Year one experience in the Los Angeles County Care Connections Program: Redesigning primary care delivery to the sickest and most vulnerable patients through community health worker integration

The Los Angeles County Department of Health Service (LAC DHS) is transforming care delivery for the sickest, most vulnerable LA County residents by integrating Community Health Workers (CHWs) into primary care teams in LAC DHS practices. Through a 2-year demonstration that began in 2014, the LA County Care Connections Program (CCP) will hire, train, and deploy 50 CHWs at 5-10 primary care sites.

With the support of engaged LAC DHS leaders and primary care team champions from each site, CCP leaders led the design and implementation of the complex care management model.  Model design elements included developing:  1) policies, procedures and workflows (e.g. hospital-to-home care transitions) to ensure seamless integration into primary care, 2) a robust CHW training and supervision approach, 3) a mobile, care management information technology platform that provides decision support and allows remote documentation, 4) an analytics approach that tracks key processes and outcomes and supports continuous data-driven improvement, and 5) a community engagement approach to reduce fragmentation of services and optimize communication between entities.

We will share tools, strategies, and lessons learned from our work across these areas of development.  We will discuss issues surrounding CHW integration into healthcare teams and approaches we used to address issues that arise.  We will describe how we developed linkages to community-based behavioral health and social service resources. Finally, we will present early program data on acceptability and feasibility of the program.