Model Programs

Modern Health Interview with the CEO of Columbia-Presbyterian health system in NYC who lists CHWs as a centerpiece of their population health strategy

Targeted Care Initiative
Key paragraphs:
MH: What did you do programmatically in the Washington Heights area?

Corwin: We called it the Targeted Care Initiative. We take care of roughly half to 60% of Washington Heights’ 250,000 population in our ambulatory-care network. We identified those patients that were at very high risk. We did a pretty extensive predictive analysis. Once we identified those patients, we put targeted-care initiatives in place: community health workers, community mental health workers, home visits. If you visit the home of an asthmatic child and you remove mold and allergens from that home, it dramatically reduces that child’s likelihood of coming into the emergency room. You can improve childhood immunizations. You can improve diabetes control. We found all of that. So, of that initial hundred-and-some-odd thousand patients, we targeted 10,000 patients. Of those, we put intensive monitoring in place for about 1,700 patients. That proved to be a big difference for us.

MH: This obviously affects your utilization, and these programs cost money. Where do you come up with the wherewithal to do community outreach programs?

Corwin: We’re a not-for-profit institution, so we exist for the public benefit. The board of the hospital has consistently said to me and to our management team, “We exist for the public good, so let’s make sure we do the public good.” Having said that, we can’t afford these programs unless we generate some margin. And we’ve been fortunate to be able to do that. We feel very strongly that to help the country reduce its healthcare costs we should be in the vanguard of reducing utilization, improving quality, reducing variation. We think that our strategy is a sound one because we think that our quality will make sure that people come to us who need our care. We’re comfortable with our ability to sustain this business model.



State Reform Resources –   State Community Health Worker Models ( Chart)

Like all State Refor(u)m research, this chart is a collaborative effort with you, the user. We are actively researching state CHW activity and will be updating this chart regularly. Know of something we should add to this compilation? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment, or email with your suggestions. (Last updated Jan 2016)



Community Connectors

September was the kick-off month for a new Molina Healthcare program called Community Connectors. Community Connectors are a high touch extension of an RN or Social Worker Case Manager who will literally meet the member in their home, PCP’s office or in the community; they are the eyes and ears in the field. Community Connectors provide outreach to locate and/or provide support for disconnected members with special needs. They educate members and are advocates engaging and assisting the member in managing and navigating the healthcare system. Community Connectors provide non-clinical paraprofessional services and are thoroughly familiar with the member’s community and available resources. Community Connectors assist members with all aspects of their health and wellness by collaborating with Molina Healthcare staff, primary care providers, social services and community resources. If you have a member that could benefit from the services of a Community Connector please call Member Services at (888) 898-7969.

Molina Healthcare’s Community Connector Program provides a vital bridge between case managers and the communities with which they work by using CHWs’ personal relationships with the community and their ability to build trust to connect targeted individuals to appropriate care. In the role of Community Connectors, CHWs function as extenders for case managers. The program, which targets members who Molina has identified as having high-cost utilization patterns, complex medical or behavioral health needs, or chronic conditions, originated in New Mexico in 2004.

There have been changes in the approach to primary care as a result of Molina’s promotion of the service to primary care providers in the community; they now may opt to refer non-compliant members to the Community Connectors. Members are also referred to Community Connectors to assist with their completion of preventive screenings. While it is not necessarily possible to equate improved health outcomes with cost savings, the Community Connector Program in the original pilot site of New Mexico resulted in a return on investment of 4:1 when comparing the six-month study period data with data for the six months preceding and following the intervention.

With evidence from the New Mexico program, Molina’s leadership fully supports the Community Connector Program and has made the decision to now expand the model enterprise-wide across nine states, including California.


Molina Healthcare’s Community Connector Program plays a highly visible role in connecting its members with health care providers and the community at large. The program is structured with two primary components: collaborative partnerships and behavior change designed to improve members’ access to care in appropriate settings in order to decrease overall costs associated with their care, and to deliver improved quality of care and improved health outcomes for members. In the role of Community Connectors, these community health workers provide education, support, and advocacy that empower members to develop self-management skills which contribute to improved quality of life.

The Community Connector Program targets members who Molina has identified as having highcost utilization patterns, complex medical or behavioral health needs, or chronic conditions. Members are identified through various internal Molina reports, such as members with three or more ED visits in the previous quarter, and internal case management referrals. Face-toface contact is a key feature of the program, as is the participation of health care providers. Community Connectors invest considerable effort in providing members with critical education on the importance of being connected to a health home as well as important self-management skills and understanding of their health conditions.

The Community Connector Program originated in New Mexico in 2004 through a contractual agreement with the University of New Mexico’s Health Sciences Center and the Community Access to Resources and Education in New Mexico Consortium. The goal was to provide Molina members with education on alternatives to frequenting the emergency department for non- 53 emergency conditions, to identify barriers to their care, and to assist them with health care navigation. Poor self-management skills with chronic conditions, a high frequency of use of the emergency department for non-emergency conditions, and a high cost associated with care for emergency department visits and re-hospitalizations were the clinical and financial issues that the intervention addressed in the target population.


The Community Connector Program has been designed to target specific populations who could benefit from direct contact interventions. Members are identified through various internal reports, which flag members with high-utilization rates for the emergency department as well as high-dollar costs associated with their care, and case management referrals.

Specific interventions with the member may include:

  • connecting members to a health home;
  • educating members on alternatives to visiting the emergency department;
  • removing barriers members may face in accessing care;
  • bridging communication between members and health care providers;
  • teaching members concepts of prevention and chronic disease management;
  • guiding members in the practice of self-management skills;
  • linking members to community resources.

The Community Connector is a vital member of the integrated care management team in Molina’s health care services department. As an extender to the case manager, the Community Connector serves as the “eyes and ears” of the case manager in the community and thereby plays a highly visible role in connecting members with appropriate health care services. Through the Community Connector’s presence in the member’s home, they are able to assess immediate needs; in the provider’s office they are able to listen to provider treatment recommendations; and in the community setting they are able to ensure they access appropriate resources. All of the Community Connector ‘s activities are documented in Molina’s electronic care management software platform, Clinical Care Advance System.

A unique feature of the program is the high-touch, face-to-face approach in the member’s home, health care, and community settings. Critical to the program’s ultimate success is the initial contact made by Community Connectors with members and the opportunity that affords to build trust. One of the key challenges identified prior to implementation was the inability to contact or locate members of the target population, as some were homeless, and the possibility that members may refuse face-to-face interventions. The ability of Community Connectors to develop trusting relationships with members ensures members’ acceptance of the education, advocacy, and support that Community Connectors provide in order to facilitate members’ access to the health care system. Moreover, members are also more likely to become empowered to develop self-management skills that contribute to an improved quality of life. Further to the program’s success has been the ability to improve health outcomes and decrease health care costs.

Program Description

The initial contact with a member generally takes place in the member’s home. Subsequent contacts may occur when the Community Connector accompanies a member to a health care appointment or while providing assistance to connect them to community resources. The length of time that a member receives direct face-to-face services from a Community Connector is dependent on the individual member’s needs. A health risk assessment (HRA) may be completed by a Community Connector during the initial visit to a member’s home. The assessment identifies each individual’s primary health concerns. Specific interventions with members through the Community Connector Program may involve health coaching, care coordination, health education, chronic disease self-management, system navigation, and cultural liaising.

Program Recruitment and Training

Core skill requirements sought in the recruitment of Community Connectors include communication, cultural competency, health promotion, health literacy, ethics, and an understanding of the managed care environment. All newly assigned Community Connectors are required to participate in initial and ongoing training of specific core competencies and in areas of clinical documentation that Molina employs.

Molina has purchased a training curriculum that addresses many of these components. It also provides additional trainings, including:

  •  diabetes training
  •  motivational interviewing
  •  communication and advocacy
  •  HIPPA and medical ethics
  •  behavioral health
  •  cultural competence
  •  understanding poverty
  •  tobacco risks and cessation
  •  essentials of medical terminology
  •  nutrition and healthy eating

The Community Connectors function as an extender for case managers. They receive guidance and coaching from the case managers in identifying specific tasks and interventions that will be required to ensure the successful realization of targeted goals. As Molina currently rolls the Community Connector Program out in nine other states where Molina is present, it is using a train-the-trainer model that involves a week-long orientation on the role of community health workers as Community Connectors. Upon return to their respective states, training participants then train hired community health workers in the role.

Program Results

The enterprise roll-out of the Community Connector Program is based on evidence from an evaluation of the impact that community health workers providing community-based support services have on high consumers of health resources in Molina’s New Mexico Medicaid managedcare plan. The retrospective study, involving 448 enrollees assigned to Community Connectors compared with a control group who did not receive the intervention between October 2007 and October 2009, found a significant reduction in both numbers of claims and payments related to emergency department, inpatient service, non-narcotic and narcotic prescriptions, as well as outpatient primary care and specialty care after the community health-worker intervention. The calculated return on investment based on comparing the six-month study period data with data for the six months preceding and following the intervention was 4:1. The total cost differential post intervention, compared to pre intervention, was $2.04 million. The estimated program costs, including salaries and benefits of employees managing the program and services provided by the University of New Mexico Medical Group and Hidalgo Medical Services, was $520,000.

Program Evaluation and Data Capacity

Clinical reviews of all open cases are conducted monthly to ensure that health behavior changes through the application of self-management skills contribute to improved health outcomes and cost savings. From a health plan perspective, HEDIS measures related to members compliance with prevention screenings are tracked as a core metric. Another important source and type of data used to assess the performance of community health workers in this intervention are claims data, specifically pre- and post-claims costs of members who are eligible to participate in the intervention. However, member satisfaction, provider satisfaction, and social determinants impact are recognized as substantial and positive community health-worker contributions — but they are difficult to measure.



Inland Empire Health Plan (IEHP)

Health Navigator Program Overview Program Background: Inland Empire Health Plan (IEHP) has developed an innovative program called Health Navigator designed to help IEHP members better understand how, when and where to get their medical care. The program is funded by IEHP and First 5 San Bernardino. Launched in June 2010, the Health Navigators serve most of San Bernardino county and Riverside metro. It aims to increase preventive-care visits and reduce avoidable emergency room visits (ER) and hospitalizations. The program will serve as a link among members, providers and IEHP, ultimately leading to better communication and care.

Program Description: Based on the “Promotores” and Community Health Worker models, IEHP is the first health plan in the nation to have a full-time, in-house team dedicated to helping IEHP members navigate the healthcare system. In addition, collaboration with IEHP’s primary care physicians (PCP) is a key element for the program’s success. Prior to the launch, the Health Navigators connected with PCPs to inform them about the program’s promotion of preventive-care visits and how the program plans to help connect families to their offices. The Health Navigators, who are bilingual in English and Spanish, schedule in-home visits with IEHP members and their families. To prepare for the first visit, the Health Navigators utilize the members’ health records to identify any medical needs, such as immunizations, and preventive-care services. Furthermore, during the first visit, the Health Navigators conduct an initial assessment to determine any other medical and social service needs. These efforts allow the Health Navigators to provide personalized education, guidance and advice on subsequent visits.

Specifically, Health Navigators will educate IEHP members about the following: • What services their PCP provides • When they should see their PCP for a medical need • The importance of preventive care to stay healthy and prevent disease • Three options to get non-emergent medical help – PCP, the IEHP 24-Hour Nurse Advice Line and extended or after-hours urgent care clinics • Community resources they may find helpful After the initial visit, the Health Navigators conduct two more visits to continue education and to see if the members’ knowledge on how to access care has increased. To measure this, an assessment is done at the final visit.

Program Results: Health Navigator Program families’ knowledge change on how to navigate healthcare: ▪ 41% decrease in avoidable ER visits ▪ 99% of families visited now know what the IEHP 24-Hour Nurse Advice Line is and how to use it compared to 58% at the first visit ▪ 99% of families visited now know the difference between urgent care and ER compared to 12% at the first visit

Since its inception, the Health Navigator Program has presented at the American Public Health Association and various other conferences, and serves as a model for healthcare services across the nation. The program will continue to share best practices and look for additional funding to expand to underserved areas. ©2014 Inland Empire Health Plan. All Rights Reserved. MK 01567-0512-1

Contacts: Jessica Castillo-Lauderdale and  Guadalupe Castañeda

Guadalupe Castañeda
Community Outreach Coordinator
Health Navigator Program
Inland Empire Health Plan (IEHP)
Office (909) 890-4490 Fax (909) 890-2149