Cost, Community Health Workers, and the Quintuple Aim

 

The Quintuple Aim is a framework developed by the Institute for Healthcare Improvement (IHI, 2025) to understand and improve health system performance. Originally proposed as the Triple Aim in 2012, the framework focused on improving population health, enhancing patient experience, and reducing health care costs. Over time, the model expanded to include other human and equity dimensions of care, resulting in the Quintuple Aim: population health, patient experience, cost, provider well-being, and health equity.

In prior discussions, we explored population health and patient experience, highlighting the essential role Community Health Workers (CHWs) play in delivering high-quality, team-based care. This month, we will discuss cost, which is often considered the most challenging aspect of the Quintuple Aim.

What does “cost” mean in the Quintuple Aim?

In the context of the Triple Aim, cost refers to the total cost of care for a population.  While total cost of care (TCOC) includes the price of services, it is broader and more complex.  TCOC includes avoidable emergency department use, inpatient admissions and readmissions, duplication of services (such as tests and medications), inappropriate utilization, and waste caused by inefficiencies. 

Increased health care costs place financial strain on patients, families, employers/purchasers, payers, and government programs (e.g., Medicare and Medicaid).  The Organisation for Economic Co-operation and Development (OECD) is a group of 37 economically developed member countries that shape policies that foster prosperity, equality, opportunity, and well-being for all (OECD, 2025).  The United States has the highest health care cost per capita of all OECD countries.  However, this increased spending does not consistently improve outcomes. For example, certain important U.S. health outcomes (life expectancy, maternal mortality, and hospitalizations for heart failure and diabetes) also exceed all OECD countries (Peterson KFF Health Systems Tracker, 2025). 

Consistent with the Quintuple Aim and the Chronic Care Model (Wagner, 1998), achieving health care value (decreasing cost while simultaneously improving quality outcomes) will depend on shifting from reactive care to proactive, coordinated, community-based approaches that address utilization drivers. 

Cost and Social Determinates/drivers of Health (SDOH)

A significant portion of health care spending is driven by Social Determinants/drivers of Health (SDOH).  We often refer to “upstream” and “downstream” care.  Downstream care occurs after a problem is identified by treating symptoms and managing associated complications.  Upstream care focuses on prevention, root causes, and addressing conditions before illnesses or problems occur. When individuals have unmet SDOH needs (e.g., food insecurity, unstable housing, transportation barriers, lack of access to primary care) they are more likely to delay care and experience worsening chronic conditions. This cycle often results in high-cost services, such as emergency department visits and inpatient admissions where care remains downstream.  Moving care upstream will require us to understand how social and environmental factors influence downstream utilization and to invest in strategies to prevent avoidable costs before they occur.

The role of Community Health Workers (CHWs) in cost reduction

Community Health Workers (CHWs) play a critical role in advancing the cost dimension of the Quintuple Aim. As we have discussed, CHWs are trusted members of the communities they serve and bridge gaps between clinical care and everyday life. Their lived experience and cultural responsiveness, including using the patient’s primary language, enable CHWs to identify SDOH needs and other barriers to support patients and health teams.  The figure below estimates the percentages of TCOC components and potential CHW impact:

CHWs help reduce costs by:

-       Educating patients on self-management using evidence-base “teach-back,” “show-back,” and motivational interviewing techniques to increase preventive care utilization and reduce inpatient admissions

-       Improving follow-up after emergency department visits, redirecting patients to primary care and potentially preventing future inappropriate ED use

-       Connecting patients to community-based resources that address SDOH

By addressing root causes rather than symptoms alone, CHWs help shift care upstream, improving outcomes while lowering unnecessary utilization and TCOC.

Investing in CHWs as a cost containment strategy

Increasing evidence shows that CHWs are not an added expense but a high-value investment. When integrated effectively into care teams, CHWs contribute to lower utilization, improved quality outcomes, and improved patient and provider experience, advancing multiple dimensions of the Quintuple Aim.

The Practice Transformation Institute (PTI) CHW educational programs are designed to strengthen CHW knowledge, performance, and impact. PTI is an approved provider of Community Health Worker training by the Michigan Department of Health & Human Services (MDHHS), following a rigorous approval process and years of community and health system partnership. PTI is also uniquely distinguished by its IACET accreditation, underscoring its commitment to training excellence.

PTI’s CHW program teaches the nationally recognized C3 Council competencies and equips participants with the skills needed to function effectively across a variety of community and health care settings. This robust training supports CHWs in contributing meaningfully to cost reduction, improved outcomes, and sustainable system transformation.

Investing in prevention, care coordination, and community-based solutions can improve outcomes while managing costs more effectively. CHWs are central to this effort, helping align clinical care with SDOH and other patient needs to advance the Quintuple Aim in practice.

References

Agency for Healthcare Research and Quality (2025).  National healthcare quality and disparities reports.  Refer to reference in figure.

Institute for Healthcare Improvement. (2025). The Quintuple Aim.

Organisation for Economic Co-operation and Development (2025).  The OECD: Better policies for better lives.  Retrieved from https://www.oecd.org/en/about.html

Peterson KFF Health Systems Tracker (2025).  How does the quality of the U.S. health system compare to other countries?  Retrieved from https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/

Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1, 2–4.

 

January is Social Determinants/Drivers of Health (SDOH) Month!

Social determinants/drivers of health (SDOH) are conditions in the environments where people are born, live, learn, work, play, worship and age.  These fall under broad categories: Health Care Access and Quality, Neighborhood and Built Environment, Social and Community Context, Economic Stability, and Education Access and Quality. 

Examples of SDOH include safe housing, access to nutritious foods and physical activity, education, jobs, transportation, language and literacy skills, education, jobs, and physical safety.  Although often non-clinical, these conditions have a major impact on health, well-being, and quality of life.

Addressing SDOH is a priority for the U.S. Department of Health and Human Services to improve the health and well-being of people in the United States (Healthy People 2030).

Community health workers (CHWs) are non-clinical members of care teams uniquely positioned to address SDOH needs.  CHWs have lived experience, cultural humility, and deep knowledge of the communities they serve.  They interact with patients and families to address SDOH, making crucial contributions to improved health.

Please join the Practice Transformation Institute (PTI) in recognizing CHWs and their ongoing commitment to patients, families, and care teams.    

For more information on CHWs and PTI programs, visit the website: https://transformcoach.org/learning-solutions/community-health-worker-chw-program/

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved 1-7-2026 from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

 

Patient Experience, Community Health Workers, and the Quintuple Aim

 

The Quintuple Aim is a framework developed by the Institute for Healthcare Improvement (IHI, 2025) to understand and improve health system performance.  Originally proposed as the Triple Aim in 2012, the model was widely adopted as a strategy to improve population health, patient experience, and reduce health care costs.  The Triple Aim has been expanded beyond quality and cost to include human and equity dimensions of care: population health, patient experience, cost, provider well-being, and health equity.   Last month, we explored population health, how it differs from public health, and the essential role community health workers play in the delivery of excellent team-based care.   The second dimension we will address is patient experience.   What is patient experience? The Agency for Healthcare Research and Quality (AHRQ, 2025) defines patient experience as “the range of interactions that patients have with the healthcare system, including their care from health plans and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities.”    This definition is expanded when we consider the Chronic Care Model (CCM, ACT Center, 2025).  Originally developed by the MacColl Institute (now the ACT Center), the Chronic Care Model serves as the foundation to understand the delivery of high-quality patient care.  In addition to the AHRQ definition, the CCM identifies communities and self-management as essential for productive interactions between informed patients and providers. These productive interactions drive improved patient experience and patient-centered quality of care.    Like population health and public health, the terms patient experience and patient satisfaction are often used interchangeably.  However, to understand patients’ experiences of care, we need to look beyond satisfaction to consider other factors that patients value: self-management support, shared decision making, getting information, communication with clinicians, access to care, courtesy and respect, care coordination, and culturally appropriate care.      AHRQ, 2025   What is the community health worker’s role in patient experience?   CHWs play a critical role in improving patient experience, which directly impacts population health and the Quintuple Aim.  Trusted in the community, they bring lived experience and cultural responsiveness to build trusting relationships with patients and families (CHCS, 2025).  CHWs address social, cultural, and other barriers that health care teams may not be able to resolve.  They accomplish this though education, care coordination, and connection to community resources.  CHWs build trust and contribute to factors patients value: self-management support, communication, getting information, access, and culturally appropriate care. The Practice Transformation Institute (PTI) CHW educational programs strengthen CHW knowledge, performance, and contribution to improved health outcomes.  PTI is an approved provider of Community Health Worker (CHW) training by the Michigan Department of Health & Human Services (MDHHS). The approval follows a rigorous application process and more than two years of PTI providing CHW training through community and health system partnerships and support. Among one of the CHW training programs approved by the state, PTI is the only organization with the coveted IACET* accreditation. The program teaches the National C3 Council skills and health knowledge necessary to function as a CHW in a variety of community settings. This robust training offers teaching excellence along with a leading-edge curriculum that supports the participants in achieving the learning objectives of the program. For more information on PTI CHW training, visit https://transformcoach.org/learning-solutions/community-health-worker-chw -program/ or call (248) 475-4736.    References: Agency for Healthcare Research and Quality (2025).  What is patient experience?  https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html. Anhang Price, R., Elliott, M.N., Zaslavsky, A.M., Hays, R.D., Lehrman, W.G., Rybowski, L, Edgman-Levitan, S., & Cleary, S. (2014).  Examining the role of patient experience surveys in measuring health care quality. Medical Care Research Review, 71(5), 522-54.  doi: 10.1177/1077558714541480. Epub 2014 Jul 15. PMID: 25027409; PMCID: PMC4349195. Center for Accelerating Care Transformation, https://www.act-center.org/application/files/1616/3511/6445/Model_Chronic_Care.pdf. Institute for Healthcare Improvement, https://www.ihi.org/library/topics/quintuple-aim. Wagner, E.H. (1998, seminal article).  Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, (1), 2-4.

What is Population Health?

Patient- or client-centered care delivered by prepared, proactive practice teams is essential for excellent healthcare delivery (Center for Accelerating Care Transformation). Community Health Workers (CHWs) are important members of healthcare teams, bridging gaps between clinical health care and community-based resources (Center for Health Care Strategies, 2025).

In healthcare, we often talk about the Quintuple Aim, a framework developed by the Institute for Healthcare Improvement (2025) to understand and improve health system performance. The Triple Aim (the initial form of the Quintuiple Aim) was proposed by the Institute for Healthcare Improvement (IHI, 2012) as a purpose statement for simultaneously improving population health, patient experience, and per capita cost reduction. The Triple Aim was adopted by the US Department of Health and Human Services as a framework for the National Quality Strategy, the Centers for Disease Control and Prevention, and the Commonwealth Fund. The Quintuple Aim expanded the Triple Aim beyond quality and cost to include human and equity dimensions of care: population health, patient experience, cost, provider well-being, and health equity.

Over the next several months, we will explore each of these dimensions and how CHWs contribute to improved outcomes.

The first dimension we will address is population health.

What is population health?

There is ongoing confusion about the difference between population health and public health. These terms are often used interchangeably, but they are separate yet related disciplines. The World Health Organization (2023) describes public health as aiming “to provide maximum benefit for the largest number of people.” Public health agencies are organized at local, regional, state, and federal levels with responsibilities for communicable disease control, chronic disease and injury prevention, environmental health, emergency preparedness, assessment and surveillance, community partnership development, and policy development (Kaiser Family Foundation, 2025).

The term population health initially surfaced in 1990 with a focus on health status and outcomes in specific groups of people (D. Kindig & G. Stoddart, 2003). Groups may be comprised of patients based on location, provider practice, payer, chronic condition(s), age, health behaviors (e.g., cancer screening, emergency department use), or other variables. The goal of population health is to proactively identify and implement interventions to optimize health status within a group. This is done by implementing targeted, evidence-based interventions that often go beyond physical and behavioral health care to address social, economic, and environmental factors impacting health.

What is the community health worker’s role in population health?

CHWs play an important role in population health, particularly with increased recognition of Social Determinants/Drivers of Health (SDOH). CHWs bring lived experience and cultural responsiveness needed to build trusting relationships with patients and families (CHCS, 2025).

They are educated in SDOH assessment and evidence-based approaches such as motivational interviewing, goal setting, and action planning. CHWs have a deep understanding of community-based services and assist clients, families, and caregivers with navigating complex healthcare systems.

CHWs provide outreach, education, and social support for issues such as unstable housing, food insecurity, and transportation. CHWs may also support patients with chronic health conditions such as diabetes by reinforcing the importance of medication adherence, monitoring, and follow-up (CHCS, 2025).

The Practice Transformation Institute (PTI) CHW educational programs strengthen CHW knowledge, performance, and contribution to improved health outcomes. PTI is an approved provider of Community Health Worker (CHW) training by the Michigan Department of Health & Human Services (MDHHS). The approval follows a rigorous application process and more than two years of PTI providing CHW training through community and health system partnerships and support. Among one of the CHW training programs approved by the state, PTI is the only organization with the coveted IACET* accreditation.

The program teaches the National C3 Council skills and health knowledge necessary to function as a CHW in a variety of community settings. This robust training offers teaching excellence along with a leading-edge curriculum that supports the participants in achieving the learning objectives of the program.

For more information on PTI CHW training, visit https://transformcoach.org/learning-solutions/community-health-worker-chw-program/ or call (248) 475-4736.

References:

Center for Accelerating Care Transformation, https://www.act-center.org/application/files/1616/3511/6445/Model_Chronic_Care.pdf

Institute for Healthcare Improvement, https://www.ihi.org/library/topics/quintuple-aim

Kindig, D. & Stoddart, G., (2003, seminal article). American Journal of Public Health, 93, 380-383.

Michaud, J., Kates, J., Oum, S., & Rouw, A., U.S. Public Health 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-u-s-public-health (accessed 11-5-2025).

Roux, A.V. (2016). On the distinction – or lack of distinction – between population health and public health. American Journal of Public Health, 106(4), 619-62. Doi: 10.2105/AJPH.206.303097. PMID: 26959262. PMCID: PMC4816152.

Patient Engagement: The Key to Better Health Outcomes

 

Engaging patients in their own care is one of the most powerful strategies to improve health outcomes, strengthen relationships, and support long-term self-care management and behavior change. When patients feel heard, understood, and empowered, they are more likely to actively participate in their care and treatment plans, making informed decisions that improve their overall well-being.

One proven way to enhance patient engagement is through Motivational Interviewing (MI). MI is a patient-centered communication technique that has been developed to help motivate ambivalent patients. Also, it guides care teams to have collaborative, empathetic conversations, empowering patients to explore their motivations and overcome barriers.

 Why Motivational Interviewing Matters

• Builds trust: Patients feel respected and valued when care team members listen with empathy.
• Encourages self-motivation: Through MI, care teams guide patients to find their own reasons for making health changes.
• Improves adherence: Patients are more likely to follow treatment plans when they are part of the decision-making process.
• Supports diverse care settings: MI is effective across primary care, behavioral health, Medication Assisted Treatment (MAT), palliative care, and more.

At Practice Transformation Institute (PTI), we believe engaging patients is the heart of quality care. PTI supports patient engagement by equipping care teams with tools, skills, and educational courses, such as Patient Engagement Foundations, to foster productive, patient-centered conversations. Through the Patient Engagement Foundations course, participants will learn the core principles of motivational interviewing and how to apply these skills across different care settings.

 Course Objectives:

• Describe the patient-centered approach of MI
• Explain the conversation style that represents the Spirit of MI
• Demonstrate basic MI skills
• Discuss how to use patient language cues (change talk and resistance) in practice
• Explain how to engage patients in the four MI processes necessary for health behavior change
• Identify barriers to patient engagement and behavior change
• Identify how to make cultural adaptations to MI

(It is strongly recommended to complete Introduction to Team-Based Care before taking this course.)

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Course Details: (Live Virtual)

November 13, 2025 | 8:30AM – 4:30PM

Cost: $300 per participant

This training provides practical tools to enhance patient engagement and strengthen care team communication, skills that benefit both patients and providers alike.

 Register Today: https://cvent.me/RD8o9E

Let’s continue building stronger connections, improving outcomes, and transforming care—one patient conversation at a time.

 

References

1. Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2), 207–214.
2. Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93(2), 157–168.
3. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.

HIMSS Michigan Chapter 2025 Fall Conference

HIMSS Michigan Chapter, a mission-driven nonprofit, offers unique experts in health innovation, public policy, workforce development, research, and analytics to support leaders and organizations across the healthcare ecosystem. Through a community-centric approach, HIMSS delivers insights, education, and events that help providers, payers, governments, startups, life science, and other health organizations make informed decisions and drive meaningful change.

The HIMSS Michigan Chapter 2025 Fall Conference brought together professionals from across Michigan for two days of valuable learning and discussion on topics such as:

• Community Information Exchange (CIE)
• Data Exchange between POs and Payers
• Patient Satisfaction
• Driving Transformational Change
• Enterprise Virtual Care Transformation
• Cybersecurity in Healthcare

…and much more.

Practice Transformation Institute (PTI) was honored to share insights on the importance of Community Health Worker (CHW) Sustainability, specifically the role of CHWs and billing for services, and sustainable models of care. PTI remains committed to helping clarify strategies that support CHWs and partners, particularly in the areas of CHW core roles, recertification, and billing.

A key question raised during our session was: “Is there a single process for CHW billing and reimbursement across all payers?” The answer is no! Each payer has unique requirements for registration, reimbursement strategies, and the specific ICD-10 codes reimbursed.

To address these differences, PTI is offering a two-part educational series designed to provide clarity on the billing and reimbursement process for CHW services.

The program will cover how to:

• Identify services for which a CHW can bill
• Explain billing requirements for Michigan’s primary payers
• Utilize HCPCS codes to report services provided
• Apply ICD-10-CM Z-codes to report social determinants of health
• Discuss potential functions and workflows in organizational settings
• Identify documentation requirements

…and more

When (Live Virtual):

• Part One: November 20, 2025
• Part Two: November 21, 2025
  (Must attend both days to receive CEUs)

Time: 8:00 AM – 12:00 PM (Both days)
Cost: $99.00

Click here to register.

Community Health Workers (CHWs) Enhance Transition of Care to Reduce Readmissions

 

Every hospital readmission is more than just statistics and data – it disrupts lives, renews stress for patients and families, and signals missed chances for better continuity of care. According to CMS (2024), thirty-day readmission rates are a key quality measure, often reflecting “quality of hospital care, poor discharge planning, and ineffective coordination of post-discharge services.” Evidence shows that reducing preventable readmissions requires multiple interventions, such as patient education, discharge checklists, medication reconciliation and review, post-discharge follow-up, and addressing social determinants/drivers of health (SDOH) and disparities (CMS, 2024).

The period after discharge, or transition of care (TOC), is a critical time for these interventions. Patients may leave hospitals or other settings with new medications, complex instructions, unanswered questions, unmet social needs, or limited abilities. Missed follow-up visits, confusion about care plans, or unaddressed social challenges often lead to readmissions. Community health workers (CHWs) play a vital role in bridging these gaps. By leveraging shared culture and language, CHWs build trust, simplify instructions and address health literacy, coordinate follow-ups and transportation, provide phone or home check-ins, and connect patients to SDOH resources such as housing, food, or utility support.
Preventing readmissions is not just a medical process – it is a human one. CHWs support individuals where they live, work, and recover, helping ensure safe transitions, reducing avoidable hospital stays, and providing the connection and support patients and families need.  

Practice Transformation Institute CHW Training Program prepares CHWs to do this and more.

• To learn about the program, visit us at https://transformcoach.org/learning-solutions/community-health-worker-chw-program/
  

• To listen to our Informational Session Zero about the CHW Program, click here: https://youtu.be/fvf-qmY66k8?si=B_1FhqDCvtS_dlgy
  

• Don’t miss out! Registration for our next CHW training is now open. To register, click here: https://cvent.me/OvBWe0
  

September 25, 2025 – February 19, 2026

Thursdays | 9:00 AM – 4:00 PM (Live Virtual)

Learners will receive 0.6 IACET CEUs per session

Reference:
CMS Office of Minority Health. (2024). Guide for Reducing Disparities in Readmissions. https://www.cms.gov/about-cms/agency-information/omh/downloads/omh_readmissions_guide.pdf

Empowering Communities Through the Work of CHWs

August is Immunization Awareness Month—a time to highlight the importance of vaccination across the lifespan and the role of disease prevention and screening in maintaining community health. Community Health Workers (CHWs) play a vital role in educating individuals and communities about the benefits of immunizations and improving health literacy to increase vaccine confidence. As trusted members of the community, CHWs are uniquely positioned to address barriers to care and improve health outcomes through targeted outreach and culturally relevant education, not only in closing immunization gaps but also in disease prevention and screening.

Practice Transformation Institute (PTI) CHW Program, approved by the Michigan Department of Health and Human Services (MDHHS), offers seven (7) full-day training sessions covering Public Health and Health Literacy, Healthy Lifestyles, Screening and Prevention, Chronic Conditions, and Behavioral Health.

These sessions provide CHWs with a strong foundation in public health, focusing on their essential role in addressing community health needs. Training topics include public health, research methods for identifying community health needs, and the importance of health literacy. CHWs also receive education on nutrition, physical activity, sleep, oral and sensory health, and preventive services, like cancer and communicable disease screenings. Additionally, chronic conditions sessions identify how the Chronic Care Model facilitates behavior change in individuals with chronic conditions and explore behavioral health concepts, including mental health, cultural stigma, and life-cycle impacts. Health disparities, inequities, and barriers to care are central themes woven throughout these sessions and this training program.

Don’t Miss out, Our Next CHW Training Registration is Now Open
September 25, 2025 – February 19, 2026
Thursdays | 9:00 AM – 4:00 PM (Live Virtual)
Learners will receive 0.6 IACET CEUs per session

To learn more about our program, register for Session Zero

Link to register: https://transformcoach.wufoo.com/forms/zbdij0ezl4zc/

 

Community Health Worker Sustainability Program

Did you know providers can bill Medicaid, Medicare, and select Michigan payers for CHW services? If your billing staff or revenue cycle team isn't yet familiar with the reimbursement process, it's time to start the conversation.

CHWs are an indispensable part of healthcare, social services, and community organizations. With the right training, CHWs can develop core competencies while helping your practice achieve financial sustainability. But how do we ensure their continued integration and sustainability? What sources are available to reimburse the services they provide to sustain their role within an organization or provider practice?

This new two-part program will explore just that, and more by covering the following:  

·        Identify services for which a CHW can bill, along with the payer enrollment process

·        Explain the link between ICD-10-CM codes and reporting health conditions

·        Discuss how ICD-10-CM Z codes are used to pinpoint social determinants of health (SDOH)

·        Clarify the documentation needed to bill for CHW services

·        Identify billing codes approved for CHW payment by the primary payers in Michigan

This live virtual program will be in two parts on August 14 and August 21, 2025, from 9 AM – 1 PM. PTI is authorized by IACET to offer 0.8 CEUs for this program after completion.

Link to register: https://web.cvent.com/event/d6393617-f390-461e-acf9-70c2f942033f/summary

2024 Community Health Worker Advisory Council Final Report

MDHHS has released the 2024 Community Health Worker Advisory Council Final Report, which outlines a framework for statewide CHW certification and expands on the Medicaid reimbursement policy (MMP 23-74).

This report, based on the 2023 CHW Subcommittee's work, showcases Michigan’s commitment to a sustainable and impactful CHW workforce, further aligning with the state’s Social Determinants of Health (SDOH) Strategy. CHWs continue to serve as essential bridges between healthcare systems and communities, advancing equity and access at every level.

View Full Report
https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Inside-MDHHS/Policy-and-Planning/Social-Determinants-of-Health-Strategy/CHW-Advisory-Council-Final-Report-FINAL-0715.pdf?hash=859D7E4069802A02F255269AD4F992F9&rev=73fb11faaf654477a4c7b534e397bd24&utm_campaign=&utm_medium=email&utm_source=govdelivery

Get Involved

Whether you’re a provider, administrator, or aspiring CHW, PTI offers comprehensive training and education programs tailored to your needs. Visit our website or contact us directly to learn more!

Together, we can empower the next generation of Community Health Workers—and strengthen the health of every Michigan community.

Improving Community Health: The CHW

 

 

Our blogs have talked a lot about community health workers (CHWs) and their role in helping to build a healthier community. CHWs are an advocate and liaison to connect individuals and families to health care and social services. They have a strong connection to the community they serve and may share the same ethnicity, race, language, socioeconomic characteristics, cultural, spiritual beliefs, and life experiences found in the community. CHWs can work in urban or rural environments with low-income, minority, immigrant, underserved communities, and populations with limited English proficiency. They have diverse job descriptions as well as job titles depending on the organization in which they work.

The demand for CHWs is growing as they have a crucial role in improving health equity and supporting the public health system, especially in underserved communities.

Home visits. CHWs can do home visits for patients/clients. Their training teaches them how to be prepared for a home visit, recognize hazards in the home, and ways to assess the overall environment. CHWs might discuss lifestyle changes while keeping in mind the cultural customs of the patient. They can see firsthand in the home what the physician office can’t. How important is that to really know your patients/clients?

Culture. Understanding cultural influences such as communication preferences, beliefs about health and illness, family and community, preferred healthcare practices, and addressing potential challenges can lead to more effective and appropriate care. This is an important part of what CHWs do.

SDOH. CHWs can complete a social determinants of health screening (SDOH) which includes questions about housing, food security, transportation, healthcare access, childcare, utilities, employment, income, and other social factors that may affect a patient’s/client’s health. CHWs can see what is in the refrigerator and if the patient/client could use a referral to a local food bank. CHWs can help with transportation issues for physician office appointments and financial assistance needs to help with paying utility bills. If they don’t know what is specifically available for a problem, they will investigate.

Community resources. Referrals to needed community resources are a big part of what a CHW can do along with assisting patients/clients in accessing these services. It could be a health department, food bank, community center, transportation, mental health support, housing, appointments, and other related social needs. CHWs can help with barriers to obtaining needed preventive services. Knowing what is available in the state, city, county, zip code is vital.

CHWs may call 211 or go to www.mi211.org to learn about agencies in the county to help with energy bills, for example. State of Michigan emergency relief programs, Michigan Energy Assistance Program (MEAP) for low income residents, and utility companies all have programs that may provide certain types of assistance. There is an outreach toolkit for energy assistance on the Michigan.gov website:

https://www.michigan.gov/mpsc/-/media/Project/Websites/mpsc/consumer/info/toolkits/Energy_Assistance_Outreach_Toolkit.pdf?rev=32219a29ba9547c98f72ad5e5ffc117d&hash=2FF0B41D07770AE02FFC6606FA608863

SMART goal and action planning. CHWs can develop SMART goals and action plans around the priority needs of patients/clients and do follow-up at the next contact with them. They are trained in motivational interviewing techniques and brief action planning.

As you can see, all of the items above interconnect with one another. As CHWs perform these tasks, they build trusting relationships with their patients/clients. There is a critical link between identifying SDOH needs, understanding cultural influences, and integrating community resources to improve the health outcomes of patients.

Community Health Worker Program

The next CHW Program will begin on September 25, 2025, and conclude on February 19, 2026. Live virtual webinars will be on Thursdays from 9 AM – 4 PM. PTI is an approved provider of CHW training by the Michigan Department of Health and Human Services (MDHHS). We are the only CHW training program that offers 0.6 IACET CEUs for each individual session.

Register here: https://web.cvent.com/event/c92a52ee-4fd1-4741-9107-c95e1910be8a/summary

Community Health Worker Sustainability: Advancing the Profession

The new dates for this program will be August 14 and 21, 2025 from 9:00 AM - 1:00 PM. This series is designed to provide in-depth knowledge on documentation, billing, coding, and the role of CHW interventions in improving population health. Practice Transformation Institute is authorized by IACET to offer 0.8 CEUs for attending both days of the program. IACET CEUs are recognized by a wide range of organizations including universities, regulatory boards, corporations, and professional organizations.

Goals of this educational opportunity are:

· Educate CHWs about the payer enrollment process and billing services.

· Strengthen the understanding of coding systems (ICD-10-CM, Z-codes) for reporting health conditions and Social Determinants of Health (SDOH).

· Improve documentation skills to align with payer requirements and reimbursement processes.

· Enhance knowledge of how CHW interventions contribute to improving population health, increasing access to care, and reducing health disparities.

Register here: https://cvent.me/KMvL4V

Continuing Education

Practice Transformation Institute is accredited by the International Accreditors for Continuing Education and Training (IACET) and offers IACET CEUs for its learning events that comply with the ANSI/IACET Continuing Education and Training Standard. IACET is recognized internationally as a standard development organization and accrediting body that promotes quality of continuing education and training.

Education is a Lifelong Journey

 

School will be out soon for children as they begin a summer break before the next school year begins. They may look forward to a family vacation, a summer camp, or just hanging out in the backyard. Oh, to be young again and have that kind of freedom. As adults it is important to make use of our time off for fun activities for sure! But learning new skills whether it be through hobbies or continuing education for our occupation or volunteer work or expanding our career opportunities all help with the lifelong learning that fosters personal growth.

At Practice Transformation Institute (PTI) we are almost at the last session of our Advancing the Patient Experience of Care six-part series. Overall, this six-part series was designed to identify and develop the skills essential for providing a positive patient experience of care within the clinical setting. A patient’s experience is enhanced through effective communication, obtaining patient feedback, interacting with diverse generations, using the spirit of motivational interviewing (MI) and MI tools, and exhibiting cultural competency and humility. Using survey data results obtained in determining areas for quality improvement in the patient experience of care will be explored in Part Six.

Part Six: Using Data to Create Excellence in the Patient’s Experience of Care

Wednesday, June 25, 2025

This activity will identify ways in which to measure a patient’s experience of care and use the results to improve care within the clinical setting. Common tools used to measure patient experience of care will be identified. Motivators and barriers related to completing experience of care surveys/questionnaires will be explored with potential ways to resolve barriers.

This is a live virtual activity lasting 90 minutes with two choices for attendance, either from 7:30 AM – 9:00 AM or 12:00 PM – 1:30 PM. Each of the six-part series activities could be taken separately for 1.5 AMA PRA Category 1 Credits™ if not registered for all six. Please see the link below for registration for this activity.

https://transformcoach.org/learning-solutions/advancing-the-patient-experience-of-care-series/

Target Audience: Physicians, advanced practice providers, nurses, social workers, pharmacists, CHWs, and other members of the healthcare team

Continuing Medical Education (CME):

Statement of Accreditation
The Practice Transformation Institute is accredited by Michigan State Medical Society to provide continuing medical education for physicians.

AMA Credit Designation Statement
Practice Transformation Institute designates this live course for a maximum of 1.5 AMA PRA Category 1 Credit(s)^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Community Health Worker Program

Community Health Workers (CHWs) can change a person’s life. We will have a new CHW Program starting in September. You have the summer to think about what you’d like to do with that information. Have you thought about hiring a CHW or training a staff member to become a CHW for the value they provide for your patients/clients? Have you thought about becoming a CHW yourself?

Practice Transformation Institute (PTI) is an approved entity by the Michigan Department of Health and Human Services (MDHHS) to provide training for individuals seeking Community Health Worker (CHW) certification. We are the only CHW program in Michigan that is accredited by the International Accreditors for Continuing Education and Training (IACET) and able to award CEUs for each activity. PTI’s program includes a robust curriculum of 103 hours of virtual classroom learning that meets the requirement of the National C3 Council. Topics include communication, motivational interviewing, action planning, social determinants of health, community resources, chronic conditions, healthy lifestyles, health promotion and disease prevention, and more.

The next CHW Program will begin on September 25, 2025 and conclude on February 19, 2026. Live virtual webinars will be on Thursdays from 9 AM – 4 PM. PTI is authorized by IACET to offer 0.6 CEUs for each individual session. IACET CEUs are recognized by a wide range of organizations including universities, regulatory boards, corporations, and professional organizations.

Stay tuned for registration details for this next CHW Program coming soon.

Please visit PTI’s website at www.transformcoach.org or by contact yyang@transformcoach.org or hkinkle@transformcoach.org for more information.

PTI offers a wide range of educational programs for all types of health care professionals. We know the benefits of working collaboratively on interprofessional teams and how they help improve patient outcomes.