1. Integrating CHWs into Primary Care Practices
Katherine Cauley, PhD,
Wright State University
Ohio Community Health Worker Conference 2016

2. Context
With support from the MEDTAPP HCA CHW funding program, CHWs are imbedded into primary care practices (PCPs).
To prepare for utilization of CHWs, the PCP completes a training program prior to the arrival of the CHW.
Prior to the beginning of the training program the PCP identifies specific clinical, cost and quality measures they hope to improve as a result of the integration of the CHW.
Currently, CHWs are embedded in seven PCPs as follows:
Colbert Family Health and Wellness
Dayton Children’s Hospital Asthma Clinic
Equitas Health
Five Rivers Community Health Center
Miami Valley Housing Opportunities
PriMED Dunbar
Wright State Physicians Family Medicine Practice
Wright State Physicians Geriatric Practice

3. Context
Primary Care Practice recruiting to work with CHWs began with members of the choir, and evolved through word of mouth, with more requests coming in on a regular basis.
Two models emerged: embedded physically and embedded procedurally.
CHW supervision provided jointly by the CHC CHW supervisor and the site based supervisor initially. The role of the CHC CHW supervisor has diminished as the sites have embraced the CHW, ad effort has shifted to outcome studies.
Lessons Learned:
Front load focus and attention with interprofessional team
Track CHW attendance—this is often predictor of difficulties
Monitor referral process
Monitor physical space for CHW at practice
When there is a social worker, engage them for success

4. Meetings
The first meeting is with the physicians, the practice manager, the CHW and the Center for Healthy Communities (CHC) CHW supervisor.
Review role and scope of practice of CHW
Review literature demonstrating efficacy of CHWs in primary care
Preliminary discussion re: clinical, cost and quality measures the PCP wants to improve
The second meeting is with the full interprofessional team, the CHW and the CHC CHW
supervisor.
Introductions of everyone’s roles and responsibilities
Discussion of Best Practices and typical interventions provided by CHWs
Discussion of patients that would benefit most from CHW interventions

5. Meetings
The third meeting is with the members of the interprofessional team most likely to be
making referrals to the CHW, the CHW and the CHC CHW supervisor
Discussion of referral protocol including specific patient population and referral process
Discussion of on-site supervision of CHW and interfacing with CHC CHW supervisor
Discussion of ongoing CHW continuing education and monthly seminars
The fourth meeting is with the physicians, the practice manager the IT person from the
PCP and the CHW and CHC CHW supervisor
Finalize clinical, cost and quality measures to be addressed
Determine process for CHW to chart interactions with patient, when to complete training on the EHR, and when to complete HIPAA training
Determine process for accessing data in order to document clinical, cost and quality measures reporting

6. Meetings
The fifth meeting is with the members of the interprofessional team, the CHW, the CHW
and the CHC CHW supervisor
Official introduction of the CHW to the team
Discussion of patient population and protocols for referring patients to CHWs
CHWs location in the PCP
Schedule of ongoing interprofessional team meetings
The sixth and subsequent meetings occur various subsets of the interprofessional team and the full interprofessional team on a quarterly basis to address ongoing issues associated with CHW and outcomes studies
Evaluative and troubleshooting discussions re: integration of CHW into PCP
Patient satisfaction feedback
Clinician satisfaction feedback

7. Documents Best Practices and Services Provided by CHWs CHW Script
CHW Patient Support Plan
CHW Daily Log Sheets
CHW Patient Report
Memorandum of Understanding
Business Associate Agreement
Certificate of Liability