| Description |
The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Older adults are at significant risk for having unmet social needs and chronic health conditions. Community health workers (CHWs) have demonstrated positive impacts on patient outcomes in the older adult populations by addressing social determinants of health. Local Problem An integrated healthcare system in the Mountain West, serving urban and rural areas, faces challenges in providing comprehensive care to older adults. Three geriatric clinics within this system lack adequate information about patients' home conditions, functioning, and social needs. Current models utilizing county health departments for CHW support encounter barriers, hindering effective intervention. Methods A needs assessment was conducted within three geriatric clinics to evaluate the feasibility and usability of hiring CHWs as integrated health system employees. Interventions Key stakeholders within the healthcare system were engaged in planning and designing the needs assessment. Retrospective chart reviews for geriatric patients (over age 65) identified social needs status and eligibility for CHW referral. 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. Population-specific data from the 2019 U.S. Census and Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) screener tool informed the needs assessment. Results The chart review analyzed 2,065 Utah-only patients in 3 geriatrics clinics over 11 months. All patients had the PRAPARE screener documented (n=5,867). Demographics included 1,888 (91%) as White, followed by Hispanic, Latino, or Spanish Origin n=75(3%), 1266(61.3%) were female, and 766 (37.1%) were male. The average patient age was 76.6 years, ranging from 65 to 100. Patients (n=2,065) self-reported social needs were analyzed; the primary social needs for all age groups were referral 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). Conclusion 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. Multiple strengths were identified to support the integration. Gaps were also revealed that would need to be addressed before implementation. Ongoing collaboration with key stakeholders is crucial for successful implementation and sustainability. |
