WHO: Kyle McClure

JOB: Community Health Worker

INITIATIVE: Mountain-Pacific Quality Health’s ReSource Team, Billings Montana

POPULATION: Participants must have: (1) two or more hospital admissions within the past six months; and/or (2) two or more emergency department visits within the same time period. Those eligible include uninsured patients, as well as those covered by Medicare, Medicaid, commercial insurance, the Veteran’s Health Administration, and the Indian Health Service.

KEY FEATURES: Uses tablet computers to assist community health workers in connecting patients in isolated rural areas to health care providers and community resources.

Kyle McClure,* a community health worker (CHW) for Adult Resource Alliance, which contracts with Mountain-Pacific Quality Health in Billings, Montana, served for five years in the U.S. Army’s airborne division. While there, he learned to be patient, observant, and a good listener — critical skills for a CHW. His army background also helps him engage with military veterans, an often underserved and medically complex group.

Montana has the second highest rate of veterans per capita in the nation. With just six people per square mile, it is extraordinarily rural, and has a reputation for attracting people with an independent streak. Despite loving his work, McClure admits that these barriers — both cultural and physical — often make his work challenging. However, he is far from alone. As part of Mountain-Pacific Quality Health’s ReSource Team, McClure works with a registered nurse and a remotely based team of physicians, pharmacists, and behavioral health specialists who collaborate to help patients with complex needs improve their health and independently manage their own care. And though McClure does not work exclusively with veterans, his background has been instrumental in connecting patients with military service histories to health care and community resources.

New Faces of The Complex Care Workforce

In communities across the nation, complex care management teams are deploying “non-traditional” health care workers — including individuals with lived experience or skills that transcend the traditional bounds of health care — to better connect with high-risk patients. The New Faces of the Complex Care Workforce series showcases how these workers are helping in innovative ways to address the needs of adult Medicaid beneficiaries with complex health and social needs.

Many veterans are eligible for lifelong free or subsidized medical care through the Veterans Affairs Administration (VA). However, as with any large institution, interacting with the VA health care system can sometimes be intimidating. This was the case for one veteran, Gary,** who during McClure’s first meeting was extremely withdrawn. “He absolutely refused to answer most questions. He would look to his wife to answer everything for him.” Gary, who suffered from depression and anxiety, spent the majority of his time indoors watching television. However, over time, McClure began sharing his own stories and experiences at the VA. He told Gary how the VA helped him receive affordable medications and other services while he was struggling financially. Eventually, Gary agreed to be connected with the care team.

“Being a veteran, knowing the lingo, and what they came from…makes it more likely for them to work with us, instead of against themselves.”

Kyle McClure, Community Health Worker, Mountain-Pacific Quality Health's ReSource Team

McClure was able to coordinate Gary’s care together with a dedicated VA “pack team,” including nurses, a phlebotomist, and a counselor who provides care in the hospital or even Gary’s home, greatly reducing travel time and expense. McClure shared information with the VA team, helped to coordinate appointments, and reinforced their instructions with Gary at home, using a tablet computer during home visits to connect with a nurse or other provider as necessary to address specific medical needs. McClure noted that Gary underwent a “complete personality change” with the more personalized care, noting he is brighter, more alert, and engaged with his surroundings.

The key, suggests McClure, is to look beyond behavior and instead listen carefully to what patients have to say. Many chronically ill patients “are irritated with hospitals and ‘systems’ at large,” says McClure. “They’re frustrated, they don’t think people are listening to them. But when a person they trust is willing to explain complicated medical jargon, or help fill out their paperwork, real change can happen.”

*Kyle McClure no longer works for Adult Resource Alliance.

**Patient’s name has been changed to protect their privacy.

Additional Resource

Case Study | Mountain-Pacific Quality Health Pilot: Closing the Gaps in Rural Complex Care – Provides details about Mountain-Pacific Quality Health’s ReSource Team, which pairs community health workers and volunteers with technology to connect patients in hard-to-reach rural or frontier areas to health care and social services. October 2017

Author: Mariel Gingrich, MPH