprofit and elected leaders.
Related to developing collaborations, lessons learned from the practice have included two key things. First, originally, the project has hoped that the community health clinics (including the Federally Qualified Health Centers) would help track where clients had heard about their services, but this proved to be beyond current capacities. Second, the navigators were able to reach audiences that Health Department staff would not have had access to, and their outreach efforts allowed this program to triple its reach in the community.
1. The SCHD staff member attended a national conference for Community Health Workers to learn techniques for community engagement and strategies to develop lay health advocates.
2. Partnerships: This program relies on the work of many others through an on-going collaborative with the community health clinics, United Way, Project Access and additional safety net programs.
3. Materials Development: Staff worked with clinics to get current hours and locations, assess health information/literacy needs that clients have. Then, materials were created with assistance from the Sedgwick County Communications department to assure a professional look. The demographics card was developed to assure uniform collection of participant and navigator data.
4. Program Development: Goals and expectations were developed for navigators. Training academy materials were developed as well as a schedule for conducting trainings. An incentives structure was designed to support Navigator activities, such as gas cards for Navigators reaching certain numbers. A data management system was created to collect information from the cards and analyze outreach efforts. Outreach goals were established.
5. Deployment: Using existing networks and building new ones, SCHD staff seek opportunities to present the program to audiences throughout the community to recruit additional Navigators. 6. Communication: On-going news about the Navigator work is communicated with Navigators and other interested parties through a quarterly newsletter.
The timeframe was from January 2009 to the present as this practices is ongoing:
1. Training: Attended Community Health Workers: Celebrating Our Past and Charting the Future hosted by The Center for Sustainable Health Outreach, July 2009.
2. Partnerships: The Coalition of Community Health Clinics meets monthly and this project has worked with them from January 2009 to present.
3. Materials Development: Revisions and additions have been made but these were originally designed between January 2009 and March 2009, as the program launched during the March, 2009 Cover the Uninsured Week.
4. Program Development: This work began in January 2009, but design changes are made to meet program demands.
5. Deployment: Continuous.
6. Communication: Quarterly since January 2010.
Process & Outcome
Two objectives are described for this practice:
• Provide health access formation and materials to community residents through one-on-one conversations or group settings. One of the innovative components to this outreach effort has been the strategy to document who received the information and by whom. Thousands of residents heard the presentations about the community health clinics and other free or low-cost options. The unique evaluation effort for this project has been to capture information about those reached. Willing recipients completed cards with their basic demographic information. These data that follow are from information cards attached to the materials. 3,927 residents have received education about services available in this community. In the beginning, Health Access Education Kits were distributed and a total of 1548 were tracked and had client information cards returned. These kits had self-care books, prescription drug discount cards. Evaluations led staff and navigators to determine that the community health clinics directory was the most important feature; 2,155 residents received paper copies of the directory. The latest revision moved from paper forms to a pen with a directory of clinics as well as 2-1-1 information on a pull out banner; thus far 191 residents have both received the pens and completed the feedback card. Residents reached through this outreach program span the age spectrum: 1.6% under age 18, 12.8% ages 18-24, 23.2% ages 25-39, 20.9% ages 40-54 and 12.5% were age 55 or over. This program was intended to reach residents most vulnerable to poor access to care, and the data shared in this application show that non-Whites are more likely to lack access. The race/ethnicity of program participants included 47.0% White, 31.7% Black, 12.8% Hispanic, 4.4%% Asian and 4.1% other. The majority of residents reached were women, 63%. An additional data point gathered through these demographics cards reported the venue where the outreach took place. Over 100 unique venues have been identified. Tracking venues helped demonstrate that the program reached diverse audiences in unique places. Venues where the most clients were reached included the Food Handler’s Class; 992 people participating in a training that allows them to work in food service establishments. Another 848 were reached at the Laid Off Workers Center. The list of venues includes worksites, faith community groups, student groups, women’s shelters, health fairs and more.
The evaluation of this program has led to changes in information delivery. Field observations during large group presentations and phone surveys were used to collect recipient feedback regarding health care access materials presented and distributed by Community Health Navigators. Feedback through these evaluation methods resulted in changes to the materials from a large envelope with multiple brochures and guides about clinics to a simple but useful pen that has a pull out banner with information about how to prepare for a visit with a health professional, a list of locations for community health clinics, and contact numbers for the Health Department and 2-1-1. These structured and planned evaluation strategies help staff evaluate and improve this program. But unexpected testimonials from community members provide rich, qualitative feedback that also energizes the work. Here is a brief excerpt from an unsolicited letter received by SCHD staff from an uninsured resident who received care through safety net programs and now serves as a navigator in this program. She wrote about her husband’s experience with cancer, loss of sight, restoration of sight and experience with the safety-net programs: “My husband became disabled in 1995. … It was 12 years later that he was granted disability from the state. Meanwhile, we were raising our two sons on my single paycheck. The boys qualified for state medical cards but my husband and I were uninsured. Although insurance was offered at my work, I couldn’t afford the cost. … Chris, my husband, was sick because his blood sugar was “600 ”. … In 2007, he became blind in his left eye. I began looking for resources to help. … I can tell you that my husband would be dead today without the healthcare system we have in Wichita. So many people I talk to don’t know how to access these services. People suffer because they don’t know where to go or how to get help. This program is so important and the material essential.”
• Recruit, train, and deploy prepared volunteers to take information and materials to their peer groups and organizations. A total of 52 Community Health Navigators have been trained thus far and more are trained each month. These volunteers represent the diversity of the community; navigators are African, African Americans, Caucasians, Mexicans, Latinos, Pacific Islanders, and Vietnamese. On an as needed basis, volunteers address audiences in English, French, Portuguese, Spanish and Vietnamese. Further, their experiences and networks are diverse as some serve as pastors, government employees, neighborhood advocates and community health clinic clients. Most of the volunteers are women (80%). The SCHD staff member serves as the project data and evaluation manager. Navigators collect information about recipients of information at the various venues. Among the 3,927 recipients of information who provided client information cards, the SCHD staff person reached 1267 residents. One navigator reached over 500, two navigators reached over 200 and eight more reached more than 100 residents. Fifteen navigators have reached fewer than ten recipients. This illustrates that the outreach efforts really are tailored to the individual skills of the volunteer, opportunities available to the volunteer, and needs of the community. Five quarterly newsletters have been sent to keep volunteers informed and engaged in the process. The objective of training and deploying a diverse corps of volunteers has been met and is an ongoing process.
This application demonstrates the many formal community engagement forums that have identified access to care as an issue. This project has the support of the Board of Health, particularly one member who led the 2007 Health Access Summit activities that identified “navigation” as a barrier to care. Like many local health departments, budget cuts have created opportunities for re-structuring and refocusing efforts to assure work is meeting the strategic goals of the department and this program meets that test and has been protected in that process. The project is funded entirely with local funds, and thus is not dependent on a one-time grant to sustain future work. As the testimonial provided by one volunteer demonstrates, there is a strong commitment to this Community Health Navigators program by the navigators themselves. And finally, as the SCHD continues work on the Community Health Improvement Plan, this program serves as an action step toward meeting the goals for linking people to health services and increasing utilization of the Community Health Clinics (FQHCs).
Strengthening the evaluation component of this practice will assist in sustaining the program over time. The fact that two-thirds of the outreach is accomplished through volunteers demonstrates that the practice already leverages resources effectively in the community and there is potential to increase that proportion. The program does require focused staff time and there is a commitment to this effort as it demonstrates one key way this LHD meets the essential service of linking people to health services.
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