Connecting Community with Providers & Resources

May 6, 2016   |  Tags: Blog   |  Tags: Eastern Oregon , Rural , Care Coordination , Community Health Workers
Maggie McLain McDonnell, MPH

Maggie, a Project Manager with ORPRN, interviewed Juli Gregory, RN, Education Director and Director of ConneXions at Good Shepherd Medical Center to learn more about how community health workers and primary care providers can work together to improve the health of their patients.

How can the services that community health workers deliver enhance the services provided by primary care practices?

Juli: In addition to clinic referrals to community health workers (CHWs), CHWs can attend primary care appointments with patients to provide “two pairs of ears” to hear provider instructions. After the provider visit, the CHW is able to verify the patient’s understanding of the provider instructions, help the patient follow through on provider instructions, connect patients to other resources that may be identified during an appointment, and start an education plan and care plan. We have found that the providers love it. While it can be time consuming and takes coordination, it is especially helpful for CHWs to attend provider appointments with patients who have lower health literacy, reduced memory function, or medication adherence concerns.

In situations where interactions between CHWs and primary care providers have been the most successful, providers have been welcoming and communicate with both the patient and community health worker to ensure the community health worker is part of the healthcare team and care planning team. CHWs can also create an education plan to help patients to “take the elephant one bite at a time,” so that information is thoroughly understood before adding another piece.

Do you have any advice for primary care practices looking to start a community health worker program within their practice, or to engage with existing community health worker initiatives in their communities?

Juli: For those looking to start a CHW program in their clinic, it’s ideal to hire a CHW with a medical background (such as certified medical assistant), and a behavioral health background or someone with strong connections to mental health resources in the community. It’s also crucial to make sure that their role is clearly defined, so that they don’t get pulled into doing other tasks, such as cleaning exam rooms or answering phones. Under the provider’s supervision, they could help with medication adherence and also provide home assessments. Some patients will not always tell providers what is going on at home.

A home assessment can provide a better picture. Practices can also build relationships with local emergency departments and utilize the Emergency Department Information Exchange (EDIE) reports. Ideally CHWs will follow up with patients admitted to the emergency department in real time rather than waiting a day or two. It’s recommended that CHWs participate in area multi-disciplinary team (MDT) meetings. The networking and resource sharing that occurs during MDT meetings is very valuable to learn about local resources and share approaches. Lastly, warm hand offs from either the medical assistant or provider to the CHW is critical to help everyone work together as a team to create a care plan and education plan while keeping the patient at the center of their care.

To engage with existing programs, invite a program representative to talk to your providers and staff to understand what CHWs can and cannot do. Be aware that these programs are there, and then access them. Don’t be afraid to refer. It needs to be part of a provider’s everyday thought process to think about a patient’s possible social and health education needs. Also have a release of information in place to have conversations, keep patients in the center, and allow building of trust between organizations. As you work together more, more trust is built.

This interview has been condensed and edited.

About ConneXions

ConneXions is a community health worker program led by Good Shepherd Medical Center that closely partners with Umatilla County Human Services and Lifeways (behavioral health services provider for Umatilla and Malheur counties) 7-8 . Current staffing includes five community health workers (including two who are bilingual in Spanish and English) and one part-time nurse. The program aims to both reduce avoidable emergency department visits among “high utilizers” and to reduce hospital readmissions by connecting Umatilla and Morrow county residents to primary and specialty medical care, behavioral/mental health, substance abuse services, general social services, and resources for basic needs such as housing, transportation, food, and interpretation/translation.

Referrals come from Emergency Department Information Exchange (EDIE) alerts; the Good Shepherd Medical Center emergency department; hospital case managers; primary care providers; community agencies; and word of mouth. Weekly multi-disciplinary team meetings with community partners support care coordination and keep patients at the center of care.

Initially funded by grants from the Eastern Oregon Care Coordination Organization (EOCCO) and Medicare, Connexions grew from the Healthy Communities Coalition, a multi-stakeholder group that includes the Oregon Department of Transportation, Fire/EMS, Head Start, Department of Human Services, law enforcement, public health, and area schools 9. Since November 2014, ConneXions has served over 1,300 community members in Umatilla and Morrow counties.

Maggie McLain McDonnell earned a Master's degree in Public Health and Bachelor of Business Administration degree from The George Washington University in Washington, DC.  Prior to joining ORPRN, she was curriculum development manager for OHSU's employee wellness program and research coordinator for the Pregnancy Exercise & Nutrition study. In her role with ORPRN, she serves as the project manager for the Eastern Oregon Care Coordination project. She is particularly interested in preventive care and wellness in primary care to improve health outcomes and reduce costs.

This article was originally produced for ORPRN’s 2016 Newsletter. See the original article here.