Full integration of community health workers into patient centered medical home - an in-depth case study

New York is addressing the challenge of improved health care at lower cost through its Medicaid Redesign efforts, which will improve health services for the neediest Medicaid patients and those with multiple chronic conditions. In addition, it must also absorb the thousands to be enrolled with the Medicaid expansion, many of whom may have long-neglected health and social needs. Two Medicaid Redesign models focus on the needs of those with chronic or complex health and social needs:patient-centered medical homes (PCMHs) and health homes (HHs). To be successful at achieving the triple aim of improving access and outcomes at lower cost, both these Medicaid Redesign models incorporate a revisionist view of the provider team and its objectives. Providers are charged with supporting the attainment of health and well-being, not just disease management. This holistic approach to health is generally not within the expertise of medical providers nor the health care system as we know it. This presentation documents an in-depth case study of one particular health care provider organization that evolved into a level 3 PCMH while fully integrating CHWs into their system of care. Thge study identifies key elements and best practices that led to the successful integration of CHWs into their health care teams and organizational structure. The presentation also identifies improved outcomes and lowered costs realized through the full integration of CHWs.