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Featuring Hilltown Community Health Center

This is one in a series of stories about strategies primary care practices are using to increase patient engagement. MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care, as we have recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts with the support of CRICO.

One of the most effective methods for primary care practices to engage its patients is through direct patient outreach by Community Health Workers.

“If the mountain will not come to Muhammad, then Muhammad must go to the mountain,” so the saying goes. In healthcare, this is perhaps most true with chronically ill patients, especially in under-served populations and in rural settings. Many practices have discovered the best way to engage patients and motivate them to be active in their own care is through dedicated resources engaging with patients in the community. These are workers whose job description is “whatever it takes.”

One exemplar of this strategy is Hilltown Community Health Center, a network of community health centers in rural Western Massachusetts. We spoke with Eliza Lake, Hilltown’s CEO, and Kim Savery, the practice’s Community Programs Director, about their efforts in this area. 

Eliza Lake:

Q: Can you tell us about the role of patient engagement in your health center?

The community health centers in general use a model that is all about patient engagement. FQHCs are required by federal regulation to be patient-focused. In fact, our boards are required to be comprised of 51% patients. We are private non-profits, and our mission is to serve everyone regardless of ability to pay, with a particular focus on unmet needs in the community and low-income populations, populations of different ethnic groups who, for one reason or another, do not have reliable access to care. So that means that we already will do relatively well on patient engagement issues.

As a community health center, we are able to spend more time with individual patients talking about their specific situation, potentially beyond the clinical issue that is the reason for the visit. Since we are a small community and a small health center, we have strong connections to the patients and focus on the patient’s whole health. To do so, you have to engage with the patient and know what else is going on in their lives – transportation issues, domestic violence, all of the family navigation, etc. Our Community Programs can address all of those issues here; our providers know we have those resources in-house, and they know the questions to ask.

Q: Can you tell us about the nuts and bolts of how the community health workers engage with patients?

We’ve had community health workers (CHWs) for many years, funded by various grants. One of the challenges has been that they are all grant-funded and there’s currently no direct reimbursement in the health care system for that role. Sometimes the CHWs are focused on specific populations, such as elders or people with diabetes, but in general, our CHWs are available for providers to turn to when they see that somebody needs more support in achieving or maintaining their health goals, or coping with a chronic condition.

We’ve had incredible success with diabetes prevention programs in the community, in which patients get together and talk about disease self-management. The groups have been successful while they’re meeting, and then patients have created their own list-serves, keeping in touch with each other, continuing to meet after the classes. We also received a grant focused on mammogram outreach, which was extremely successful, supporting hundreds of women who needed to be screened. The CHWs reached out to women at risk individually and with community events, and were able to offer them support in the form of gas cards or caregiving respite while they went to their mammogram.  We also had staff dedicated to contacting hospitals to learn who had gotten a mammogram and who hadn’t.

Q: How have the CHWs been received by the other providers?

The CHWs have been very well received by all of our providers. Everybody appreciates having them here and understands the work that they do and how crucial it is to ensure the patients are engaged between visits. That’s the big thing – when a patient leaves an appointment, the providers don’t necessarily know what they will do to support their health until the next appointment. With CHWs, there can be continued contact with and support of patients outside the clinical encounter. 

Kim Savery:

Q: What’s unique about your community outreach program?

"Hilltown is a very rural health center. We cover thirteen towns. We serviced people from, I think, 121 zip codes last year in one way or another. We have social service workers here on site that help people access food stamps, fuel assistance, employment training, that kind of thing. We have two Domestic Violence Advocates on staff, we have two Health Access Navigators, three Community Health Workers, (including a CHW who specializes in doing Outreach and Engagement work for a consortium of Councils on Aging,) and two Family Support workers. They’re all health center employees. We also have a family center on site and offer groups for families with young children here and at other sites across the hilltowns.

It’s a very isolated area with a high incidence of domestic violence. There is no public transportation and resources are virtually non-existent. So, there are all sorts of barriers, left and right. We started our community health worker program about 10 years ago. The family center has been here a little bit longer and social services about the same time. We went from those basic services to community health workers and we started working at the time helping people with self-management of chronic disease and we’ve just kept expanding those programs to help meet patients’ needs. And I think we’re a little bit ahead of the curve. It’s sexy now to look at social determinants of health, but I don’t think it was 10 years ago. For us, it was a necessary step in looking at the health of our patients and our community.

This is a large geographic area, but in terms of community and number of people, it’s small. People know our programs now, they have the expectation that, if they are in need, we will do our best to find a way to help them. Whether it is a social or concrete need, or even if they need help understanding or navigating medical or other issues, we are here. We are also out in the community, listening and talking with people. Patients know that they can stop by our offices at any time. For example, the day before Christmas is always a big day here. People run out of fuel or what-not. We have that ability right here on site to help them with these kinds of things.

How would you get them fuel the day before Christmas?

We have a Salvation Army Service unit that is comprised of three staff members on site. We have the ability to make decisions to write checks without tracking down some distant unit. We also have connections with the local community to provide fuel, a local guy who has an oil company right in Chester. And he will gladly, if we guarantee it, he will get them 50 gallons of fuel – he’ll be there that day.

Is there anything that’s off limits? Any needs where you won’t or can’t respond?

The hardest thing for us, well, there’s so much that’s hard, but housing and transportation are huge here and there’s not much we can do about that. To be perfectly honest with you, our CHWs and everybody else who works here are driving patients to medical appointments or appointments at DTA or Social Security. Housing stock is limited here, and for the economically disadvantaged, it is incredibly difficult to find local housing. Homelessness also looks a little different here. In the summer, people camp out. At this time of year, they are “couch surfing.” We find a way to help people in some way or another in most situations. It’s not ever ideal, but we figure out how to mitigate the barriers to health.

How many CHWs do you have on staff?

Right now, we have three amazing CHWs on staff. All have at least a Master’s level education (one has a PhD) and are highly skilled at what they do. But, it’s not enough. The providers will say the ideal model would be for every provider to have one on their care team, but that’s not going to happen in the current climate. We have had up to six at one time and that seemed to work pretty well. But, the numbers fluctuate with the funding. It still would have been nice to have more. Years ago, when we’re writing proposals and looking for funding for them, people were just starting to look at quality measures and we had trouble justifying the impact. Now it’s out there. People recognize these interventions do work and we can now measure it in ways that clearly show the impact on outcomes and dollars. 

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