TeamWork: Leadership for Healthy States

CASE STUDY

MISSOURI
2015-2016

Team Members:

Peter Lyskowski*
State Senator Shalonn Kiki Curls
Representative Keith J. Frederick
Celesta Hartgraves
Brian D. Kinkade
Harold Kirbey
Steven A. Ramsey

*Team Leader
** Mr. Lyskowski departed the Department as of April 2017

For additional information, contact:

Celesta Hartgraves
Director of Division of Senior and Disability Services
Missouri Department of Health and Senior Services
Phone: 573-526-3626 | Email: celesta.hartgraves@health.mo.gov

The TeamWork: Leadership for Healthy States programpreviously known as the Excellence in State Public Health Law
Programstrengthens relationships within and across branches of government, builds understanding of population
health issues, and opens channels of communication and problem-solving that can be used to address future population
health challenges.
The Health in All Policies Vision

The Health in All Policies (HiAP) vision has five elements: promoting health and equity, supporting
intersectoral collaboration, creating co-benefits for multiple partners, engaging stakeholders, and
creating structural or process change. The Missouri team initially approached the HiAP concept by
looking at the rapid aging of the population and its need for chronic disease prevention and control.
Older adults are disproportionately affected by chronic diseases, which are associated with disability,
diminished quality of life, and increased costs for health care and long-term care. In 2011, about 95% of
Missouri seniors over the age of 65 had at least one chronic disease or condition. More than 80% had at
least two chronic diseases or conditions and approximately 65% had at least three chronic diseases or
conditions. Missouris national ranking on various health determinants and outcomes provided the
evidence basis for where intervention could improve outcomes in chronic disease prevention.

The initial planning stages for this project consisted of a state senator, a state representative, a
representative from the Governors Office, the directors of the Department of Health and Senior
Services (DHSS) and the Department of Social Services, the DHSS legislative liaison, and directors of
the senior services and public health divisions within DHSS. Using health data, the group identified the
need to address diabetes in senior populations, especially in four regions of the state with some of the
largest health disparities: the St. Louis region, Kansas City, the Bootheel and Phelps County. In addition,
the group identified a need to include more statewide and local partners in the implementation of the
pilot project.

The Missouri TeamWork project focused on the importance of increasing self-management and
prevention of chronic disease through education, informal counseling, social support, advocacy, and
referral to preventative services within urban and rural communities in Missouri. From the beginning,
the team viewed improvement of the health of senior citizens by the prevention and management of
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chronic disease among older Missourians through the HiAP lens. It emphasized collaboration between
members of the affected population, health agencies and other sectors both governmental and private.

Project Summary

Through funding from the Centers for Disease Control and Prevention, DHSS built the foundation for
incorporating CHWs into health system teams. A needs assessment conducted in 2013 determined the
characteristics, education and training needs of CHWs. DHSS subsequently approved a CHW
definitionand scope of work, and a Statewide Community Health Worker Advisory Committee was
established to develop a statewide infrastructure for CHWs, including standards, curriculum and scope
of practice.1

The Patient Centered Health Home model has shown that high utilizers of health care benefit from
intensive care coordination. Inclusion of CHWs allows for the shifting of healthcare services to an
outpatient setting which improves health outcomes. CHWs are mediators between health system
providers and communities who promote the appropriate use of primary and follow-up care. Research
has shown that inclusion of CHWs has reduced health disparities, expanded access to coverage and care,
increased health care cultural competence, and reduced costs.

Missouris team planned to deploy CHWs into local community locations, including Senior Centers.
Initially, the goal was to improve the health of senior citizens by preventing and managing all chronic
diseases, but as the cohort progressed, Team Missouri narrowed the project to focus on diabetes.
Regional planning meetings were held in each of the four targeted regions. These meetings provided an
opportunity for local input and adaptation of the implementation plans to more closely fit the social and
cultural aspects of each of the communities. They also provided an opportunity to identify local
champions, assign local tasks and roles, and build consensus on the desired outcomes.
Missouris plan had been to use these local meetings to clearly define roles, communication and
interactions between the community partners as well as to engage local partners to recruit CHW
candidates from the participants in the Senior Center programs or seniors active within the identified
communities. It was clear after the initial meetings that each of these communities had numerous
stakeholders that were engaged with this concept. Each location identified additional partners that
needed to be included in expanding this concept. Team members learned through the meetings that
there was not as much collaboration between the Local Public Health Agencies and the Area Agencies
on Aging as expected.
After the team members had met in the local and regional partners meetings, Team Missouri decided to
use its technical assistance funds to contract with a lead agency in each of the four regions to facilitate
Regional Planning Groups (RPG) to move this project forward in their region. RPGs were used
successfully as a tool in AIDS prevention and management efforts in Missouri, and served as a template
for the TeamWork project. The RPGs will develop needs assessments and work plans to obtain input

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As defined by the Community Health Worker Section of the American Public Health Association: A Community Health
Worker (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 delivery. (http://mnchwalliance.org/who-are-chws/definition/)
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from all partners. In addition, representatives from the RPGs will become voting members of the
Statewide CHW Advisory Committee.
Regional Planning Groups have now been established in St. Louis, Kansas City, Rolla and the Bootheel
region of the state and meetings have started. These groups will complete needs assessments in 2017.
To support the infrastructure building for CHWs, free tuition for individuals interested in the CHW
course has been available in Kansas City, St. Louis and Springfield. This was recently expanded to the
Bootheel, Moberly and Columbia. A diabetes module was developed to enhance CHWs understanding
of diabetes. In 2016, the community college in Springfield began a hybrid course using a learning
management tool making the course available partially on-line. To further increase infrastructure,
activities are underway to develop an on-line interactive course.
In addition:

DHSS sought training support to recruit CHWs through additional regional community colleges.
DHSS assumed responsibility to pay educational costs for CHWs.
Using technical assistance and DHHS funding, the Department planned to provide training to
community partners on the chosen Chronic Disease Self-Management Program.
DHSS established a baseline of health data on program participants that can be used to evaluate
program efforts and to share with individual participants health care provider.
DHSS established a communication strategy for CHWs and the local health care providers.
The team envisions a sustainable model. The funding sources that DHSS plans to use to underwrite the
elements above will come from federal grants already in place from CDC for chronic disease
management and prevention.
Over the course of the project, no lobbying took place with Robert Wood Johnson Foundation funds.

Cross-Sector Collaboration

The greatest strength of Team Missouris project was the collaborative relationships formed with local
agencies. In spring 2016, team members met in groups with Local Public Health Agencies, Area
Agencies on Aging, federally qualified health centers, adult protective service staff, community
partnerships and foundations in each of the four identified regions. These partners had a wealth of
knowledge about their communities and existing programs and partnerships. What was especially
helpful in each meeting was that these partners identified other entities from their communities that
should be involved in further developing the project. All of the stakeholders invited were positive about
the concept, but had many questions about implementation.

Interbranch collaboration within Team Missouri itself was both a challenge and opportunity during the
cohort period. At the outset, team members were primarily selected due to shared values concerning the
well-being of senior citizens in Missouri. State Representative Keith Frederick and Brian Kinkade, the
Director of the Department of Social Services, were very engaged in brainstorming ideas and thinking
outside of the box to improve outcomes for seniors. Senator Shalonn Kiki Curls is a strong advocate
for underserved minority populations.

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The team was able to weather a leadership change during the middle of the project. Gail Vasterling was
the Director of DHSS and the Team Leader at the beginning of the project. With her departure for
another position in October 2015, Peter Lyskowki became the Director of the DHSS and the Team
Leader. Director Lyskowki previously served on the team as the representative from the Governors
Office and led the project to the end of the cohort period.

The Benefits of TeamWork

This project afforded many of the team members their first exposure to the HiAP vision;
readings on collective impact and systems theory and leadership allowed the team discussions
and planning to take on a very different tone from previous encounters.

Discussions became much more inclusive of the various social and cultural factors that can
impact state efforts to help Missourians lead healthier lives.

Dedicated project time at off-site retreats, building and reinforcing trust in relative isolation from
the day-to-day work in Jefferson City, allowed a much more relaxed and open discussion of the
issues, challenges, and potential resources, as well as the chance to gain different perspectives.

Inter-branch teams that include a member from the Senate and the House have been successful
for this project, and will be replicated for other policy issues.

TeamWork made possible the development of relationships across branches of government, the
fostering of well-considered and nuanced policy dialogues, and the deepening of a joint
commitment to drive policy.

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Community Health Worker
Regional Planning Groups:
Purpose: To ensure the dissemination of resources
and information among community partners and
CHWs in an effort to effectively carry out CHW
activities specifically with the Senior Population
relating directly to Diabetes Prevention and Control
 Community Planning Group (CPG)
REGIONAL PREVENTION ADVISORY GROUPS

Each regional planning group is facilitated by a lead agency co-chair as well as

a community co-chair. Members of these groups are expected to address
social determinates of health in an effort to provide services and resources to
senior individuals within the community that otherwise would not have access.
 Community Health Worker Regional Planning
Groups(CHWRPG)
Carry out a logical, evidence-based process to
determine the highest priority, senior population-
specific diabetes prevention needs in the
jurisdiction. This is accomplished through:

The state epidemiological profiles

that provide information about
defined senior populations at high
risk for diabetes for the CHWRPG to
consider.
The development of a community
services assessment that focuses on
services needed for this population.
The development of a plan on how
to address need.
 CHWRPG Partners

Senior Centers

Missouri Primary Regional Arthritis

Care Association Centers

Hospitals and State

CPG
Associations Government

Local Health
Local FQHCs
Departments
CHWRPG and
Community Agency
Representatives
 Community Health Worker Regional
Planning Group (CHWRPG)
The expectations of the group are to:
Involve members of the RCHWPG in the planning of
CHW interventions and/or programs that meet the needs
of the senior population at risk or with diabetes
Assess needs
Prioritize unmet needs
Identify effective interventions
Prioritize effective interventions
Evaluate effective interventions