Community Health and Integrated Programs

Care Connections Program

The Care Connections Program (CCP) aims to improve care for a subset of the sickest, highest-risk primary care patients in the Department of Health Services by integrating Community Health Workers (CHWs) into the Patient-Centered Medical Home (PCMH).

CHWs come from the communities that they serve, and have had prior experience in health care.  They were selected following a rigorous screening process and received extensive training on topics such as patient engagement, health system navigation, medication review, coping skills, health coaching, and more.

CHWs work on multidisciplinary complex care teams to support existing PCMH nurse care managers and extend the reach of the primary care team into the community. They work with complex patients to reduce unnecessary utilization of services and costs, and accompany high-risk patients toward better health outcomes by: 1) enhancing the patient’s ability to self-manage and navigate a fragmented delivery system, 2) connecting patients to available resources, and 3) facilitating their coordination of care as part of the PCMH. 

CHWs currently support primary care practices at LAC+USC Medical Center, the Martin Luther King, Jr. Outpatient Center, and the Edward R. Roybal, El Monte and Hubert H. Humphrey Comprehensive Health Centers.  Each CHW works with up to 50 high-risk patients at any given point in time, and the CCP will collectively serve between 1250-1500 patients in the first year of the demonstration.