Online Program

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

Tuesday, November 3, 2015 : 11:10 a.m. - 11:30 a.m.

Ami Shah, MPH, Department of Health Services, Los Angeles County, Los Angeles, CA
Simon Ma, Department of Health Services, Los Angeles County, Los Angeles, CA
Arleen F. Brown, MD, PhD, General Internal Medicine Health Services Research, UCLA, Los Angeles, CA
Mark Ghaly, MD, Los Angeles County Department of Health Services, Los Angeles, CA
Clemens Hong, MD/MPH, General Medicine Division, Massachusetts General Hospital, Boston, MA
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.

Learning Areas:

Administer health education strategies, interventions and programs
Chronic disease management and prevention
Program planning
Provision of health care to the public
Public health administration or related administration
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Describe successes and challenges programs face when hiring and training CHWs to work as part of the healthcare delivery team Explain how the program built upon successes and addressed early challenges Discuss how the program developed linkages to community partners

Keyword(s): Community Health Workers and Promoters, Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the director of the Care Connections Program in LAC and have over a decade of experience documenting and combating health disparities by informing the redesign of health care delivery for vulnerable populations.
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.