Connecting Provider to Home: A Home-Based Social Intervention Program for Older Adults

Gerardo Moreno
Carol M. Mangione
Chi-Hong Tseng
Melanie Weir
Rosaneli Loza
Lisa Desai
Jonathan Grotts
Eve Gelb
Peer-Reviewed Article
March 2021


Home-based social program provided by a community health worker (CHW) and social worker reduces acute care use and improves care for older adults with complex health and social needs.


Many older adults with complex medical needs also have unmet social needs, which can lead to poorer quality of care. Interventions that engage CHWs and social workers have demonstrated positive outcomes in addressing health-related social needs and improving clinical outcomes for patients in home- and community-based settings. This study evaluates Connecting Provider to Home, a home-based pilot program led by SCAN Health Plan, a Medicare Advantage plan in California. This program, which is for older adults with multiple chronic conditions and complex social needs, deploys a social worker and community health worker to connect patients to social services and support access to primary care.

Program Implementation Highlights

Structure: Teams, based within medical group offices, have one case manager/social worker and one CHW with a caseload of 50-60 members per team.

Training: Social worker and CHW participate in a three-month training administered by SCAN Health Plan that focuses on available community resources (see slide 18 for details).

Infrastructure: Assessments include PHQ-9, SLUMS, Assess for Suicide Risk, Home Safety, Medical History, Medication Review, and SDOH Needs; tools include UpToDate and Find Help community referral platform.

Funding: The initial pilot was funded through SCAN Health Plan; funding has since diversified to include additional at-risk provider, foundation, government, and community-based organization funders.


Enrollees in the program experienced significantly reduced emergency department visits and hospitalizations 12 months post-enrollment compared to 12 months before enrollment, when compared with a matched comparison group. Patients also reported improved satisfaction, quality of care, and communication from the CHW-social worker care team.


Interventions that integrate social workers and CHWs into the care team can potentially lead to improved patient outcomes for adults with complex health and social needs. Through this type of intervention, health plans as well as provider partners with shared or full risk may experience cost savings through resulting reduced acute care utilization.

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