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

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 .