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ADDRESSING SOCIAL NEEDS TO ENABLE SUCCESSFUL CARE TRANSITIONS FOR PATIENTS HOSPITALIZED WITH COVID-19: THE CRITICAL ROLE OF COMMUNITY HEALTH WORKERS
Journal of General Internal Medicine ; 37:S593-S594, 2022.
Article in English | EMBASE | ID: covidwho-1995775
ABSTRACT
STATEMENT OF PROBLEM/QUESTION The COVID-19 pandemic highlights the disproportionate burden of disease on communities made vulnerable by structural inequities. The pandemic has increased economic hardship, including housing instability, food insecurity and ability to pay bills. Hospitalization for COVID-19 is an opportunity to address unmet healthrelated social needs (HRSNs) and connect patients with community resources. DESCRIPTION OF PROGRAM/INTERVENTION Community health workers (CHWs) play a critical role in response to public health crises. To address the inequitable burden of COVID-19 on Austin's Latinx population, we implemented a pilot program at an academic hospital where a CHW helps patients navigate care transitions and address unmet HRSNs. The care team referred patients with COVID-19 to the CHW, who met with patients to establish rapport, provide language-concordant communication between the care team and patient/family, deliver health promotion education, and assess HRSNs. MEASURES OF SUCCESS This includes three typical cases describing key components of the CHW pilot program. CHWs connected patients and families to community resources and facilitated discharge planning and connection with primary care providers. The CHWs continued to follow patients for at least 45 days after discharge to assist with care coordination. We provide qualitative data from patients and healthcare professionals. FINDINGS TO DATE Patient 1 is a 38-year-old day laborer with hypertension hospitalized with COVID-19 pneumonia. His family of four is undocumented and faced economic insecurity due to loss of work from the pandemic. The CHW assisted with utilities, bills, food and rent through coordination with local organizations to provide direct financial assistance to the family. Patient 2 is a 45-year-old woman with diabetes hospitalized with COVID-19 pneumonia. She is a mother of three children, two with disabilities. In addition to financial insecurity, she identified transportation as a primary HRSN. The CHW arranged financial resources to fix their car, which allowed the family to access school and clinic resources. Patient 3 is a 36-year-old man hospitalized with COVID-19 pneumonia. The CHW connected the family, including three children, with their school social worker, enabling access to financial support for utilities, food and clothes. The CHW arranged free food delivery to their home for four months. The CHW also secured county-based indigent care coverage for the patient, enabling hospital follow-up with a primary care provider. The patient's wife noted, because of the CHW, “We never felt alone” and now feel “capable of navigating a health system that we never felt we had access to.” KEY LESSONS FOR DISSEMINATION CHWs, as patient advocates and skilled care navigators, build trust, establish longitudinal relationships with patients and address unmet HRSNs that can enable successful care transitions. CHWs can alleviate the disproportionate burden of COVID-19 on individuals with unmet HRSNs. Supporting the work of CHWs within hospital care teams can improve care transitions.
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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Journal of General Internal Medicine Year: 2022 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Journal of General Internal Medicine Year: 2022 Document Type: Article