(Part two of a three-part story)

Everything is connected.

That, in a nutshell, sums up the current state of health care as we strive to promote wellness, improve outcomes and tame costs. Traditional boundaries are vanishing. There’s renewed recognition that an individual’s well-being involves both medical and social factors and that caring for him or her takes place across a continuum — a continuum of time and people. As we strive to promote community health and ensure that we deliver the most effective care possible, we must recognize that a provider’s responsibility no longer starts when patients walk in the door and it certainly doesn’t end when they walk out.

In this special report, we offer case studies of hospitals and a physician network that explore different ways to enhance clinical integration to improve the quality of patient care and, in the process, reduce unnecessary costs. We hope the lessons they learned and the insights they provide guide other hospital leaders as you move your own integration efforts to the next level.


Spectrum Health, a Michigan health care system serving both urban and nonurban areas, is striving to quantify the benefits that community health workers provide to patients with chronic conditions. The initiative demonstrates how wide-ranging health care networks, like Spectrum, can adapt specific strategies to meet the needs of sometimes very different patient populations.

On any given day, community health workers from Spectrum Health United Hospital and Spectrum Health Kelsey Hospital make home visits to residents living near the hospitals’ small-town locations in Greenville and Lakeview, 30 and 45 miles north of Grand Rapids, respectively. They may be following up on a recent hospital discharge, monitoring diabetes or educating patients about how to manage their chronic obstructive pulmonary disease. The visitors' clients appreciate the personal attention and education, and now a Spectrum Health study has documented the visits’ positive impact on health outcomes.

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“We have been using community health workers for many years,” says Kenneth Fawcett, M.D., vice president of the Healthier Communities department at 12-hospital Spectrum Health in western Michigan. “We are very data-driven and want to use this precious community resource for the best possible outcomes.”

The effort began when Healthier Communities created its Core Health program to focus on urban communities in Grand Rapids, the Spectrum system’s home. With an annual operating fund, Core Health works to improve access to care and resources for the city’s underserved adults, children and infants as well as those at risk for poor health outcomes, including adults with chronic conditions. The program predominantly employs local community health workers who often have overcome the same obstacles and access barriers their clients confront.

“These individuals have faced challenges many of us take for granted, such as food insecurity, a lack of transportation and poor housing,” Fawcett says.

The results are impressive on two key fronts, he says. First and foremost, health outcomes have improved. Second, the program provides a positive return on investment through cost savings, chiefly through fewer emergency department visits and hospital admissions.

Spectrum Health next wanted to explore whether the Core Health program could be replicated successfully in the surrounding countryside. “We exported our program into the Greenville market, where our United and Kelsey hospitals serve rural communities and have a history with this type of work,” Fawcett says. “Although the challenges of a rural environment are different, we find the Core Health program is every bit as effective [there as in Grand Rapids], possibly even more so.” In some cases, people are using the ED more than in the past, but, he says, “That’s an incremental expense offset by early intervention that has prevented hospital admissions and readmissions.”

Running the numbers

The rural Core Health study was conducted with the two community hospitals between March 1, 2013, and June 30, 2015. It included 277 volunteer patients with heart failure, diabetes or both who were identified as study candidates by their physicians, inpatient care coordinators or community agencies. The participants, ranging in age from 50 to 65, enrolled in a yearlong curriculum in which community health workers taught them self-management of their chronic conditions. Asthma and COPD have been added to the program's eligibility criteria for 2016.

Over the course of the 27-month study, researchers found that both cardiac and diabetes patients who received at least one home visit a month had fewer readmissions, lost weight, increased their activity level, improved their blood pressure and even had fewer dentist visits than before. Total inpatient readmission charges for diabetes patients dropped by almost 39 percent, while inpatient readmission costs for heart failure patients fell by 9.5 percent, and readmission costs for those with both conditions dropped slightly more than 14 percent from figures for the participant group in the period prior to the study. The reduced number of hospital readmissions saved the hospitals $495,131. More than 200 days of inpatient hospitalization were avoided, a 48.5 percent reduction. Although ED use did increase among patients who had been taught to be more proactive with symptom management, overall ED use still fell, resulting in cost savings of more than 29 percent.

“It’s very gratifying to see the impact of the program on patients’ lives, but the principles of the relationships built and the trust gained between caregivers and patients transcends a rural or urban setting,” says Brian Brasser, president of both United and Kelsey hospitals. He estimates that the rural program averages a caseload of 80 to 100 patients and acknowledges that geography is its biggest challenge. “But we’ve bridged that gap,” he says.

As for return on investment, Brasser says, “Our investment is in the community at large, and they experience the return on that investment.” He adds, “As we measure our expenses, what patients spend on health care, claims and discharge data, we can see we’ve reduced the number of ED visits and the overall cost of care because of the Core Health program and specifically because of community health workers.”

On the job

Spectrum’s community health workers come from all over Michigan and are sometimes former clients and patients. “It can be anyone in the community who wants to help,” Fawcett says. “There are more people wanting to do this work than we have open positions available.” Following training on the program’s core competencies, including patient advocacy, documentation, legal and ethical boundaries, and healthy lifestyles, community health worker teams typically carry a panel of 25 patients, overseen by a nurse case manager and sometimes a social worker, who also conducts patient site visits.

 “I know how I struggled with taking care of myself,” says Ardreen Adair, who has been a Core Health community health care worker for 10 years. “I saw others struggling in the same areas, and I wanted the opportunity to give back, to break down the barriers I had.”

The rural outreach workers have been able to reduce a 20 percent no-show rate for physician appointments by seeing patients in their homes. The workers set goals with patients — from exercising to recording what they eat — and follow up to make sure the goals are achieved. And, because they are local, too, outreach workers tend to connect quickly with area residents.

“Community health workers establish trust with our patients and help create individualized care plans,” Fawcett says. “They address the social determinants of health as well — for example, are patients forgoing medication for groceries? We’ve told them, ‘You can be the eyes and ears of the primary care physician.’ They are connected to community resources, so they can help patients move beyond survival mode to managing their health.”

According to Kenneth Anderson, D.O., chief operating officer of the American Hospital Association’s Health Research & Educational Trust: “The theme running through all of our research is that different communities express different needs — there is no one-size-fits-all approach — but the usefulness of community health workers runs through them all. Community health workers create a bridge between hospitals and community needs.”

Community health worker initiatives typically follow one of four basic models, Anderson says, based on outreach goals:

Anchor role: Community health workers are part of a holistic, comprehensive set of health care services, anchoring community infrastructures.

Specialist role: The hospital or health system focuses on a chronic condition, such as diabetes management, and community health workers help to disseminate best practices to the targeted community.

Convener role: Community health workers help to provide targeted outreach responses by bringing together relevant stakeholders.

Promoter role: Community health workers provide education, outreach and comprehensive disease management in a focused collaboration with the hospital or health system.

 “The complexities of care need a quarterback to connect resources around the individual, and that quarterback knows the resources of the community and understands its unique culture,” Anderson says. “This process has evolved through the recognition of the complex needs of people in the community and hospitals’ recognition that they need patient-centered, coordinated care across services.” Anderson adds that over the past 10 to 20 years, more social service needs have been identified in community needs assessments.

“If we really want to improve the health of the community, we will have a greater impact if we work on the social determinants of health,” Fawcett says. “And it has to start at the top. The board and the C-suite need to ask, ‘Are we a health or a health care organization?’ And we must define ‘community’ more broadly than those to whom we provide health care services.”

The chief executive’s role 

Anderson says, “The CEO needs to rally the resources to support connection points with the community." Patient and family advisory councils, networking with other health systems and ongoing attention to regular community needs assessments can ensure that the chief executive is customizing the organization’s efforts to its community as well as embracing population health management strategies driven by health care reform, he says.

“The key is to first understand the health care needs of the community, then make use of the available resources and keep an open mind,” Brasser says. “Look to proven models and adapt them to the specific needs and resources of the community served.”

In designing an effective community health worker program to match those needs, Brasser says: “It’s a process of change management. All stakeholders need to be informed so there are no unforeseen challenges, and it needs to be easy to make referrals. The information on the program needs to be available and understood by the community. It took time for that to happen, but we have a really talented group supporting this effort and, once we had results that showed value, it really took hold.”

Being a part of a large integrated system also has been key, says David Mack, chairman of both the Kelsey and United hospital boards. “Our community health worker efforts took off when we joined Spectrum. In today’s health care world, it’s all about resources and expertise. They gave us the technology, the training, the additional staff resources for this program — it’s the best thing we ever did as an organization.”

“It’s amazing the need that’s out there,” Mack says. “It’s very rewarding for us as a board to see this program materialize. We’ve always had a visiting nurse program to help people when they were sick, but this has expanded to be so much more. … We’re all very proud to represent these two hospitals.”

Fawcett agrees. “That’s the beauty of community health care workers — they are a tremendous resource with unlimited potential for the future of health care,” he says.

“Alternative models of health care will continue to evolve and spread,” Brasser says of Spectrum’s community health worker initiative. “As we think about moving care to the most appropriate setting, we will continue to make this a compelling opportunity to create patient-centered care.”

A journey to wellness — and more

What Gordon Graham (pictured at right) initially thought was a bad case of the flu on April Fool’s Day 2013, turned out to be a heart attack. The 58-year-old resident of Howard City, Mich., some 35 miles north of Grand Rapids, had open heart surgery and is doing well today.

“I had a widow-maker and lived — I’m the luckiest man alive,” he says.graham-community-workers

While still an inpatient at Spectrum Health Medical Center’s Fred and Lena Meijer Heart Center in Grand Rapids, Graham was invited to participate in a Core Health Program study of community health worker home visits as part of his cardiac rehabilitation as well as to address his diabetes. He said yes and attributes much of his quick recovery and improved health to his community health workers’ visits.

“Their personalities were fantastic — like good friends you’ve known for a long time,” Graham says. “Cindy and Shelly came to our house, took my blood pressure, checked my weight and tested my blood sugar. They gave me pamphlets on blood sugar and foot care, told me things to watch — and they taught my wife how to chart everything I ate, how many carbs per day.”

A nurse from the medical center also saw him for regular home visits for two months following his surgery. Cindy and Shelly checked on Graham twice a week for two months, eventually tapering their visits to once every two weeks and then once a month over the course of a year.

 “They said they couldn’t see coming any more once my wife got the charting down,” Graham says. “She told them they were good teachers.”

“Anything we asked them, they had an answer or brought the answers back the next time they visited,” he says. “My wife asked a lot of questions — and I learned a lot by listening.” Graham says he now understands what he can and can’t eat and the basics of healthy nutrition.

“Diet was the biggest change I made,” he says. “Now I look at labels — I know that just because something says it’s low sugar doesn’t mean it doesn’t have carbs ... and that carbs [that most often reduce to sugar] are not just sugar.”

Ten weeks after his surgery, Graham returned to his job as the grounds operator for Ferris State University in nearby Big Rapids, and he gives Cindy and Shelly a lot of the credit for his readiness. “They gave me the confidence to go back to work,” Graham says. “I’m pretty active — the students who work with me can’t keep up.” The proof: A year after his surgery, he challenged one of his students to match him in one-armed pushups. The student did seven; Graham did 10.