To effectively reach individuals with complex medical and social needs, health care delivery systems are increasingly incorporating alternative roles into care teams, including community health workers, volunteers, neighborhood navigators, community paramedics, or pharmacists. This three-part webinar series from the Center for Health Care Strategies (CHCS) is exploring emerging innovations in the complex care workforce. This first webinar highlighted strategies for integrating community health workers and volunteers into care teams that serve high-need, high-cost individuals in both rural and urban environments.

  • Mountain-Pacific Quality Health discussed its innovative ReSource Teams serving rural Montana communities as well as its robust volunteer network that helps connect beneficiaries with complex needs to health and social services.
  • Johns Hopkins Community Health Partnership provided an urban perspective, describing its successful approach to connecting East Baltimore residents to health and social services through community-based partnerships, neighborhood navigators, and community health workers.

The webinar series is a product of the Complex Care Innovation Lab and Transforming Complex Care, two national initiatives focused on advancing and spreading innovations in complex care. Future webinars will focus on integrating community paramedicine and community pharmacy resources into complex care.


I. Introduction

Speaker: Caitlin Thomas-Henkel, Senior Program Officer, CHCS

II. Cultivating a Resource Network for Complex Beneficiaries in a Rural Setting

Speakers: Lara Shadwick, Program Director, Mountain-Pacific Quality Health and Jane Emmert, Director, ASSIST

Ms. Shadwick discussed Mountain-Pacific Quality Health’s efforts to reach complex patients in rural communities, including the use of ReSource teams, tablet technology and case conferencing as well as partnerships with volunteers to connect Montanans to community resources and social services. Ms. Emmert discussed the work of ASSIST, a nonprofit organization that established a volunteer network to support physically and socially isolated Flathead Valley residents.

III. Leveraging Community Partnerships to Connect East Baltimore Residents to Health and Social Services

Speakers: Linda Dunbar, Vice President, Population Health & Care Management, Johns Hopkins HealthCare; Reverend Debra Hickman, Co-Founder/CEO, Sisters Together And Reaching, Inc. (STAR); Demetrius Frazier, Program Manager, STAR; and Will Torriente, CHW Supervisor, STAR

Ms. Dunbar discussed John Hopkins Community Health Partnership and their relationship with two community-based organizations to help East Baltimore residents lead healthier lives. Reverend Hickman, Mr. Frazier, and Mr. Torriente discussed their work at STAR.

IV. Q&A with Panelists

 Moderator: Rachel Davis, Associate Director, Program Innovation, CHCS