SummaryThe Community Health Educator Referral Liaisons project helped patients to reduce risky health behaviors (e.g., drinking, smoking, physical inactivity) by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians. Originally implemented between February 2006 and July 2007, the program included four liaisons who worked with 15 primary care practices in three Michigan communities, referring patients to community preventive health services and offering counseling and encouragement to help patients achieve their health-related goals. The program resulted in improvements in body mass index and self-reported health status, with these gains being largely the result of reductions in risky health behaviors. Although the Community Health Educator Referral Liaisons project was discontinued in these practices after grant funding ended, the same basic approach is now being used with similar success by Genesys HealthWorks with two other at-risk populations in Genesee County, MI.Moderate: The evidence consists of before-and-after implementation comparisons of key measures of health-related behaviors and health status.
Developing OrganizationsGreat Lakes Research Into Practice Network (GRIN)
The project was initially a joint effort of researchers from the Great Lakes Research Into Practice Network (GRIN), the Michigan State University Department of Family Medicine, and Genesys Health System. As noted, Genesys HealthWorks has now adopted the model.
Date First Implemented2006
Patient PopulationThe program was originally implemented with patients in 15 primary care practices in three Michigan communities. At present, Genesys HealthWorks uses the model with more than 26,000 low-income, uninsured adults who receive access to a patient-centered medical home and basic health services through Genesee Health Plan, and with more than 48,600 patients of 27 primary care practices in the Genesys Physician Hospital Organization.
Problem AddressedUnhealthy behaviors contribute to high mortality rates in the United States. Those who engage in risky behaviors typically receive limited (if any) behavioral counseling services from physicians. Patients who are referred to external counseling often do not pursue these services.
- 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
- Little counseling 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 ActivityThe Community Health Educator Referral Liaisons project helped patients to reduce risky health behaviors (e.g., drinking, smoking, physical inactivity) by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians. Originally implemented between February 2006 and July 2007, the program included four liaisons who worked with 15 primary care practices in three Michigan communities, referring patients to community preventive health services and offering counseling and encouragement to help patients achieve their health-related goals. Although the program was discontinued in these practices after grant funding ended, the same basic approach is now being used by Genesys HealthWorks with two other populations in Genesee County, MI (although Genesys uses the term “Health Navigator” rather than “Community Health Educator Referral Liaison”). Key elements of the program included the following:
- Referral to liaison: Clinicians described the liaison services to patients with one or more of four unhealthy behaviors—smoking, alcohol use at a risky level, unhealthy diet, and physical inactivity. (At Genesys, the focus for Genesee Health Plan patients is primarily on supporting healthy behaviors for those with identified tobacco use, chronic disease, and/or a recent visit to the emergency department and the focus for Genesys Physician Hospital Organization is on engaging patients in healthy behavior change through a patient-centered medical home initiative.) For interested patients, clinicians completed a basic liaison referral form and faxed it to the liaison, who worked out of a community location such as a home office.
- Initial and followup telephone contact: The initial conversation with the liaison 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 liaison helped the patient set goals and create a plan for behavior change. The liaison provided services according to one of three patient tracks, as follows:
- Referral to external resources: The liaison referred patients to community-based resources. Liaisons 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 liaison made one followup call 2 weeks later to confirm that the patient contacted the resource(s) and, if not, encouraged the patient to do so.
- Ongoing counseling: After the initial call, the liaison 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 liaison.
- Communication with physicians: Liaisons 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, liaisons sent physicians additional letters at 3 and 6 months providing updates on patient goals and progress.
- Followup assessment and tracking: The liaison telephoned all participants at 3 and 6 months after program enrollment to collect followup data related to health behaviors. Liaisons used a computerized support system to store self-reported patient data and to track calls, dates of service, and clinician feedback.
- Liaison oversight and support: The project's primary investigators provided ongoing support to the liaisons through periodic, as-needed conference calls (usually once or twice a month) and via e-mail communication. The liaisons also communicated with each other on a biweekly basis 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.
References/Related ArticlesHoltrop JS, Dosh SA, Torres T, et al. The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors. Am J Prev Med. 2008;35(5 Suppl):S365-72. [PubMed]
Community Health Educator Referral Liaison (CHERL): A potential new role for primary care practice; slide presentation from the AHRQ 2009 Annual Conference. Available at: http://www.ahrq.gov/holtrop2009
Contact the InnovatorJodi Summers Holtrop, PhD
University of Colorado Denver School of Medicine
Mail Stop F-496, Academic Office 1
12631 East 17th Avenue, Room 3505
Aurora, CO 80045
Phone: (303) 724-5339
Trissa Torres, MD, MSPH, FACPM
Medical Director, Genesys HealthWorks
Genesys Health System
One Genesys Parkway
Grand Blanc, MI 48439
Phone: (810) 606-6256
Fax: (810) 606-5617
Innovator DisclosuresDr. Jodi Summers Holtrop and Dr. Trissa Torres have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe initial Community Health Educator Referral Liaisons program resulted in improvements in body mass index (BMI) and self-reported health status, with these gains being largely the result of reductions in risky health behaviors. These improvements occurred across age, race, gender, and socioeconomic status. Use of the same model by Genesys HealthWorks has yielded similar types of improvements.
Results From Initial Implementation of Community Health Educator Referral Liaisons
Results From Genesys HealthWorks
- Improvements in BMI and health status: Among the 800 participants served, average BMI fell during the first 6 months after enrollment in the program, from an average of 35.6 to 35.1. Over the same time period, average self-reported health status improved, falling from 3.2 to 2.9. (Lower scores indicate better health status, 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.
To date, Genesys HealthWorks has engaged more than 6,000 Genesee Health Plan patients and more than 6,000 Genesys Physician Hospital Organization patients with the same basic approach, achieving success in helping patients to set goals, improve lifestyle-related behaviors, and enhance health outcomes, as outlined below:
Moderate: The evidence consists of before-and-after implementation comparisons of key measures of health-related behaviors and health status.
- Many patients setting behavior-related goals: Within the Genesys Physician Hospital Organization, 6,261 patients have set 12,359 goals over a 16-month period, with the goals most commonly focusing on nutrition, physical activity, weight management, tobacco use, and stress management.
- Improved behaviors: A comparison of Genesee Health Plan patient self-reports at baseline and 6 months after joining the program shows substantial increases in the percentage of patients adopting healthier lifestyle-related behaviors. More than half of sedentary participants increased their level of physical activity, more than half of all participants increased fruit and vegetable intake and consumed more low-fat foods, and more than 15 percent of smokers quit. Between 75 and 90 percent of those who adopted healthier behaviors have maintained them.
- Better outcomes: The above health behavior improvements have been associated with an approximately 50 percent decline in hospital use rates for engaged patients. For a subset of patients with diabetes, each positive lifestyle change has been associated with an approximately 0.8-point decline in blood glucose levels.
Context of the InnovationThis program was 1 of 10 included in the Prescription for Health Initiative, a 5-year collaboration between the Robert Wood Johnson Foundation and the Agency for Healthcare Research and Quality (AHRQ). Great Lakes Research Into Practice Network, a practice–based research network that participated in the study, includes approximately 300 primary care practices in Michigan. As noted, 15 of these practices participated in the initial study, including three hospital-owned family practices in Marquette, six family practices (including two Federally Qualified Health Centers) in Grand Rapids, and six family practices (including two Federally Qualified Health Centers) in Flint. Practices varied in size and the types of patients served, with significant differences in patient populations in terms of income, ethnicity, race, and insurance coverage. As noted, Genesys HealthWorks, an integrated health system in Genesee County, MI, has adopted the model for use with more than 25,000 low-income, uninsured adults and with more than 45,000 patients of 25 primary care practices in the Genesys Physician Hospital Organization. A former General Motors town with 435,000 residents, Genesee County struggles with chronic unemployment, poor health status indicators, and limited community resources.
Planning and Development ProcessKey steps in the planning and development process for the initial project are outlined below; a similar approach was followed by Genesys HealthWorks, with specific aspects of the process being tailored to meet the unique needs of the local community.
- Practice selection: Great Lakes Research Into Practice Network invited practices to participate in the research effort. Each practice was visited by study investigators, who described the liaison service and referral process.
- Hiring of liaisons: Participating practices initially hired three liaisons with health-related backgrounds who lived in the local community. A part-time liaison was later added to accommodate demand.
- Training: Liaisons received 4 days of initial training (led by the primary investigators) on behavior change counseling and motivational interviewing, followed by 3 months of iterative training on counseling techniques. In addition, investigators provided feedback after listening to recordings of several patient counseling calls for each liaison. (At Genesys, training has been incorporated into the Genesys Learning Institute, which provides education and training to Health Navigators within the Genesys Physician Hospital Organization and the Genesee Health Plan.)
- Developing resource guide: Liaisons developed community resource guides that listed available programs, costs, eligibility criteria, and insurance company reimbursement provisions.
- Creating referral plan: Liaisons and representatives of the practices developed a site-specific plan to identify and refer patients to needed resources and programs.
- Developing patient brochure: Study investigators developed a brochure for patients that describe the liaison’s role.
Resources Used and Skills Needed
- Staffing: Four liaisons worked on a part-time basis, serving three to six practices each. Each liaison worked with between 58 and 137 enrollees. All liaisons 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. Genesys HealthWorks uses four health navigators to work with the patients of 14 providers within the Genesys Physician Hospital Organization who collectively serve 24,000 patients (meaning that each navigator handles roughly 6,000 patients), and uses 4.4 navigators to handle the 26,000 uninsured patients who receive care through the Genesee Health Plan’s patient-centered medical home. Each full-time equivalent health navigator provides direct support services to approximately 500 patients per year.
- Costs: The program cost $380,000, consisting primarily of liaison salaries. For implementation through Genesys HealthWorks, the program costs on average approximately $69,000 per full-time equivalent health navigator.
Funding SourcesAgency for Healthcare Research and Quality; Robert Wood Johnson Foundation; Michigan Department of Community Health
The initial liaison program was funded by a $300,000 grant from the Robert Wood Johnson Foundation as part of the Prescription for Health Initiative, as well as an $80,000 grant from the Michigan Department of Community Health. AHRQ provided in-kind support through its Practice-Based Research Networks. Although the liaison program was discontinued when funding ran out, the Robert Wood Johnson Foundation provided a transition grant of $80,000 to fund the development and packaging of a Liaison Technical Assistance Center.
Initially funded through local foundations, implementation of the Genesys HealthWorks model within the Genesee Health Plan is incorporated into Genesee Health Plan’s operating budget. Genesys Health System supports the implementation of the model within the Genesys Physician Hospital Organization Patient-Centered Medical Home initiative, along with incentive funding provided by the Blue Cross Blue Shield of Michigan Physician Group Incentive Program.
Tools and Other ResourcesThose interested in obtaining more information on Health Navigator training through the Genesys Learning Institute or discussing development of a new program should contact Trissa Torres, MD at (810) 606-6256, or firstname.lastname@example.org, or visit the Community Health Educator Referral Liaisons Web site at http://www.aboutcherl.org or the Genesys HealthWorks Web site at http://www.genesyshealthworks.org. As one of several activities, the Liaison Technical Assistance Center has developed an implementation guide and training program that can be used by would-be adopters; those interested can visit http://www.aboutcherl.org and/or contact the program developers.
Getting Started with This Innovation
- Obtain resources: Pursue a variety of potential funding sources, including insurance companies, provider organizations, and grants from local, regional, and national organizations.
- Work closely with practices: Explore the appropriate degree of integration (e.g., whether to use on- or offsite navigators) and communication for the program. If feasible, consider locating the liaison within the practice so that he/she can meet with patients face-to-face, at least for the initial meeting.
- Consider retraining or redirecting existing resources: Existing resources dedicated to disease and care management services can potentially be redirected to focus on liaison activities, such as prevention, practice support, and linking of patients to resources.
- Ensure adequate training in dealing with depression: Many patients who need to make a behavior change also suffer from depression. Liaisons must be knowledgeable enough about depression to identify and refer those who need assistance.
- Take broad view of resource guide: The resource guide should include information on a wide variety of resources, including some that may seem tangential to behavior change (but really serve as basic underpinnings for it), such as mental health services, food pantries, and financial assistance programs.
Sustaining This Innovation
- Update resource guide: Because community resources are constantly changing, the resource guide should be updated periodically. To that end, liaisons or health navigators should develop relationships with providers to ensure that information within the guide remains accurate and up-to-date.
- Approach insurers about reimbursing for liaison services: Some insurance companies may be willing to provide reimbursement for these types of services.
Additional Considerations and Lessons
- Develop team approach: Liaisons/navigators should have varying levels of expertise and various types of experience, with backgrounds such as health education, social work, nutrition, or nursing. This diversity helps to create a strong, team-based approach.
- Consider serving entire patient population: This program can provide benefits to low-, medium-, and high-risk patients.
Use By Other OrganizationsSeveral communities are implementing projects based on the principles and lessons learned from the initial project. Since July 2009, more than 20 organizations have contacted Genesys HealthWorks to receive more information about the model. In addition, Dr. Torres has been invited to present the model at a number of conferences, including meetings of the Institute for Healthcare Improvement Triple Aim Project, the Michigan State Medical Society, and the Local Integration Health Networks of Ontario, Canada.
Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45. [PubMed]
Holtrop JS, Dosh SA, Torres T, et al. The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors. Am J Prev Med. 2008;35(5 Suppl):S365-72. [PubMed]
Glasgow RE, Ory MG, Klesges LM, et al. Practical and relevant self-report measures of patient health behaviors for primary care research. Ann Fam Med. 2005;3(1):73-81. [PubMed]
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Service Delivery Innovation Profile
Original publication: December 10, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.