SHM Converge Scientific Abstract ePoster Gallery-Integrating Community Health Workers Into Interprofessional Hospital Medicine Based Teams

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The document describes a pilot program at Thomas Jefferson University Hospital that integrated Community Health Workers (CHWs) into an inpatient Hospital Medicine team to address social determinants of health (SDoH). The effort builds on prior work at Sidney Kimmel Medical College, where CHWs precepted pre-clerkship medical students to screen patients for social needs and connect them with resources. In August 2021, the hospital medicine division partnered with this program to bring CHWs into the inpatient setting.<br /><br />The goals were to assess feasibility, better understand common social barriers among hospitalized patients, and compare SDoH barriers found through unit-based patient screening versus direct referrals from care teams. A CHW joined the interprofessional team in August 2021, with medical students added in September 2021. Patients with significant social needs were helped during hospitalization and, when needed, after discharge. Early implementation focused on clarifying roles with social workers and case managers, establishing screening and referral workflows, and improving data collection. An electronic health record consult order was added in September 2022.<br /><br />Results showed a high burden of unmet social needs. Among 419 screened patients, 156 (37.2%) had at least one SDoH barrier. In addition, 97 patients were directly referred by the care team, and 93.8% of them screened positive. Screening identified more utility and food insecurity issues, while direct referrals were more likely to involve housing insecurity. Between September 2022 and February 2023, 160 CHW consults were placed, mostly by hospital medicine attendings, residents, social work, and case management.<br /><br />Overall, the project found that integrating CHWs into inpatient medicine is feasible and may help uncover and address social needs not otherwise identified by standard care teams. Future plans include strengthening social work partnerships, expanding community resources, and tracking outcomes such as length of stay and readmissions.

Asset Subtitle

Alyssa M. Yeager

Meta Tag

Author List Alyssa M. Yeager, Geoffrey Hayden, Paula Ostroff, Rebecca C. Jaffe, Rebecca Horowitz, Sonia Bharel

Category Innovations

Concept Community Health Worker

Concept Social Determinants of Health

Concept Health Barrier

Concept Hospital Medicine Team

Concept Inpatient Care Team

Distinguished Finalist

Presenter Organization Thomas Jefferson University Hospital

Presenting Author Alyssa M. Yeager

Track Quality Improvement

Keywords

community health workers

hospital medicine

social determinants of health

inpatient screening

social needs

Thomas Jefferson University Hospital

housing insecurity

food insecurity

patient referrals

feasibility study

Community Health Worker

Social Determinants of Health

Health Barrier

Hospital Medicine Team

Inpatient Care Team