key: cord-0898241-cfv96dgt
authors: Salvatore, Alicia L.; Ortiz, Jacqueline; Booker, Erin; Katurakes, Nora; Moore, Christopher C.; Johnson, Carla P. Aponte; Mapp, Alexandra M.; Waad, Alex; Axe, Michelle L.
title: Engaging Community Health Workers and Social Care Staff as Social First Responders during the COVID-19 Crisis
date: 2020-07-01
journal: Dela J Public Health
DOI: 10.32481/djph.2020.07.022
sha: 0624b8fcf23813a754e1ff6995b20d2a2c33c29c
doc_id: 898241
cord_uid: cfv96dgt

In this public health practice vignette, we describe an ongoing community and system intervention to identify and address social determinants of health and related needs experienced by ChristianaCare patients and the greater community during the Coronavirus pandemic. This intervention, being conducted by the ChristianaCare Office of Health Equity, in partnership with ChristianaCare’s embedded research institute, the Value Institute, and the Community Outreach and Education division of the Helen F. Graham Cancer Center and Research Institute, engages more than 25 community health workers, health Guides, Latinx health promoters and other social care staff as social first responders during the COVID-19 crisis. These experienced front-line social care staff screen patients and community members for social needs; make referrals to agencies and organizations for needed assistance (e.g., food, housing, financial assistance); assess people’s understanding of COVID-19 and preventive measures; provide education about COVID-19; and, connect patients and community members to COVID-19 testing and any relevant clinical services. While this ongoing intervention is under evaluation, we share here some preliminary lessons-learned and discuss the critical role that social first responders can play in reducing the growing adverse social and health impacts of COVID-19 across the state of Delaware.

The social and health impacts of COVID-19 have been unprecedented and continue to unfold. This pandemic has increased stress and social adversity across all communities. However, where the impact is felt greatest is amongst underserved and vulnerable populations. 1 Prior to the COVID-19 crisis, these communities faced a myriad of challenges in meeting basic needs, accessing health services, obtaining reliable and understandable, culturally and linguistically appropriate health information from trusted individuals and sources, as well as safeguarding the health and well-being of their families. As has been noted by many, the COVID-19 crisis has elucidated, underscored and exacerbated existing societal inequities and vulnerabilities here in Delaware, as well as nationwide and globally. 2 To support our patients and community members during the COVID-19 crisis, ChristianaCare's Office of Healthy Equity, in partnership with the Value Institute and The Helen F. Graham Cancer Center and Research Institute at ChristianaCare developed and initiated a responsive intervention to address COVID-19 related social and health care needs as well as access to COVID-19 information, testing and resources. This intervention, which was implemented in March 2020 and is currently ongoing, engages over 25 of ChristianaCare's front-line social care staff, including community health workers (CHWs), health guides, health promotors (promotoras) and others. These staff act as social first responders both for the ChristianaCare patients already enrolled in these programs as well as for community members identified through community outreach and community-based COVID-19 testing conducted by ChristianaCare.

In this public health practice vignette, we describe our ongoing intervention and the ChristianaCare social first responder teams, and share some early findings and lessons learned from this work. We conclude with observations about the public health significance of this work and the importance of social first responders for mitigating, and addressing, the disparate social and health impacts the COVID-19 crisis in Delaware.

The overall goal of this social care intervention is to contribute to the reduction of inequitable impacts of the COVID-19 crisis on our patients and communities. To these ends we are engaging ChristianaCare social care teams in identifying and meeting social, informational and health care needs brought about by the COVID-19 crisis. The objectives of this intervention are to: 1) Identify social needs of enrolled patients and community members with social determinants of health (SDoH) screening;

2) Refer enrolled patients and community members to resources to address identified SDoH needs via the UniteDE platform 3 and other programs;

3) Assess levels of understanding of COVID-19 and recommended strategies for staying safe; 4) Provide instructional materials and guidance to families about COVID-19 and recommended strategies; 5) Identify patients and community members who may need to be referred to available resources for health care consults, testing, and additional services.

Several existing ChristianaCare social care programs are engaged in this intervention. These social care staff, which include Community Health Workers, Health Guides, health promoters (promotoras), are well positioned to participate in this intervention as its activities are an extension of and/or well-aligned with their standard workflow and program of work.

ChristianaCare has seventeen CHWs, or "natural helpers" who work closely with patients and care teams in Primary Care, Women's Health, CareVio Community (a network of care coordination support services) and in school-based health centers. While the work that CHWs do with patients in each of these settings differs somewhat, key areas of CHW support include assessment of SDoH and referrals to necessary resources and services; support of patient-centered goal setting and achievement; and connection to care teams and services to meet additional medical and non-medical needs. CHWs provide ongoing support for enrolled patients who may work with them for a period of a couple months up to nine months, depending on the care program.

Health Guides. ChristianaCare's four health guides function as collaborative members of ChristianaCare primary care practices and primarily support uninsured, underinsured and vulnerable patients, including undocumented patients. They provide immediate supportive services related to referrals or assistance with health insurance, financial assistance, prescription assistance, medical and wellness appointments, and community resources. They also coordinate with CHWs, clinicians, and social workers to ensure delivery of care and that health and identified SDoH related needs are met.

Latinx families. Three health promoters (promotoras) work with enrolled families to improve knowledge of healthy behaviors, screen for social and health needs and make connections to appropriate services and programs. The promotoras working with this program are bicultural and bilingual in Spanish and English.

This intervention was initiated in March 2020, just after the COVID-19 crisis commenced and is ongoing. While the majority of people supported by this intervention reside primarily in New Castle and Kent Counties, some reside elsewhere in Delaware, northwestern Maryland, southeastern Pennsylvania and south western New Jersey. The population served includes both ChristianaCare patients and the wider community. Patients served include those already enrolled in our social care programs (e.g., patients enrolled in our Primary Care or Women's Health CHW programs) and also patients newly referred to our teams. Starting in March, social first responders contacted their enrolled patients to assess emerging and changing needs and to provide them with education and materials about COVID-19.

The intervention also serves community members. We employ two main outreach strategies to identify and recruit community members who may benefit from our intervention: 1) screening for SDoH during registration at ChristianaCare COVID-19 testing events and 2) establishing and advertising a bilingual hotline number for COVID-related assistance.

During the registration process at ChristianaCare COVID-19 testing events, people are screened for SDoHrelated needs using the following single-item yes or no question: Those indicating "yes" to the social need question are asked if they would like someone from ChristianaCare to assist them with their needs. Those who do are contacted to coordinate a follow-up from a CHW.

Bilingual Assistance Hotline. During the first month of the crisis, the Office of Health Equity established a bilingual hotline for people to call for information and support. A flyer promoting this hotline (see Figure 1 ) was created and is circulated at food distribution events and via social media and community partners. People who call the hotline are screened for needs and then routed to either a social first responder or to appropriate testing or health care resources. 

Once connected with a patient or community member, our social first responder teams use an 11item social determinant of health screener to assess individual and family needs. The screener includes questions about financial insecurity, food insecurity, interpersonal safety, difficulties with transportation, and other related issues. Time permitting, they also asked follow-up questions that assessed whether the stated needs started or were made worse since the COVID-19 crisis. Depending on their program, social first responders enter this information into either a REDCap database and/or directly into the SDoH screening form in UniteDE. 2 UniteDE is a coordinated care network of health and social care providers, sponsored by ChristianaCare, that are connected through a shared technology platform that enables them to send and receive electronic referrals. In the UniteDE platform, each SDoH need entered is met with an additional form that refers the person to one or more suggested resources. For example, if a person screens positive for food insecurity, a form to refer him or her to the food bank, a food pantry or other food assistance resource is provided. UniteDE uses the person's address to provide the most locally-relevant resources. Social first responders select the appropriate resource that is then, upon receipt, accepted or returned by the selected agency or organization. Based on the decision made, social first responders either make an additional referral or the agency or organization (who has accepted the referral) directly follows up with the individual. To date, over 50 community-based organizations and programs throughout the state participate in the UniteDE platform and additional organizations are being recruited to join the UniteDE network and platform.

All patients and community members served by our social first responders also are asked additional questions that assess their level of understanding of COVID-19 modes of transmission, preventive behaviors and similar topics. Each person is provided with "real time" educational and educational materials, in English and Spanish, to use themselves and/or share with others (see Figure 2 for one example).

The evaluation of this intervention is ongoing. We have, however, several notable key lessons to share:

Our experiences to date indicate immediate and extensive needs both among our patient population and the community members we have served. For example, 19% of the 300 people tested at one of our early testing events in Wilmington screened for a social need and requested assistance from our program. Stories shared by our social first responder teams indicate not only extensive and increasing social needs but also reveal a great need for supportive and emotional care. In debriefs with our intervention teams, they have shared that calls can often last more than 45 minutes as people want and need to talk not only about the things we ask about but about their experiences, feelings and fears about the COVID-19 pandemic. Additional programs and interventions are needed to meet the growing social and behavioral needs and provide culturally and linguistically appropriate care in these areas, especially to communities with limited health care access.

While the use of our SDoH tool has proven challenging at times for social care teams balancing high volumes of calls and urgent needs, we have found this tool to be useful in systematically capturing and helping us to target referrals that meet people's needs. These questions are assisting us to document not only the spectrum of issues that have been impacted but also the increases in these needs that have occurred during even during the initial months of the COVID-19 crisis. For example, in just a two month period, the SDoH data from only one of our social first responder teams reveal great need associated with the COVID-19 crisis. Sixty-three percent of those seen reported that they were worried about or unable to pay their bills prior to COVID-19; 84% of whom stated these needs started or were made worse during the crisis. Similarly, 63% also reported that they worried about their food running out prior to COVID-19; 77% of whom indicated that this need started or was made worse since the crisis began. More than half (55%) indicated that the food that they bought didn't last and they couldn't buy more; 88% of whom indicated this started or was made worse by the crisis. Almost 20% of those screened indicated that they had an urgent need. Nonetheless, more brief ways of assessing SDoH and other needs may allow intervention teams to better balance the needs of documentation and serving more patients and community members. We are currently in discussions about how we may adapt our questions to these ends. 

To our knowledge, this intervention has not had any adverse or unintended consequences. However, despite best efforts of our teams, this intervention alone is not enough to satisfy the enormous needs of many of our patients and community members. In order to meet the growing needs of patients and community members, in an equitable manner, additional investment in social first responders, in communities across the state are needed. Additionally, policies and programs to address the underlying issues of inequity that render some communities more vulnerable not only to COVID-19 but also to its ongoing adverse social and health sequelae will be critical for promoting and safeguarding public health.

The costs of this intervention continue to be supported by ChristianaCare. Additional support mechanisms and resources are needed beyond these to further scale-up, support and maximize the positive public health impact statewide. CHWs and social care workers from other health systems as well as lay health workers and natural helpers serving in community-based organizations and in communities at large will be critical to building a broader social first responder workforce across the state and to meeting current and longer-term social care and health needs.

In this public health practice vignette, we have described a responsive intervention raised up by ChristianaCare in order to meet patient and community needs and mitigate potentially ongoing and inequitable impacts on individuals, families and communities. While this intervention and the use of social first responder teams have likely helped to meet some social, informational, and health needs of our patients and communities, in many ways, our lessons learned, and the stories shared by these teams point to an enormity of need beyond what our teams can support. While these teams have worked tirelessly -supporting needs and providing listening ears -to our patients and community members, they are not enough. Our experiences, as well as a robust public health literature demonstrate that natural helpers such as CHWs acting as social first responder teams are critical to the reduction of health disparities and meeting emergent community needs during pandemics. We encourage public health and health leadership, insurers, philanthropists and policy makers to support the expansion of social first responder teams across the state. 4 ChristinaCare's Office of Health Equity has already started to expand UniteDE, a critical platform for making and tracking "real time" referrals to SDoH and other related services, throughout the state. This tool, as well as the experiences and lessons learned from this intervention and other similar programs, may be critical elements of a successful statewide social first responder initiative.

Although social first responder interventions are valuable, they are only one of many required elements of a robust and equitable response to the COVID-19 crisis. Programs and policies that address and reverse the adverse sequelae of the COVID-19 crisis across the spectrum of SDoHhousing, jobs, food insecurity, to name a few -as well as address the root causes of the inequity that render some communities more vulnerable in the first place are fundamental to safeguarding and promoting public health and healthcare equity for all of Delaware.

COVID-19 and racial/ethnic disparities

The COVID-19 pandemic: A call to action to identify and address racial and ethnic disparities

To strengthen the public health response to COVID-19, we need Community Health Workers

Delaware Academy of Medicine / Delaware Public Health Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License