With this funding, Marshall Health will integrate CHWs at 10 new sites to support patients with chronic conditions, including hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, cancer and metabolic syndrome.
In assisting patients with chronic conditions, CHWs work closely with local health care providers; regularly follow up with patients in their homes and communities to help them navigate clinical services; manage their chronic condition; and facilitate linkages to other (non-clinical) community-based services such as food assistance, transportation access, financial assistance, etc. that could be barriers to wellness.
This innovative chronic care management model is ideal for any community and has been implemented with academic health systems including Marshall Health, community health centers, free clinics, and school-based health centers. Community health workers are foundational to Marshall’s unique approach to managing chronic disease as the model enhances community-clinical linkages, improves chronic disease self-management and addresses social drivers of health to improve outcomes.
“Our vision is to build a new chronic care management system that can better serve the needs of those with chronic disease and the health care system as a whole across rural Appalachia,” said Deb Koester, Ph.D., D.N.P., assistant professor and director of the division of community health at the Marshall University Joan C. Edwards School of Medicine and principal investigator on the grant. “The Marshall model seamlessly integrates the community health worker into the care team to serve as the bridge between the health care delivery system and patients in order to improve outcomes and access and reduce health-related costs. Community health workers and health plans, such as Aetna Better Health of West Virginia, are the centerpiece of the model.”
The Joan C. Edwards School of Medicine’s department of family and community health initiated the community health worker model nearly a decade ago with support from the Claude Worthington Benedum Foundation. Since then, the model has continued to expand sites and new target populations, demonstrating improved health outcomes and a sustainable business model. Currently, the Marshall community health worker model has been established in health care organizations in more than 25 counties in West Virginia, Ohio and Kentucky.
For more information, contact Koester at koesterd@marshall.edu.