Improving the Health of Our Community: The Health Ambassador/Health Guide Connection

Background: Coordinating the medical care of our patients to ensure the best clinical outcomes and optimal health for our community is a challenge.  Most of the barriers to care are not related to medical services provided, nor are they visible when patients walk through our doors. These patients live in poverty and substandard living conditions and don’t always have access to nutritious food or feel safe in their neighborhood.  Patients often lack access to transportation to the healthcare services they need including the provider visit, and picking up their prescriptions.  They have low health literacy or language/cultural barriers, which prevents them from understanding what others take for granted.  Many still do not have health insurance.  Even when patients access primary care, they are faced with navigating a complex and fragmented healthcare system.

Methods: Christiana Care’s Department of Family and Community Medicine implemented a health guide program in 2007 to address these issues.  Health guides assist in navigating patients through the health care system. The health guides coordinate services for patients seen at our major primary care practices in Wilmington, Delaware.  They provide financial screening and connection to Medicaid and the Marketplace. They also provide prescription assistance. Patients are connected to other medical and public health resources as well.  The health guides are also in the community at health fairs and work closely with Christiana Care’s School-Based Health Centers adolescents and families, to ensure primary care linkages. The Health Ambassador Program was introduced in 2013, and is funded by the Delaware Division of Public Health. The ambassadors are “the feet on the ground” in our community, working with families across New Castle County, Delaware. They provide maternal and child health education which includes safe sleep and breastfeeding information. They connect families to home visiting programs and to primary care. Health ambassadors provide families with referrals to critical services that will support their health.  Health guides and health ambassadors work collaboratively as a team to link our community to health care through support, education and resources that eliminate barriers.

Results: Three health guides see an average of 232 patients a month. They provide financial screening and assistance, aiding over 1700 patients seeking dental services in the past year. The guides help patients find prescriptions at reduced costs through referrals to the community and by aiding in the completion of applications for pharmaceutical company assistance, helping 137 patients over the past year.  There are five health ambassadors out in the community daily. They reached 24,751 individuals in the last year and made 6,194 referrals for services including primary care and home visiting. The ambassadors attended 149 events such as health fairs.   Together the guides and ambassadors build trust with patients both inside the walls of the health care system (i.e. in primary care practices) and in their community. Relationships are forged and health outcomes improved through the connections provided by the guides and ambassadors. They are the missing link for optimal health care, addressing the social determinants of health and connecting the community to the providers who care for them.

Conclusion: The community work of the Department of Family and Community Medicine has strong support from Christiana Care Health System along with the State of Delaware Department of Health and Social Services and AstraZeneca. Our expertise in managing community programs with evaluation support along with funding has allowed us to grow both the Health Guide and Health Ambassador Programs. This growth has benefited the health and wellbeing of our community. The guides will soon be embedded in our health care center supporting patients as they are cared for by our providers. Our plan for the ambassadors is to expand their role and provide additional support in the community for our neighbors. While our guides and ambassadors have strong relationships with patient care providers, there is an opportunity to strengthen the communication and interactions providing feedback in a more formalized manner which benefits patients.