A subsidiary of Mind Springs Health, Inc., Whole Health, LLC was designed to implement the Community Health Worker (CHW) pilot program, which is aimed at supporting repeat emergency room users and helping them adopt behavioral modifications to reduce unnecessary emergency room visits and hospitalizations.
Whole Health, LLC’s Community Health Workers engage with patients in health behavior change and connect them with medical, behavioral, and social services needed to improve quality health and wellness in the community. CHWs facilitate patient access to these services through a variety of outreach activities including community education, informal mentoring and social support. Plus, CHWs enhance communications with primary care physicians, serving as a vital link between patients and providers to ensure enduring collaborative partnerships.
Essentially, Community Health Workers are highly motivated individuals trained to help others reach their health goals while connecting them with the best community resources and reducing ER visits in the process.
Potential candidates for the CHW program are selected based on claims data that participating medical providers receive from Rocky Mountain Health Plans (RMHP). Repeat emergency room users are identified and invited to attend a meeting with both a provider and a CHW present to introduce the program’s aims. If the patient chooses to participate, the CHW will then follow up with the patient to conduct a wellness assessment, identify health goals, and develop plans for achieving those goals.
Since CHWs are mobile, they can schedule meetings in the locations where patients feel most safe, whether that’s at home, in a coffee shop or at the grocery store. The frequency, type and location of meetings is based on the patient’s individual needs, and CHWs can assist patients in any or all of the following activities, among others:
• accompanying patients to appointments for extra support
• obtaining medical supplies
• completing healthy grocery shopping within a budget
• finding affordable housing
• starting an exercise routine
• completing paperwork for agencies
• connecting with various agencies for additional resources
While the aims of the CHW program are many, this program’s primary goals all fit within realm of the Triple Aim, which involves the three key goals of improved individual health care, improved population health and lowered health care costs.
The Community Health Worker program is currently offered in Colorado’s Mesa, Montrose, Garfield and Pitkin counties. The following medical practices are able to use this service:
Foresight Family Physicians; Primary Care Partners; St. Mary’s Residency; coming soon: Juniper Family Practice
Montrose Medicine; Pavilion Family Practice; The Practice of Lars Stangebye, MD; The Practice of Miller, MD & Peterson, MD; San Juan Family Medical
Mountain Family Health Centers (offices in Rifle, Basalt, Glenwood Springs); MidValley Family Practice
Additionally, one CHW is assigned to Rocky Mountain Health Plans to work with unattributed members, helping them find primary care physicians and offering support in their pursuit of improved health.
As the CHW pilot program anticipates future expansion, please check back here for updates, or contact Whole Health, LLC for more details.
Whole Health, LLC continually evaluates the necessity for additional programming. Criteria for program admission may be expanded based upon partner, patient, and community needs. Additionally, Whole Health is working with the Valley Health Alliance (VHA) in Aspen to hire and deploy a Health Coach to their employers.
Amy C. Gallagher, Psy.D.
Whole Health, LLC