CCC Outreach Workers Fill Gaps in Health Care

Friday, October 21, 2016

On Monday, PBS Newhour aired a fascinating and insightful segment on the rise of utilizing community health workers—already popular in other parts of the world like Sub-Saharan Africa—to better serve vulnerable and hard-to-reach patients. (You can watch the video above or on the PBS website.) As the segment makes clear, community health workers play a vital role in helping patients improve their health.

At Central City Concern, a number of our specialized health care programs rely on Outreach Workers to engage those we serve in direct, meaningful ways that truly exemplify our commitment to meeting patients where they are.

The Community Health Outreach Workers (CHOW) team works to bring individuals who are newly enrolled in the Oregon Health Plan (Oregon’s state Medicaid program) into our Primary Care Home, where patients can find barrier-free access, team-based care, integrated mental health and addiction treatment, and additional wellness resources. They’ve also been working with the care teams at Old Town Recovery Center, CCC’s mental health clinic, to help their clients get connected with primary care.

CHOW team members may meet people on the street, at shelters or hospitals, or in their own homes, and often check in with patients to ensure that they are engaged comfortably into the care available to them.

Members of the CCC Health Improvement Projects (CHIPs) team, also known as our Health Resilience Specialists, are embedded in the four main care teams at CCC’s Old Town Clinic (OTC). CHIPs team member work closely with OTC patients (what we call “high touch” support) who have shown a high rate of hospital emergency utilization, helping them decrease unnecessary hospital use by providing intensive case management and addressing social determinants of health. CHIPs team members meet patients at home, on the street, in the hospital, or wherever else the patient needs engagement to happen most.

For those already living in our housing, CCC’s Housed + Healthy team provides a direct pipeline from housing to CCC health care. By performing a needs assessment with new residents as they move into their CCC home, the Housed + Healthy team can identify high needs residents who have gaps in their health care support. The Housed + Healthy team can streamline the referral processes to connect residents to care and even increase coordination between service providers. Further, our Housed + Healthy team provides on-site wellness education programming to encourage healthy living.

The work and impact of Outreach Workers are so important that they can be found beyond the three teams we highlighted here; programs like CCC's Bud Clark Clinic, among others, also lean on Outreach Workers to build relationships with those who are vulnerable in order to connect them with basic health care and services.

The flexibility of CCC’s Outreach Workers allows them to bring care and compassion to our patients. Maintaining and improving health outcomes takes work outside clinic walls, and our Outreach Workers are there to walk that journey with those we serve!