Wellbeing (e.g. Youth, Community, Mental)
Sharing Session - 60 Minutes
Access to health care continues to be a priority community need in East Texas; yet, access to care is not the only issue. The existence of health disparities and poor utilization of health services are also key areas of concern. Given the complexity of access and barriers to care, a collaborative approach to addressing these issues became the foundation of a new project housed at the Northeast Texas Public Health District (NET Health).
CommUNITY Cares is an innovative project initiated by administrators and leaders from several social service agencies, medical clinics, hospitals, mental health providers and the LHD, NET Health. This project was developed as a way to improve health equity and reduce health disparities through enhanced access to appropriate and affordable medical care.
Through a network of clinical and community partnerships the project addresses: insufficient access to primary health care services, high costs due to potentially preventable hospitalizations and inappropriate emergency department utilization by individuals seeking primary-related care in local Emergency Departments (ED).
To create synergy among partners, CommUNITY Cares utilizes a cloud-based navigation system to connect uninsured individuals to certified Community Health Workers (CHWs) at NET Health’s Center for Healthy Living (Center). Referrals are electronically sent through the navigation system from participating hospitals and social service partners. Eligible individuals are also enrolled through NET Health’s participation in community events and through clients of the Center who meet eligibility criteria.
Once a referral has been initiated and the referred client contacted, the CHWs use an assessment questionnaire to identify potential barriers to care and needs of the client to develop an individualized navigation plan. This navigation plan includes a referral to the most appropriate primary care medical home and/or social service agencies. Once the client completes a primary care appointment, the CHWs conduct a post-appointment assessment to evaluate project satisfaction, assist with additional needs, and provide education on appropriate ED utilization.
Currently in the pilot phase, launched on December 5th, 2017, 770 individuals have been referred to the project with 68% of all referrals originating from the participating Hospital’s ED and inpatient discharge. Of clients referred, all are uninsured, 65% are unemployed and average household monthly income is $850. ED visits, among referred clients, range 0-20 times per year with an average of three visits. A total of 87 clients have completed the referral process and are now established with a primary medical home. Average client satisfaction for the project averages 9.5 out of 10.
Offering sufficient access to healthcare and social services can present numerous challenges and our project is not immune to those challenges. The biggest obstacle faced in the first year is the often difficult task of reaching the referred clients by phone or letter. A majority of referred individuals required more than one call attempt from CHWs and nearly half (n= 323) of those referred to the program were unable to reach/no response.
While challenges exist, there are several strengths of CommUNITY Cares that has made its pilot phase successful. One key success factor is through open communication among project partners. Partners from participating agencies meet at least once a month to discuss strategies for project improvement and to measure success.
Looking ahead, the project will soon gain participation from another large hospital system and expand partner invitations to neighboring clinical, mental health and social service agencies. Additionally, the project is in the early stage of developing a formal evaluation study to determine a return on investment for sustainability.
In conclusion, CommUNITY Cares demonstrates a potential solution for reducing health disparities and improving health equity to the medically underserved population of East Texas. The project accomplishes this task through enhanced access to primary care and addressing social determinants of health through the utilization of CHW-led navigation within a clinical and community collaboration.