September 19 th , 2019

1. SJHS Community Health Worker Initiative September 19th, 2019

2. What is a Community Health Worker? • The community health worker delivers culturally-competent, patient-centered case management services. The CHW may conduct assessments in health care settings, in homes, and by phone. They provide individual and family-centered health promotion and education as well as referral and linkage to other services and resources. They are instrumental in reducing health care costs, improving access to care, and advancing quality of care. • - Indiana Community Health Worker Association

3. Culturally-Competent, Patient-Centered Case Management • CHW’s extend Case Management by: • Breaking instructions into do-able steps • Offering tailored explanations • Building Rapport and Trust with patient • Assisting with Communication

4. Health Promotion and Education • CHW’s enhance Health Competency by: • Giving basic Chronic Disease and health education • Encouraging and modeling healthy lifestyles • Providing access to training and supports • Facilitating day-to-day management strategies

5. Referral & Linkage to Services & Resources • CHW’s become experts on resources and how to access them. Attendant Home Care Insurance Coverage Assisted/Independent Living/Long-Term Care Benefits/Disability Services Safe Home Environment Transportation Medication Cost Savings Stable & Affordable Housing Home Delivered Meds/Meals Financial or Utility Assistance Primary Care/Medical Home Condition Management Education

6. Focused on Social Influencers of Health • Housing • Access to Food • Transportation • Medical Home • Health Insurance Coverage • Access to Benefits • Medication Access • Mental Health • Education • Income • Socialization

7. Coordination Process • Referral Sources: • Inpatient, Ambulatory, or ED Case Managers • Physician Network & Health Clinics (OLOR, SMBHC, FMC) • Oaklawn • Real Services Expanded referral sources • HealthLinc made possible by CFSJC. • Indiana Health Center • Communication: • Funnell notes back to Primary Care Doctor • Partner with patient to connect with services • Act as an advocate to formal systems CHW CHW Patient Community Resources, Social Supports Hospital Doctor, RN Case Manager

8. Impact • Current Program: • 3 CHWs • 600 Patients in 19 mo’s • 85 Assisted w/ Housing • 37 Helped w/ Insurance • 681 Social Svc Referrals This graph shows the 6 months prior to working with a Community Health Worker and the 6 months after a Community Health Worker works with the patient.

9. Impact ER Visits Inpatient Admissions Readmissions This graph shows the number of Inpatient Admissions, 30-day Readmissions, and ER Visits during the 6 month period of time the Community Health Worker works with the patient.

10. Lessons Learned • Start Simple • Connect to the community • Connect CHWs to the clinical workflow • Think outside the box