Community Health Workers improving care for older adults
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About Connected Care for Older Adults
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Background
Connected Care for Older Adults was developed by the Columbia Gorge Health Council, a nonprofit organization that partners to deliver Medicaid services to patients in rural Hood River and Wasco Counties, Oregon. Starting in 2017, clinicians began exploring ways to improve care for frail older adults in these communities. With support from the Health Council, the Clinical Advisory Panel, and other funders, an interdisciplinary team of physicians, Community Health Workers, mental health liaisons, advocates, and program administrators worked collaboratively to create the Connected Care protocols for Community Health Workers (CHWs) based on the 4Ms of Age Friendly Health Systems.
The Connected Care Model
- Connected Care serves patients 55+ who are identified as frail by their Primary Care Provider who are not currently in assisted living, hospice, or receiving home health services
- CHWs conduct home visits and implement the Connected Care Protocols based on the 4Ms - What Matters, Medication, Mentation, and Mobility
- CHWs provide information and education to patients and families, connect them with existing community services, and refer them for further assessment and support
- CHWs work to include family members and loved ones in care planning and help initiate important conversations about the future
- CHWs chart directly in the EMR, and route important information or actions needed back to the patient’s Primary Care Clinician and health care team
- Patients graduate from the program when all relevant protocols are complete - roughly 90-days
Goals of Connected Care
- Improve the quality of care delivered to older adult patients
- Improve the patient, caregiver, and provider experience with care
- Decrease or delay the need for higher levels of care
- Decrease high cost utilization (hospitalizations and ED visits) among participating patients
- Advance health equity by prioritizing enrollment of non-English speaking patients, Indigenous patients, patients enrolled in both Medicare and Medicaid, and uninsured patients
PILOTING CONNECTED CARE
Connected Care for Older Adults first launched at One Community Health, a Federally Qualified Health Center in Hood River, Oregon in October, 2022. It expanded to include the Asher Community Health Center in Fossil, Oregon in 2023. Patient, provider, and administrator feedback from early pilots was utilized to update the Connected Care Protocols and processes related to pilot implementation and evaluation. Beginning in February, 2024 the pilot has expanded to include five additional primary care clinics with the capacity to serve 250 - 3patients per year.
AGE Friendly PROTOCOLs for community health workers
The Connected Care Protocols were developed by a multidisciplinary team of clinicians, service providers, older adult advocates, and Community Health Workers. They are based on the 4Ms of the IHI’s Age-Friendly Health Systems Framework - What Matters, Medication, Mentation, and Mobility. Each protocol includes tools, scripts, and resources that help CHWs discover important information about a patient’s well being, wishes, and priorities. This information is shared with primary care provider and the patient’s health care team. All protocols include a referral guide to support appropriate follow up.
THE Connected Care protocols
WHAT MATTERS
WHAT MATTERS
WHAT MATTERS
Patients are guided through a What Matters conversation. This is a chance for patients to share about their health care priorities and what matters most to them. Patients also receive information and support to complete the Advance Directive form. This is a legal document that states a patient’s wishes and assigns a health care representative if they are not able to speak for themselves.
MEDICATION
WHAT MATTERS
WHAT MATTERS
CHWs provide information about how to safely store and dispose of medications and review all of the medications that a patient is taking, including OTC and supplements. They communicate discrepancies to the Primary Care Provider for follow up. If a patient is having trouble refilling or paying for their medications, the CHW connects them with medication resources.
MOBILITY
WHAT MATTERS
MENTATION
CHWs use the CDC's STEADI Assessment to determine if a patient is at risk risk for falling and refers to their Primary Care Provider for follow up as needed. The CHW also checks the patient’s shoes for fit and stability, assesses the home for safety hazards such as rolling furniture or electrical cords, and shares information about local strength and balance resources.
MENTATION
WHAT MATTERS
MENTATION
Patients are screened for changes in memory and mood, and flag any concerns about depression, anxiety, or social isolation. Patients are referred to their Primary Care Provider or Behavioral Health Specialist as needed. CHWs provide information about brain health and aging, and connect patients and families with local supports and social services.
