300167
A Hospital-Community Partnership Model to Reduce the Burden of Chronic Disease
In 2006, local hospital and community leaders came together to develop a community-based iniative designed to bridge gaps in care for families of children with poorly controlled asthma. Bilingual Community Health Workers (CHWs), based in local community based organizations, served as the single point of contact for families who received education, customized support, referrals for social services, and assistance navigating the local system of care.
In 2011, this successful pediatric asthma-focused model was expanded to serve adults with poorly controlled type 2 diabetes and their caregivers. At the same time, the CHWs were integrated into 6 community-based, Patient Centered Medical Homes (PCMH) where they have become key members of the health care teams.
To date, these 9 CHWs have enrolled more than 900 children in a year-long asthma program, 236 adults in a year-long diabetes program, and have provided PCMH-based support and education to more than 3,000 patients.
Among graduates of the pediatric asthma program, asthma-related ED visits decreased by 54%, inpatient visits decreased by 65%, and 97% of the caregivers felt in control of their child’s asthma. Among graduates of the diabetes program, 71% of A1C scores improved, 42% of LDL scores improved, and 95% of participants reported to feeling able to cope with stress. These outcomes suggest that a hospital-community care coordination model led by bilingual community health workers is an effective approach to reduce the burden of chronic disease in our community.
Learning Areas:
Chronic disease management and preventionImplementation of health education strategies, interventions and programs
Learning Objectives:
Describe key components of a successful hospital-community care coordination model
Discuss the benefits and challenges associated with building an effective hospital-community partnership
Keyword(s): Community-Based Partnership & Collaboration, Community Health Workers and Promoters
Qualified on the content I am responsible for because: I have been the principal or co-investigator associated with multiple studies related to chronic disease prevention initiatives. I am particularly interested in partnership models and community health worker led initiatives.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.