Improving Access to Care of Vulnerable Elders - The Role Of Community Health Workers in Transitions of Care

Background

Vulnerable elders (VE) are a marginalized and silent segment of our community. Those 60 and older use the emergency room and as access to primary care. Through a grant-funded initiative, an enhanced HBPC Program was implemented in 2009 in an attempt to alleviate health disparities affecting community dwelling vulnerable elders in the South Bronx.

Methods In the late 1990s Saliba et al. validated a vulnerability screening tool that assigns risk for further functional decline and death at 12 months. Six Community Health Workers used the survey to identify vulnerable in the acute setting and offerred HBPC. Patients with a score of 3 or more were educated on the program goals and objectives and were offered enrollment.

Results Between July 16 and November 30, 2009, 131 VE > 60 were screened in the acute setting. Screening time ranged from 15-20 Minutes. Of the 131 patients screened, 97 (74%) scored 3 or higher.

Conclusion As our current health care system faces the challenges in providing care to the older adult, community heath workers prove to be effective in facilitating transition in care.