- Finding and accessing care and support can be difficult for people with complex health and social needs
- An innovative care coordination program centered around a community-based workforce in SW Washington aims to break down those barriers
- Providence CORE’s evaluation of the program offers evidence of the impacts and opportunities for community-based care coordination models
Past research has shown that a more coordinated approach to healthcare and non-medical support contributes to healthier communities. Yet finding and accessing care and support can be difficult for people with complex health and social needs, who must navigate a fragmented landscape of healthcare, behavioral health, and social service systems to find essential support and services.
In Southwest Washington, local partners are working to address this challenge through an innovative care coordination model supported by shared technology and centered on Community-Based Workers (CBWs) such as Peers and Community Health Workers. The Providence Center for Outcomes Research and Education (CORE) is studying this effort, helping provide new evidence about the model’s impacts, and highlighting opportunities for community-based care coordination models.
Coordinating Care through the HealthConnect Hub
The Southwest Washington Accountable Community of Health (SWACH) launched the HealthConnect Hub in 2019 to serve as a central care coordination system for Clark, Klickitat, and Skamania counties. The Hub relies on local CBWs connected through a shared care coordination software platform and partnerships with a wide range of local service providers. Through this framework, CBWs identify program participants’ health and social needs; coordinate referrals across physical health, behavioral health, and social services partners; and assist in navigating care.
SWACH partnered with CORE to help evaluate and improve the program. Through interviews with participating HealthConnect CBWs and their supervisors, CORE studied the impact of the HealthConnect Hub on partners, the community-based workforce, and program participants.
The power of a community-based workforce
CBWs are frontline public health workers known by various titles, including Community Health Workers, Peer Support Specialists, and Health Advocates. SWACH’s model relies on a network of CBWs across the three counties it serves to help create a more coordinated care ecosystem that helps people get the help they need when they need it.
Researchers and public health leaders often cite CBWs’ unique ability to build trusting relationships with community members and break down barriers to navigating the complex web of healthcare, social services, and other systems. CORE’s research of this and other programs involving CBWs highlights some of the ways these workers can help advance community health.
Findings from the HealthConnect Hub evaluation
CORE’s evaluation of the HealthConnect Hub identified a variety of positive impacts on program participants, partner organizations, and the CBWs, as well as opportunities to invest in, grow, and improve the model for the future.
Impact on program participants
The HealthConnect Hub had a positive impact on program participants’ connection to outpatient health care (e.g., primary care, specialty care, outpatient mental health care)
The Hub also positively impacted program participants in more intangible but equally important ways, including increased self-confidence in navigating the fragmented healthcare and social services systems.
The research showed that housing is a significant need and that the impacts of the housing crisis are felt beyond the Vancouver area, including in Skamania and Klickitat countries. However, even the most dedicated and well-resourced program staff cannot help people find housing if there isn’t enough affordable housing available.
Impact on partner organizations and the community-based workforce
The HealthConnect Hub’s success is heavily dependent on the community-based workforce. An effective CBW network requires that CBWs have appropriate training and support, both within the organizations that employ them and through the Hub.
A wide variety of organizations of different sizes, locations, population focuses, and services have engaged in the HealthConnect Hub, reflecting Hub clients’ diverse needs.
The HealthConnect Hub's infrastructure strengthened partners’ ability to take on work, problem-solve, and learn from each other. Partners recognized the value of this network and utilized it to seek knowledge and support from other organizations with different specialties.
“We have different agencies, which is great… We're medical and then they help us with the homeless population. If we are struggling to help a client with housing… we could reach out and ask for more guidance or assistance.” - CBW
Next steps: translating evidence into action for the HealthConnect Hub
In 2023, CORE will continue working with SWACH to help apply the evaluation’s findings to sustain, improve and spread the Hub model. In addition to providing insights into how the HealthConnect Hub can improve care coordination in the three-county region and beyond, this work is useful for other practitioners and researchers pursuing similar care coordination models. It also raised other important questions about the need for affordable housing solutions and the importance of training and support for the community-based workforce.
Additional information & Resources
- CORE blog post: CORE Insights: How community health workers strengthen care coordination relationships
- Providence blog post: Community Health Workers can improve cancer care delivery, according to new research
- CORE journal article: The Role of Community Health Workers in Developing Multidimensional Organizational Relationships
- Read about the HealthConnect Hub on SWACH’s website