Martin Molly A, Perry-Bell Kenita, Minier Mark, Glassgow Anne Elizabeth, Van Voorhees Benjamin W
1 University of Illinois at Chicago, Chicago, IL, USA.
Health Promot Pract. 2019 May;20(3):409-418. doi: 10.1177/1524839918764893. Epub 2018 Apr 3.
Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.
美国各地的医疗保健系统都在考虑为高危患者提供社区卫生工作者（CHW）服务，尽管关于如何建立和维持有效的CHW项目的数据有限。我们描述了在一个国营医疗系统中为5289名高危患者提供CHW服务的过程。该项目包括30名CHW、6名护理协调员、护理协调主任、医疗主任、一名注册护士、心理健康专家和法律专家。CHW被组织成地理和专业团队。所有CHW都接受包括口腔和心理健康在内的基础培训；一些人还接受额外的特定疾病培训。CHW与患者制定个性化的护理协调计划。这些计划的实施涉及提供广泛的社会服务和协调支持。CHW的接触次数由患者风险决定。CHW大约60%的时间在办公室环境中度过。为了最佳地实施该项目，我们不得不制定多个CHW工作类别，以实现CHW的专业化。我们创建了新的技术系统来管理运营。实地问题导致项目做出改变，以改善服务提供并确保安全。我们的经验为如何将CHW融入临床和社区系统提供了一个范例。
