Background: In 2005, NewYork-Presbyterian Hospital (NYP) and community leaders developed a community health worker (CHW) program to address the burden of pediatric asthma in Northern Manhattan. This co-led program was designed to bridge gaps in care and empower caregivers with tools and resources to improve their children’s health and well-being. Over the last 15 years, this program expanded to become the Center for Community Health Navigation (CCHN) at NYP, supporting both pediatric and adult patients, and their caregivers, across multiple hospital sites and communities throughout New York City.

Model: Today, the nearly 40 bilingual CHWs are based in 10 community-based organizations (CBOs), and are jointly supervised by the CBOs and CCHN. Within the CBOs, the CHWs gain in-depth knowledge about case management and social services, and become involved in local community advocacy efforts. Within CCHN, they gain core competency skills, learn about chronic disease management, and are trained to administer surveys and to document their findings. In addition, as members of healthcare teams, the CHWs participate in interdisciplinary team meetings and inform patient care plans.

Outcomes: Between September 2006 and December 2020, 2,354 patients enrolled in the Pediatric CHW Program. Among patients with asthma, hospitalization decreased by 78% and caregiver confidence to manage their children’s asthma increased to 97%. Between January 2012 and December 2020, 1775 patients enrolled in the Adult CHW Program. Among adults with 2 or more chronic conditions, 84% met medication management goals and 91% met patient navigation goals. In response to the COVID pandemic, since March 2020, the CHWs conducted 18,821 wellness calls to help address urgent needs, including food insecurity and access to medication refills. In addition, they helped 7,900 patients enroll onto NYP’s patient portal and reached out to more than 4000 patients to help schedule the COVID vaccine.

Conclusion: The successful evolution of CCHN over the last 15 years demonstrates the benefits of a hospital-CBO partnership model, leveraging the strengths and expertise of each organization, and the integral role that CHWs play to address urgent and evolving community needs while serving as a trusted bridge between health care settings and communities for patients.

BACKGROUND: Approximately 19% of US children have special health care needs (CSHCN). CSHCN from traditionally underserved backgrounds (e.g., racial and linguistic minority groups) often face the extra burdens of poverty and lack of resources for adequate food and housing. Marginalized CSHCN often have difficulty accessing appropriate medical, social and educational services. The development of CHW corps who are trained to assist CSHCN is a potential solution.

MODEL: Special Connections, is a training and mentoring program for CHWs that assists them in engaging with families of CSHCN. The 10-module program provides training on the common experiences of the children and their families, the types of care and therapies the children receive, the mental health and behavioral and educational concerns of the families, the process of transition, and financial and insurance needs and social determinants of health.

OUTCOMES: Over the past 3 years, the Special Connections program has trained over 150 learners in multiple states from hospitals, ACOs and one state’s Department of Public Health. Through train the trainer activities, 30 CHWs have been able to share the curriculum with other CHWs, and with foster parents. As a result, the program has impacted hundreds of families. Graduates of the Special Connections trainings report greater comfort working with children and youth with special health care needs. Special Connections has recently expanded to include a mentoring program for CHWs in the field. In conjunction with the ECHO Institute at the University of New Mexico, Special Kids/Special Connections offers monthly sessions to CHWs to provide on-going education and group support. Using the ECHO “all-teach, all-learn” methodology, the ECHO program provides the opportunity for deep sharing and collaborative thinking among the CHWs about addressing the complex, interwoven challenges that face families of CHSCN. The program stresses positive thinking, resiliency and the identification of resources within families and communities.

CONCLUSION: Adult-centered learning, using case-based discussions and group problem solving affords CHWs caring for Children with Special Health Care Needs opportunities to obtain new knowledge and to bolster their confidence in engaging with CSHCN and their families.

BACKGROUND: St. Christopher’s Hospital for Children (SCHC) is a 188-bed free standing children’s hospital located in northern Philadelphia, in one of the nation’s most impoverished Congressional Districts. As such, the community health workers (CHWs) at SCHC have a critical role in supporting patients and families in garnering resources, addressing the social determinants of health, and in care delivery. For the last seven years, SCHC has partnered with Medicaid to support the community health worker model and expanded this with training and leadership positions among the workforce of CHWs.

MODEL: The teams at SCHC screen families for SDOH and needed resources. During the COVID-19 pandemic families found themselves without necessary resources including transportation, access to care, prescriptions, necessary supplies (e.g., diapers, wipes formula). While many community-based organizations, schools, and agencies were closed, shutting down, or went to fully virtual service delivery, families in Northern Philadelphia found themselves lost and vulnerable.

OUTCOMES: Approximately one third (33.6%) of families screened live in the five zip codes in Philadelphia with the highest family poverty rates and over 81% of families screened live below the Federal Poverty Level. Families screened revealed the most prevalent needs identified and addressed by the CHWs and team were: utility insecurity (19.8%), food insecurity (13.5%), lack of transportation (19.4%), difficulty affording diapers (34.7%), and unmet home nursing need (13.4%). In addition, during the COVID pandemic several specific issues were addressed: intimate partner violence, urgent utility shutoffs were prevented, rises in post-partum depression were identified and addressed, formula delivery occurred for families unable to access WIC, and pharmacy medications during shutdown were delivered by CHWs. The CHWs develop unique partnerships with community-based organizations to screen and support families with social determinants of health screening and interventions (eg. transportation, food insecurity). Their support can improve parenting supports, promote prevention, provide linkage to appointments, foster needed medical therapies and behavioral health support for both patients and families.

CONCLUSION: CHWs play a unique and vital role for vulnerable families with children with medical complexity across community, medical and behavioral health systems. Their value as interdisciplinary team members continues to be explored and developed.

Background: Many Community Health Worker (CHW) programs in the United States are based in healthcare delivery systems. But what does this look like when health care is not the entry point for a CHW program? This presentation will describe a CHW model based in a federally-funded, place-based, multi-sector, collective impact initiative, the West Philly Promise Neighborhood (WPPN).

Model: WPPN includes multiple positions where trusted community members are employed to link families to services and programs, including Peer Family Support Specialists at public schools, Early Learning Family Navigators at a community-based organization, and a Community Resource Coordinator (CRC) based at Drexel University. During the early months of the pandemic, Drexel conducted a rapid phone survey with an existing longitudinal sample of households with children 0-18 year-olds living in the WPPN geographic footprint. The CRC reached directly out to families who consented, and focused follow-up phone calls, case management, and referrals on the household needs prioritized by each caregiver.

Results: The household COVID survey demonstrated that access to healthcare was not a primary concern of the majority of West Philadelphia families during the pandemic. The most important household needs reported by caregivers during the pandemic included food (43.3%), utilities (41.0%), and rent/mortgage (34.0%), followed by medical care (25.3%). The CRC was able to connect families to resources in these areas through established and new partnerships. Survey data also informed Additional information that the CRC gathered about families’ needs also informed neighborhood-wide interventions (e.g., materials, resources, and basic needs distribution) led by the WPPN Outreach Coordinator, and advocacy for city-level systems interventions (e.g., more neighborhood food distribution sites).

Conclusions: Opportunities created by WPPN’s CRC not being embedded in a healthcare delivery setting include the ability to holistically assess and address caregiver-prioritized household needs. However, sustainability of funding, and funding investing in community systems for CHWs is a major challenge. Case studies and lessons learned from place-based CHW models like Promise Neighborhoods are critical as we think about transforming these models to be adopted within various systems of support for families, and better able to navigate more effectively between these systems.