🏗️ For Programs — Implementing Connected Care

Resources for clinic administrators, program directors, and organizations outside the current Connected Care footprint who want to understand or replicate the model.

About the Connected Care Model

Connected Care for Older Adults is a community health worker program embedded in primary care clinics to support older adults with complex health and social needs. CHWs work with patients over an extended period — typically 6–18 months — to address the social determinants of health, support advance care planning, manage medications safely, screen for cognitive and mood concerns, and reduce fall risk.
The program is built on the Age-Friendly Health Systems framework and the 4Ms: What Matters, Medication, Mentation, and Mobility.
📋 Add here: fuller model description — request from Connected Care team, or draw from the published journal article

Your role as a Connected Care CHW

📋 Placeholder — content to be added. Include: what a CHW does day to day, relationship to the clinical team, patient population, visit structure.

Goals of Connected Care

📋 Placeholder — content to be added. Include program outcomes, target metrics, what success looks like for a patient.
Research and evidence base

Implementation Guide

📋 Placeholder — content to be added by the Connected Care team. Should include: what a clinic needs before starting (EMR access, CHW hire, supervisor structure, clinic buy-in), how to adapt the protocols for a new region, how to localize the resource library, training sequence and estimated time to first patient visit, how to connect with the Connected Care team for support.

Training Manual

The Connected Care CHW Training Manual is a downloadable template that programs can adapt for their own CHW onboarding.
📋 Upload the Word version of the training manual here as a Notion file attachment. Add a note: “This document is a working draft. Oregon-specific content (regional contacts, specific Zoom links, local resources) should be replaced with content appropriate for your region.”

Evaluation and Data Collection

Connected Care collects data at intake and exit for each patient, as well as encounter-level data for each protocol visit. This data is used to evaluate program outcomes and support continuous quality improvement.
Core metrics
  • Advance directive completion rate
  • STEADI fall risk scores at intake vs. exit
  • Emergency department visits and hospitalizations (90 days before enrollment vs. program period)
  • Medication discrepancy identification rate
  • Mentation screening completion rate
  • Patient-reported goal achievement
Data collection options
Programs implementing Connected Care may collect data in several ways:
  • Digital forms (recommended): JotForm or Google Forms versions of each protocol tool, with responses feeding into a shared database. Contact the Connected Care team for guidance on setting up JotForm versions.
  • EMR integration: Some clinics build protocol documentation directly into their EMR. Contact the Connected Care team for example EMR documentation templates.
  • Paper with OCR: For clinics committed to paper documentation, Adobe Acrobat Pro or Azure Document Intelligence can extract structured data from scanned forms. Design paper forms with OCR in mind — high contrast checkboxes, clear field boundaries, consistent layout.
📋 Add callout (yellow, warning icon): “Paper documentation significantly increases the burden of data collection and analysis. Where possible, encourage digital data collection from the start. Even a simple Google Form version of each protocol will produce cleaner data than the best OCR pipeline.”
Sharing data with the Connected Care team
📋 Placeholder — add data sharing process, frequency, format, and contact when finalized.

Accessing Patient Support Funds

📋 This section is a placeholder — content to be added by the Connected Care team. Include: what the fund is for, dollar limits, approval process, what can and cannot be purchased, how to document purchases.

Working with Clinicians

📋 This section is a placeholder — content to be added by the Connected Care team. Include: how to communicate protocol findings to the PCP, what warrants same-day contact vs. next visit, how to use the EMR for documentation, do’s and don’ts.
📋 Add bookmark link to: [Video on working effectively with clinicians — TBD]