Los Angeles Department of Health Services’ Care Connections Program

California

The Los Angeles Department of Health Services’ Care Connections Program cares for high-risk, high-cost patients by integrating Community Health Workers (CHWs) into a Patient Centered Medical Home model. Ultimately, the primary care physician, nurse case manager and CHW share responsibility for a patient - CHWs come from the communities they serve and support physicians and nurse case managers by extending the team's reach into the community. The project was a demonstration from March 2015 - March 2017, before expanding and replicating in mid-2017.

Partner Organizations

• LAC+USC Medical Center
• Martin Luther King, Jr. Outpatient Center
• Edward R. Roybal, El Monte, and Hubert H. Humphrey Comprehensive Health Centers
• Anansi Health
• LA County Health Services

Target Population

Patients with: complex biopsychosocial needs, high utilization of healthcare, high cost of healthcare or those who are difficult to engage

Care Team

Physician, nurse, case manager, community health worker

Timeframe

2015 - present (demonstration phase ended in March 2017)

Results/ Studies

N/A

Funding

Private grants

Resources

Program website

LA County Department of Health Services webinar slide deck (2015)