Community Health Worker Expansion Pilot Program


CHW

Pictured are Community Health Workers Nicollette Echevarria, Noemia Monteiro-DoCanto, and Maria Pinto.

In December 2015, the health center was chosen to receive funding through the Executive Office of Health and Human Services (EOHHS) to support an innovative and exciting Community Health Worker expansion pilot program. With this funding, we have been able to build upon our previous experience with Community Health Workers and better engage in population management and outreach to our highest risk patients.

This particular pilot program focuses on our Care Coordination Resource Team, a multi-disciplinary team of nurses care managers, social workers, physicians, and community health workers focused on providing high quality, accessible, integrated care to patients with an emphasis on population and high risk care management. Since April 2016, we have added two new Community Health Workers to the team for a total of three and have begun to systematically review and reach out to high risk patients with complex needs.

Many of our patients struggle to engage with primary care as a result of language barriers, financial strains, housing instability, competing social responsibilities, and difficulty navigating the often confusing and overwhelming health care system. We know from our patients that these complex social challenges greatly impact physical health and mental health. For these reasons, the role of the Community Health Worker is absolutely pivotal.

The challenges that many of our patients face have not historically been well addressed by traditional care management and our efforts to help patients can be limited by the boundaries of the clinic. Knowing this, we have made a commitment to using innovative ways to help our patients and going outside the bounds of the health center. CHWs coordinate with ongoing team-based care management efforts and assist with patient navigation, care coordination, culturally tailored education, and social resource connection. CHWs have proven to be incredibly important in providing key outreach and advocacy for the most disadvantaged and disenfranchised patients.

We hope that through the work of CHWs within our teams, we will be able to impact health disparities, reduce unnecessary costs, and improve continuity of care among patients who struggle to manage their health due to medical and social complexities.

Even in the short amount of time that this pilot project has been in effect, we have stories of patient progress and improved health outcomes. One patient experiencing severe hypertension and depression in addition to social isolation and financial instability has worked with a Social Worker and Community Health Worker to connect with a culinary training program and work, the YMCA, and local healthy food sources and as a result has seen decreased blood pressure, much improved mood, increased social connection, and increased income. Another patient coping with a diagnosis of lymphoma, having great difficulty getting to specialty medical appointments due to lack of transportation and lack of family supports, feeling quite overwhelmed by navigating the healthcare system, and with an inability to read written health information given to him has begun working with his PCP, a CHW, and a Nurse Care Manager to ensure that he has transportation, that he understands his condition and recommended treatments, and that he has accompaniment to those appointments that are particularly important.

These are only two of many stories of patients who are benefiting from our CHW Pilot Program. As we further refine the program and coordinate our efforts, we look forward to hearing many more.