Strategic Models for Incorporating CHWs into Health Homes and PCMH

New York State has recommended the use of patient-centered medical homes (PCMHs) and health homes (HHs) as key elements for reducing costs of care for its neediest Medicaid patients, those with multiple chronic conditions such as diabetes and cardiovascular diseases. New York State aims to have one million people enrolled in PCMHs and approximately 700,000 people with complex chronic disease conditions enrolled in HHs. These new models of care require integrated and coordinated services across a continuum of medical, behavioral and social services, as well as linkages to supportive community resources such as housing. Community health workers (CHWs) can reduce health care costs and improve health outcomes for people with diabetes and other chronic diseases, but to date there is little experience in integrating CHWs into PCMH or HH. We present the business case for integrating CHW into HH including (1) Cost-effectiveness data for CHWs working to promote chronic disease management elsewhere in the US (2) Cost-effectiveness data from NY PCMH and others using CHWs (3) Details of the roles and tasks provided by CHWs in the NY cases (4) Feedback from CHWs and PCMH leadership on the experience of integrating CHWs into their medical home. We summarize the practice-based guidelines for integrating CHW services into PCMH and HH practices and workflow, based on our collaboration with a selected HH in New York. These guidelines detail the organizational flowchart for CHW services and steps needed for CHW recruitment, training, supervision, and monitoring of the CHW services.