Evolution of CHW's in a primary care setting: Taking behavioral health care integration and recovery beyond the clinic walls

Primary care settings frequently lack the resources necessary to address the complex needs of persons with combined addiction, mental illness, and physical illness.  As a result, these people often cycle through costly disconnected services without experiencing lasting recovery or improved health outcomes. One of the driving forces behind the inclusion of CHWs in our federally qualified health center was to provide a level of relationship-based care to these vulnerable high-need populations not traditionally available in a primary care setting.  CHWs in our setting, or Community Health Coaches as we call them, have lived experience in recovery from mental health or substance use disorders. Through the use of an integrated model, the multidisciplinary team “walks alongside” persons served creating solutions together.   The CHWs are key to this model as they are able to share their story and engage with individuals in a way not realized before, resulting in higher quality care, improved health outcomes and recovery experiences, and lower costs as high-end service utilization is reduced.  Our CHWs work closely with the Emergency Department, area homelss shelters, the local housing authority, and a variety of other community groups providing safety-net services to vulnerable populations. The intensive care coordination provided by the CHWs promotes multiple pathways to recovery and connects them to the community. This presentation includes one CHW presenter.  Our CHWs have worked on the development of this program from its inception, are responsible for the data collection, and actively use that data to inform and expand the program.