Investing in outreach community health workers improves access to primary care services at a safety net hospital system

In 2014, Hennepin County Medical Center began an outreach CHW program to provide education and outreach to health plan members that are not connected to primary and dental care. This presentation will describe the model, process measures, preliminary outcomes, communication strategies across community and health system settings, and patient stories. The presenters will include at least one CHW. 

The outreach CHW serves as a link between health/social services and the community to facilitate access to services. CHWs connect with members at specific sites in the community such as the Emergency Department, Adult Correctional Facility, Homeless Shelter, and Day Center. The ultimate goal is for the members to establish primary care, reduce inappropriate utilization, and increase access to services. This approach also fosters a trusting relationship and support system with the patient in the community which will hopefully result in reducing social disparities such as homelessness and recidivism. A pathway to primary medical and dental care was created based on the CHAP model for connecting patients to health and human services. Success is evaluated through the number of primary care or dental care appointments completed, the number of life-style overview surveys completed, and decreased ED utilization.

We have learned that patients that have transitioned from the community setting and have worked with an Outreach CHWs come to primary care with a very clear idea of what they can expect from their clinic CHW and are more familiar with standard tasks such as scheduling appointments, requesting transportation, and connecting with clinic staff.