Implemtentation Guide for Community Partnership Model

Improving Health Outcomes by Linking Community-based Community Health Workers with Health Systems

Portland, OR (February 27, 2017)-The Community Partnership Model demonstrates a method for linkage between an established Latino-serving Community Based Organization, Familias en Acción, and a Health System, Kaiser Permanente Northwest. The Community Partnership Model was developed to initially serve Latinos and serves as an important tool for other identified racial, ethnic and immigrant patient populations. Culturally competent care is central to the Community Partnership Model. 

Two year funding for the Community Partnership Model was provided by Meyer Memorial Trust, The Collins Foundation, The Oregon Community Foundation and the Kaiser Permanente Community Benefit Program.

This model is unique in that it is a partnership where resources are shared. Rather than hiring Community Health Worker/Health Navigators internally, (which requires mid-level management, cultural competence and community contacts) Health Systems can rely on the cultural background, business expertise, and community reputation of a local Community Based Organization to provide highly qualified workers.

The Community Partnership Model can provide an effective working partnership in order to offer culturally specific, patient-centered care that addresses social needs in order to:

  • Strengthen cross-cultural communication with patients
  • Provide culturally appropriate health information for patients
  • Enhance health literacy and patient/family engagement
  • Facilitate patient navigation of the healthcare system
  • Link patients to supportive community resources to address social needs that may deter positive health outcomes

The Community Partnership Model includes templates with a timeline and steps for program implementation including:

1. Organizational Internal Planning Identify the need and select patients with medical needs who experience social needs that impede their utilization of health care. Ensure administrative support and readiness to develop the partnership.

2. Find and Build the Partnership Find appropriate Community Based Organization: Select a Community Based Organization that culturally represents, has strong connections to, trust of, and history of serving the identified population, employs and will continue to supervise Community Health Workers/ Health Navigators who can bridge cultural and community knowledge with understanding of the Healthcare System. 

3. Formalize the Partnership Work together to refine the selection of the patient population to be referred. Develop partnership and business contracts. Negotiate payment agreements and select Pathways or another method for payment.

4. Build an Integrated Team Define and develop the referral process and work flow. Clarify roles and job descriptions to successfully embed Community Health Worker/Health Navigators into patient care teams.

5. Mutual Training and Education Provide orientation and ongoing training of Community Health Worker/Health Navigator on clinic protocols. Offer training of Health System staff around cultural competence and inclusion of Community Health Worker/Health Navigators on care teams.

6. Conduct Program Evaluation Collect health care data. Collect narrative data and Patient Activation Measurements (PAM).

Familias en Acción was founded in 1998, in response to the need for a culturally specific organization to promote health for Hispanics. Its mission is to promote empowerment and holistic family well-being for Latinos through compassionate community engagement, education, research, and advocacy for social change. Services include: 1- Patient navigator services for Latinos diagnosed with chronic diseases including cancer, diabetes, end stage renal disease and cardiovascular disease; 2- Community health education, a Spanish language support group and chronic disease self-management classes; and 3- Training for Health Professionals. This includes the annual Latino Health Equity Conference and online/in person health professional training with Continuing Education Units.

Kaiser Permanente is committed to helping shape the future of health care. It is recognized as one of America’s leading health care providers and nonprofit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of its members and the communities they serve. It currently serves approximately 10 million members in eight states and the District of Columbia, including more than 520,000 medical and 240,000 dental members in Oregon and Southwest Washington. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. The medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health.

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