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Coordinating Care through Community Health Workers: Impacting Health Inequities, Cost and Care Outcomes

By Marianne Longo, Chief Clinical Officer

The Centers for Disease Control (CDC) reports that up to 80% of health care outcomes are influenced by social, economic and environmental factors which are defined as Social Determinants of Health (SDoH). These factors not only cause challenges for those affected, but also create additional costs. In fact, according to a Deloitte study that equates to $320B annually in health care costs.

Help at Home is pioneering a new, successful model that includes Community Health Workers to support a program working to improve health and cost outcomes. Our CHWs are a resourceful and empathetic team of connectors who are familiar with the communities they serve and whose goal is to identify health-building solutions for our clients by addressing their social determinants of health

Help at Home leads with health disparities in mind. Our CHWs understand our clients’ unique situations, most of whom are dual-eligible, qualifying for both Medicare and Medicaid. These are clients who are sometimes the most underserved populations and commonly have food insecurity, housing insecurity and financial insecurity, as well as lack adequate transportation. They often have language or literacy challenges that make it hard for them to understand instructions from providers or pharmacists. They often do not have internet access. These access insecurities have obvious implications on health outcomes. For example, you can’t manage diabetes effectively if you do not have access to fresh, healthy meals.

In these cases, CHWs serve as advocates to connect clients to resources in their communities like food pantries, helping them identify and access those resources. When our CHWs meet our clients, the clients can sometimes be wary because of past experiences. Garnering trust and respect are important so that they can be empowered and have a voice.

We are truly leading the charge as an in-home personal care service leader with this care coordination approach. With 50 years of experience managing dual-eligible populations – in their home, face-to-face, and hand-to-hand, we have 50,000+ caregivers who are the first to notice if someone is struggling to keep food on the table or is having more trouble standing. These observations are collected and analyzed so that the needed intervention by a clinical team including CHWs can take place.

For example, sometimes these interventions are very specific. In one case, a client put off recommended bariatric surgery because he feared he would not be able to manage the recovery process. His CHW was able to reassure him that Help at Home could assist him during recovery. The surgery has improved his physical health and made it possible for him to drive again. He gained his ability to socialize again which has decreased his anxiety and depression.

In areas where community health teams are working, we have seen a reduction in emergency room visits and an increase in the clients’ likelihood of keeping primary care appointments. Coordination of care activities in one value-based provider group in Illinois led to a 22% cost savings after just 6 months of client engagement.

We are honored to provide clients with additional in-home personal care services layered on activities of daily living that can allow them the opportunity to age-in-place in their own homes and allow them the opportunity to live healthier lives.