142nd APHA Annual Meeting and Exposition

Annual Meeting Recordings are now available for purchase

Preliminary Findings for a Patient Engagement Program Using Community Health Workers to Address Social Determinants to Health

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Monday, November 17, 2014 : 9:30 AM - 9:50 AM

Onelis Quirindongo-Cedeno, M.D. , Deparment of Medicine-Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
Tara Nelson , Intercultural Mutual Assistance Association, Rochester, MN
Karen Vargas , Intercultural Mutual Assistance Association, Rochester, MN
Jean Gunderson, PhD , Mayo Clinic Employee and Community Health, Rochester, MN
Michael O'Brien, MSW, LICSW , Administration, Mayo Clinic, Rochester, MN
Joyce Balls-Berry, PhD, MPE , CCaTS Office for Community Engagement in Research, Mayo Clinic, Rochester, MN
Background: Social determinants of health affect patient outcomes. To address patients at high risk for social determinants of health Mayo Clinic Employee Community Health (ECH), Intercultural Mutual Assistance Association, and United Way of Olmsted County are working together to improve holistic care by building care teams and patient’s capacities in order to reduce cost of care. The Community Health Workers (CHW) Program is a new initiative in our community.

Methods: The CHW Program consists of working collaboratively with care coordinators, care teams, and patients to examine complex care needs, targeting early intervention services, and diverting patients to primary care through collaborative partner sites. CHW receive patient referrals through ECH, and conduct services at the patient’s home. Patients received scores for social determinants to health to determine their most pressing needs. Program evaluation involved a collaborative process between CHW and community partners to determine workflow, referral opportunities, and programmatic changes.

Results: Currently, more than 100 patients participated in the program with over 300 completed visits. Survey conducted of patients enrolled indicated high level of satisfaction with services and better understanding of their health conditions. Care coordinators expressed satisfaction with CHW helping manage their patient panels.

Conclusion: The creation of a CHW program by the partnership of three community agencies has allowed for better coordination and service delivery for patients. Ultimately, the preliminary results of this initiative have indicated that CHW are vital in helping patients navigate not only the health system, but other social and community services in Olmsted County .

Learning Areas:

Implementation of health education strategies, interventions and programs
Other professions or practice related to public health

Learning Objectives:
Describe the integration of Community Health Workers into care teams providing care to high risk patients. Discuss ways to measure the impact of Community Health Workers in traditional patient outcomes.

Keyword(s): Community Health Workers and Promoters, Evaluation

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the physician leader for Community Engagemet for Employe and Comunity Health and physician leader for integration of CHW into the new model of care teams.
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.