November 19, 2018

Community Health Workers: A Vital Support for Addressing Social Determinants of Health

Community Health Worker with patients

Mona Joseph (R), a Community Health Worker at the MGH Chelsea HealthCare Center, talks to a group of patients.

Social determinants of health can have a significant influence on a person’s overall health and quality of life. Patients with social determinants that negatively impact health, such as lack of access to transportation or food, can be exceptionally challenging to keep healthy and often rely on the emergency department (ED) for care. Reaching and engaging with patients in primary care settings can be vital to addressing patient needs. The positive influence of community health workers (CHWs) acting as a bridge between vulnerable patients and the health care system has shown to improve patient outcomes and decrease emergency department visits and hospital admissions.

Partners HealthCare recognized that meeting the needs of vulnerable patient populations was an opportunity to improve patient outcomes as well as reduce cost. Through its integrated care management program (iCMP), the Partners system has had some success in improving the care delivered to underserved communities. Brigham and Women’s Hospital and Massachusetts General Hospital conducted pilots which focused on the Community Health Worker role; one model that empowered community health workers to serve as care leads, and one model that incorporated community health workers into the care team.

“The addition of CHWs to our “triad model” of care management (registered nurses (RNs), social workers (SWs), community health workers (CHWs) as team leads) has allowed iCMP to expand its reach to support high-risk patients who have significant social needs,” says Maryann Vienneau, Program Director for Care Management, Partners Population Health. “The CHWs have helped patients address these needs, allowing the patient to focus on their medical issues. They are real asset to our ever evolving program.”

The integration of community health workers into the integrated care management program is yielding positive results for both pilots. When comparing the difference in six months post-program outcomes to six months pre-program outcomes:

When the CHW functions as a lead, results include a:

  • $664 larger PMPM reduction in total medical expense and an 11 percent larger reduction in ED visits compared to the control group.

When the CHW functions as a part of the care team, results include a:

  • $635 larger PMPM increase in total medical expense. However, patients with a CHW team member had a 28 percent larger reduction in ED visits, and an 11 percent larger decrease in office no-show rates compared to the control group.

Read the full Health Catalyst case study.



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