Promising Practices: Community Health

Methodology: This practice enables health organizations to use an operational framework to successfully integrate Community Health Workers (CHWs) into HIV care teams, leading to measurable improvements in patient access, adherence to Antiretroviral Therapy (ART), and viral suppression rates.

To replicate this practice, an organization should follow these steps:
1. Establish the CHW Program Structure. Implement an Operational Framework that provides step-by-step guidance covering CHW recruitment, standardized training, and ongoing supervision. Address barriers to integration, such as unclear CHW roles or lack of standardized training.
2. Identify Priority Patients. Identify clients for intensive CHW intervention by reviewing program rosters, surveillance data (to obtain lists of clients who have had a viral load test in the past six months), and clinic testing data (to find newly diagnosed individuals who have never linked to care). Priority patients should include those who are not virally suppressed, have a new HIV diagnosis, have a history of missing or late appointments, or have unstable housing.
3. Conduct Regular Patient Encounters. Implement weekly client check-ins to measure progress, check medication compliance, and provide appointment reminders. Document each patient encounter as a separate note on the Electronic Health Record (EHR) to ensure better collaboration with the rest of the care team.
4. Provide Targeted Education and Counseling. Conduct regular education sessions with patients on subjects like HIV transmission, ARV medication basics, chronic disease-HIV connections, patient safety, and wellness.
5. Coordinate Services and Partnerships. Assist patients by helping them adhere to ARV treatment, explaining health benefits, and coordinating referrals for social or behavioral needs. Strengthen partnerships with HUD and local agencies to improve patient safety and coordinate services.

Methodology: This practice implements the comprehensive Mental Health First Aid training for CHWs, positioning them as trusted community members uniquely able to provide immediate and meaningful support by identifying distress signals and intervening before a mental health crisis escalates, particularly among populations at greater risk for issues.

To replicate this practice, organizations must provide the specialized MHFA training to their CHWs to ensure they can execute real-time responses and reinforce support networks:
1. Provide Comprehensive Training: Offer CHWs comprehensive Mental Health First Aid training (either Youth or Adult MHFA) led by a certified instructor.
2. Recognize and Identify Crisis Signs: Ensure CHWs are equipped to identify warning signs of mental health distress, which might otherwise go unnoticed, to intervene quickly. Common indicators include difficulty with daily tasks, extreme mood swings, withdrawal, or increased aggression.
3. Provide Immediate Support and Reassurance: Empower CHWs to act quickly to offer comfort and initial support to individuals experiencing crisis or non-crisis situations.
4. Connect Individuals to Resources: CHWs must connect those in need to professional care and accessible resources, such as referring them to trained counselors via the 988 Suicide & Crisis Lifeline.
5. Apply Real-Time Skills: CHWs utilize hands-on skills learned through training to respond effectively, strengthening the individual’s support network and reducing the risk of severe mental health outcomes.

Methodology: This practice implements a comprehensive, four-phase strategy to ensure health centers are prepared to address the heightened incidence and impact of intimate partner violence, human trafficking, and exploitation that occurs during public health emergencies and natural disasters. This involves adopting standardized interventions like CUES, formalizing community partnerships, and leveraging data systems for proactive patient care.

To replicate this practice, health centers should integrate specific actions across all phases of disaster management:

1. Mitigation (Pre-Crisis Actions):
◦ Formalize Partnerships: Establish formal partnerships with community-based domestic and sexual violence (D/SV) programs, anti-trafficking programs, and legal services.
◦ Standardize Assessment: Integrate healing-centered non-clinical factors of health assessments (like PRAPARE) into routine care to better understand patient needs and risks.
◦ Staff Education: Adopt the CUES Intervention and educate all staff on the dynamics of IPV and lessons learned from past disasters.

2. Preparedness (Pre-Crisis Planning):
◦ Establish MOUs: Establish Memoranda of Understanding (MOUs) with community organizations specializing in IPV and HT to ensure seamless referrals during a crisis.
◦ Invest in Training: Invest in comprehensive staff training focused on empathic listening, healing-centered care, and emergency response protocols.
◦ Adapt Protocols: Adapt identification and response protocols to ensure all patients receive education about available resources during emergencies.

3. Response (Crisis Implementation):
◦ Leverage EHRs: Utilize EHR systems to identify patients with a history of IPV, HT/E to proactively check on their well-being and provide timely support.
◦ Use Assessments: Utilize PRAPARE assessments to quickly identify specific patient needs and guide response efforts.
◦ Maintain Communication: Develop and implement a communication plan that keeps patients informed during an emergency, including specific details on IPV and exploitation resources.

4. Recovery (Post-Crisis Restoration):
◦ Provide Universal Education: Continue providing universal education about legal, social, and safety resources through the evidence-based CUES intervention, collaborating with community partners.
◦ Evaluate and Debrief: Evaluate the response post-emergency and debrief with staff and CBO partners to assess effectiveness and improve future preparedness plans.

Methodology: This practice utilizes a multi-step implementation framework derived from the COMMIT group (Child Obesity Management Models in Teams) to establish an Intensive Health Behavior Lifestyle Treatment (IHBLT) program for children with obesity within a primary care setting, focusing on long-term wellness rather than solely weight loss.

To replicate this practice, a health center should follow these steps:

1. Assess Capacity and Partnerships (Step 1)
◦ Identify and recruit motivated staff for the FHWP team, including Nutrition Leaders and Exercise Leaders, along with billable providers (medical providers, Registered Dietitians, or behavioral health providers).
◦ Designate a Project Champion to advocate for the program and a Project Manager/Coordinator to handle logistics, training, and follow-up.
◦ Establish partnerships with Community-Based Organizations (CBOs), such as YMCAs, churches, or recreation centers, to potentially share space, equipment, or staff assistance.

2. Select Curriculum and Determine Billing (Steps 2 & 3)
◦ Select an evidence-based FHWP/IHBLT curriculum (like MEND, chosen by the COMMIT group) that meets the American Academy of Pediatrics' recommendation of at least 26 contact hours.
◦ Adapt the curriculum to ensure cultural competency, including utilizing familiar language, relevant food examples, and actively avoiding language that promotes weight stigma.
◦ Research reimbursement opportunities and involve billing and coding experts early to build billable services (such as group visits or individual assessments by RDs or providers) into the FHWP for sustainability.

3. Configure Logistics and Workflow (Steps 4 & 5)
◦ Plan space by reserving safe locations, which may include dedicated group rooms, staff lounges, waiting rooms (after hours), or shared CBO space.
◦ Work with the IT team to establish a data infrastructure to capture necessary measures in the Electronic Medical Record (EMR) and create standardized documentation templates.
◦ Create a consistent workflow for each session, including pre-launch checklists, supply gathering, team huddles before class, and brief team debriefs afterward for continuous Quality Improvement.

4. Recruit Participants and Ensure Retention (Step 6)
◦ Recruit families with children diagnosed with obesity, overweight conditions, or Type 2 Diabetes.
◦ Employ varied recruitment methods, such as EMR referrals, word-of-mouth promotion by providers, social media advertising, and sending personalized letters.
◦ Focus on FUN, flexibility, and support to aid retention, including offering reminders (calls/texts), providing incentives (gift cards, cooking supplies), and being accommodating regarding missed classes.

5. Evaluate and Reflect (Step 7)
◦ Define success with patients and families, focusing on long-term benefits such as improved confidence, physical fitness (e.g., exercise recovery heart rate metrics), and mental health, rather than just weight loss.
◦ Track key clinical metrics, including changes in BMI z-scores, blood pressure, A1C, and lipids.
◦ Conduct regular team reflection, including short debriefs after each class, to review fidelity, discuss challenging dynamics, and identify Quality Improvement (QI) opportunities.

Methodology: This practice provides enrollment specialists with five defined actions to overcome barriers that prevent domestic violence (DV) survivors from obtaining critical health insurance and healthcare access. The strategy emphasizes staff education, client awareness, and formalizing partnerships with local DV programs.

To replicate this practice, health centers should focus on training and implementing the following five core actions within their enrollment and outreach teams:
1. Know Special Enrollment Periods (SEPs): Ensure enrollment specialists know that survivors of DV and their dependents may purchase health insurance at any time during the year by requesting a Special Enrollment Period (SEP) through the Call Center.
2. Understand Financial Supports: Train staff to help legally married survivors who do not live with their spouse and file taxes separately to qualify for financial help based solely on their own income, making health insurance more affordable.
3. Build Local DV Partnerships: Direct enrollment specialists to build formal bridges with local DV programs (via state, territory, or tribal coalitions) to collaborate on increasing health insurance enrollment, providing staff medical coverage, or offering supportive services onsite for clients.
4. Increase Survivor Awareness: Ensure staff proactively educate clients about their eligibility for the SEP and related financial provisions using an adaptable script, such as informing clients they may be eligible for coverage at any time and financial support not tied to an abuser.
5. Increase Team Knowledge: Work as a team (including clinic staff and enrollment specialists) to support survivors and their dependents in getting enrolled, regardless of whether they are staff or patients, recognizing that all survivors may need help with coverage for long-term health consequences of abuse.

Methodology: This practice implements a comprehensive, person-centered model, based in a safety net community health center, to establish continuity of care and housing stability for formerly incarcerated individuals, particularly those with HIV, given that linkage to housing is vital for viral load suppression and decreased recidivism.

To replicate this practice, health centers should implement integrated care planning and utilize peer staff across the pre- and post-release phases:

1. Start Discharge Planning Early: Begin programming and comprehensive discharge planning 60 to 90 days before an individual’s release from incarceration.
◦ Use this time to secure necessary paperwork, including medical records and documentation required to continue medications.
◦ Conduct pre-release sessions focused on linkage to community-based care and individualized goal setting.

2. Prioritize Medicaid and Benefits Enrollment: Enroll individuals in Medicaid as early as possible, ideally pre-release, when operating in states that have received a Centers for Medicare & Medicaid Services (CMS) Reentry Waiver.
◦ Ensure the released person receives support to reinstate their suspended Medicaid coverage upon release to ease the burden and promote continuity of care.
◦ Enroll eligible individuals in specialized programs like the Housing Opportunities for Persons With AIDS (HOPWA) and the Ryan White HIV/AIDS Program (RWHAP) to secure supportive housing and services.

3. Integrate Peers and Navigation Services: Incorporate peers who have lived experience of incarceration as Community Health Workers (CHWs) and members of the integrated medical team.
◦ Provide navigation and accompaniment services (in addition to case management) to support participants in attending their appointments and engaging with community-based care.

4. Ensure Immediate Post-Release Linkage: Schedule the first outpatient appointment with a community-based medical provider shortly after release (e.g., within 48 hours, as seen in Project Start PLUS).
◦ Provide essential medical services, including comprehensive physical and medical history assessments, baseline lab testing (CD4 count and viral load), and ongoing HIV care.
◦ Ensure the individual obtains necessary medications, utilizing the provision for a 30-day supply upon release.
5. Address Co-occurring Illnesses: Utilize evidence-based practices to reduce risk for individuals with co-occurring illnesses, such as substance use disorders (SUDs).
◦ Employ Medications for Opioid Use Disorder (MOUD), peer recovery specialists, and risk planning.

Methodology: This practice provides a standardized data strategy that enables health centers and supportive housing partners to reduce the administrative burden associated with developing new tracking mechanisms by leveraging existing data systems (UDS, HEDIS, HMIS) and clinical coding (ICD-10) to monitor the impact of housing on chronic conditions and utilization measures.

To replicate this practice, health centers and housing providers should implement the following steps:
1. Utilize Existing Data Systems for Tracking Outcomes: Focus on tracking outcomes using established data sets already collected by health centers and housing providers.
◦ Health Centers: Analyze existing UDS measures (e.g., chronic conditions, infectious diseases, mental health) and HEDIS measures (e.g., effectiveness of care) at the patient level.
◦ Housing Providers: Leverage data from the Homeless Management Information System (HMIS) regarding housing status, chronic conditions, substance use disorders, and health insurance information.
2. Ensure Point-of-Care Coding for Housing Status: Encourage hospitals and health care providers to use the specific ICD-10 code for homelessness (Z59.0) to allow reports to be generated specifically for patients who have experienced homelessness.
3. Use Screening Tools for Holistic Data Capture: Integrate standardized tools to collect data on social needs and quality of life that may be impacted by housing.
◦ Utilize the PRAPARE tool to screen for patient needs, which provides a holistic view of patients’ health that can be added to the Electronic Health Record system.
4. Analyze Data Based on Housing Milestones: When analyzing health outcomes (e.g., reduction in ER utilization or improvement in chronic conditions), ensure the analysis focuses on the pre- and post-housing move-in date rather than the project start or enrollment date.
5. Include Qualitative Data for Storytelling: Supplement quantitative data with anecdotal evidence regarding people’s experiences—such as increased engagement in care, better medication management, or reported feeling better—to tell the story of success that may not yet be quantifiable.

Methodology: This practice guides Federally Qualified Health Centers (FQHCs) and other eligible facilities to utilize the VA MISSION Act Section 403 GME Pilot Program to expand community-based training opportunities for medical residents, which is designed to increase the primary care workforce in rural and communities with additional needs through two structured reimbursement models, Model A (existing programs) and Model B (new programs).

To replicate this practice, FQHCs and other covered facilities should implement the following steps:

1. Determine the Model and Identify Partners: Decide whether to participate via Model A or Model B and identify necessary partners.
◦ Model A (Existing Programs): Partner with an existing ACGME-accredited GME Sponsoring Institution (e.g., a university or hospital) to allow their residents to rotate at the FQHC or covered facility. The VA Office of Academic Affiliations (OAA) issues Requests for Proposals (RFPs) for Model A, and the sponsoring institutions apply to OAA.
◦ Model B (New Programs): The covered facility (e.g., FQHC) serves as the GME sponsor, attains provisional accreditation status, and starts a new residency program.

2. Align Program Goals with Workforce Needs: Ensure the program addresses the need for providers in surrounding areas, as priority is given to facilities located in a Health Professional Shortage Area or rural/remote areas.

3. Establish Financial and Operational Structure: Understand the reimbursement mechanism offered by the VA for the pilot.
◦ Model A: The VA reimburses the GME sponsor for the resident's salary and benefits for time spent rotating at the covered facility.
◦ Model B: The VA reimburses the covered facility for the resident's salary and benefits, as well as the startup costs for the new GME program, including curriculum development, accreditation costs, faculty salaries, and recruitment.

4. Engage VA Leadership and Faculty: Proactively engage VA leadership, including the local Designated Education Officer (DEO), to foster partnerships and collaborate on developing curriculum and resident experiences, such as offering specialty rotations (e.g., Dermatology, Surgery) and Veteran-Centered instruction.
5. Utilize Data Reporting for Monitoring: Be prepared for comprehensive data reporting required by the MISSION 403 program, including the number of residents, medical specialties, program costs, clinical appointments for Veterans, and the number of residents hired by the VA.

Methodology: This practice utilizes a detailed Memorandum of Understanding (MOU) template to formalize roles, responsibilities, and resource sharing between a Health Center and a Domestic Violence/Sexual Assault/Human Trafficking (DV/SA/HT) CBO to strengthen collaboration, promote patient safety, and ensure bidirectional warm referrals for patients and staff.

To replicate this practice, organizations should implement the following steps:

1. Formalize the Partnership and Define Purpose: Establish the agreement by having designated agents from both the Health Center (HC) and the DV/SA/HT/CBO agency sign the MOU.
◦ Define the core purpose of the collaboration, such as strengthening staff collaboration, promoting health and safety outcomes, and coordinating services including health enrollment and transportation.

2. Define Mutual Roles and Responsibilities: Clearly outline the specific duties and roles for each entity within the MOU structure.
◦ HC Responsibilities: Include serving as a primary healthcare referral for clients, training DV/SA/HT/CBO advocates on health center enrollment and services, and drafting and reviewing IPV/HT policies and procedures.
◦ DV/SA/HT/CBO Responsibilities: Include training health center providers and staff on DV/HT dynamics and community supports, serving as a primary referral for HC patients or staff in need, and offering advocacy support (onsite or virtual via telehealth).

3. Commit Resources and Structure Meetings: Ensure the partnership is supported by dedicated resources and consistent communication.
◦ List specific resources (e.g., additional staff time, mobile health services, office space for co-located advocates, 24/7 hotline support) that each entity will provide to support the project’s efforts.
◦ Schedule initial and recurring meetings between representatives of both agencies to understand services, discuss needs, and maintain the recurring schedule.

4. Establish Tracking and Evaluation Mechanisms: Agree on tools to measure the success and challenges of the collaboration and outcomes.
◦ Agree to review and discuss evaluation tools, such as a referral tracking tool and a Quality Assessment/Quality Improvement tool used every six months.
◦ Include plans for collecting data via client/patient satisfaction surveys and provider/staff training evaluations.

Methodology: This practice uses mobile medical units or street outreach teams (backpack medicine) to meet communities with additional needs directly in their environments (encampments, overpasses, streets), providing immediate primary and specialized care (HIV/Hepatitis C testing, wound care, MAT) to build trust and facilitate linkage to sustained brick-and-mortar services.

To replicate this practice, a health center should follow these steps:

1. Conduct Community Assessment and Partnership
◦ Meet with existing community-based organizations (CBOs) and other mobile medical units to coordinate efforts and avoid duplicating services.
◦ Survey intended clients (members) to get input on services, location, and branding to ensure comfort and increase utilization.
◦ Establish strong, frequent collaborations with community partners, including hospitals (specifically emergency rooms), police, fire, and EMS.

2. Define Program Mission and Prepare Infrastructure
◦ Dedicate time (up to a year) before deployment to research, read, and define the mission, specific services (e.g., HIV/Hepatitis C testing, wound care, overdose prevention), and target areas.
◦ Comply with all local laws and ordinances regarding testing waivers, additional insurance liability, ADA requirements, and restrictions on operating near schools or parks.
◦ When purchasing vehicles, seek input from peers and references, and consider buying used units or smaller vehicles (like golf carts or vans) for hard-to-reach encampments.
◦ Design the mobile unit for flexibility, including dual exam rooms, full medical exam capabilities, medical refrigerators, and secure lockboxes for medications (like PrEP).
◦ Ensure the unit has essential infrastructure like a generator that runs the entire unit, reliable Wi-Fi/connectivity, and two air conditioning and heating units for year-round service.

3. Implement Outreach and Trust-Building Strategies
◦ Staff the unit with a multi-disciplinary team, including physicians, nurses, case managers, intake staff, and peers, to provide real-time services and warm hand-offs.
◦ Prioritize building trust by engaging community members with compassion, respect, empathy, and dignity, meeting them where they are at.
◦ Use tools of engagement, such as hygiene packs, water, over-the-counter medications, and pet treats, to address basic needs before clinical care.
◦ Ensure vehicle branding avoids stigmatizing language and logos, as client discomfort can prevent them from utilizing the service.
◦ Provide real-time services such as Rapid ART and same-day prescription refills, helping newly diagnosed individuals achieve viral suppression faster.

4. Ensure Financial Sustainability and Oversight
◦ Look for non-restricted grants and community sponsorships (e.g., pharmacies) to build a sustainable budget that can survive the loss of a single grant.
◦ Factor high operational costs into the budget, including gas, repairs, and unexpected expenses (like replacing a generator engine).
◦ Hire a dedicated fleet manager to manage maintenance, routine oil changes, and upkeep, treating the unit as a key asset.
◦ Track key performance metrics, including billable versus unbillable services, and continuity of care (e.g., the percentage of individuals achieving three or more visits).
◦ Ensure all staff are well-trained on equipment use, medical compliance (HIPAA, OSHA), and safety procedures.

Methodology: This practice enables a health center to improve maternal and newborn health outcomes in the critical fourth trimester (the first 12 weeks after birth) by integrating screening for social and medical needs, providing education, and coordinating care with community partners. This structured approach addresses the high rate of maternal morbidity and mortality that can occur during this period.

To replicate this practice, an organization should formalize a process that includes screening, care coordination, and continuous partnership:

1. Integrate Screening for Challenges.
◦ Review postpartum medical needs, screening, patient education, and community support to identify potential complications or medical concerns.
◦ Screen for patient challenges that impact health and well-being, such as those related to Economic Stability, Neighborhood and Physical Environment, Education, and Food Safety.
◦ Utilize validated social needs screening tools such as PRAPARE, the EveryONE Project tool, and the CMS Health-Related Social Needs Screening Tool.

2. Formalize Warm Hand-offs and Care Coordination.
◦ Formalize a process within the organization or community to provide warm hand-offs for patients in the fourth trimester.
◦ Develop a dyadic strategy for the maternal-newborn dyad that includes continuous support, coordinated care between different providers, strong emphasis on early attachment, and integration of physical and mental healthcare for both mother and baby.
◦ Embed enrollment into care plans by ensuring care plans include standing on enrollment during visits, and regular monitoring by Medicaid-managed care organizations (MCOs).

3. Develop and Leverage Community Partnerships.
◦ Identify programs in the area and develop relationships with local community resource programs (e.g., local WIC office, churches, and schools).
◦ Partner with community champions, such as Baby2Baby (provides maternal health and newborn kits) and ShareBaby (distributes diapers and other essentials).
◦ Establish referrals to evidence-based home visiting models like Family Connects International, Healthy Families America (HFA), and Healthy Start (HS), which provide trust-based support and address health, economic, and parenting needs,,,.
◦ Collaborate with community partners to enhance participant engagement and explore re-engagement opportunities for participants lost to care.

4. Measure and Evaluate Program Impact.
◦ Identify the metrics that can measure the impact of the fourth-trimester strategy.
◦ Monitor key metrics by consistently tracking referrals to enrollment rates and measuring and analyzing retention rates in home visiting programs.
◦ Host quarterly meetings with partners to measure the impact of the partnership.

Methodology: This practice enables a health center to leverage legal expertise to address underlying causes of poor health outcomes and reduce costs by aligning legal interventions with covered services and supports under Medicaid waiver policies.

To replicate this practice, an organization should focus on strategically aligning Medical-Legal Partnership (MLP) activities with state Medicaid objectives:

1. Understand Alignment with Medicaid Objectives.
◦ Recognize that the Medicaid-eligible population and those served by legal services organizations significantly overlap, sharing demographic similarities and access gaps.
◦ Align common MLP legal interventions with covered services and supports recognized by Medicaid, particularly within Value-Based Care (VBC) models.

2. Utilize Key Medicaid Waiver Policies (Section 1115 and HRSN).
◦ Consider two related Medicaid waiver policies: Section 1115 "demonstration projects" and Health-Related Social Needs (HRSN) guidance, which allow states flexibility to test new ways to improve their programs.
◦ Explicitly link legal interventions provided by MLP teams with CMS-approved health-related needs interventions, referencing the I-HELP® framework (Income & Insurance, Housing & utilities, Education & Employment, Legal status, and Personal & family stability).

3. Implement Legal Interventions Focused on Health Outcomes.
◦ Focus on legal services that address health-related needs, such as appealing denials of food stamps or health insurance benefits, securing housing subsidies, preventing evictions, and improving substandard living conditions.
◦ If full legal representation is not reimbursable through Medicaid, offer education on roles, rights, and responsibilities, which may be reimbursable as part of case management services.

4. Track Data and Leverage Partnerships.
◦ Support the Medicaid objective by tracking the relevant legal interventions provided and outcomes achieved through blended and braided external funding, especially where specific legal services are not directly covered by Medicaid.
◦ Leverage partnerships, such as seeking free technical assistance from the National Center for Medical-Legal Partnership (NCMLP), which is supported by organizations like HRSA and Kaiser Permanente.

Methodology: This practice enables health organizations to leverage legal services as a standard part of the way they respond to the social and complex legal needs of older adults, helping to improve their health and quality of life.

To replicate this practice, an organization should follow the eight core Medical-Legal Partnership (MLP) components while tailoring services and multidisciplinary workforce training specifically toward the older adult demographic:

1. Establish the MLP Framework and Partnerships.
◦ Establish a formal partnership agreement between the legal and health entities.
◦ Define the patient population intentionally as older adults (60+ years of age).
◦ Staff a "lawyer in residence" within the healthcare setting.
◦ Engage partners like health networks, veterans affairs, and clinics serving a large, high-need older adult population.
◦ Implement multidisciplinary workforce training that includes law students, medical students, and residents.

2. Tailor Screening and Identification.
◦ Conduct health-related legal needs screening, focusing on issues associated with aging, such as advance planning, housing, income/health benefits, conservatorship, and guardianship.
◦ Examine the existing patient population to identify older adults at risk of loss of capacity, institutionalization, or conservatorship.
◦ Leverage existing data to identify how many clients are in the 60+ age range and could benefit from proactive planning conversations.

3. Deliver Specialized Legal Services and Training.
◦ Provide holistic wrap-around legal representation focused on advance care planning (ACP), including planning for care transitions, housing, personal care, and support for activities of daily living.
◦ Develop free, targeted training for healthcare partners on how to conduct capacity assessments and early cognitive screening and follow up on dementia care.
◦ Assist family caregivers with their own health-related legal issues, such as paid family leave or medical leave protections.
◦ Build relationships with older adults and the people in their lives to assess risk and help protect them from abuse or neglect.

Methodology: This practice utilizes intentional, popular education exercises (Dinámicas) led by Community Health Workers (CHWs) to build authentic relationships and trust, enabling participants (including those who may be hesitant to discuss personal topics) to feel comfortable sharing their health needs and engaging in preventive care.

To replicate this practice, CHWs and facilitators should implement the following steps:
1. Prioritize Relationship Building Over Content: Use Dinámicas as a tool to create opportunities for participants to share, listen, and connect with others in a supportive space.
◦ Approach each activity with an open mind and ensure the goal is focused primarily on the goal: to form connections.
◦ Apply the communication strategy of "Connection Before Content".
◦ Allow learning to begin with participants’ own real-life experiences.

2. Implement Facilitation Strategies to Promote Discussion: Use effective communication to enhance engagement and foster stronger relationships.
◦ Use open-ended and probing questions, find common ground, and relate back to the individual.
◦ Employ active listening continuously, and focus only on one or two key points to avoid overpowering the conversation.
◦ Use affirmations, give options, and avoid lecturing.

3. Leverage Trust to Tailor Support: Utilize the comfort and trust established through the Dinámicas to initiate more delicate conversations about health and resources.
◦ Based on participants’ willingness to share their lived experiences and health needs, tailor support and provide resources that fit the individual’s unique needs and strengths.

Methodology: This practice equips health centers to implement youth-centered health care by integrating social and emotional screening, trust-building techniques, flexible access points, and community partnerships to serve adolescent and young adult patients.

To replicate this practice, a health center should follow these steps:

1. Systematically Collect Data and Build Trust
◦ Routinely use validated screening tools, such as the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE®) and the Hunger Vital Sign™, to assess family dynamics, economic resources, and social factors.
◦ Document and track these social and economic factors in the electronic health record using ICD-10 Z-codes (Z55-Z65).
◦ Develop organization-wide policies that explain how data flows, how it is secured, and how patient data will be used and protected, and communicate these processes clearly to patients.
◦ Focus on building authentic relationships with youth by practicing honesty, respect, and empathy, and using shared decision-making guided by the patient's self-directed goals.

2. Integrate Mental Health and Practices Responsive to Adverse Experiences
◦ Integrate mental health professionals into the primary care team or ensure that primary care and mental health care are accessible at one location.
◦ Train primary care teams to routinely screen for mental health challenges and provide early interventions, warm hand-offs, or referrals to mental health professionals.
◦ Implement universal protocols for responding to disruptive behaviors, recognizing that these behaviors are often maladaptive responses to stress.
◦ Utilize healing-centered engagement by focusing on the patient's assets and strengths rather than weaknesses, and celebrating milestones.

3. Enhance Access and Support Autonomy
◦ Offer flexible scheduling options, including drop-in hours for certain services and adjusted or eliminated late arrival policies for youth.
◦ Provide evening and/or weekend appointments to accommodate youth schedules, and use digital methods like online scheduling, telehealth, and text messaging for appointment and medication reminders.
◦ Create resources that help youth become autonomous managers of their health care by learning to navigate the system (e.g., scheduling, referrals, patient portals) and proactively manage their health needs (e.g., track prescription refills).

4. Engage Youth and Formalize Partnerships
◦ Form Youth Community Advisory Groups (YCAGs) to provide regular input and feedback on health center services, programs, and decisions.
◦ Remove barriers to YCAG participation by offering food, transportation, small stipends, and flexible meeting formats (virtual, in-person, or hybrid).
◦ Partner with community organizations (e.g., schools, housing, behavioral health) to align services and share resources.
◦ Formalize these collaborations through a Memorandum of Understanding (MOU) that establishes a standard system for bidirectional referrals.