Whittier Street Health Center, a community health center in the Roxbury neighborhood of Boston, MA, runs a grant-funded, community-based model of diabetes care that brings best practices to the community by letting community members tell their own stories. Osagie Ebekonien, manager of quality assurance and performance improvement at Whittier Street recently spent some time with us, opening a window into the program that he manages. The program has the twin goals of improving access and improving clinical outcomes.

Whittier Street pays stipends to “health ambassadors” who live in a public housing development near the health center.  The health ambassadors spread the message among their neighbors. This initial communication leads to increased attendance at health screenings sponsored by the health center. Once someone is identified as a person with diabetes, other aspects of the outreach program kick in.

The health ambassadors maintain contact, modeling healthy behaviors, and telling other patients about choices they’ve made that improve their health. It’s a health communication model built on storytelling.

(Read/listen to the full conversation after the jump)

The health ambassadors help bring people into the system, where in addition to clinical services they enjoy communications with patient navigators and case managers.

By surrounding high-risk individuals with communications about easy-to-adopt behavior changes, and by having folks who have been down the same road tell ther own stories, Whittier Street’s program is successfully improving health status and lowering costs.

Join Osagie Ebekozien at Diabetes Innovation 2013, and hear more about his community-based approach to health care improvement.

Listen in to our fifteen-minute conversation (press play); read the transcript below.

Interview with Osagie Ebekozien, Whittier Street Health Center, Boston, MA

August 2013

David Harlow:  This is David Harlow for Diabetes Innovation.  I have with me Osagie Ebekozien from Whittier Street Community Health Center in Boston, Massachusetts, where he is manager of Quality Assurance and Performance Improvement.  Welcome, thank you for joining us.

Osagie Ebekozien:  Thank you for having me.

David Harlow:  Please tell us a little bit about your organization as a whole and then let’s segue into what you are doing to hack diabetes.

Osagie Ebekozien:  Whittier Street Health Center is a Community Health Center.  It has been in existence for the past 80 years.  Now, we just celebrated our 80th Anniversary this year.  We are located in Roxbury, Boston, Massachusetts and we provide a whole range of services.  We describe ourselves as a one-stop shop.  Patients can come in and access primary care and also our specialty services here at Whittier Street Health Center.  Currently, I work as the manager of Quality Assurance and Performance Improvement at the Whittier Street Health Center.  One of my roles is to manage our community-based programs and projects.  One of the projects that I am currently managing is our diabetes program to improve access and to also increase the clinical outcomes for patients with diabetes.

David Harlow:  How long is that program going on?

Osagie Ebekozien:  The program in reference now, we have been working with a lot of different programs involving creating access for – the program I referenced in particular has been going on for over two years.  It’s being funded by Bristol Meyers Squibb Foundation (BMS) and it’s pretty much been there for the past two years now.  A little over two years that has been going on.

David Harlow:  What are the sorts of interventions that you are using and what do you see as the beneficial outcomes? How is it going so far?

Osagie Ebekozien:  I think the program is going great.  One thing we started – we have two broad goals.  The first goal is improving access, what we are trying to do is try to get patients to come in that have been screened for diabetes are not aware of their status in terms of whether or not they have diabetes because lot of surveys have been done and also from the Boston Public Health Commission shows that in this area there is a very high prevalence of diabetes.  We have a smaller target in this area, which is a public housing development, that is within five miles of Whittier Street Health Center.  Our strategy is to have residents of this public housing that are Whittier patients being paid stipends.  These residents are called — we call them the “Health Ambassadors”.  These residents are paid educators, paid leaders.  They go out to the community, in fact they are able to come for screening, talk to their friends and families in the community, in the public housing development, to attend screening services and to attend other community activities that we have going on daily in the community.

During these outreaches, we screen residents for diabetes and we have identified a lot of residents with high blood sugar, which we refer to the health center for further evaluation.  So far, we have screened over 1000 community residents in the past 2 years.  That’s the broad goal of trying to increase access.

The second one is of improving clinical outcomes, we are more focused on helping patients get activated.  Patient activation and helping them see the sense that they should be actively involved in their health care and they are primarily responsible for their clinical outcomes.  We use a lot of evidence-based methods of helping patients develop self-management goals and coming up with an action plan.  We talk to patients about very minor little changes that may appear to be but these little changes that they can make to improve their clinical outcomes.  Things like reducing the amount of soda intake a day, things like walking an extra ten minutes.  We want to hold that patient accountable for those goals and really follow up to make sure they change it.  For over two years that we have been doing this, we have seen significant improvement in A1C levels of 160 African-American women, we have seen such great improvement in the weights, lot of participants have lost significant amount of weight, we have seen significant improvement in blood pressure control.  All of them are helping patients to follow some of the self-management goals, it has really shown that model really does improve clinical outcomes of patients.

David Harlow:  What’s the secret?  How do you get these people activated, people who have been up until now sort of invisible to the health care system, that you have gone out, you have screened people in the community, how do you get people activated and involved in their own care?

Osagie Ebekozien:  I think the secret is you telling people that you are familiar with their story.  We believe a lot in storytelling.  We have five African-American women that are Whittier patients now and also have developed their own goals, have adhered to their own goals and have shown improved outcomes.  We get these patients to go in the room with the other patients and speak to them.  They talk to them on issues of personal issues or this is how I dealt with my own weight issue, this is what I did to make sure I was taking my insulin regularly and this is what I…  Share their personal stories with community members to encourage them, for them to see the sense of – to understand the importance of being activated and being involved in their care.  These are of some of the questions I asked my provider ….

What we see is the thought like that, when they see their neighbor, last I saw that this neighbor was with a weight of 300 pounds and in six months this neighbor has lost 60 pounds, so they are also curious to know what exactly are you doing that makes you look healthy, what are you doing that is making you not visit the emergency room like you used to.  The community patients are interested in knowing what is happening and at the same time, the ambassadors, the paid educators that we pay stipends to reach out to us are also happy to be able share their stories and really help all those get activated and get involved.

After that, we have patient navigators and we have case managers.  The patient navigators are involved in calling and following up on people who are described as just high-risk patients, while we have case managers, including a nurse case manager that actually calls the high-risk patients — those with clinical outcomes that are above a certain cut-off according to a risk classification method we have.  We have this sort of support staff that works with the providers, and works with the paid educators to ensure that each person is getting the attention that is needed to be activated.

It is a work in progress so there are still some patients that even with all of these efforts might still not be activated but we are using tools to see where each patient is and you are able to tell when they need help and when you can offer help to them.

David Harlow:  Right, that’s, of course, the key issue is being able to know when is the patient going to be receptive to the message and be able to make some changes.  Do you see this as a model that could be easily replicable and adopted by other providers?

Osagie Ebekozien:  Yeah, I think so.  I think it is definitely a sustainable model and it is something that can be more wide-scale.  The one thing really in designing community-based programs is if you want that program to be successful to a large extent you need inputs, you need active participation and even in program design by community members.  I think, in terms of replicability, other community interventions that are being done with community members more actively involved even in the delivery of the program, we can have better outcomes because they see it as their thing and they see it as something that would definitely benefit themselves and benefit their families.  I think definitely this is how – this is a trend we should be moving towards in many community programs.

David Harlow:  Sure. So the high-customization and high-touch sort of program that you described must be a lot more expensive than a typical primary care focused practice or clinic.  How do you end up paying for this? You described a grant, but I guess the question is: Is it sustainable?

Osagie Ebekozien:  With the new changes in health care now, with the Affordable Care Act and with the new payment reforms we are having, right now, I know that in the near future, Medicare, Medicaid will actually begin paying for care coordination services.  The extra amount of efforts put into it, which is actually being covered by the grant now, the salaries of the ambassadors and the navigators — it is all being covered by the grant but we know that what we foresee is, even with a business model of covering the cost of this patients and paying for the navigators and paying for the case managers, we see that if the changes in clinical outcomes would actually be substantial enough for you to actually to want to sustain a program like this.  But beyond that, I know that we are moving towards that delivery of health care where the provider has to be willing to pay for care coordination services and I think that’s the only way to make it a sustainable program.

David Harlow:  Have you been able to point — In order to support the payment that you need to seek from other payors, are you able to point to savings down the road?

Osagie Ebekozien:  Yeah, we are.  For example, in terms of emergency room utilization and in terms of hospitalization, we have been able to show significant reduction in the patients that used emergency rooms as a result of the active followup.  Actually, we have a goal of following up our patients within two days of contact.  Once we are notified that any of our patients have been to the emergency room, we want to contact them within two days and be able to followup on this patient and find out why they went to the emergency room and find out how that can be prevented.

The rising cost of health care is with inappropriate utilization.  It is people using emergency room for things they can see their primary care physician for and it is also patients who have been hospitalized for very preventable conditions, complications of diabetes, complications of hypertension.  Those things have resulted in the rising cost of health care.  What we are trying to do now is to show that our efforts are helping people stay out of the emergency room and stay out of intensive care units and reduce complications of chronic conditions like diabetes, our efforts in care coordination and patient navigation and in patient support, all of these efforts can result in reduction in inappropriate utilization, which actually increases cost.  That is one thing which we are actually trying to show now that all of this will pay off if we put a lot of our attention into patient navigation services and care coordination.

Beyond that, actually, Whittier Street Health Center is a recognized patient centered medical home.  All that we are doing actually we’re recognized by NCQA, that’s the National Committee for Quality Assurance.  We have Level 2 recognition, the highest level, recognized as a health center that is patient centered.  All of these activities also tie into what we are doing to strengthen our role as a patient centered medical home, to actually make it a home for all the patients that walk in through our doors.  This and the funding is all going in line with what we want to do.

David Harlow:  Excellent. What do you hope to learn, what sorts of people do you hope to meet at the Diabetes Innovation Conference in DC this fall?

Osagie Ebekozien:  I think I will be interested in meeting program directors, program leaders for community-based programs like ours.  I will also be interested in meeting quality improvement experts. Those are the two sets of people I will be very interested in meeting.  I have my own personal story with regard to diabetes, my grandfather died of diabetes, one of my uncles is diabetic.  I am interested to find out what are latest innovations in diabetes, what is groundbreaking, what else are we doing.  I am interested in meeting innovators. I’m interested in learning more about the new discoveries and updates on what has been done in fighting this condition.

David Harlow:  Excellent, well, we look forward to seeing you there.  Thank you very much for taking the time today.

I have been speaking with Osagie Ebekozien at the Whittier Street Health Center in Boston, Massachusetts.  This is David Harlow for Diabetes Innovation.

Diabetes Innovation 2013

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