A Real-World Community Health Worker Care Coordination Model for High-Risk Children

Abstract

Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.

Trends in School Attendance for Low‐Income Children with Chronic Health Conditions: Results from a Randomized Controlled Trial

“…Once identified, patients were sent a letter stating they were officially enrolled in CHECK. CHECK community health workers (CHWs) attempted to contact patients by mail, phone, in‐person home visits, or visits during clinical encounters 15 . Patients were considered “engaged” if they completed the CHW intake assessment.…”

“…Patients were considered “engaged” if they completed the CHW intake assessment. Patients were categorized as high, medium, or low risk based on health care utilization/costs (emergency department visits or hospitalizations via claims data) 15 . Priority for engagement efforts was given to patients with higher risk.…”

“…CHECK provided educational and support services to partner clinical practices, community partners, and schools. Details on the CHECK program services are provided elsewhere 14‐17 …”

“…The Coordinated HEalthcare for Complex Kids (CHECK) program was funded in 2014 by a Centers for Medicare and Medicaid Award to the University of Illinois at Chicago (UIC). CHECK was designed as a quality improvement program to provide comprehensive care coordination and a range of services to Medicaid‐enrolled children and young adults with chronic health conditions in the Chicago area 14‐17 . CHECK services targeted health disparities through a multi‐level population health approach that incorporated individual, family, and community determinants 14 .…”

Chicago Public School nurses examine barriers to school asthma care coordination

“…Asthma represents 72% of the patients enrolled in CHECK. The full CHECK model is described in detail elsewhere (Bansa et al., ; Glassgow et al., ; Martin, Perry‐Bell, Minier, Glassgow, & Van Voorhees, ; Minier et al., ).…”