Improving Access Through Community Health Worker Coaching (IACWC)

Grantee: International Community Health Services
Timeframe: July 2018 – June 2021 | Total Amount: $599,660

Year 1: July 2018 – June 2019. Amount: $199,734
Year 2: July 2019 – June 2020. Amount: $200,000
Year 3: July 2020 – June 2021. Amount: $199,926.47

Community Health Specialists at ICHS will support the care teams by connecting patients with social determinants of health related needs and chronic conditions to internal and external resources.

In the third year, ICHS will build on the first and second year successes in enhancing CHSs’ role supporting the clinic care teams and improving the CHS workflow and referral to other services at ICHS. CHSs will continue to follow up with patients according to their needs. CHSs will refer patients to ICHS’ or partner organizations’ healthy eating and active living (HEAL) classes to achieve their health goals. During the second year of the grant ICHS expanded their classes to two ICHS clinics (International District and Holly Park). ICHS will assess the need for classes at their two other clinics for the third year of the grant. In order to help specific ICHS patients overcome SDOH, CHSs will perform outreach and assist patients in navigating health care and enrolling in programs such as Hopelink and SNAP. CHSs will continue to develop their knowledge and networks in housing and other SDOH areas of need identified by patients.

CHSs will need continuous training and regular meetings to improve their skills, share resources, and strengthen their case coordination. This will help CHSs continue to build their knowledge of systems and resources to address SDOH. For instance, ICHS is currently working on forming partnerships with hunger relief agencies in order to better address food insecurity. ICHS is also exploring options to provide additional training on homelessness and housing issues to our CHSs. The real-time data gathered from the daily reporting system described above will be used to design ongoing training for CHSs and also will provide added value to ICHS’s recurring community needs assessment.

ICHS’ objective is population health management through the delivery of care in a Team-Based Care model. This requires proactive risk stratification of our population based on their medical and behavioral health risks as well as SDOH. The main outcome will be improved care for individuals with chronic diseases and adverse SDOH. Patients are referred to one of eight CHSs in the IACWC Project who can provide services in the patients’ preferred languages.

Healthy Eating and Active Living (HEAL) Classes:

In order to provide health education and keep patients active outside of the clinic, CHSs will refer 100 ICHS patients to HEAL classes. ICHS provides classes taught by PHCs and ICHS-sponsored physical activity groups for diabetic, hypertensive, and at-risk patients. CHSs also provide referrals to community-based resources such as the YMCA and community centers. Lessons and activities are formed to educate participants in healthy habits and simple exercises to progress towards goals set in their health plans. CHSs provide culturally and linguistically appropriate support to patients to ensure that patients understand lessons and figure out ways to use them in daily routines.

Community Outreach:

Patients who are identified as in need of additional support will receive consistent, regular contact from a CHS who speaks their language and understands their cultural beliefs and practices. In order to provide ongoing support and ensure patients access care, CHSs will perform 1100 patient contacts, in-person or by telephone. Contacts will include appointment reminders, patient navigation, and referrals to services as needed to address SDOH.

Patients Referred to CHSs:

ICHS aims for 520 referrals this year, including not only individuals with chronic disease but also, medication and visit non-adherence, and SDOH conditions that require community-based support.