Introducing the Rural Chronic Disease Management Toolkit
Date:
Duration: approximately
minutes
Featured Speakers
|
Amy Rosenfeld, Senior Research Director, NORC Walsh Center for Rural Health Analysis |
|
Doris Boeckman, Project Director, Mobile Integrated Healthcare (MIH) Initiative at the Great Mines Health Center in Farmington, Missouri |
|
Gilbert Rangel, HRSA Programs Coordinator at Lake County Tribal Health Consortium in Lakeport, California |
The Rural Health Information Hub and the NORC Walsh Center for Rural Health Analysis will present the Rural Chronic Disease Management Toolkit, designed to support rural communities and organizations looking to develop and implement chronic disease management programs.
This webinar will provide an overview of approaches for managing chronic diseases in rural populations. It will feature existing programs that have successfully provided rural chronic disease management and discusses lessons learned related to establishing and sustaining rural programs.
From This Webinar
Transcript
Kristine Sande: I'm Kristine Sande, the program director of the Rural Health Information Hub, and we are excited to have you here with us for our webinar, Introducing the Rural Chronic Disease Management Toolkit. And now it is my pleasure to introduce our speakers for today's webinar.
Amy Rosenfeld is a senior research director with the NORC Walsh Center for Rural Health Analysis. She has conducted rural health research on a variety of topics including HIV/AIDS, prevention and treatment, unintentional injury prevention, health literacy, social determinants of health, economic development, and chronic disease management. With the Walsh Center, she has supported or led the development of nine evidence-based toolkits on behalf of RHIhub.
And next we'll hear from Doris Beckman. Doris is co-founder and one of three partners of Community Asset Builders LLC, or CAB, and has 35 years of experience in healthcare. CAB is also one of three organizations that comprise the Washington County Mobile Integrated Health Network, a nonprofit organization working to expand Mobile Integrated Healthcare both statewide and nationally. Doris serves as a founding board member. The Washington County MIH Network was awarded first place in the Health Resources and Services Administration's Competitive National Primary Care Challenge in 2023 for its novel rural healthcare model. Doris has a degree in business administration with an emphasis in marketing from Lincoln University and is active at the state and national level in promotion of MIH expansion and sustainability.
And finally we'll hear from Gilbert Rangel who works at Lake County Tribal Health as the HRSA Program's coordinator where he promotes health education programs for patients with chronic diseases, primarily focused on diabetes self-management. His approach incorporates cultural elements, recognizing the importance of integrating traditional practices to improve health outcomes in Native American communities. Rangel also serves on the Kelseyville Unified School District Board and advises the Middletown Arts Center, continuing to influence both education and cultural development in his community. And with that, I'll turn it over to you, Amy.
Amy Rosenfeld: Thank you so much, Kristine, for those introductions. And thank you to everyone for joining us on this webinar today. I'm very excited to be able to showcase the new Rural Chronic Disease Management Toolkit that was released on the RHIhub website a few months ago. And today I'll walk through the toolkit and some of the content that you will find when you review it.
Just to start with some background on who we are and how this toolkit came about, the NORC Walsh Center for Rural Health Analysis was established in 1996 and is now part of the Public Health department at NORC at the University of Chicago. NORC is an independent and nonpartisan research organization that provides expertise in public health and other areas. And the NORC Walsh Center conducts policy analysis, research and evaluation to address the needs of policymakers, the healthcare workforce and the public on issues that affect healthcare and public health in rural America.
And so the toolkit was developed through a project funded by the Federal Office of Rural Health Policy in partnership with RHIhub. And the project was conducted by our team at the NORC Walsh Center for Rural Health Analysis and was first published on the website on June 14th of this year. And you can see a list of the contributors from the Walsh Center.
The main focus of this work in these toolkits more broadly is to establish and disseminate a rural evidence base through resources like these toolkits that share information about the experiences of FORHP grantees and other rural communities implementing similar programs, in this case, chronic disease management and in rural areas of the US.
And so this project in our toolkits have three main aims. The first is to identify evidence-based and promising programs and strategies that have been successful in rural communities. The second aim is to study the experiences of these programs, including identifying and understanding the facilitators of their success. And then the third aim is to disseminate and share lessons learned from these programs and rural communities through the creation of these evidence-based toolkits.
And so this slide just shows a brief look at the process for toolkit development and overall methods. We start with an extensive literature review and look at existing resources and materials on the topic relevant to rural communities. And then we pick rural programs, usually several grantees to interview to hear their real world experiences about implementing, in this case, chronic disease management programs. And then we ask about lessons learned that we can share with other communities looking to implement similar programs. And then we follow these program interviews with several expert interviews. We identify individuals with subject matter expertise in chronic disease management to see if there are any gaps to fill in the information we've identified. And we ask them to weigh in on our evidence-based models and promising approaches. And then the last step is putting it all together, so to create the final toolkit, which includes all of the information, resources, and feedback from the interviews we've conducted.
Today I'm going to walk through just at a high level of the organization of the Rural Chronic Disease Management Toolkit, and we'll preview some of the evidence-based and promising models we highlight throughout. Just to start with an overview of the organization of the toolkit, like many of our evidence-based toolkits, this one is organized into seven modules. And with this screenshot of the opening page, you can see that all of the modules on the left-hand navigation, you can click on each one to open the module and learn more. And so I am again just going to preview a few of the modules at a very high level, mostly focusing on module two and some of the models and promising approaches.
Just to start with our module one, this is our introduction to the topic. You can see it includes an overview of rural chronic disease management, the need for addressing in rural areas, and facilitators and barriers to chronic disease management in rural areas. And again, this is just one section from one page of this module, but in module one in our overview section, we define and describe chronic disease management and note that rural areas face higher rates of many of the most prevalent chronic diseases. Chronic disease management focuses on improving the quality of care and well-being of people living with chronic diseases by improving access and coordination of healthcare services to facilitate self-management as the ultimate goal. And there are many strategies and approaches that have been identified for managing chronic diseases, which we'll look more at on the following slides, which is what we focus on in module two. But some activities like regular screenings, medical visits, patient monitoring, care coordination, medication management, those are some of the things we found.
This is module two. We present different program models rural communities may use for chronic disease management. And this toolkit organizes the models into eight different categories of strategies and approaches that can be used for chronic disease management to improve outcomes. We note that some programs may choose to use more than one of these models or approaches depending on their goals and the community needs. And again, you can find more information on each of these models in the toolkit. Each of these have their own page and also rural program examples, so we highlight successful rural programs that are implementing these models.
And so I'm just going to quickly walk through again at a high level what these models look like. And again, all of these have their own pages with more examples, this is just a high level. But we start with chronic disease self-management programs. And self-management refers to the activities and behaviors an individual uses to control and treat a chronic condition with the goal of improving health, quality of life and minimizing disease related impairments. And the chronic disease self-management program, CDSMP is one of the evidence-based programs we saw come up a lot. And this program has been adapted in different languages, and it's also being used for several different chronic conditions and is really designed to help people learn skills to better manage their chronic disease is on their own.
And then another model we discuss are medication management models. They're also seen as an important approach for managing chronic disease. And medication management involves helping patients manage use of prescription medications with the goal of helping to ease symptoms and disease progression. Often focuses on medication adherence. And then some of the medication management models, some of the specific ones we included also are medication therapy management and comprehensive medication management. And we also identified behavior change models and care coordination models for chronic disease management. Behavior change models aim to help individuals adjust behaviors to promote and improve health, and care coordination models seek to streamline care strategies and coordinate communication among providers to minimize disease progression. And so we actually have two other toolkits on the RHIhub website that focus much more in depth on these models, so we point readers to the Rural Health Promotion and Disease Prevention Toolkit for more information on behavior change models. And then there's also a Rural Care Coordination Toolkit for more information on care coordination.
And so community health workers and community paramedic models are also identified for programs implementing chronic disease management. And community health workers, or CHWs provide chronic disease management by helping address individual and community level factors affecting chronic disease care and outcomes. And they can help overcome barriers to accessing care by providing services that meet patient needs and meet people where they're at. And then similarly, paramedics and EMTs can serve as a bridge between patients and providers. Community paramedics can provide medical services in the home. They might facilitate telehealth visits, and they can connect people with care and other providers for additional support.
Another model we talk about in module two is the chronic care model. It is another model using chronic disease management and as a framework for improving the quality of chronic disease management delivered to patients. And it provides evidence-based guidelines that can be implemented within different parts of a healthcare system. And next, we have the care transitions models, which can help patients with chronic diseases who are transitioning between healthcare settings. And the main goal of these models is to build a personalized patient care plan that addresses patients' needs. We identified three care transitions models that are being successfully implemented in rural communities, and again, provide examples in the toolkit. And these include the transitional care model, the community-based transition model, and the Coleman Care transition intervention.
And then finally, palliative care models are also being used for chronic disease management. Palliative care is a type of specialized care that eases symptoms and the stress of managing disease and focuses on improving quality of life. It can include hospice care, but it doesn't have to. A patient doesn't have to receive a terminal diagnosis to be able to use palliative care services. And in rural areas, what we saw is that palliative care is being implemented in community settings, in hospitals, and also delivered through home health services.
And so I know this slide has a lot going on, but it's just to give you a sense of what we have included in module three. That is our program Clearinghouse where we provide real-world examples of rural chronic disease management programs in action. And these are all programs we interviewed that shared lessons learned. And each has its own page in the toolkit with more information. And you'll be hearing from two of the programs that we featured here. And you can learn about these programs in the toolkit. And there's links to their website with more information.
And then in the last slide, this is just a look at module four, which includes implementation strategies and lessons learned for rural chronic disease management programs. And this includes considerations such as staffing and resource needs, the importance of community partners and outreach, transportation considerations for these programs, and specific population considerations. And so when developing a chronic disease management program, just some of the lessons learned we heard from other programs, communities can benefit from considering resources needed for implementing these programs like the right staff, training, technology, equipment, and funding. And then we also heard that partnerships are always important component of many programs because they can provide different types of support and share limited resources.
That is all from me. Thank you for taking the time to learn more about this toolkit. We hope you'll spend some time looking through the sections more in depth. And now I'm very happy to turn it over to Doris Beckman who will tell us more about the Mobile Integrated Healthcare model and how it's being used for chronic disease management.
Doris Boeckman: I am excited to be here. And I just want to say I do wear multiple hats, as the introduction indicated. My primary role is probably community asset builders. We've been around for 23 years, but my secondary role is serving as one of the lead organizations in the Washington County Mobile Integrated Healthcare Network. And really, my discussion today is around the network and the impact that it's having on chronic disease in Washington County and the surrounding area, talking a little bit about how our model aligns very well with the Rural Chronic Disease Management Toolkit.
Just to give you some background, because I know everyone's not familiar with Mobile Integrated Healthcare, but it's used a lot synonymously with community paramedicine, but it's probably, in my book, a little bit broader than that. Community paramedicine falls under the umbrella of Mobile Integrated Healthcare. But the project down in Washington County, which has been expanded to include St. Francis County and Reynolds County is really about whole person care. The mission is to provide diverse, inclusive, whole person care. And the system design is utilizing community paramedics and community health workers and, as indicated, serving as the bridge often to the provider who can provide those services outside of an actual clinic facility. And the care, if needed, is... If there's a clinic visit needed, a lot of times it can be done by telehealth. A lot of visits are done actually from the home, in the home environment, and the care is initiated by the community paramedic. The core values, and you may have heard this if you've heard anything about Mobile Integrated Healthcare, or MIH, as we refer to it, is providing the right care in the right place at the right time. And this is just a photo of the community paramedics in Washington County.
Since we received the award for HRSA's Challenge, Mobile Integrated Healthcare in Missouri has really taken off in rural Missouri. We've partnered with some state level partners who have really seen the value of this, and we work very closely with our Medicaid program. But you can see Washington County is south of St. Louis in the blue next to St. Francis County. And we have many other rural counties that are providing MIH through MIH networks. And have actually just recently added two more, Ray County and Caldwell County. Those counties were interested, and they have now been funded. Plus we are supporting three additional communities on the Kansas side, so we were excited with that. And the map shows some of the existing programs, which were all urban based in gray, and then it just shows or displays the interest across Missouri in this particular model.
This really just outlines a little bit about what the primary goals of the program are, which is to take healthcare to the patient, serve as the bridge and the glue between the patient and all of their providers and community health worker and navigators. The system is a difficult system to navigate, so it takes an entire team. It's flow-based with standing orders. The CPs, they actually operate as physician extenders. They do a lot of care coordination in the home. And in Washington County, our community paramedics are also dual certified as CHWs, so they have a really good understanding of those social determinants of health and how to address non-clinical needs as well as clinical needs.
The telehealth is available 100% of the time. And if you're from rural communities, you know how difficult broadband is and internet connectivity. And a lot of the patients we serve don't have phones that have data or good internet capability. EMS and MIH programs, they actually have opportunities to bring internet to the home. And in Washington County, they have gone so far as to even provide satellite service when needed to be able to make telehealth connection.
We have taken the model from provider-centric to patient-centric. It's very much a patient-centered model. And we engage and collaborate with all provider types. While our model is very focused on an FQHC EMS relationship, the community paramedics and the EMS agency, they work with all providers in their community. The majority of their patients are health center patients, but they also have private providers, the hospital, rural health clinics that also refer patients to them and enroll in the program. One of the things that we learned, which was a huge lesson learned, is data collection isn't bidirectional across the EMR platforms and has been very challenging, so the EMS agency is looking to be the hub and investing in an EMR that has the capacity to collect clinical metrics as well as their EMS metrics.
This is just a graphic that's easily understood. And really, it's to indicate that referrals can come from everywhere. And most of the referrals go through a community health worker. The community health worker can be the community paramedic that's dual certified or it can be a community health worker within the health facility who coordinates the pre-scheduled visits with the community paramedic. And that is key because it's a warm referral most often. And what we've learned is that when you do that and you send out the community paramedic, they can do a home environment safety assessment, a Medicaid reconciliation, basic labs, all the things that are typically done in the clinic if you can get them to the clinic. This takes the transportation barrier away.
And then if the patient's assessed and their risk history indicates a need for a physician visit, a telehealth visit is scheduled real-time through the community health worker. And if they're specialty care referral needed, then the community health worker will schedule that visit, and they'll arrange for transportation to get that patient to be seen at a specialty visit. And the cycle just continues that way instead of the other cycle where 9-1-1 is called, the transports to the hospital, they get released, they're scheduled to see a primary care provider, but they don't go, they call 9-1-1, they end up back in the hospital. It's just changing the culture of both the way a patient seeks care and the way care is delivered.
This is a picture of what an MIH vehicle looks like. Most people think it's an ambulance or the same vehicle that 9-1-1 uses, and it is not. This is much more cost-effective. And it keeps the ambulances available for real emergencies and traumatic care. This is actually supplied with everything that an ambulance would have on it except the stretcher, and in some cases can be pulled off from a primary care MIH visit to actually respond to an emergency to do life-saving services until an ambulance can be dispatched. And we can go into more detail on what types of things are housed on the vehicle if anybody has questions about that.
This isn't an all-encompassing list of the MIH services that are provided, but as you can see at the top, chronic disease management is one. And it is really where the program started, and the model has grown from there. It includes telehealth provider, appointments, in-home diagnostics. Point-of-care testing can be done, infusions, vaccines. The community paramedics can help the CHWs close care gaps. They do lab draws, wound care, wellness checks. They can do SDOH assessments and help navigate and link to resources, in-home safety assessments, med recs, care coordination, everything, non-emergency medical transportation. It's not an all-encompassing list, but it is a very robust set of services that are provided.
And this just goes back to we were very excited when we applied for and won HRSA's Primary Care Challenge in 2023. We were able to demonstrate not only do clinic metrics improve for patients and patients are healthier and happier, cost for inappropriate utilization of emergency services, whether it's a hospital ED or an ambulance declined. It is having a huge impact in this rural area.
And that impact really results from integration of care and gap closure. Because we're focused on whole person care, the point of entry may be they're chronic disease management, they're a no-show at the health center, they're not getting their labs, their metrics exceed what the standard is, so by going into the home and really working with the patients doing patient education and really reducing all the barriers that come up that prevent them from getting into the clinic or taking away some of the... And I don't want to call them excuses necessarily, but there's always a reason for why they didn't go. This removes that, and so you just naturally see their clinic metrics go up.
What we found was there is a lot of communication between the providers. And you have to have the buy-in and the provider champions, and the medical director really needs to be on board. And in Washington County, the ambulance district and the health center actually have a shared chief medical officer because that really streamlined and improved quality because there wasn't always any... Communication can sometimes get out of sync when you have multiple agencies working together, so this removed that barrier. And they've actually even started co-locating some of their shared talent. They have CPs that are paid for that serve the ambulance district as well as the health center and are involved in quality. And they are all housed out of the same location. They more or less have a campus where their MIH folks are housed.
The care gap closure is really around the engagement of the CHWs and the work that they do and linking patients to telehealth. And one other thing that was a real gap that we identified early on was workforce training and education. Obviously in Missouri when you promote to a CP, you're taken out of EMS as a paramedic and moved to a primary care role, and that created gaps on the EMS side so we needed to backfill a lot of those positions. And so then you would promote an EMT to a paramedic, but then it left a huge hole on the EMT side. We had to really look at how to bolster workforce and a career ladder that was supported to make that happen to continue to sustain MIH.
Why it works; again, it's integrated care. They may present with chronic disease, but they may have co-occurring substance use or a co-occurring behavioral health issue. They may be a chronic care patient that also is pregnant and needs maternal healthcare, prenatal visits. This is just some pictures of an individual of an elderly lady who her biggest issue was actually non-clinical. She was a hoarder and lived in a horrible housing environment and was chronically sick because of the environment she lived in. And they actually were able to relocate her to new housing and were able to really improve her clinical measures, so it was a win all the way around. And she is still in the program and doing very well.
Data and compliance. We learned early on that data is essential to make your case on anything. What we collect and why, clinical data, clinical metrics, we have to be able to demonstrate that the services being provided are making a difference, especially on those chronic care measures. But we also realized even if you address the clinical measures, if you didn't address the non-clinical measures, it had an impact on the clinical data, so we started tracking both so that we knew what most patients were requiring and the time investment needed for both.
And where to collect it is the big challenge. We started out collecting it in the health center EMR; that didn't meet all the needs of the data, so then it was tracked manually. And now we've kind of moved to it needs to be at the EMS because they're kind of the hub. They work with multiple providers. And so you can't document in nine different EMRs; it has to be one that can then push to those other EMRs. And I think we're getting very close to overcoming that challenge. And we also have to do a lot of compliance work. Obviously anybody that does quality and data collection knows garbage in is garbage out. And we have to really focus on are we documenting the right things in the right place? And is it mapped correctly so that when we get the reports, we get the data that we want? And ultimately, data integration, that's just really the focus for our project moving forward. And that is time consuming and it's also can be costly so it's a slower process than we wished.
The impact of care gap closure, and that's utilizing the CPs and the CHWs, has improved patient adherence for appointments, fewer ED visits, fewer EMS calls, improved medication compliance, and obviously all of those things improve quality of life.
The clinical quality data, this is what I really wanted to get to because this is the chronic disease management. And the HEDIS measures that are being tracked by the health center. And as you can see, when looking at all of the health center's clinic patients, that's the column in yellow, compared to the MIH cohort in 2023 where they got the CP services in the home with the support of the CHW to address their social determinants of health, every clinic metric improved. And I won't go into this. When you get the slide, you can look at it in more detail.
This is just another example of how to show it. If you look at the bottom of the slide, you can see 2022 clinic compared to 2022 MIH. Those are the two lower lines. The MIH was always much higher. Same for 2023. And really with the exception of the A1C9 or... I can't read it on my screen, but the third metric, everything was much higher, so it really has a tremendous impact.
Documenting and analysis. Again, we can't stress enough from our perspective for not just funding but for research and just local network support good documentation and analysis is what drives the quality and helps us ensure sustainability long term. And we learned early on that we needed to enlist help of others with knowledge and resources, so we've got funders to the table, our MO HealthNet, which is our Medicaid program and the Medicaid MCOs, are all of the table, and our Missouri Primary Care Association, which is the association that supports all of our FQHCs. And by involving them, we've been able to gain their support because we've been able to demonstrate some of these results for them.
This is very specific to our FORHP HRHI Heart Disease Project. And you're one of the first to see this publicly. This is preliminary data; I do want to qualify that. But our primary care association was looking at our data for particular cohort. And while this cohort is very small, it's only 18 patients because we had to rule out a lot of... We had to have very specific criteria to make it analytically correct. And so we looked at 12 months pre, 12 months post enrollment. And what you can see is a huge reduction in inappropriate ED utilization. And then you see a little bit of an increase on the medical side, which makes sense. And you see an increase in pharmacy costs, which also makes sense because patients are taking their meds, they're becoming more compliant. It does cost more on the primary care side. But had the CP program, MIH program not been implemented, not only would you have been at the same level of cost, it would've been more because many of these patients are complex. Some of them have COPD. It's really just redirecting care to the primary care setting in the home.
I really just wanted to really thank RHIhub and NORC because MIH networks and programs address key elements of chronic disease management best practices, and it's all of the same things that are similar to those that they have in the toolbox, so it's a great referral source. As we roll out new networks, we will be directing them to these resources to help them if they don't have expertise in this area. FQHCs obviously have a lot of knowledge on many of these things, but our EMS agencies do not, so it's a great tool to help get them up to speed. And it's really a great resource for helping address SDOH and health equity and health literacy, which all of these things are. Everything on this slide are addressed through MIH programs, every single one of these things.
Our most recent project, and then I'm going to wrap up, is the Cardiovascular Disease Intervention Project, which is a contract between our Missouri Department of Health and Senior Services and our Missouri EMS Association. And they were funded by the Centers for Disease Control to educate clients on the risk of elevated blood pressure, hypertension, screening clients for SDOH and collaborating with CHW. We're in year two. We started rolling this out with our MIH networks. We have two enrolled in this program, and our goal is to have six. And basically, the trained community paramedics will be providing services in the home that can link patients to self-measured blood pressure kits and remote monitoring and really doing a lot of patient education.
These are just a few of the things that the project will collect mostly around hypertension, cholesterol, SDOH screening, and connection to lifestyle change programs. And ideally, we hope all the sites will monitor their clinical metrics. And this is my information. And I will turn it over to Gilbert.
Gilbert Rangel: Well, good afternoon, everybody. And thank you for having me here. And really excited to talk to you about our project here in Lake County, California. We're about two hours north of San Francisco, just to give you a location. And a little bit about Lake County is that we are a rural community, as most of our presenters might be familiar with, or some of our attendees. And in California, we were rated the poorest county, I think about three years ago three years in a row. Really under resourced and trying to work collaboratively within all our agencies to leverage those resources to be able to help people. Today we're going to talk about the power of using culture to really reach patients that are in dire need of attending their wellness. It's a really down at the ground level presentation of how we get people to participate in their wellness. I'll be discussing that with you.
I want to first highlight what is holding us back in terms of patients and individuals being able to live healthier lives. The first is limited medical resources. Just to give you an idea of what I mean by that, in Lake County, we're about over 1,300 square miles, and we have three facilities not fully equipped that are medical facilities offering services to our residents, which we're about 68,000 residents here. One dialysis clinic and kidney disease linked to diabetes is one of our growing conditions here that we're pretty much putting a burden on that dialysis clinic and having to sometimes have patients travel out of county to seek that dialysis as three times a week. We have a huge reliance on telehealth. While most of our patients prefer in-person appointments, we're having to push more and more into the telehealth resources because we don't have enough medical professionals here to be able to help address the challenges that we face.
The second thing holding us back would be poverty and the culture of poverty. Lake County, as I mentioned, was deemed the poorest county in California. And as you heard in my introduction, I've worked in education and now in the health field. We find that poverty really affects people's ability to attain success or progress. To give you an example is sometimes folks aren't used to receiving help because there's this sense of dignity related to that, or they don't want to disclose that they're in need. Those type of perspectives really cause a hindrance on getting help and resources out to our community. That culture, obviously with poverty, that means that our diets and the things that we eat are probably of less health value per se. We're consuming foods that are more damaging to us. We're living lifestyles that are not conducive to proper health. That is what I mean by the poverty of culture.
Language, specifically Spanish, you would assume that in California being a border state with Mexico we would have ample Spanish speakers, and that is true for most of southern California and bigger cities, but here in rural communities, particularly northern California, we don't have the bilingual staff or certified professionals to be able to offer services in Spanish. This becomes a big frustration in the community as well as a roadblock in agencies and organizations trying to get services out to the community. Some of those frustrations, to highlight those, I was just in a community meeting probably about two weeks ago and it's something that I've witnessed is the translators that try to help or interpreters that try to help doing the best they can sometimes will misinterpret the message and relay the information incomplete or not totally correct. Imagine this type of situation in a medical setting where they're giving you a diagnosis or a treatment plan or something. If you tend to rely on your medical assistant that might not have the full skills necessary, this could be challenging.
And particularly even more, we do know that medical institutions do rely on professional translators via video conferencing, for example, but when we do these health education programs out in the community, if we don't have the people with the language skills necessary that we cannot communicate properly and a lot is missed. And also, the cultural relevance to language when patients communicate back what they're trying to tell us about their own health can be also hindered because of the language barriers.
The next would be cultural understanding and connection. One thing about working with native communities... And I'm not Native, by the way; I’m of Mexican descent. One thing for me that was challenging walking in to do these services where Native communities was our Native tribes here tend to be really closed in. They keep to themselves. It's a really tight circle to get into. Then that could be off-putting for someone and trying to get in and trying to work with those communities and really not having that connection or understanding of how things work can really cause a lot of delay or just not efficiently delivering the education or anything you're trying to achieve with the certain groups. There's a need for that here. While our clinic is Lake County Tribal Health and it is formed by the six tribes that are here, they all put in to have this clinic. And here, if you come in person to the clinic, you'll find a lot of cultural relevance and connections, but sometimes we do hire staff like myself that are not Native, and going out to deliver these services can be a little bit challenging in that sense.
Then the big one here is poor self-management. Because of the prior things that I've mentioned, that leads to people not managing properly. And what I mean by that is with the lack of cultural and linguistic connections, sometimes we don't even know how to interpret our own medical context. We're being told things that are related to our health, but we can't put it into a context based on our culture or language to understand exactly the seriousness or the need that we have pertaining our health, so we often feel confused or we feel alone trying to figure things out. We have existing cultural habits that are not aligned with the healthcare that we need. For example, from my community, the Mexican Latino community, we tend to have big meals. And if you go to a home and you don't finish your meal, you're looked at in an ugly way because you left some food behind. And on the flip side, your host is always prone to give you more than you need. Those type of existing cultural practices really get in the way of managing conditions properly.
And then finally, I primarily work with elders within our tribe, so isolation is one. Some folks just not having a family or friend to motivate them to take care of themselves is also a barrier in achieving self-management.
And then finally, I have negative views of our healthcare system. You might've heard this as well in your own areas is people believe that a diagnosis is because they want to say you have something to be able to make more money off of you or get you on medicines. And that's a general perspective. It's just not understanding the need for wellness and health and equating it to an economic driven system so to speak.
We also feel, for example, I know from the field I get a lot of commentary that, "My doctor really doesn't listen to me. I go there and I have this and I really can't get to say it." And what happens is they hear locally for us, they don't understand that our healthcare system is burdened. We're right at the limit. Our clinic here operates from 7:00 AM to 7:00 PM. Some doctors stay after 7:00 PM to catch up on notes. It's a really limited resources community that is causing a burden and taxing really hard on our healthcare system, which is why, for example, appointments here are about 10 minutes to 12 minutes. And sometimes patients have a long list of things that they want to discuss, and we probably don't get to even have of those. And it's that lack of understanding, so part of my work is also to educate on that aspect, on get yourself a list and find your three main bullet points; bring those and talk. And if you need a follow-up appointment, then schedule a follow-up appointment because you're not going to get everything through.
The adverse impact of all that that I just mentioned, when the resources are limited, there's barriers in our culture and language, there's a lack of confidence in the healthcare system, the challenge is just amplified for patients trying to manage their health. If we put out education and people can't connect to it because it's not culturally relevant and all those sorts of barriers that we face, then we continue with our unhealthy habits or we adopt new ones. There's an ongoing joke here, and to me it's a sad joke is the tribe here or the Native people here are Pomo people. And they call Pepsi the official sponsor of Pomo people because it's just something that they drink a lot. I have some classes where they bring soda thinking that we offer a meal and that's what they bring. As we're speaking about nutrition and all, we're talking about sodas and the effects of consuming soda, folks just really are ingrained in these practices with their own health that are not conducive to healthy lifestyles.
And then one thing is, as we all know, you start off with diabetes at some point in your life, you don't take care of it, then you end up with neuropathy, kidneys, other conditions. The conditions are compounding over time. Many of our patients, like I said, are elderly. And these programs that I oversee, they have a number. I would say average is about four chronic conditions with those patients. And obviously quality of life declines. But the other factor is what are we role modeling to our children? Within Native communities, we need to remember that it's a tight community, well knit. We see what our elders do. We learn from our elders, we learn from our adults, and we practice what we see, then we end up continuing the cycle of poor health management affecting the community at large.
And you've heard the statistics, Native Americans tend to live five years less than non-Natives. The average life cycle would be about 73 years. We've seen other that Native Americans on the chronic health death index, they hold the five top positions in diabetes and chronic respiratory disease and those type of conditions. It's an impact that we're facing. Primarily with Latinos here, diabetes type two is what's prevalent there. There are conditions that we're trying to face to be able to help these communities.
Why the cultural integration? First of all, for us it's important. And as you see the image, we have an image where we use some of the Native patterns as tablecloths there to create that environment. You see in the room, we have a dream catcher back there and some other things that people can relate to in 45.12terms of culturally and cultural integration. But primarily, we want to build trust. This is how we build rapport. The belief is that if you're familiar with something or there's something you connect with, you're going to be more comfortable. It's going to be your safe space. Think of yourself as in a different country where you don't speak the language there and you find a fellow person that speaks English and you feel that relief, that connection. It's the same thing that we try to approach here with doing the cultural integration that we bring for the Native American and Latino communities.
If we're able to successfully connect people that way, and that starts for us from the moment we put a flyer together that connects culturally to our potential patients, then we know they're more likely to participate. And it's as simple as putting something in Spanish. People will call and say, "Hey, I saw this diabetes class. Can I come and join?"
And once we have them in, once we get them to participate, we tend to keep those folks engaged for the long run. It's not a come to do your DSMP for six weeks and everybody on their own way, but we often offer other service supplemental programs to keep people engaged. And one of our sites, it's a tribal site, they've been with us for two years now, another Spanish speaking site called La Voz. They've been us with about a year and a half. We have this continuum of services to be able to improve health outcomes and definitely break the cycle of health disparities.
I hear just put in an outlay fashion, the cultural integration strategy. As I mentioned already a couple of times, I'm a non-Native, so for me to work with the tribes, I had to build relationships first. My first approach to that was I'm going to offer two options; they could come to the clinic or I could go to the tribes, to the reservations and do the classes there. Everybody opted for having me come out. In the photo there, you see me with one of our patients. That is at a reservation and one of the elder meeting rooms.
And starting to build relationships for me started with the question, "What tribe are you from?" I wasn't going to try to stretch it and say I was from an Aztec tribe, because that wouldn't be true being that I'm from Mexico. And obviously I wasn't going to lie, said I was from the local tribe, so I just was honest and said, "No, I'm Mexican guy here. I'm also diabetic. And I've had my own journey in health. And I'm here to help spread the word on how we could get better." And from that point, we started building relationships. I learned a couple things that were culturally relevant. For example, when elders speak, everybody listens. Those little details are really valuable to pick up on because they help you create a good rapport and a good connection. And eventually, now at this point where I'm at right now, I'm not only welcomed by the elders groups, but their family members now recognize what I do and what I bring. And it's just a really good community to be part of and bring these programs.
And the other thing I came to understand about working with our tribal communities was that the sense itself of community; everything's done together. We have meetings; they're always together. And we have something to discuss, whether it's personal or related to the content of the meeting. We all listen and be respectful to people speaking. If we're asked to share our perspective, we'll do that. It's this sense of community that's really oriented to be more like a family that really has helped me build those relationships in the tribes that I work with currently.
The next piece is culturally relevant materials. As you see, I have an example of a flyer. When I first came out to the job here, we had a generic flyer that had a non-Native and a non-Latino couple looking on the horizon in English. And that's where I thought, well, we need to bring something that represents more of the people we want to get engaged. This one's all in Spanish. We have family, people that look familiar to our target population. And even that to the color schemes of things that we use, when we do presentations and our materials that we give out for different courses that we do, for example here, Pomo culture is really, if you see anything, the regalia, it's a lot of orange, brown, earthy tones, so we bring those even to slide decks that we do so people can see those hints of culture in what we present.
And the other thing I like doing is I like cross-walking information. For example, if we're talking about physical activity, I will cross-walk it to a cultural point of reference. For example, when I'm doing a class with our tribes, I say, "What do we do when we dance in ceremony?" And we'll talk about movement and we'll talk about what muscle groups are being affected by that movement. We'll talk about the stamina. And then we'll relate back to our presentation of physical activity and exercise.
We always foster culture in the program. In the picture here you see a sample menu for a... This was Day of the Death celebration a year ago. And that day patients wanted to try... Well, they wanted to test me to see if I could put together a mole, which is a traditional dish for Day of the Dead using tofu and cauliflower rice. I stepped up to the challenge. The dish you see there is tofu and the mole sauce, which is a dark brown, and then the cauliflower rice over there with tomato sauce and the red.
And then with that, we actually made a whole nutrition exercise. We discussed my plate and integrated again the culture and fostering that culture in the program. This speaks a little bit more to the cross-walking of what the materials say. If you've done the SMRC self-management courses, you know that they're pretty much straightforward frameworks. They don't have cultural relevance, so we cross-walk as much as we can to be able to get folks to understand things.
And essentially, as Doris mentioned at some point in her presentation, it's all about behavior change so we use these tools and these strategies to get people to change behaviors. Here, essentially for us was try foods that could be conducive to health, portion sizes, serving sizes and all that. We taught a whole class just based off of this mole and celebrating the Day of the Dead on that particular day.
Then the other part as a strategy is continuity. And what I mean by this is we're more successful if we keep chipping at the block of our wellness. For us as a clinic, we're in the position where we could send somebody out weekly to the tribe to do these services. And like I said, we have a tribe that's been with us for two years. I think the newest add-on has probably been with us for about eight months already. We have longevity with these particular patients, and new patients keep folding in. That definitely shows off in the clinical measures. We track A1Cs, blood pressure and all that.
I haven't checked this year, but in our first year we got people to within range A1Cs, 60% of our cohort. And then 80% of those got blood pressure under control, and then 50% were able to get to healthy weight. And it's because we continue. We typically start off with introducing one of the self-management courses, and then we do the supplement programs like Bingo Size. And we'll do them for the full extent of 20 weeks or 10 weeks, whichever the group prefers, and then we'll move into a nutrition-based program that what can I eat? We're reinforcing and we're reteaching everything we talked about in chronic disease self-management.
And my key rule for myself and the other facilitators is we need a model and we need to reteach and we need to speak to what we learned and everything we do. In the picture there below with continuity was having a cake. We talked about how much cake could we have. It wasn't going to be an eighth of that cake, it's going to be a 16th of that cake that we were all going to get. We made sure that those that were on sliding scales for insulin brought their insulin that day. We reinforced the things that we need to do when we have these sort of opportunities. Sometimes somebody will bring in a bag of salad or something to share in a potluck, and we'll take the labels and we'll start charting out how many carbs and how much can we eat of everything to make it all within the range of what's acceptable for our diets? Again, reteach and reinforce what we've learned contributes to that continuity of our programs.
In terms of results, for us it's really promising that we create safe spaces rooted in cultural understanding. We see the picture here of the two elders giving each other hug. That day after class, one of the elders just wanted to share that they were living in isolation, and because of our class, they were more motivated to come out, more motivated to connect with friends again after being two years in isolation. We respected that. We let them take over and share what they had to share. They wanted to get up and hug each other. Again, creating that safe space to just talk and learn and be on this journey for our wellness.
Empowering self-advocacy with cultural relevance, we want to make sure that what we teach has a cultural relevance so that people feel empowered whether it's we say it in their own language, whether we bring cultural elements to what we're teaching. At the end of the day, the message we want to say is for who you are and what you are about, continue to advocate for your own wellness.
Promoting health improvements. Like I mentioned earlier, we have a continuum of programs. You could see here now these are some folks that already been through our diabetes self-management and a chronic self-management, and now they're doing Bingo Size here. And believe me, this class has been one of the favorites across most of our groups. This particular class you see in the picture, we have them now at a point where they could do cardio for 30 minutes straight. And reminding you that these are elders 55 or over in age. Our oldest elder in this class was 83, and she was keeping up with the exercise. We constantly celebrate those milestones. I continued to say, "Hey, stop. Wait for a minute. You did 30 minutes." And you only come once a week. Imagine if you exercise more often, what would your endurance, what would your stamina, your strength be at what level?
And then when we get clinical measures, we share those back with them. "Hey, I noticed you went to do your labs. Here's what you have. You're doing really good. Have you met with your doctor yet?" And we also encourage now building that relationship with the doctors. And through the self-management courses, we teach them how to communicate to their doctors to make it more efficient for them and effective for the doctor, which leads to the next piece which is rekindling the trust with culturally sensitive care.
For us, it's bringing a full circle. The clinic, if you walk into our hallways, it is representative of the culture that we have here. We see artwork, we see... Every little corner, you see something that reminds us of culture. Our staff are aware of the culture. For us to do these education programs outside of the clinic and connect it back to culture is full circle for the patients. And we've actually seen increase in patients coming to their appointments and keeping up with their labs and checkups since they've been participating in these programs.
Kristine Sande: If our speakers are able to stay on for a couple of minutes, we could maybe take a couple of questions. There was one question about billing for Mobile Integrated Healthcare and whether you're able to bill CHI to Medicare. And does your Medicaid reimburse.
Doris Boeckman: Mm-hmm. And I basically indicated that we are currently testing six CPT codes through our Medicaid, MCOs, managed care organizations. We're working toward getting reimbursement through that route. It'll take a state plan amendment in order for Medicaid to fully do CP reimbursement. Our hospital EMS networks are actually billing chronic care management codes and getting reimbursed through Medicare. A lot of the sustainability for the program is through the health centers who bill the telehealth visits. And they contract funds over to the CPs and grant funding right now. But we're working toward that sustainability feature.
Kristine Sande: All right. Great, thanks. And a couple of questions for Gilbert. One, could you tell us a little more about Bingo Size?
Gilbert Rangel: Yes, of course. Bingo Size was created through the Western Kentucky University. It's a proprietary program; you have to get a license. But essentially what you do is, as you saw in the images, we integrate bingo with physical... Well, exercise or physical activity. And Bingo Size has modules. You could choose to do the fall prevention or the exercise or nutrition. Essentially what it is, it's doing the things we need to do or learn and giving us ourselves little breaks to do some bingo.
Bingo Size, typically what you do is you call numbers for your bingo. And then after certain number of calls, you'll put in an exercise that runs perhaps for about a minute. You use exercise bands or you could use just small weights or no equipment at all. And it's all done seated. If you choose to do it seated, you can do it seated or standing. And so that's why it's really more conducive for elders and elderly people to do. But I put in the link to Bingo Size if anybody just wants to click on it and store it. But essentially that's what it does. What we've done, we altered it a little bit because the elders were feeling that the one minute intervals were not challenging, so we gradually went from five minutes to now a full 30 minutes of exercise, and then we just do the bingos at the end for them. But essentially, you'll find more in the Bingo Size link that I sent.
Kristine Sande: Great. Thank you. And Gilbert, another question for you. Are any of your resources translated to languages other than Spanish?
Gilbert Rangel: They're all in Spanish, primarily because that's the big group that we have here right now, currently serving them. And so we translate them in-house.
Kristine Sande: Great. And then one of the other questions was from a certified health and wellness coach and certified pain management coach, and wondering if in these programs there's consideration for incorporating coaching into patient care.
Gilbert Rangel: Is that for Doris, for me, or-
Kristine Sande: I think both of you.
Doris Boeckman: Yeah. And for MIH, I indicated that we haven't explored it specifically, but because we do utilize heavily community health workers to identify needs, and if that is a need that was identified by either the CP, the provider team or the community health worker, they would certainly link them to that. But we'll actually bring that back to our team to make sure they're looking into that. Great suggestion.
Gilbert Rangel: I think for us, it feels like we're headed that way with coaching patients or at least almost like a case management of patients, making sure they're getting all their services. As Doris mentioned, we also work with CHRs here at the clinic, so getting those social determinants of health needs met along with just helping people keep up with their healthcare in terms of reminding of appointments. Sometimes we end up facilitating communication. Someone might be stuck trying to get their medicine, so we'll run by the medical office and, "Hey, can you look into this and work on this refill?" It seems like we're headed that way. And we would like to really incorporate a coaching model because, again, just because of the consistency that we have, the continuity we have with patients over time, I think it's fit for that.
Kristine Sande: Thank you so much to our speakers for the great information that you've shared with us. The slides used in today's webinar are currently available at www.ruralhealthinfo.org/webinars. Thanks so much for joining us, and have a great day.