Positioning Community Health and Social Workers to Address Older Adults’ Social Needs: Lessons from SCAN Health Plan

April 2022

Team-based care models that maximize the roles of social workers and community health workers (CHWs) can improve outcomes for older adults with complex needs. As health systems and health plans explore incorporating these positions into care teams, they need to identify how to best structure these positions and how to sustain these models for the long-term to address the deep complexity of patient needs.

SCAN Health Plan, based in California, developed Connecting Provider to Home (CP2H), a community-based intervention embedded in primary care practices and led by a social worker and a CHW, to address unmet social needs of older adults. The program connects patients to social services while supporting access to primary care. In a recently published pilot study that compared program enrollees to a comparison group, this program was associated with significant reductions in acute care use and improved patient satisfaction, quality of care, and communication with the care team.

This webinar illustrated implementation considerations of the CP2H program, with a focus on: (1) the benefits for health plans and for provider groups with full-risk or shared-risk arrangements in developing community-based models of care that leverage the strengths of social workers and CHWs; (2) design for the program including workflows, referrals, and team ratios; (3) training for the program team members of social workers and CHWs; and (4) ensuring culturally and linguistically appropriate care to address health disparities.



I. Welcome and Introduction

Speakers: Logan Kelly, MPH, Senior Program Officer, Center for Health Care Strategies (CHCS)

L. Kelly provided an overview of the Better Care Playbook.

II. Implementation Considerations for CP2H

Speakers: Rosaneli Loza, Geriatric Social Worker, and Eve Gelb, MPH, Senior Vice President of Health Care Services, SCAN Health Plan

R. Loza and E. Gelb described the rationale for SCAN Health Plan to develop the CP2H program, the program design, and the evidence on how the program impacts older adults with complex needs. They discussed implementation considerations and lessons for other stakeholders interested in using the strengths of CHWs and social workers to improve care for older adults with complex needs. They also shared lessons on the value proposition for this type of intervention within health plans and provider groups.

III. Moderated Q&A 

Moderator: Logan Kelly, CHCS


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