Transform - fchip

Transforming Care with Community Connection

IMPACT SUMMARY
SEPT 2022 – AUG 2023

Since 2017, we've been dedicated to improving community health through collaborative efforts with local Community Health Workers. Our approach prioritizes culturally-affirming care, fostering trust and delivering sustainable solutions to historically underserved neighborhoods. Join us as we reflect on our progress and celebrate the positive impact made possible by our shared commitment.

In Pursuit of Lasting Care

Our approach centers around a network that prioritizes supportive relationships between the Community Health Workers (CHWs) and the communities they serve to effectively mitigate health disparities.

By diminishing linguistic and cultural barriers through community connection, we establish trust for sustainable, real and lasting solutions. During the reporting period, Fresno HOPE convened seven Care Coordination Agencies with 35 CHWs to serve the community of Fresno County.

Note: the data used in this report was obtained thought a HIPAA compliant electronic health record system which collects health information. The demographic data presented includes those who consent to participate in the data collection.

For Community, By Community

The first step to a successful outcome is to identify a primary Community Health Worker who can develop a supportive relationship with the Resident.

CASE STUDY

The case study is based on a combination of several cases to protect resident information and privacy.

Angela is a mother to four children ages nine months, four, ten, and thirteen years old. When her school-aged children were absent from school, the district connected the family with a Community Health Worker (CHW). The CHW, Andrew, informed the family about Fresno HOPE services and what resources can be provided for her and her family.

Prior to meeting, Angela disclosed that she is currently fleeing a domestic violence situation which led her to be unhoused. Angela’s family was immediately placed at a motel.

Angela began to share her story after she welcomed Andrew into their space.
Andrew assessed the surroundings and began to build rapport by sitting calmly across Angela and her children on the motel bed. Angela shared she needed assistance with housing, personal items, food, and immigration.

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THE IMPACT ON OUR COMMUNITY

64% of CHWs speak more than one language

51% of CHWs reside in the same zip code as the people they serve

BUILDING FOUNDATIONS

allocation of county funding toward care coordination agencies to support in workforce development and infrastructure building

16,500 minutes provided to agencies for Technical Assistance and Quality Improvement

34,400 minutes provided to CHWs for Workforce Development and Training

Reimagining Pathways to Whole Person & Household Health

Once a relationship between the Community Health Worker and Resident forms, successful outcomes are measured by the Evidence-based Pathways Community HUB
Institute™ (PCHI) Model, which helps identify risk factors and barriers that impede the resident’s ability to thrive through a whole person, whole household approach.

CASE STUDY

Andrew assessed Angela’s risks through trust-building and active listening. An initial Social Determinant of Health screening helps identify and assign five immediate Social Service Pathways for Angela’s family:

Personal items
Clothing, diapers, and hygiene items

Citizenship
Birth certificate requirements for Angela’s two eldest children

Financial
Money to support day-to-day living and child items during the holiday season

Housing
Permanent and stable housing is foundational for Angela and her family to thrive

Food Security
Accessed adequate food for the entire household

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COMMUNITY HEALTH WORKERS IN ACTION

91% Pathways completed successfully under the PCHI Model

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THE AVERAGE IMPACT OF ONE COMMUNITY HEALTH WORKER IN ONE YEAR

Individualized Care Plans for Individual Needs

After each assessment, an individualized Pathways-based care plan is developed to help prioritize residents’ unique needs in order to live a full life.

CASE STUDY

Together with their school district, community resources and other partners, Andrew was able to provide the family with the following:

Permanent housing

$600 dollars in gift cards

Hygiene items, clothing and diapers

Food

Culturally-affirming mental health services

Assistance with obtaining the birth certificates for two eldest children to continue path to citizenship

The top priority of the five categories of needs is meeting the basic needs of the family by providing direct financial assistance. From short- to long-term solutions, these pathways help create immediate and lasting solutions for Angela and her family.

DIFFERENT NEEDS FOR DIFFERENT DEMOGRAPHICS

9 out of 10 residents are people of color and half range from ages 26 to 55 years old

61% of all enrolled clients identified as female

Long-term Outcomes Completes a Pathway

As a care plan is completed over time and Pathways are closed, barriers can be identified in the community service structure both at the individual and population level. Pathways not completed are also documented. The community can use this information to assess gaps in services and address these issues on a policy level.

CASE STUDY

Andrew continues to assist the family with is long-term pathways such as Housing and Citizenship. He works consistently to get Angela and her children safe and stable affordable housing permanently. A local resource will support with a full year rent payment to allow Angela time to stabilize her family. Angela is connected resources for housing and down payment assistance to get her family their own place to call home and stabilize the children to increase their attendance in grade school.

BEHIND THE NUMBERS