Health Connectors: Lessons learned from a resource-coaching program for diabetic patients at a Federally Qualified Health Center (FQHC)

Background: Certain areas of Orange County, California, are designated as Medically Underserved Areas with populations experiencing limited access to community resources. Health Connectors (HC), a volunteer run program, helps diabetic patients addresses factors that impact health and wellness.  By providing help with basic resources (e.g., locating fresh, low-cost foods, transportation assistance), HC coaches address social determinants that pose barriers to diabetes management.

Methods: Volunteer coaches are Spanish-proficient, college/post-graduate students trained in motivational interviewing and supported by 3 volunteer coordinators. During primary care visits, coaches assess patients’ needs using a structured checklist and provide referrals for community resources at the end of the visit.  The process lasts 10-20 minutes.  Patients receive a 3-week follow-up call to ensure ability to access the referrals.

Results: Since September 2013, HC has trained 12 coaches serving 93 patients.  The top 3 patient-identified needs are affordable dental services (54% of patients requested a referral), low-cost food options (34%) and transportation (19%).  Challenges to implementation included 1) limited time spent with patients and 2) creating a sustainable volunteer base.  Gaining trust from clinic staff reduced barriers to seeing patients. University faculty provided volunteers with pre-med career/academic guidance as a benefit of volunteering.  Major facilitators for success included 1) regular meetings to systematically review cases and administrative issues and 2) partnering with a faculty advisor to develop formal longitudinal program evaluation.

Conclusion:  This is an innovative model for a clinic-based, health promotion program.  Identification of lessons learned may help other sites implement programs following a similar low-cost model.