Transitioning Patients from the Emergency Department to Primary Care Utilizing Community Health Workers

The National Health Care for the Homeless (HCH) Council received a CMMI Health Care Innovation Award in June 2012. The project seeks to address the over-reliance of persons experiencing homelessness on emergency department services. Such over-reliance has resulted in inflated Medicare, Medicaid, and uncompensated care costs while failing to link underserved patients with primary care services.

To refer these populations to appropriate primary care settings, this project employees Community Health Workers (CHWs) to target patients experiencing homelessness who frequently utilize emergency departments and other hospital settings for primary care services, regardless of insurance status. This project seeks to accomplish the triple aim of CMS through CHW interventions to transition care of homeless persons from inappropriate hospital utilization to HCH primary care sites funded by the Health Resources and Services Administration (HRSA). The National HCH Council has partnered with 12 HCH sites to accomplish this goal.

The project period ends June 2015, at which point data will be available regarding intervention impact on the health and quality of life of enrolled patients, as well as change in emergency department utilization.

Participating Sites

  • Boston Health Care for the Homeless Program | Boston, MA
  • Care Alliance Health Center | Cleveland, OH
  • Catholic Medical Center – HCH Program | Manchester, NH
  • Charles Drew Health Center | Omaha, NE
  • Duffy Health Center | Hyannis, MA
  • Harbor Homes, Inc. | Nashua, NH
  • Health Care for the Homeless – Houston | Houston, TX
  • Heartland Health Alliance | Chicago, IL
  • John Wesley Community Health (JWCH) Institute | Los Angeles, CA
  • Lincoln Community Health Center | Durham, NC
  • Northeast Valley Health Care | San Fernando, CA
  • Santa Clara Valley Health | San Jose, CA
Community Health Workers and National HCH Council staff involved in the CMMI project at a training in Nashville, TN (2012).

Community Health Workers and National HCH Council staff involved in the CMMI project at a training in Nashville, TN (2012).