As part of our ROCKET T1D initiative (Remote Outreach & Care for Kids’ Empowerment and Technology use in T1D), we launched a CHW program to address social drivers of health (SDOH) in youth with T1D at high risk for DKA. Eligible patients are identified using the Risk Index for DKA (RI-DKA) and the CHW serves as an extension of the care team with a focus on 5 goals: improving communication, accessing healthy food, navigating barriers to diabetes technology, applying for public benefits, facilitating transition to adult care.
To enable focused CHW care, we leveraged EHR-based “Episodes of Care” as structure for setting goals, identifying needs/resources, and tracking outreach tasks. Episodes are groups of linked program encounters with the ability to demonstrate outcomes from enrollment to completion via discrete data fields. The SDOH tool allows the CHW to monitor progress over 5 domains (food insecurity, housing, transportation, education, financial resources). “Goal Setting” allows the CHW to set goals, track progress, and share this information with the patient. “Outreach Tasks” on the CHW dashboard are used to view upcoming outreach for active participants.
Our CHW program went live in fall 2023 and outcomes will be tracked on our enterprise data warehouse, which integrates clinical, operational, and financial megadata produced from multiple sources across our system.
M. Craven: None. K.D. Timmons: None. S.A. Dei-Tutu: None. R. Butler: None. A.L. Martinez: None. A. Jones: None. S. Lyons: None. R.Y. Sonabend: None. D. DeSalvo: Advisory Panel; Insulet Corporation. Consultant; Dexcom, Inc.
The Leona M. and Harry B. Helmsley Charitable Trust (2206-05307)
