Connected care for older adults: A pilot intervention engaging community health workers to advance age-friendly care in rural oregon

BACKGROUND: Aging in a rural setting presents unique challenges including limited access to in-home care, lack of social support, language and cultural barriers, and the lack of transportation. We conducted a pilot study embedding community health workers (CHWs) into rural primary care teams to assist with implementation of the 4Ms of the Age-Friendly Health System: What Matters, Mentation, Medication, and Mobility. 

METHODS: The Connected Care for Older Adults model embeds CHWs in primary care and they conduct home visits to implement 4Ms protocols for patients 55 and older, living independently, and considered to be "medically frail" by a PCP, or meet criteria by the Edmonton Frail Scale. Patients complete the program in approximately 90 days. Feedback was collected from patients, caregivers, providers, and CHWs; health care impact was collected from electronic health records. 

RESULTS: We enrolled 388 patients from 79 PCPs at 7 clinics. Patients were 63% female with an average age of 77 years. Over 95% were public payer, 49% had been to the ED in the past 12 months, and 34% had been hospitalized. The program made a positive difference for 95% of responding patients (n = 120) and 100% of responding providers (n = 19) were "very satisfied" with the program. Clinicians cited the CHWs' ability to support resource connections, address social isolation and social needs, provide regular check-ins, and help to get patients and families engaged in care as positive components of the model. Early data suggests this program may reduce health care utilization. 

CONCLUSIONS: Connected Care for Older Adults incorporates CHWs in primary care settings to deliver age-friendly care to rural, underserved adults 55 and older. Early findings and feedback from participating patients, caregivers, providers, and CHWs suggest that this is a promising approach to delivering age-friendly care.