An implementer's toolkit: Practical lessons learned about how to effectively integrate community health workers into care management programs

Decades ago, pediatricians launched patient-centered medical home programs to provide integrated care for medically complex children. But the model has evolved, and in the context of healthcare reform, primary care systems are now searching for innovative ways to apply medical home principles to all patient care. The Prevention and Access to Care and Treatment (PACT) Project, which provides CHW-centered care to complex patients, recently helped implement a pilot pediatric care management program for high-risk Medicaid patients. This program's interdisciplinary team works hand-in-hand with primary care providers to offer integrated support to complex families. Five team members – a nurse practitioner, two licensed mental health specialists, and two CHWs – provide 700 children with home-based and telephonic care. The team supports pediatricians by providing comprehensive care between medical visits – including coordination, navigation, self-management education, and behavioral health support. Through the lens of this innovative program, we describe practical implementation tools that facilitated success. We highlight strategies that helped CHWs integrate into an interdisciplinary team, including cumulative hiring and team-based training. We discuss program features that clarified the CHW role and empowered team members to work at the top of their skillsets – including quality-improvement meetings, co-location, and patient-centered sub-teams. Finally, we describe activities that promoted integration with practices and hospitals – including close partnerships with pediatricians via jointly-developed care plans, and involvement of physician thought-leaders in program design. Thoughtful program design can promote effective implementation of care management programs – where CHWs are integral, and interdisciplinary synergies are actively nurtured.