Prior to her child’s visit to the doctor, a mother noted on the clinic’s survey she was having trouble paying for utilities. During the doctor’s visit, she shared with a community health worker that her water bill was nearly a thousand dollars. The community health worker helped the mom set up a payment plan with the water utility company. She then connected her with a nonprofit organization who covered the utility bill, as well as three months’ rent, allowing the family to catch up on bills.
Having water, electricity, and a place to live ensured the family could maintain a stable home. A sense of security can also help reduce stress, enabling the mother to focus on family interactions that support her child’s healthy development.
This is just one example of how MercyOne’s focus on addressing the social determinants of health is improving the overall health of patients. A Mid-Iowa Health Foundation grant expanded the health care system’s community health worker model beyond primary care clinics into the pediatric setting, demonstrating success in connecting families with resources that support a safe and nurturing environment children need for well-being.
“You can do everything correctly and have really good health behaviors, and still have negative health outcomes because of the environment where you live,” said Emily Fletcher, Division Director of Social and Clinical Care Integration within MercyOne.
“Community health workers are a bridge to resources that improve patients’ health,” added Pamela Brown, a community health worker at MercyOne Waukee Family Medicine.
"The community health worker model is a proven solution to increasing access to resources for community members often underserved by our traditional health and social service systems,” said Dr. Nalo Johnson, President of Mid-Iowa Health Foundation. “We are grateful to see MercyOne embrace the community health worker model within its pediatric clinics to increase access to resources for children and families in our community."
Increasingly, health care systems across the nation are looking at how to address many factors influencing patients’ health. Research shows economic and social factors especially play a role. In fact, the ZIP code in which one lives is the biggest predictor of health outcomes.
“It’s not just how well a doctor takes care of a patient, or a patient takes meds, or the doctor-patient interaction is,” said Dr. Timothy McCoy, a family medicine physician who has been a champion of the community health worker model across MercyOne. “If they can’t get basic needs met, the patients do poorly.”
Because the health care sector reaches most community members, leaders increasingly view the doctor’s office as a place to address the social determinants of health. The community health worker model has gained recognition as a way of connecting clinical care with social care.
MercyOne has long had health coaches, or nursing professionals who help connect patients to community resources. Leaders recognized health coaches did not always have time to build relationships with community-based organizations or keep up to date on community resources. A grant from the Robert Wood Johnson Foundation with an equal match from Catholic Health Initiatives enabled the health system to test a new approach.
Starting in 2017, MercyOne hired three community health workers to implement social needs screening and support patients with unmet needs. The program has since grown to eleven community health workers connected to 31 clinics. More than 80,000 social needs screenings have been completed with 19% detecting a social need.
“That’s significant, knowing almost two of every 10 patients we serve is experiencing a social need,” said Fletcher.
This also demonstrates the importance of offering the screening to every patient at every visit, said Fletcher. The most common needs reported in family medicine include loneliness followed by food insecurity.
Physicians have been very receptive to the idea of having someone embedded in clinics who can connect their patients to resources when there are concerns, says Fletcher.
“In the past, not only did we not know if a patient had issues, but we also didn’t know what to do if they asked,” said McCoy. “Now we ask the questions, providers are then made aware if the patient has potential issues, and we have resources that can help.”
With a grant from Mid-Iowa Health Foundation, MercyOne was able to hire a community health worker and begin screening patients for social needs at its central pediatric clinic. Community health workers embedded in family medicine clinics also support parents and children. The results in the pediatric clinic have been similar to family medicine clinics, with about 20% of families having needs. The most common concerns are food insecurity and paying for housing and utilities.
While community health worker models vary across health systems, MercyOne has implemented its model in the following way:
A patient is offered social needs screening at every appointment after the initial visit to the clinic. The screening tool asks about social needs, including food, housing, transportation, utilities, medication affordability, loneliness, and health literacy skills. Patients are asked if they would like to complete the screening tool and if they would like support if a social need is identified. About a quarter of patients participate.
If a social need is identified and the patient wants support, or if a provider identifies a social need during the appointment, the patient is referred to a community health worker. The worker then partners with the patient and/or their family to further understand their needs and connect them with resources. The community health worker helps families apply for assistance programs and will follow up to determine if the needs were met.
“I feel like sometimes, in a situation, it’s hard to think about what’s next or what can happen,” said Amy Garcia, the community health worker at the MercyOne Des Moines Pediatrics Care. “You’re stuck in a box. The community health worker is the person who helps you open up that box, so you can get to the resources that help you out.”
Initially, the percentage of patients connecting to resources and following up with the community health worker was low. Training in motivational interviewing helped community health workers approach patients in a way that builds engagement and follow through.
Motivational interviewing has especially helped community health workers go beyond the screener to understand the context of what is happening with a patient and their family and to help prioritize the need they want to address first. Patients are asked to share what connections they have already tried and, on a scale, how likely they are to take next steps. These questions help the worker assess readiness to address any barriers.
“The information we started to get was very different,” said Fletcher. “We know more about the person as a whole, including their environment, supports, and strengths. We have a really high percentage of patients answering our follow-up calls and following through with resources.”
Community health workers try to meet with patients at least twice – an initial interaction to identify needs, set a goal and connect with resources – and at least one follow up to determine if the resources were helpful and assess for additional needs. But the community health worker may work with a patient over several interactions.
Lead Community Health Worker Savanna Richardson says needs often extend beyond the seven questions on the survey, but for the most part, workers can help connect patients with the right resources. While many of the resources are the same across age ranges, some families with young kids have access to different programs, such as WIC (a supplemental nutrition program for women, infants and children) and 1st Five (Iowa’s healthy mental development initiative).
Workers at clinics in rural areas tend to have fewer options for patients who don’t have their own transportation, and most clinics have seen an increasing need to connect patients with behavioral health services. Often the community health worker role involves building relationships with the community-based organizations providing services and staying current on available resources and how to access services, especially through changes in response to the COVID-19 pandemic.
Community health workers also spend time engaging clinic staff in supporting patients’ social needs. Community health workers keep hygiene supplies on site for patients in need. Community health workers have also engaged clinic teams in donations to community-based organizations.
To meet more community members’ needs, MercyOne also launched an online community resource directory in 2021 to directly connect patients and community members to social services.
“The MercyOne Community Resource Directory extends support into the community and allows community members to search for services available to them,” said Fletcher.
Although COVID-19 slowed the process of implementing the model in the pediatric clinic, the community health worker there saw a rapid increase in referrals once the clinic transitioned from paper screening to electronic screening.
Over two years, the pediatric clinic screened 4,000 unique patients. Most patients were younger than 12 years old and half were insured by Medicaid. Among those surveyed, 533 patients’ families met with the community health worker.
“The stories have been amazing,” said Fletcher. “The community health workers have been able to help people find jobs and housing, they have helped people apply for health insurance, and have delivered food to families in need. They live our mission of service each and every day.”
Richardson says one example of success in her adult clinic was helping a diabetic patient on a limited income apply for food assistance so she could access healthier food options to better manager her diabetes.
Garcia said you can see the impact when interacting with patients: “When you’re talking with someone, you can hear that sense of, ‘Oh okay, there’s hope. I don’t have to worry about where we are going to get food for the weekend or where am I going to get diapers because I have $3 in my bank account.’ You can see them take that breath and feel things are okay.”
Dr. McCoy has been involved with the community health program for four years, helping pilot the model in the first clinic and supporting expansion to other clinics. While he wasn’t trained to focus on the social determinants of health in medical school, he understands the impact of unmet social needs on his patients’ health. Other health care providers are becoming more aware as well. Almost 30% of referrals to community health workers come from providers and their care teams.
“We’ve done our best to control blood pressure, diabetes and other chronic conditions,” said McCoy, “but there are so many social factors affecting patient health we thought we knew about and empirically make sense to us as providers, but there was not a good way to ask or act. It’s an evolution of learning to take care of patients better, which is what we do.”
The community health worker model also has sustained after the grants supporting the work have ended. MercyOne is actively expanding the community health worker program to additional communities and care settings.
Community health workers across the MercyOne system would eventually like to see this model expand to every clinic.
“When we get the referrals and get great resources and the patient connects with resources and the resources meet their needs, it feels like we’re walking along the journey with them,” said Richardson. “It’s an awesome feeling, because I’ve had several situations where I’ve had great outcomes.”
Learn more about MercyOne's approach to improving health through its Population Health Services Organization.
MercyOne's community health worker model improves outcomes for families.
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