Targeting the Non-Clinical Needs of Older Adults through the Integration of Community Health Workers in Primary Care Practices

Directing efforts to both healthcare and social needs will be necessary to improve healthcare and health outcomes for an aging population. Community Health Workers (CHWs) can play a vital role in addressing the non-clinical needs of elderly patients. In developing an interdisciplinary approach to elderly primary care, home visit teams, with the inclusion of CHWs, were integrated in primary care practices. During the initial home visit, CHWs conduct the social services intake and financial assessment to link elderly patients with appropriate resources available in the community. After 2 years of implementation, CHWs have conducted more than 800 home visits and over 1,800 telephone contacts. CHWs document patient outreach activity in the electronic medical record and communicate with clinicians and the rest of the care team to share information gathered from home visits. In addition, CHWs participate in practice team meetings to inform decision-making of treatment plans. Healthcare utilization is measured 6 months prior to and after services among elderly patients enrolled in the program for at least 6 months (n = 573). Early findings show a reduction in emergency department utilization from 1.88 to 1.55 visits per patient, while hospitalizations have decreased from 1.35 to 0.98 hospital visits per patient. These findings are not limited to CHWs’ interventions, but include the collective efforts of the entire interdisciplinary care team. Presenters will demonstrate CHWs are well-suited to work in clinical settings, as well as discuss the strategies used for integration of CHWs in care teams and describe initial challenges encountered

Promoting Social Engagement in Spanish-Speaking Older Adults through Memory Cafes

As the population ages, the number of individuals with cognitive impairments is projected to increase over the next few years. Studies have shown that feelings of loneliness and social isolation are linked to cognitive decline in older adults (Shankar et al., 2013). Memory Cafes can, however, enable those who suffer from mild cognitive impairments and their caregivers to take part in gatherings in a positive social environment. At Lehigh Valley Health Network, the Geriatrics Workforce Enhancement Program holds four Memory Cafes for the community-dwelling older adults, which most sessions are facilitated by Community Health Workers (CHWs). Three of the 4 Memory Cafes target Spanish-speaking elders in community settings, while the fourth Memory Café targets English-speaking residents at a continuing care retirement community. Investigation through case studies will explore the facilitating factors and outcomes of Memory Café participation in Spanish-speaking elders and caregivers. Participation of Spanish-speaking elders in Memory Cafes have particularly shown great success, and participants’ responses have been overwhelmingly positive. Participants and caregivers have been highly engaged in activities and discussions at each Memory Café session. Approximately 10-20 elders and their caregivers have participated in each monthly Memory Café, with participants returning to subsequent sessions. Successful Memory Cafes in Spanish-speaking older adults may be explained by CHW’s ability to connect with participants through similar language and cultural backgrounds