Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health Status

Problem Addressed

• Preventable, unhealthy behaviors lead to high mortality rates: Smoking, physical inactivity, poor diet, and problem drinking account for approximately 37 percent of deaths in the United States.¹
• Lack of counseling services by physicians: Primary care physicians often identify patients with unhealthy behaviors but typically provide little if any counseling services due to time constraints, lack of reimbursement, lack of available staffing, and inadequate training regarding behavioral change.² 
• Failure to seek external services: Even when physicians recommend behavioral changes and external counseling services, patients often do not follow up on these recommendations.³

Description of the Innovative Activity

• Referral to CHERL: Clinicians described the CHERL services to patients with one or more of four unhealthy behaviors (smoking, alcohol use at a risky level, unhealthy diet, and physical inactivity). For interested patients, clinicians completed a basic CHERL referral form and faxed it to the CHERL, who was located in a community location such as a home office. 
• Initial and followup telephone contact: The initial conversation with the CHERL included data collection on the patient’s health-related behaviors, the patient’s preferences for activities (e.g., group-based activities or self-improvement activities), and the patient’s insurance coverage. Using motivational interviewing techniques, the CHERL helped the patient set goals and create a plan for behavior change. The CHERL provided services according to one of three patient tracks, as folows: 
  • Referral to external resources: The CHERL referred patients to community-based resources. CHERLs used an internally developed guide to identify resources including telephone counseling, self-help guides, group programs, dietitians, Web sites, exercise facilities, and Alcoholics Anonymous meetings. The CHERL made one followup call 2 weeks later to confirm that the patient contacted the resource. If not, the CHERL encouraged the patient to do so.
  • Ongoing counseling: After the initial call, the CHERL called the patient three additional times at 2-week intervals, encouraging him or her to continue with positive changes and set revised goals.
  • Combination of referrals and counseling: This track combined the external referrals with ongoing calls from the CHERL. 
• Communication with physicians: CHERLs sent clinicians an update letter outlining the referred patient’s goals and intervention plan or indicating that the patient could not be reached after multiple attempts. For patients served, CHERLs sent physicians additional letters at 3 and 6 months providing updates on patient goals and progress.
• Followup assessment: The CHERL telephoned all participants at 3 and 6 months after program enrollment to collect follow up data related to health behaviors.
• Computerized tracking: CHERLs used a computerized support system to collect self-reported patient data and to track calls, dates of service, and clinician feedback.
• CHERL oversight and support: The project's primary investigators provided ongoing support to the CHERLs through conference calls and via email communication. The conference calls were scheduled on an as-needed basis and usually were conducted once or twice per month depending on the project timeline and the needs of the CHERLs. The CHERLs also communicated with each other bi-weekly either through e-mail or via conference call during the first 6 months of the project and monthly thereafter, allowing them to problem-solve and share experiences as well as resources.

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Results

• Improvements in BMI and health status: Among participants, improvements were achieved over a 6-month period in BMI (which fell from an average of 35.6 to 35.1) and self-reported health status (which rose from 2.9 to 3.2, with a score of "1" representing excellent health and "5" representing poor health).
• Driven by reductions in risky health behaviors: Participants improved their diet, drank and smoked less, and became more physically active, as suggested by the results below comparing behaviors at baseline to 6 months after entering the program: 
  • Better diet: Self-reported diet score (using a 7-question instrument) fell from 12.8 to 11.3, with lower figures representing a better diet (a score of 7 represents the best diet, while 21 is the worst). 
  • Less smoking and drinking: The percent of participants who smoked fell from 30.9 to 25.6 percent, while the average number of drinks per occasion in the past month fell from 1 to 0.9.
  • More physical activity: The median number of minutes per week engaged in physical activity rose from 150 to 180. The average number of days in the past month that participants were not able to complete their normal activities because of mental or physical dysfunction fell from 4.8 to 3.5.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Practice selection: GRIN invited practices to participate in the research effort. Each practice was visited by study investigators, who described the CHERL service and referral process.
• Hiring of CHERLs: Participating practices hired one CHERL with a health-related background from the local community. (A fourth part-time CHERL was later added to accommodate demand.)
• Training: CHERLs were trained in behavior change counseling and motivational interviewing. CHERLs received an initial four-day training (provided by the primary investigators) followed by 3 months of iterative training on counseling techniques. In addition, each CHERL tape-recorded several patient counseling calls over the course of the study; tapes were given to one of the investigators for review and feedback.
• Resource development: CHERLs developed community resource guides that listed available programs, costs, eligibility criteria, and insurance company reimbursement provisions.
• Referral plan development: CHERLs and representatives of the practices developed a site-specific plan to identify and refer patients.
• Brochure for patients: Study investigators developed a brochure describing the CHERL’s role that practices could share with patients.

Resources Used and Skills Needed

• Staffing: Four CHERLs worked on a part-time basis, serving three to six practices each. Each CHERL worked with between 58 and 137 enrollees. All CHERLs had earned a college degree; received additional education and/or training in health education, nursing, or dietetics; and had approximately 10 to 15 years of experience in community health care.
• Costs: The program cost $380,000, consisting primarily of CHERL salaries. 

Funding Sources

Agency for Healthcare Research and Quality; Robert Wood Johnson Foundation; Michigan Department of Community Health

Tools and Other Resources

Getting Started with This Innovation

• Obtain resources: Pursue a variety of resources, including grant funding.
• Consider on-site location of CHERLs: While convenient and low-cost, telephone-based outreach and counseling may create a sense of “disconnect” between the patient and the CHERL. Consider locating the CHERL in the practice so that he/she can meet with patients face-to-face, at least for the initial meeting.
• Ensure adequate CHERL training in dealing with depression: Many patients who need to make a behavior change also suffer from depression. Combining mental health counseling and behavior change counseling may help CHERLs in working with patients.
• Take a broad view of the resource guide: The resource guide should include resources that may seem tangential to behavior change (but are really basic underpinnings for it), including mental health services, food pantries, and financial assistance programs.

Sustaining This Innovation

• Update the resource guide: Because community resources are constantly changing, the resource guide should be updated periodically. 
• Approach insurers about reimbursing for CHERL services: Some insurance companies may be willing to provide reimbursement for these types of services.

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