AHRQ Innovations Exchange | Expert Commentary: Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements
Community Connectors Help Seniors Maintain Their Independence
By Brenda Leath, MHSA, PMP and Christine Lehmann, MA
Training laypeople to connect low-income, Medicaid-eligible seniors with community services is a win-win situation.It helps seniors stay longer in their homes and avoid expensive nursing home care.Being able to stay in their homes longer fosters continued independence, enhances their quality of life, and results in cost savings to Medicaid.
Like community health workers, community connectors are trusted individuals who live in the same community as the people they serve.They often have existing relationships and share the same socioeconomic status and race or ethnicity, which facilitates gaining the client’s trust to share information about available services and helps them understand family dynamics and caregiving expectations.
Low-income seniors, especially those living in rural areas, tend to have unmet health needs that, if left unaddressed, put them at risk of nursing home placement. Many elderly residents of the Mississippi Delta faced that situation with limited access to care and services, high rates of poverty, and a disproportionately high number of minorities, elderly, and disabled individuals.
The Tri-County Rural Health Network trained outreach workers to identify Medicaid-eligible residents and arrange for them to receive home and community-based care such as medical equipment delivery, home health aide visits, and meals. The program required the residents’ physicians to approve all medical-related services. In some cases, they completed Medicaid-related paperwork and sorted out eligibility issues.
The community connectors usually worked with the individual and his/her family for several weeks.For example, when two elderly sisters who lived together were separated when one of them had health problems and entered a nursing home, a community connector arranged for a niece to move into the house and for the sisters to receive a range of community services, which enabled them to reunite and live together again.
As a result of the program, no participants required nursing home placement, which reduced health care costs. The average annual per-person Medicaid spending rose by only 19.3 percent for participants during the 3-year program period compared with 30 percent for a matched comparison group.This saved the State Medicaid program an estimated $3.5 million.
The factors that made the program effective include understanding the needs of the residents and training workers who are representative of the community to follow-through on connections to health and social services.This ensures that recipients benefit and are satisfied with the quality of care. If the “community connectors” are properly trained and are passionate about the work, they will ultimately help a lot of people who are undeserved.
The program could be generalized to rural and urban areas where there are elderly populations with low incomes and unmet health care needs.Knowing the community and providing training and oversight are important considerations.
About the Authors:
Brenda Leath, MHSA, PMP is a Senior Study Director at Westat. She is also the Co-Executive Director of the Center for Pathways Community Care Coordination. Ms. Leath's career spans 25 years in health services administration and research, including a focus on vulnerable populations, health disparities, and knowledge transfer and dissemination.
Christine Lehmann, MA is a research analyst and science writer at Westat. Her career as a health care writer and journalist has spanned 15 years with a focus on public health, health disparities, policy, and mental health.
Brenda Leath and Christine Lehmann are aware of the Innovations Exchange requirement to disclose any financial interests, or business or professional affiliations, relevant to the work described in this commentary. They reported no disclosures.