Promotores and the Patient-Centered Medical Home Audio Transcript

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Promotores and the Patient-Centered Medical Home Audio Transcript 2016-02-15T19:57:01+00:00

Session One Transcript

Session Two Transcript

Session Three Transcript

Session One Transcript

Welcome to the e-learning series, “Promotores and the Patient-Centered Medical Home.” Currently, there is a strong movement for health centers and organizations to adopt the Patient-Centered Medical Home model. It is believed that this model can improve health care delivery at lower costs. At the same time, the field of Promotores and Promotoras de Salud has never been stronger, and the work of Promotores can be an exciting and effective element of both newly emerging and already established Patient-Centered Medical Homes.

This three part series will define the basic concepts of Promotores and Patient-Centered Medical Homes, or PCMH, will explain the roles and benefits of Promotores supporting a PCMH, and will describe how to successfully integrate Promotores into a Patient-Centered Medical Home model.

In this series, we use the term Promotores which is commonly used in Latino communities to reflect the women and men who advocate for improved health in the communities where they live and work. In part one of the series we will introduce you to other names and terms used to describe their work.

While the examples given in this series will describe PCMHs focused on serving the migrant and seasonal population, the benefits and implications are also applicable to health centers or PCMHs serving other underserved communities.

Session 1: Introduction to Promotores de Salud and the Patient-Centered Medical Home
In this session we will give a basic overview of the Promotor(a) de Salud model as well as the Patient-Centered Medical Home.

Who are Promotores de Salud?
Promotores de Salud (literally “health promoter”) is a term used by Latino health organizations to refer to community members who promote health in their own communities. They provide leadership, peer education, support, and resources to support community empowerment. As members of minority and underserved populations, they are in a unique position to build on strengths and to address unmet health needs in their communities. Promotores integrate information about health and the health care system into the community’s culture, language and value system, thus reducing many of the barriers to health services. They also help make health care systems more responsive. With the appropriate resources, training and support, Promotores improve the health of their communities by linking their neighbors to health care and social services; educating their peers about disease and injury prevention; working to make available services more accessible; and mobilizing their communities to create positive change.

Other Titles
Other terms that have been used to refer to Promotores or people who do similar work include:
-Camp Health Aides
-Peer Health Educators
-Lay Health Advisors
-Outreach Workers
-Community Health Representatives
-Indigenous or Village Health Workers

Recently, the term “Community Health Worker”, which has been used to encompass the aforementioned titles, has gained popularity in the field. Definitions of the term Community Health Worker include the definition from the Community Health Worker Section of the American Public Health Association, which states:

“A Community Health Worker (or CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery1.”

According to a 2007 study conducted by the Health Resources and Services Administration, there was an estimated 121,000 community health workers in the US in 2005. At that time, the number was growing at over seven percent annually2.

Roles of Promotores
The nature of the training, roles, responsibilities and duties of Promotores varies considerably from program to program. Paid and volunteer Promotores may work part- or full-time with clinics, nonprofit organizations, public health departments, or other organizations.

Promotores conduct outreach and health education in clients’ homes, community centers, clinics, hospitals, schools, worksites, shelters, and farmworker labor camps.

Many Promotor(a) programs focus on serving the needs of specific ethnic or racial groups, while others focus on vulnerable segments of the population or prominent health problems.

Although Promotores engage in a broad range of activities, they share a number of common roles. Promotores provide3:
-A link between communities and health and human service agencies
-Informal counseling and support
-Culturally-competent health education
-Advocacy
-Capacity-building on individual and community levels
-First aid and emergency assistance

Qualities of Promotores
Promotores are typically empathetic, resourceful, and willing to help others. Such qualities are personal characteristics that can be enhanced but not necessarily taught4. The Promotor(a) qualities most commonly cited in the 1997 National Community Health Advisor Study are3:
-Relationship with community being served
-Desire to help the community
-Empathy
-Persistence
-Creativity and resourcefulness
-Personal strength and courage
-Respectfulness

Promotor(a) Quote #1
“People who are Promotores have a gift for service and a noble and kind heart. We think about things and take care of people. We identify with the people and the needs of the community.”

Skills of Promotores
Skills are abilities that can be gained through study and practice4. In order to do their complex work, Promotores must possess or build multiple skills. According to the National Community Health Advisor Study, Promotores are more effective in their work when they have the following skills3:
-Communication skills
-Interpersonal skills
-Teaching skills
-Service coordination skills
-Advocacy skills
-Capacity-building skills
-Knowledge base

Promotor(a) Quote #2
“A Promotor(a) is a leader and does everything possible so that his or her community will succeed. As leaders, they need to be counselors, defenders, spokespeople, and visionaries. They need to have the ability to organize the community – to discover the talents that exist in the members of the community in order to take them and work with them. But without the spirit of service, these skills are nothing.”

Contributions of Promotores
Promotores effectively address many barriers to better health for underserved populations. Some of their accomplishments include:
-Improving access to services
-Helping people understand the health and social service system
-Enhancing client and health provider communication
-Increasing appropriate rates of service utilization
-Decreasing costs for organizations and government programs
-Improving patient adherence to health recommendations
-Reducing the need for emergency and specialty services
-Improving overall community health

Promotores accomplish these and other outcomes by providing education and advocacy and building capacity in their communities5, 6, 7.

Promotores = Results
Promotores produce results because they are:
-Culturally-competent, successfully addressing cultural differences that inhibit access to health care and information;
-Accessible, since they live in the same community as the people they serve;
-Experts who intimately know the strengths and challenges of their community and which strategies will work best;
-And sustainable, serving as a resource to their communities over the long term

Promotores = Results
Next, we will outline some notable results that Promotores have achieved.

Cesarean Sections and Breastfeeding
In 2007-2008, three Promotora Doulas working with Migrant Health Promotion, or MHP, provided prenatal education classes and doula services to women in the lower Rio Grande Valley, Texas. Their work contributed to a dramatic decrease in Cesarean section rates among first-time mothers – less than 8% of first-time mothers assisted by Doulas gave birth by Cesarean section, compared to 44.5% of Hispanic women in Cameron County overall (2002-2004; http://soupfin.tdh.state.tx.us/birth.htm)

In 2009, the Doulas’ work resulted in the following:
-100% of the children in the program obtained a medical home
-100% of mothers in the program have an ongoing source of primary and preventative care
-0% low or very low birth weight babies were born to program participants, and
-Over 90% of program participants breastfed their babies.

In 2012 MHP’s doula program achieved a 95% breastfeeding initiation rate (first 48 hours after birth), as compared to the 15.1% rate in the Lower Rio Grande Valley8.

Diabetes Prevention and Self-Management
MHP’s Promotora Community Program (PCP) focuses on diabetes self-care management, community organizing, healthy eating, and physical activity. Offered in three south Texas colonias, activities emphasize family and community-based solutions that are culturally and linguistically-appropriate to the population, as well as interesting and fun. Cooking and nutrition classes, exercise groups, and health education sessions involve the participants in changing behavior such as consuming more vegetables and fruits, drinking less sugar-filled beverages, and making physical activity a part of their daily lives.

2009 program participants reported that their knowledge of diabetes and nutrition had increased. They now read food labels when shopping, make better food choices, know how to make traditional Mexican food with healthier ingredients, and feel more energetic. One participant lost 60 pounds after being in the program for four months. In 2012 participants who completed MHP’s eight-week diabetes prevention/self-management program lost an average of four pounds and decreased their waistlines by an average of three inches8.

Maternal and Child Health
During the summer of 2005, 40 Promotores at six Migrant and Community Health Centers in Michigan led individual and group education sessions, provided referrals, and hosted special events to improve the health of the women and children in their camps.

These Promotores ensured that:
-100% of pregnant farmworker women received prenatal care. In comparison, only 66.8 percent of Michigan Hispanic women received adequate care in 2007.
-95% of newborns were breastfed. Nationally, 80% of Hispanic women in all occupations breastfed and only 65% of Michigan women in all racial groups breastfed their babies.
-93% of farmworker children five years of age and under were up to date on their immunizations. The immunization rate for Hispanic children ages 19-35 months in the United States was 78% for the year 20078.

What is a Patient-Centered Medical Home (PCMH)?
As mentioned earlier, there is a strong movement for health centers and organizations to adopt a Patient-Centered Medical Home model. It is believed that this model can improve health care delivery at lower costs.

The Patient-Centered Medical Home model, which was originally developed in the 1960s by the American Academy of Pediatrics, generally refers to the provision of comprehensive primary care services that facilitates communication and shared decision-making between the patient, his/her primary care providers, other providers, and the patient‘s family.

More specifically and as defined in the publication, Practices in the Spotlight: The Medical Home and Diabetes Care, the Patient-Centered Medical Home is an “approach to providing comprehensive primary care for children, youth, and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family9.”

Next, we will describe 7 joint principles which characterize the PCMH.

Joint Principles of a PCMH
Joint principles of the PCMH include10:

Joint Principles of a PCMH: Personal Physician
Personal physician—each patient has an ongoing relationship with a personal physician trained to provide first contact as well as continuous and comprehensive care.

Joint Principles of a PCMH: Physician Directed Medical Practice
Physician-directed medical practice—the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Joint Principles of a PCMH: Whole Person Orientation
Whole person orientation—the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Joint Principles of a PCMH: Coordinated/Integrated Care
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically-appropriate manner.

Joint Principles of a PCMH: Quality and Safety
Quality and safety are hallmarks of the medical home and include the following components:
Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.

Joint Principles of a PCMH: Enhanced Access
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

Joint Principles of a PCMH: Payment Reform
Payment Reform appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.

Benefits of a PCMH
It is believed that the practice of transforming primary care to a PCMH can address the limitations physicians currently face in providing proactive and preventative care11. Patient-Centered Medical Homes could ultimately lead to:
-Better access to care – including enhanced outreach and engagement of patients11,12,13;
-Improved health care quality – with better documentation and coordination of care11,12,13;
-Reduced health disparities12,13 and;
-Decreased health care costs12,13.

In the next session, we will discuss the roles and benefits that Promotores can bring to a Patient-Centered Medical Home model in order to advance these objectives.

References
1. American Public Health Association, “Community Health Workers.” Accessed May 14, 2013. http://www.apha.org/membergroups/sections/aphasections/chw/.
2. Carl H Rush, e-mail message to author, May 15, 2009.
3. Rosenthal, EL, N Wiggins, JN Brownstein, R Rael, S Johnson, E Koch, et al. The Final Report of the National Community Health Advisor Study: Weaving the Future. manuscript., University of Arizona, 1998.
4. Wiggins, N. “Qualities of Effective Community Health Workers.” Presentation at the 13th Annual West Coast Migrant Stream Forum, Seattle, WA, January 2004.
5. Richter, RW, B Bengen, PA Alsup, B Bruun, M Kilcoyne, and BD Challenor. “The community health worker: A resource for improved health care delivery.” American Journal of Public Health. no. 11 (1974): 1056-61.
6. National Rural Health Association, “Community Health Advisor Programs.” Last modified November 2000. Accessed June 28, 2004. http://www.ruralhealthweb.org/dc/issuepapers/ipaper17.html.
7. Community health workers: Integral yet often overlooked members of the health Care Workforce. San Francisco, CA: University of California at San Francisco, Center for Health Professions, 1994.
8. Migrant Health Promotion, “Improving Health Outcome.” Accessed May 14, 2013. http://www.migranthealth.org/index.php?option=com_content&view=article&id=52&Itemid=50.
9. Practices in the Spotlight: The Medical Home and Diabetes Care. Patient Centered Primary Care Collaborative, 2011. http://www.pcpcc.net/sites/default/files/media/diabetes_guide_2011.pdf (accessed May 14, 2013).
10. The Patient Centered Medical Home History, Seven Core Features, Evidence and Transformational Change. Robert Graham Center, 2007. http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf (accessed May 14, 2013).
11. Robert Wood Johnson Foundation, “Evaluation: Assessing and Increasing Readiness for Patient-Centered Medical Home Implementation.” Last modified March 27, 2012. Accessed May 14, 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/03/evaluation-assessing-and-increasing-readiness-for-patient-center.html.
12. Zuroweste, E. “Challenges and opportunities to equal access: An approach to reduce health inequities.” Presentation at the 2012 Pennsylvania Health Equity Conference, Harrisburg, PA, August 24, 2012.
13. Community Health Workers in Massachusetts: Improving Health Care and Public Health. Massachusetts: Massachusetts Department of Public Health Community Health Worker Advisory Council, 2009. http://www.mass.gov/eohhs/docs/dph/com-health/com-health-workers/legislature-report.pdf (accessed May 14, 2013).

Resources
Migrant Health Promotion Camp Health Aide Program Implementation Guide
Migrant Health Promotion Supervision Manual for Promotor(a) de Salud Programs

Session Two Transcript

Promotores and the Patient-Centered Medical Home
Welcome to the e-learning series, “Promotores and the Patient-Centered Medical Home.” Currently, there is a strong movement for health centers and organizations to adopt the Patient-Centered Medical Home model. It is believed that this model can improve health care delivery at lower costs. At the same time, the field of Promotores and Promotoras de Salud has never been stronger, and the work of Promotores can be an exciting and effective element of both newly emerging and already established Patient-Centered Medical Homes.

This three part series will define the basic concepts of Promotores and Patient-Centered Medical Homes, or PCMH, will explain the roles and benefits of Promotores supporting a PCMH, and will describe how to successfully integrate Promotores into a Patient-Centered Medical Home model.

In this series, we use the term Promotores which is commonly used in Latino communities to reflect the women and men who advocate for improved health in the communities where they live and work. In part one of the series we will introduce you to other names and terms used to describe their work.

While the examples given in this series will describe PCMHs focused on serving the migrant and seasonal population, the benefits and implications are also applicable to health centers or PCMHs serving other underserved communities.

Session 2: Roles and Benefits of Promotores in a Patient-Centered Medical Home
In this session, we will move our discussion to the various roles and benefits of Promotores in a Patient-Centered Medical Home.

Promise of Patient-Centered Medical Home (PCMH)
The Patient-Centered Medical Home model and its emphasis on the importance of patient-provider partnerships, care coordination and integration, improved access to care, and interdisciplinary health care teams has implications for how a health center can provide services and the potential contributions of Promotores. Promotores are well-positioned to form a critical component to the health care team. The strength and advantage of Promotores over other outreach staff lies in who they are – members of the community in which they serve, who speak the same language, come from the same culture, know the community’s assets and challenges, and have the ability to relate to the life experiences of their peers1. Promotores possess a unique set of skills and knowledge that can lead the health care team to improve patient health outcomes.

The promise of a medical home is to ultimately provide patients with2, 3:
-Better access to health care
-Improved health care quality
-Reduced health disparities
-Decreased health care costs

Next, we will look at how Promotores can help to advance these objectives and how PCMHs can benefit from integrating Promotores into their health care teams.

Better Access to Care
One of the key roles that Promotores can play is helping patients access care and navigate the health care system.

Better Access to Care
For anyone who has language barriers, is new to a community, or has never used the health care system, it can be a confusing and sometimes overwhelming process. Promotores can reach patients who would otherwise be lost in the system or people who might not seek the health center’s services in the first place. They can break down stigmas or concerns that prevent people from initiating care. They also help link community members to other health and human service organizations.

Additionally, with the Affordable Care Act and the onset of health insurance marketplaces and the need to enroll in health insurance, Promotores can assist in identifying and enrolling uninsured community members.

Better Access to Care
Promotores can inform people of the availability and importance of services and keep community members informed about the health center’s business hours, schedules, and policies. They can arrange appointments, encourage necessary office visits, offer support, follow up, and make appropriate arrangements when people are unable to pay fees or find transportation. This results in community members understanding the health center’s services and using them more appropriately and more confidently.

Moreover, Promotores can identify barriers to care and advocate on behalf of the community. They possess a keen awareness of community needs and can offer a community perspective to the health care team4.

Finally, the PCMH model highlights prevention initiatives and patient education5. Promotores, by the nature of their work, promote healthy behavior changes and encourage people to use preventative services. They can also perform care coordination for patients with chronic and acute health conditions and refer them to appropriate services; promote preventative care and screening; conduct patient education in home and community settings; schedule appointments and make reminders; and track and locate clients for follow-up care.

Improved Health Care Quality
Patient-centered care has been identified as being respectful and responsive to “patient preferences, needs, and values” as a key component in improving health care quality.

Improved Health Care Quality
The characteristics of high-quality, patient-centered care include open communication between patient and provider; culturally-competent care; high patient satisfaction; and continual self-management of chronic diseases2.

Improved Health Care Quality
Promotores can address all those aforementioned points because they can spend continuous time with patients and their families through activities such as home visits. Overburdened providers cannot always take the time to provide comprehensive health education. Promotores can engage patients and their family members and teach their peers about health issues, treatment options, and how to manage chronic illness. This leads to better compliance with treatment instructions and reduced frustration for clients and staff.

Promotores also provide health support in a culturally and linguistically-competent manner. As community members, Promotores share culture and values with the organization’s target populations. They establish trust in the community more easily than outsiders which allows for improved communication such as more complete and honest conversations about patient health concerns and questions. Promotores can also encourage patients to take a more proactive role in their health care. For example, they can teach patients not only how to manage their chronic conditions, but also how to ask good questions of their providers.

Furthermore, Promotores can act as cultural interpreters and can provide information to the health center about community strengths and challenges. They explain local issues and relevant beliefs, and they can also lead staff trainings on cultural competency and related issues. This allows staff members to work more effectively and with a better understanding of the community.

Reduce Health Disparities
Underserved populations often have later diagnoses and more advanced stages of illness, thus leading to higher rates of morbidity and death2. Promotores’ patient navigation skills and emphasis on prevention and early intervention can have a positive impact on reducing health disparities.

Reduce Health Disparities
Furthermore, the Patient-Centered Medical Home’s “whole person” approach to care has implications to take into consideration the social, economic, and environmental factors that influence health – factors which are “widely recognized as influencing health disparities2”. As trusted members who are from the same culture, speak the same language, and have similar life experiences as the communities in which they serve, Promotores are in a unique position to serve as health care team members with “expertise in cultural factors and social determinants6.” They are aware of and provide referrals to a wide variety of non-medical services such as housing, food, transportation, and legal assistance.

Decreased Health Care Costs
There is also a growing amount of evidence of the cost effectiveness of Community Health Workers and Promotores.

Decreased Health Care Costs
Promotores can help reduce health care costs by providing patients with preventive health education to help them avoid illness. Further, Promotores promote increased use of preventive care and screening services and help families utilize medical services at the most appropriate times, reducing the need for emergency and specialty services. As a result, community members use the organization’s services appropriately, maximizing limited resources.

Decreased Health Care Costs
Additionally, Promotores teach patients how to manage their chronic conditions, therefore helping to reduce preventable hospitalizations. They also encourage and support follow-up care, thus reducing the risk of health complications.

Finally, by integrating Promotores into the health care team, organizations can make more efficient use of staffing resources as well as allow for the team to focus on its individual strengths and expertise.

In the next session, we will discuss key considerations when implementing Promotores into a Patient-Centered Medical Home.

References
1. Balcazar, H, L Rosenthal, JN Brownstein, C Rush, S Matos, and L Hernandez. “Community Health Workers Can Be a Public Health Force for Change in the United States: Three Actions for a New Paradigm.” American Journal of Public Health. no. 12 (2911): 2199-2203.
2. Community Health Workers in Massachusetts: Improving Health Care and Public Health. Massachusetts: Massachusetts Department of Public Health Community Health Worker Advisory Council, 2009.http://www.mass.gov/eohhs/docs/dph/com-health/com-health-workers/legislature-report.pdf (accessed May 14, 2013).
3. Zuroweste, E. “Challenges and opportunities to equal access: An approach to reduce health inequities.” Presentation at the 2012 Pennsylvania Health Equity Conference, Harrisburg, PA, August 24, 2012.
4. Holtrop, JS, and TR Jordan. “The Patient-Centered Medical Home and Why It Matters to Health Educators.” Health Promotion Practice. no. 5 (2010): 622-628.
5. Martinez, J, M Ro, NW Villa, W Powell, and JR Knickman. “Transforming the delivery of care in the post-health reform era: what role will community health workers play?” American Journal of Public Health. no. 12 (2011): e1-e5.
6. Rush, C. Northwest Regional Primary Care Association, “Community Health Workers and Your Health Center: the Time is Now.” Accessed May 14, 2013. http://www.nwrpca.org/health-center-news/219-community-health-workers-and-your-health-center-the-time-is-now.html.

Session Three Transcript

 

Promotores and the Patient-Centered Medical Home
Welcome to the e-learning series, “Promotores and the Patient-Centered Medical Home.” Currently, there is a strong movement for health centers and organizations to adopt the Patient-Centered Medical Home model. It is believed that this model can improve health care delivery at lower costs. At the same time, the field of Promotores and Promotoras de Salud has never been stronger, and the work of Promotores can be an exciting and effective element of both newly emerging and already established Patient-Centered Medical Homes.

This three part series will define the basic concepts of Promotores and Patient-Centered Medical Homes, or PCMH, will explain the roles and benefits of Promotores supporting a PCMH, and will describe how to successfully integrate Promotores into a Patient-Centered Medical Home model.

In this series, we use the term Promotores which is commonly used in Latino communities to reflect the women and men who advocate for improved health in the communities where they live and work. In part one of the series we will introduce you to other names and terms used to describe their work.

While the examples given in this series will describe PCMHs focused on serving the migrant and seasonal population, the benefits and implications are also applicable to health centers or PCMHs serving other underserved communities.

Session 3: Integrating Promotores Into a Patient-Centered Medical Home
In this session we will look at key considerations when integrating Promotores into the Patient-Centered Medical Home.

Initial Infrastructure
First, we will provide an overview of considerations when implementing a Promotor(a) program.  Promotores can be a tremendous asset to a health center and a PCMH, but a strong and appropriate infrastructure needs to be in place for the program to be successful.

First, organizational support or buy-in from top managers or administrators will ensure that the program is sufficiently funded, that program staff and participants are introduced into and known within the wider organization, and that new strategies that include Promotores are accepted and integrated properly.

Also, a staffing plan that includes key positions such as a Program Supervisor and Program Coordinator is helpful in making sure the program is well-managed both programmatically and fiscally. Job descriptions for major positions should be created and adhered to avoid blurring of responsibilities and lack of accountability. Apart from a Program Supervisor and Program Coordinator, an organization should make sure they allow for adequate business, office, and paraprofessional staff who may be asked to support the program in some way.

A detailed budget should also be established to ensure that the program monies are spent as designed and to the maximum benefit of the program and health center resources. The budget should be monitored regularly during the course of the program.

Responsibilities of Promotores
It is important to define the responsibilities of the Promotores from the beginning. As described in previous sessions, the roles and expectations of Promotores are vast and varied. Paid and volunteer Promotores(as) may work part- or full-time with clinics, nonprofit organizations, public health departments or other organizations. Promotores may conduct outreach and individual and group health education in clients’ homes, community centers, clinics, hospitals, schools, worksites, shelters and farmworker labor camps. Many Promotor(a) programs focus on serving the needs of specific ethnic or racial groups, while others focus on vulnerable segments of the population or prominent health problems.

Although Promotores engage in a broad range of activities, they share a number of common roles:
-A link between communities and health and human service agencies
-Informal counseling and support
-Culturally-competent health education
-Advocacy
-Empowerment of individuals and communities
-First aid and emergency assistance

Promotora Quote
“I feel proud of being a Promotora. You feel special because you aren’t only going to learn for yourself, but also to help and inform more people.”

Recruitment of Promotores
Once the program model is well developed and supported, the first step in launching the project is to recruit the Promotores. As mentioned in session 1, ideal qualities in a Promotor(a) include someone who has:
-A relationship with community being served
-Desire to help the community
-Empathy
-Persistence
-Creativity and resourcefulness
-Personal strength and courage
-Respectfulness

Practical traits one should look for when finalizing a group of Promotores are:
-Interest in learning about health
-Outgoing personality
-Familiarity with the area and/or services in the area
-Bilingual, if needed
-Able to commit necessary time & energy to program
-Plans to remain in area for program season (for seasonal programs)
-Support from spouse/family to participate in the program (this can be true when a Promotor(a) is the primary caregiver in the family and arrangement needs to be made to find alternative childcare when the Promotor(a) is participating in the program)
-Transportation to training
-Basic reading and writing skills
-Lives in a community that could benefit from a Promotor(a) – for example, a community that has at least 50 people, lives close together, has great need, or is located far from the clinic

Training and Supervision
Training is a very important aspect of a Promotor(a) program and is usually led or designed by the Program Coordinator. Promotores should be trained on the core competencies of being a Promotor(a) such as: skills and qualities/roles of CHWs, communication, teaching and health education, cultural awareness, service coordination skills, confidentiality and ethics, specific health topics that the program is focusing on, and health center organizational policies and procedures.

Ideally, Promotores receive an initial training and orientation at the beginning of their participation, but allowing for on-going, regular training is equally important. It is essential not to neglect training once program activities begin in earnest.

Good training is critical to the success of a Promotor(a) program, but offering regular scheduled opportunities for group and individual supervision is equally important. In group meetings, Promotores can share stories and frustrations, give and receive mutual support, and participate in team-building. Supervisors can provide ongoing training, as well as discuss progress towards program objectives and make adjustments as needed. Individual meetings between the Supervisor and the Promotor(a) allow for more in-depth discussion and trouble-shooting around accomplishments and challenges.

Supervision is an opportunity to review paperwork, flag areas needing follow up, help plan future activities, praise achievements, and provide needed supplies or resources. Importantly, regular supervision allows a Supervisor to assess professional development or training needs and monitor potential work stress or signs of burnout. Supervision is traditionally the responsibility of the Program Coordinator.

Evaluation
Evaluation should be a key component of any Promotor(a) program. Strong evaluation can help improve services, demonstrate effectiveness, encourage continued funding, and document success. It is crucial to set up the appropriate evaluation methods and tools at the initiation of a program and include Promotores in the process as much as possible.

Setting goals and objectives gives all parties a target to work toward. Determining realistic goals and objectives is important not in just securing funding, but for creating expectations of the work of the Promotores based on the amount of time they will be spending on the project.

An evaluation plan containing both process and outcome objectives, as well as accompanying documentation tools, is critical for measuring the impact of the program and for ensuring quality services. Process objectives focus primarily on tracking individual and group health encounters, referrals and follow-up. Outcome objectives measure changes in health behaviors, knowledge and attitudes, as well as health care and treatment received as a result of the programs’ interventions.

Integrating Promotores Into a Patient-Centered Medical Home (PCMH)
In the remainder of this session, we will concentrate on special considerations for implementing a Promotor(a) program into a Patient-Centered Medical Home. Although many of these suggestions are relevant to any type of Promotor(a) program, in order to emphasize their importance in a PCMH, we will refer to some of the lessons learned from La Clínica del Cariño in Oregon. La Clínica del Cariño is a migrant and community health center whose experience with Clinical Community Health Workers on health care teams has implications for CHWs or Promotores in a PCMH.

Typically, Promotor(a) programs are considered an enabling service or a supplemental outreach or health education program1. Ideally, in order to adhere to the Patient-Centered Medical Home principle of coordinated and integrated care, and to maximize the contributions and benefits of Promotores, they should be fully integrated into the health care team. In a PCMH, Promotores are valuable and critical team members when they are well-supported, trained, and integrated. Successful integration can greatly improve a health center’s ability to bring in hard-to-reach patients, provide culturally-competent care, and ensure efficient and effective functioning. Health centers with well-integrated Promotor(a) programs can experience cross-departmental awareness, less duplication of services, consistent goals, enhanced cultural proficiency of staff, more comprehensive and effective services, more consistent care both inside and outside of the health center, and improved staff retention2.

Create Awareness and Support
For successful integration of Promotores into the health care team, there needs to be awareness and support from all levels of the health center – from the administration, to providers, nurses, and front desk staff. This is often overlooked, especially if the Promotores are part-time, seasonal, or contractual since they are not often present in the health center during regular working hours. Health centers could consider developing a training or presentation on the Promotor(a) model which can include an overview of the role and benefits of Promotores in the health center. If Promotores are currently employed at the health center, they should participate in the presentations as well2.

At La Clínica del Cariño, staff did not know what the CHWs did outside the staff member’s area of work because several of the CHWs’ activities were not easily seen. For example, unknown to some staff, it was a daily practice for a perinatal CHW to call the hospital to determine whether any La Clínica patients had given birth the previous day. After receiving the names of the women, the CHW would cancel the next routine OB appointment, eliminating patients’ “no shows” and allowing the health center to schedule other patients into those appointment times and improve clinic efficiency. To help staff understand and visualize the scope of the Community Health Worker programs at the clinic, La Clínica created “patient pathway” flowcharts. The flowcharts depict how patients move through the CHW program and how patients are connected to other health center services3.

Another strategy to increase awareness is to create opportunities for health center personnel to interact with one another. Although this may be challenging since Promotores do not commonly spend significant time within an office setting and are mainly based out in the community, cross-departmental interaction is possible and should be encouraged. For example, invite clinical staff to participate in outreach with the Promotores so that they can experience firsthand the work that Promotores do. In this case, the community will also benefit from the presence of medical personnel at an outreach event. Additionally, if Promotores are expected to come in to the office for supervision or check ins, try to schedule times for the Promotor(a) to be present when other health center staff will overlap with them or even during days when staff meetings are scheduled and they may participate2.

Define Roles and Responsibilities
It is important for any Promotor(a) program to clearly define the roles, duties, and responsibilities of the Promotores. It is even more essential to clarify the function of the Promotores to maximize coordination of care and integration as part of a health care team. Each member of the health care team brings with them special knowledge or training and their role on the team should allow them to do what they do best.

It is key to recognize that the unique expertise of Promotores is as community members and peers of the target population, and assign responsibilities that can capitalize on that knowledge and their ability to provide culturally and linguistically-competent services. At the same time, Promotores should not be asked to assume roles that capitalize on these unique skills but that they are not trained for. Promotores should not be considered a less expensive option for other professions such as social workers. For example, primary care practices that are converting into Patient-Centered Medical Homes may employ a social worker to provide case management services. However, the same level of case management may be provided by a Clinical CHW, with the added benefit of cultural and linguistic competence and sensitivity. But CHWs should not provide counseling or behavioral health services that a licensed social worker or other mental health practitioner is trained to do3.

If roles and responsibilities are not well defined, boundaries can get blurred leading to miscommunication, and quality of care and accountability may suffer.

When all team members understand and respect each other’s roles and expertise, the functioning of the team is enhanced and patients benefit from comprehensive and coordinated care.

As one provider at La Clínica del Cariño observed, “I might review all of these (education topics) quickly. However, I don’t think they really hear a word I say until a lay CHW spends more time and reviews everything at a slower pace3.”

And another provider stated, “(Without the CHWs) I would have to spend more time doing all the prenatal education – probably some of it just wouldn’t get done. I would see OB and diabetes patients less efficiently3.”

Provide Adequate Training and Supervision
To maximize the potential benefits that Promotores can bring to the Patient-Centered Medical Home, they need to receive adequate training and supervision. Promotores do not usually have formal medical or clinical education; instead their expertise lies within the knowledge of their community. Therefore, initial and ongoing training on the health care system, available resources, and health topics and/or areas of outreach that they are assigned to perform is important to ensure Promotores have the necessary tools to meet established goals. In addition, supervisors of Promotores should be aware of the need for flexibility in their supervision. The job of a Promotor(a) isn’t traditional in nature. Building relationships and trust are key components to the success of Promotores, and the Promotores need the time and flexibility to do that.

View as Integral Team Member
In order for Promotores to be truly considered a necessary and integral member of the team, they need to have the same resources available to them as other health care team members, and receive training on the health center’s policies and procedures.

Furthermore, Promotores should have their work documented alongside other team members. Promotor(a) programs keep track of contacts and interactions with clients; that information should be reflected in a patient’s health record or chart since it can provide key insights to other health care team members on conditions that the patient faces that can impact their health, and it can give a more holistic perspective of the patient. Also, because of the relationship building that Promotores do with their clients, they can provide input on individual care plans and identify the best teaching method for each client3.

When a health care team is fully integrated across departments, a provider could even refer patients to the Promotores for services such as health education or assistance with benefits enrollment.

At La Clínica del Cariño , the CHWs make an entry into a patient’s chart for every interaction with the patient. This maintains the vital flow of patient information, provides continuity of care between various departments, and reflects the CHWs value and contribution to quality of care. Additionally, the CHWs work closely with the patient’s provider and the program nurse manager to ensure the coordination of care between all parties. One provider commented, “Often I hear from CHWs about things going on with patients…changes in their home situation or support network, which they (the CHWs) find out by doing home visits3.”

Finally, integration into the health care team means Promotores need to be valued as critical team players and not as just supplemental components to health care.

At La Clínica del Cariño, the providers unanimously agree that the CHW programs allow them to work more efficiently, enhance the care that patients receive, and are a valuable asset to the health center. Providers refer to assistance with registering patients for appointments and tests, staying in touch with difficult patients between visits, and ensuring follow up visits as key benefits of the work of the CHWs3.

References
1. Zuroweste, E, and J Hopewell. “Creating a Patient Centered Medical Home for Patients on the Move.” MCN Streamline, October 04, 2011. http://www.migrantclinician.org/files/MCN MayJun11_ff LR.pdf(accessed May 14, 2013).
2. Madeo, A, and J Cervantes-Connell. “MCN Streamline.”Strategies for Successful Integration of Outreach, Promotora and Clinical Services, October 27, 2009. http://www.migrantclinician.org/files/MCN SepOct09_f LR.pdf (accessed May 14, 2013).
3. Volkmann, K, and T Castañares. “Clinical community health workers: linchpin of the medical home.”Journal of Ambulatory Care Management. no. 3 (2011): 221-33.

Resources
Migrant Health Promotion Camp Health Aide Program Implementation Guide
Migrant Health Promotion Supervision Manual for Promotor(a) de Salud Programs

For information or support on integrating Promotores de Salud into a Patient-Centered Medical Home:
Migrant Health Promotion (www.migranthealth.org)
info@migranthealth.org

For information or support on establishing and implementing a Patient-Centered Medical Home for Migrant and Community Health Centers: Migrant Clinicians Network (www.migrantclinician.org)