D-H Community Health Workers "Transform" Patients' Lives
When Gary Vance woke up one morning back in 2009 he couldn’t see a thing. He’d had trouble standing for the past month and had been throwing up frequently, but the last thing he expected was to wake up blind. In addition to his rapidly worsening vision and his brittle diabetes, Vance’s primary care physician confirmed that his gastrointestinal symptoms were due to gastroparesis. “She essentially told me that my digestive system was shutting down and that I wouldn’t be around for very long,” says Vance.
Although the 48-year-old regained his sight about a month later, this was the start of his downward medical spiral. He was ultimately diagnosed with stage five kidney disease and learned that he needed a dual transplant—kidney and pancreas. Due to his worsening medical condition, he had to stop working at the mental health institution where he had been employed for 12 years. Additionally, he was coming in to the Dartmouth-Hitchcock Medical Center’s (DHMC) Emergency Department (ED) about once a month, and was often admitted for several days for colitis and other gastrointestinal issues.
As the ED staff got to know Vance from his repeat visits, Emergency Medicine physician Kevin Curtis, MD, MS, one of the physician leads for a Dartmouth-Hitchcock (D-H) ED High Utilizer initiative, believed that Vance would be an ideal candidate for a new D-H Population Health program, which matched frequent ED visitors with a D-H community health worker. The program had been launched with funding from D-H’s Population Health Innovation Fund, and two community health workers had been hired in July 2016.
“Prior to engaging the community health workers, we had taken a multi-faceted approach to try to help our ED high utilizers,” says Curtis, who is also medical director of D-H Connected Care and Telehealth. “We found that our efforts were successful for some of them, but there was still a substantial cohort that needed higher touch interventions that extended beyond the hospital to their homes and communities. Knowing this, we thought Community Health Workers were well-suited to supply that missing piece of the puzzle, and give these patients the depth and breadth of help they needed to improve their health and patient experience, while decreasing their low yield utilization of the ED.”
Shortly after Community Health Worker Karry LaHaye was hired, she was paired with Vance, her first patient. D-H Today spoke to LaHaye and Vance to learn more about their shared journey this past year, as D-H’s Community Health Worker program approaches its one-year anniversary.
“Acting as a Bridge”
LaHaye describes her job as “building a trusting relationship with our patients to act as a bridge between the institution, social services and community resources, and to communicate with and educate not only our patients but also our staff.” When she started working with Vance, she accompanied him to his medical appointments to ensure that he understood how to manage his complicated medical issues and educated him about improving his diet so that he stayed as healthy as possible. LaHaye also partnered with Lisa Buck-Rogers, PA-C, Vance’s care manager at D-H affiliate Alice Peck Day Memorial Hospital, and DHMC Continuing Care Manager Stuart Scott, MSW, who was instrumental in getting him on the transplant list.
The primary issue keeping him off the transplant list was a lack of stable housing. Although Vance lived in a motel room, for transplant purposes he was viewed as homeless. Transplant recipients need a permanent address in order for visiting nurses to do follow-up visits, LaHaye explains. She got him on the wait list for subsidized housing, and every day combed apartment listings for an affordable apartment in the Upper Valley so that he would be closer to the dialysis center and his doctors in Lebanon. Living more than an hour away, the travel time and gas costs for three weekly trips to Lebanon for dialysis were taking a toll on Vance’s health and limited finances.
After months of being on the wait list for subsidized housing, an apartment finally became available in March in Windsor, Vermont. The day he signed his lease agreement, a huge snowstorm hit the Upper Valley. But LaHaye still made the drive to Windsor because Vance lost his sight in one eye last fall and can no longer read text printed on white paper. That weekend, she and her husband also helped Vance move in and brought him a new bed.
“When I told Gary he got the apartment, his response was, ‘Are you sure? Nothing good ever happens to me.’ He asked if he could give me a hug,” says LaHaye. “Knowing that finding him a place to live, something most of us take for granted, was potentially saving his life, and hearing the excitement and hope in his voice was amazing.”
A few days after he moved into his apartment, a relative volunteered to donate his kidney, which was a huge relief for Vance. LaHaye was able to get him on the transplant list now that he had stable housing. A permanent address also enables him to receive free meals from Meals on Wheels, a national program which addresses senior hunger and isolation. Additionally, there’s a Vermont SASH (Support and Services at Home) coordinator in his apartment building, who helped with his Supplemental Nutrition Assistance Program (SNAP) application, and the apartment’s proximity to Price Chopper allows Vance to participate in the grocery store’s diabetes management program.
“I’m a lot better off now than I was a year ago; A LOT better off,” says Vance, who has only been to the ED four times since he started working with LaHaye. “My health is challenging to manage, but when they check my blood levels my numbers are usually on target for where they’re supposed to be. So I’m standing in pretty good shape, and I can give all that thanks to Karry. I don’t know what I would have done without her.”
More than 60 patients have participated in the ED High Utilizer program since its inception nearly one year ago, says Christine Dyke, BSN, MDiv, who manages the Community Health Worker program. For patients who have worked closely with the community health workers, she notes that results are promising and the program is hoping to expand in the coming year.
Vice President of Population Health Sally Kraft, MD, MPH, says she considers it one of the D-H Community Health Department’s “premier programs. Our community health workers have the time and the ability to focus on tough issues that interfere with a patient’s ability to manage their health care needs. Trying to manage a complex medical condition is challenging for any of us; trying to do so when you have no home or have difficulty with reading or the English language or any other number of ‘non-health issues’ makes matters far more complicated. Community health workers can help by removing the barriers that complicate a patient’s ability to partner with the health care team to manage health care needs.”
Kraft points out that prior to the creation of the Community Health Worker program, one group of 19 patients frequented the ED on average 28 times a month. Six months after working with this group of patients, the average number of monthly visits to the ED decreased by 50 percent. The community health workers helped coordinate appointments so patients were able to have health care needs addressed at scheduled clinic visits, while non-health issues were solved early, before they escalated to problems requiring a trip to the ED.
“To improve the health of our populations, we must address the socioeconomic and behavioral factors that influence the majority of health,” says Kraft, noting that experts have reported that health care services nationwide impact only 10 to 20 percent of health yet consume 18 percent of the U.S. gross domestic product (GDP). “Community health workers are trained to address the factors that impact 80 percent of health—access to secure housing, signing up for eligible insurance or income benefits, arranging for transportation, assisting with access to healthy nutrition, etc. They are well positioned to bridge the health system and the individual patient’s needs.”
Curtis says that initial data shows that “the community health workers appear to have improved the overall experience of the ED high utilizers, while decreasing their ED use and their costs.” Several patients also report that the community health workers “involvement and interventions have completely transformed” their lives. “I cannot picture a successful solution for the ED high-utilizer populations for which community health workers are not integral,” says Curtis. “They are a critical component of the program and without them, it is unlikely to succeed.
“As for Gary,” he continues, “what Karry did for him was technically non-medical, but addressed all those high-touch, relationship-building elements that will now allow him to get the transplant he needs and live a much healthier life.”
Helping patients achieve something they thought was impossible
When LaHaye and Vance posed together for the photo that accompanies this article, they excitedly reported that Vance began the process for his dual transplant at Massachusetts General Hospital on June 27. They hadn’t seen each other for a while because, as Vance explains, “For the most part I am pretty set. Karry gives me a jingle from time to time to check in to see if I need anything, but the only thing that I need her for now is to help me keep up with the transplant stuff because that is beyond my realm.”
As she watches Vance walk slowly to his car, due to his peripheral neuropathy, LaHaye reflects on the journey she’s had with her first patient. “He’s been dealt a bad hand,” she says. “My patients’ lives are not easy. They are very complex and it takes time and trust to peel back the layers. But seeing Gary and my other patients achieve something they never thought was possible is so rewarding, not only for them, but also for me. I enjoy what I do, and I’m grateful that every day I come to work and can help our patients lives by giving them the tools to make things just a little less complex for them.”