COMMUNITY HEALTH WORKERS AND HEART DISEASE QUALITY IMPROVEMENT INITIATIVE
Sueling Schardin, MPH, RD, Community Health Planner, Minnesota Department of Health
Introduction
Outcomes—Overall Changes From Baseline*
The MN Heart Disease and Stroke Prevention (HDSP) Unit, and 2
Federally Qualified Health Centers (FQHC), designed and implemented a Community Health Worker (CHW) pilot program. The 3
-year program utilized CHWs to help patients manage their heart
disease risk factors. One clinic primarily served urban Native
Americans in Minneapolis and the other clinic targeted medically
uninsured, underinsured and underserved residents of St. Paul.
The CHWs worked with patients to assess and eliminate socioeconomic or health systems’ barriers that inhibits successful
chronic disease management.
BMI
Goals
Short term: Implement a heart disease quality improvement (QI)
model utilizing CHWs for disparate populations in two FQHC.
Long term: Improve patient cardiovascular health outcomes and
document lessons learned for replication to other FQHCs.
Cholesterol
A1c
Smoking
Outcome Measures
CHW heart disease risk management QI service delivery
model developed.
Direct patient contact and referrals to community support
services.
Patients heart disease risk factor management.
Summary
Blood Pressure
Patient Characteristics
Median age = 53 years old.
65% female, 34% male, 1% unknown.
40% white, 27% Native American, 22% black, 11% unknown/other and 1% Asian.
90% insured (Medicare, Medicaid, MN Care, private) and
10% unknown/none.
CHWs were instrumental in their patients’ chronic disease
management, by assisting them with establishing selfmanagement goals
Patients screened for CVD risk factors to determine changes
from baseline.
The majority of patients, with baseline and exit CVD risk
factor data, maintained their baseline category or improved
to a better category by their exit date.
Partners
Outcomes—CHW Services Provided
The majority of patients successfully contacted after program enrollment.
Phone calls were the primary means of communication.
67 patients had referrals ranging from 1—19 referrals.
74% of patients developed self-management goals.
Median length of enrollment = 15 months.
* Patients with no baseline data or quarterly measurements were taken out of the overall analysis.
FQHCs: Native American Community Clinic and United Family
Medicine
Funders: Otto Bremer Foundation and American Heart Assoc.
Minnesota Association of Community Health Centers
Minnesota Department of Health, HDSP and Diabetes Units
Contact
Sueling Schardin, (651) 201-4051 or [email protected].
CHWs’ Key Duties
Community health worker assist patients with developing
and/or adhering to their case management plan by addressing socio-economic barriers that impede chronic
care management.
Referral to and assistance with securing community resources.
Reminder phone calls about patients’ medical appointments.
NACC CHW trained some clients on fitness equipment at
local gym; the other started a walking club.
Other Outcomes
CHWS integrated into care management /clinical teams.
CHWS had more time than providers to get to know patients and their family.
CHWs reinforced health messages from providers.
CHW notes on patients and feedback were valued.
Some patients and clinic staff were unsure of what to
expect from the CHW.
There were challenges of setting boundaries with some
patients, getting referrals from clinic staff and assisting
patients with limited resources.