‘I Was in Tears:’ Community Health Workers at PCMH-Designated Practices Provide Life-Changing Connections for Patients
Jake Newby
| 5 min read
Jake Newby is a brand journalist for Blue Cross Blue Shield of Michigan.
Sometimes, the healthcare people need can’t be delivered in a primary care office.
For some people – like older adults with chronic conditions and residents in underserved communities – staying healthy depends on having someone in their life who can help them navigate the healthcare system. Someone capable of improving their whole person health. Community health workers (CHWs) like Inger Blair do exactly that for countless Southeastern Michigan residents.
“One patient that’s popping into my mind is a patient with Parkinson’s disease,” Blair said. “He needed help with transportation, insurance, a travel chair and a Parkinson’s specialized walker. So, he’s got a lot of those things going on, and we try to chop those problems down, from the biggest to the smallest. The last thing that we have is to finish getting that walker to him and all of his goals will be met. That will be a big help for his health, to be able to walk around and keep him from falling.”
Blair said this patient has fallen in the past. Now, he’s better equipped to avoid falling and increase his physical activity, two keys to healthy aging. Oakland Physician Network Services (OPNS), a physician organization, added CHWs like Blair to serve the Blue Cross Blue Shield of Michigan designated Patient-Centered Medical Home (PCMH) primary care practices within their organization. Blair’s work has greatly improved patient outcomes.
Blair helps patients better understand their health and manage their chronic conditions, while facilitating the services and community resources they need. For example, she has helped patients receive the technology they lacked in their home to have telehealth calls with their doctor, a service that can be vital for people who struggle with transportation. Her work is invaluable to OPNS, an organization that prioritizes value-based care.
“When you talk to providers, they say, ‘I just want to take care of my patients. I just want to see them, make sure they’re healthy and provide the resources they need. The reality is, providers don’t have the time to do all those things,” said Resra Krull, OPNS Value Based Care Director. “In her role, when Inger receives a referral, she can identify why people aren’t following through with care and going to their provider’s office.”
Blair is passionate about helping people. It just so happens that her passion for helping people in the way that she does helps lower healthcare costs.
“Inger can identify why people aren’t following up at their provider’s office. Is it because they don’t have transportation? Is it because they rely on a caregiver who doesn’t have transportation? Why is this patient going to the emergency room when their primary care provider (PCP) is available to them? She’s able to dig a lot deeper because her role is to figure out what is holding patients back from following up with their PCP,” Krull said. “Those are the things that really help improve our cost analyzation.”
By helping patients overcome barriers to routine and preventive care, CHWs like Blair can help reduce avoidable ER visits and other costly care. When those savings add up across a patient population, they can help lower overall healthcare costs — ultimately benefiting everyone in the healthcare premium pool.
“That’s why the concept of PCMH is so important,” Krull added. “It ensures that patients are not only treated from a medical standpoint, but from a holistic standpoint.”
‘I dug a little deeper:’ Blair’s work embodies the PCMH program’s holistic approach to healthcare
It may take a few difficult chapters to get there, but Blair has enjoyed multiple success stories in her role. One of those unfolded recently when Blair was connected with a Macomb County woman and Blue Cross Blue Shield of Michigan patient, who struggled to pay her lot rent and electrical bill.
“Together it was probably about $4,500,” Blair recalled. “She owned her home, but not the lot she stayed on. So, she was getting evicted … she and I worked with different agencies to try and find funding for her. We were turned down a few times, but I kept going. It was wearing on her and starting to wear on me, too. I dug a little deeper and found a program that helps with rent and utilities.”
Blair explained the circumstances to this organization, which included the young woman’s status as a caregiver for her adult brother with a disability, on top of health issues of her own.
“With just this one program, we were able to pay off all her utilities. Then we connected her with community organizations like the Salvation Army and St. Vincent de Paul, and those three organizations helped pay off her lot rent, and she was able to stay in her place.”
“We sent letters to each program to thank them for their support,” Blair went on. “I was in tears when I saw how much money they came up with in such a short period of time. Those are some of the wins that I talk about.”
Stories like these illustrate what happens when primary care extends beyond the walls of the doctor’s office. Connecting patients with CHWs who can address transportation, financial, social and other barriers to care allows PCMH practices to treat the whole person — not just a diagnosis or a medical condition.
Click here to read more about Blue Cross’ PCMH program.
