Targeting the Non-Clinical Needs of Older Adults through the Integration of Community Health Workers in Primary Care Practices

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Directing efforts to both healthcare and social needs will be necessary to improve healthcare and health outcomes for an aging population. Community Health Workers (CHWs) can play a vital role in addressing the non-clinical needs of elderly patients. In developing an interdisciplinary approach to elderly primary care, home visit teams, with the inclusion of CHWs, were integrated in primary care practices. During the initial home visit, CHWs conduct the social services intake and financial assessment to link elderly patients with appropriate resources available in the community. After 2 years of implementation, CHWs have conducted more than 800 home visits and over 1,800 telephone contacts. CHWs document patient outreach activity in the electronic medical record and communicate with clinicians and the rest of the care team to share information gathered from home visits. In addition, CHWs participate in practice team meetings to inform decision-making of treatment plans. Healthcare utilization is measured 6 months prior to and after services among elderly patients enrolled in the program for at least 6 months (n = 573). Early findings show a reduction in emergency department utilization from 1.88 to 1.55 visits per patient, while hospitalizations have decreased from 1.35 to 0.98 hospital visits per patient. These findings are not limited to CHWs’ interventions, but include the collective efforts of the entire interdisciplinary care team. Presenters will demonstrate CHWs are well-suited to work in clinical settings, as well as discuss the strategies used for integration of CHWs in care teams and describe initial challenges encountered.


Department of Family Medicine, Department of Family Medicine Faculty, Department of Population Health

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