Hiring and Embedding Community Health Workers into an Integrated Health System: A Needs Assessment

CHWs have demonstrated positive impacts on patient outcomes in the older adult populations by addressing social determinants of health. A needs assessment was conducted within three geriatric clinics to evaluate the feasibility and usability of hiring CHWs as integrated health system employees. Retrospective chart reviews were performed to identify demographic information for eligibility for CHW referral for older adult patients and the current state of their social needs. Interviews with clinic staff were conducted. A SWOT analysis was conducted examining the current transition of care processes, policies and procedures, barriers, and opportunities for employing and embedding CHWs within the integrated health system. The chart review analyzed 2,065 Utah-only patients and 5,867 clinical encounters with a documented PRAPARE screener. Patients (n=2,065) self-reported social needs over 11 months as the primary social needs for all age groups were referrals to United Way 1,802 (41.1%), referral to CHW 1,944 (44.4%) dental care 174 (3.9%) and transportation concerns 106 (2.4%). The SWOT analysis, including staff interviews (n=28), highlighted organizational strengths (patient-centered care) and weaknesses (limited resources, communication barriers). Integrating CHWs as direct employees within the healthcare system emerged as a viable solution to address determinants of health for older adult patients within an integrated health system.