New York borrows a health care idea from Africa
NEW YORK — One fall morning in Harlem, Marisilis Tejeda sat herself down on the couch in the fifth-floor apartment of Ramon Jimenez, a 62-year-old Guatemalan immigrant who has had heart disease for 20 years.
It had been just over a month since his most recent hospitalization, and Tejeda, a community health worker, goes over his medicine list, making sure he’s taking his pills correctly and consistently. She checks that he’s properly limiting, and monitoring, sodium and fluids, essential for a patient with congestive heart failure. She reviews the warning signs that he must watch for to spot another brewing crisis and makes sure he knows who to call at the cardiology clinic if he notes sudden weight gain or shortness of breath.
They banter. “How did you sleep?” she asks. “Alone,” Jimenez replies, with exaggerated sorrow and a big wink.
Tejeda’s visit is an example of an approach that’s beginning to catch on in modern American health care, that of pushing care outward from expensive hospital settings and into people’s homes, keeping diseases in check and preventing patients from cycling in and out of the emergency room. It’s precisely in line with the latest thinking about our medical system: a cost-effective jolt of primary care that prioritizes communication and teaches patients to keep themselves as well as they can for as long as they can.
But this idea wasn’t built by consultants or a fancy medical school. It was borrowed from India and Africa.
Manmeet Kaur, the social entrepreneur who founded City Health Works four years ago, spent several years doing economic development and HIV prevention work in the developing world. She noticed that health care workers in countries like India and South Africa are particularly good at something the American system isn’t great at: helping patients take care of themselves, even in poor communities. What’s more, she noticed that those countries didn’t use doctors or nurses to do it. They used lay health care workers, some of them patients themselves, trained to go into the homes and communities of patients and help them manage their conditions.
“I personally saw that power of peers,” she recalls. “And I was amazed.”
In Africa and India, the idea of using lay health care workers was born of necessity. They simply didn’t have the money or resources to do it any other way. But Kaur realized that using community health care workers would also fill a real gap in American health care, where all too often patients with chronic conditions like heart failure and diabetes are released from the hospital with little follow-up and few options when problems arise except to go to right back to the ER. Unlike sub-Saharan Africa, Upper Manhattan is rich in hospitals, medical schools and pricey specialists. But it’s poor in effective community-based primary care, particularly the kind of care that can reach into kitchens and living rooms of patients like Jimenez.
City Health Works’ staff are homegrown, coming from the same community they serve. They speak the same language, in all senses of the word. Many have dealt with the same health challenges as their clients, either firsthand or via the struggles of a family member. They are the ground troops in a fresh approach to primary care, often the first health worker to bridge communication gaps inherent in an uncoordinated and intimidating health system that has failed and sometimes frightened patients, particularly in underserved communities.
Sitting in people’s homes, “health coaches” like Tejeda can make sure a heart patient has a bathroom scale to do those life-saving daily weight checks, that a diabetic knows how to prepare a meal that’s appetizing, healthy and culturally familiar, that a 400-pound woman in a hot pink track suit finally learns to use her asthma inhaler correctly, even midattack, when she’s fearful and gasping for breath.
As America confronts its long-term health challenges—an aging population, a seemingly unstoppable rise in the costs of procedures and drugs—community-based care models look to many experts like a grassroots opportunity to reshape health for the better without incurring an immense new national bill. In fact, the model may fit in well with emerging health payment models that reward the quality of care, not the quantity of care.
Today communities in nearly every state, urban and rural, are testing or expanding these approaches as they try to bolster a primary care workforce that is stretched thin, particularly for underserved populations. They’ve been given a window by a whole series of changes and innovations in health care, ranging from Medicare penalties for hospitals with avoidable readmissions to new Medicaid payment models that target chronic disease. And as the experience of City Health Works suggests, those innovations can come from some unexpected places.
A holistic approach
Community health worker programs began in the late 1980s and ‘90s, focusing on infant mortality and HIV/AIDS, and new iterations are now engaging in chronic disease and behavioral health, according to Gail Hirsch, co-director of the Office of Community Health Workers in the Massachusetts Department of Public Health, who has tracked these initiatives nationwide. They are particularly suited to addressing “social determinants of health” — things like housing, transportation and educational gaps that contribute a great deal to health status and are sorely lacking in the neighborhoods City Health Works serves.
“They are very good,” New York City Health Commissioner Mary Bassett said of Kaur’s organization. A physician, Bassett too has worked in both Harlem and southern Africa and she’s another believer in community-based innovation, including a city program that has placed health workers in five New York public housing developments to systematically address asthma triggers. It also organizes group outings so people can get out and exercise in neighborhoods where they may be afraid to walk alone.
With encouraging (though not yet conclusive) early data on patient outcomes and financial sustainability, City Health Works has emerged as a promising approach that differs from a lot of other health coaching or community groups. It’s a stand-alone organization, not an appendage to or a department within a larger health care entity. It runs an evidence-based training program for its staff of health coaches. And it was co-designed with clinicians in its community, from places like Mount Sinai Hospital, who are open to a team-based approach and who, like Kaur, understand that peer workers can sometimes reach where a physician cannot.
“It unburdens us,” said Dr. Gary Burke, a primary care physician and chief of General Medicine at St Luke’s Roosevelt Hospital, who works closely with Kaur’s team. “They come from the community, with a different perspective …. They speak the language. And they can look in the refrigerator.”
That hands-on, person-to-person connection is important to Tejeda, too. She worked for years in the finance and travel industries but increasingly found herself thinking about public health. Bilingual and outgoing, she went back to school and earned a certificate in community health work at LaGuardia Community College (though that’s not a requirement for City Health Works, which runs its own training program). She found her calling.
One of Tejeda’s roles is to be a bridge between doctor and patient. Accompanying Jimenez to doctor visits as needed, Tejeda helps him understand what they’re saying — and vice versa. Sometimes, she knocks heads together when his doctors fail to communicate among themselves. Once, she hand-carried an urgent message from an exasperated cardiologist to a surgeon who had not returned his calls. Polite but insistent, she didn’t leave his office until she got what Jimenez needed. Surgery was scheduled in a matter of days to repair a cardiac device implanted in his chest that had expired, threatening his health and causing understandable anxiety.
For Jimenez, a month without an emergency room visit, or a hospitalization, is a big deal. Never having learned to navigate the health care maze or master self-care, he had been on a 20-year downhill slide. The heart disease has disabled him; he can no longer work. He also has diabetes that was uncontrolled for years; both of his feet were amputated. His small living room is crowded with medical equipment, pill bottles, a walker and a wheelchair. But in the month he’s worked with Tejeda, everything’s gotten better.
“Before, I don’t feel good,” Jimenez said, switching to English. “Now – I’m brand new.”
For Kaur, it’s more proof of the power of peers.
A daughter of South Asian immigrants who ran a dry-cleaning shop, Kaur watched her mother endure domestic violence for decades before she finally left – an experience Kaur has only recently begun to speak of in public. She grew up thinking about concepts like “empowerment” and “agency” before she was old enough to put words to them, and those ideas and values are part of what propelled her overseas after college. Back home in New York, she met and married Dr. Prabhjot Singh — now the director of Mount Sinai’s Arnhold Institute for Global Health — and they have collaborated at home and abroad.
If Singh’s work spans the globe, Kaur’s hyperfocuses on a few New York zip codes. She developed what would become City Health Works as she earned her MBA and secured foundation funding to get it off the ground. That was 2013. They now have seven coaches, plus supervisors and support staff, and contracts or partnerships with several health plans and clinics that are testing new health care payment models based not on the number of office visits or procedures but on patient outcomes. They currently have 400 patients, and have served more than 700 overall.
“These coaches have practical tools and tips,” said Jamillah Hoy-Rosas, a former diabetes educator who is now director of health coaching and clinical partnerships at City Health Works. “They [patients] trust them. This is a person who understands me, understands my neighborhood, understands my language … They’ve gone through something similar. They can connect in a real way.”
Fostering new habits
That sense of connection, girded by a good grasp of chronic disease, came through at each stop of Tejeda’s day. Before leaving Jimenez’s apartment she pulled out a sheaf of photocopied heart-healthy, diabetic-friendly recipes from Guatemala and gave them to Julia, his home health aide, a native of the Dominican Republic just like Tejeda is. Guatemalan food is different than ours, Tejeda explained. “He’ll like these,” she promised. They agreed to shop together soon at the spanking new grocery store, with a cafe and aisles of fresh fruits and vegetables, that had just opened two blocks away.
Her next client was Christina R — she didn’t want her last name used — a 51-year-old with diabetes from a family in which diabetes is common. On a gloriously sunny day, the two women decided to meet on a bench overlooking a garden in Central Park, rather than in Christina’s small apartment. Christina was doing well. Her blood sugar was stable, her blood pressure had dropped, she was smiling and active. Not only had she lost 17 pounds simply by eating healthier and walking more, but the family she lived with — her 40-year-old nephew and his wife – between them had lost 88 pounds just by mimicking her healthy new habits. One diabetes case under control; two likely ones prevented.
The final house call was Louise Burwell, 65, a retired teacher in with a multitude of health problems, many either caused by or aggravated by her obesity. She weighs more than 400 pounds and considers it a small victory that her ever-so-gradual fitness regime, encouraged by Tejeda, now allows her to get up out of her big comfy recliner without assistance from her grown son. Tejeda visits for the asthma — now, finally, under control, no wheezing for the past two weeks – but will now arrange for a physician referral so she can work with Burwell on diabetes, too. Burwell is smart and open, but even though she sprung into action to control her kids’ incipient asthma 30-some years ago, she never learned to manage her own. It is only now, with City Health Works, that she’s figured out what triggers her attacks; she suspects both cold cuts and Chinese takeout can set her off. And after all these years, she’s finally learned how to use her rescue inhaler properly during an attack — pausing, counting, letting the drug reach into her lungs, before she pushes the button a second time. Just as Tejeda taught her.
“I’m a teacher, and I’m educated,” Burwell told Tejeda. “But I didn’t know all this and I need this information.
“God has sent you to me – out of the clear blue sky. You were sent here to save my life. And I’m going to have to follow what you guys are saying.”
Joanne Kenen is POLITICO’s executive editor for health.
October 25, 2017 at 06:23AM