Caring as Communities Podcast: The Role of Community Health Workers in Addressing Social Determinants of Health

In this episode of Caring as Communities, Paula Blackwell, MBA, and Allison Robinson, MPH discuss with Dr. Enrique Enguidanos the increasing importance of community health workers in supporting individuals with social determinants of health—as well as the value of having advocates with “lived experience” to help build trust between healthcare providers and communities.


  • Paula Blackwell, MBA, Executive Director, Central Maryland Area Health Education Center (AHEC)
  • Allison Robinson, MPH, Associate Program Director of the Maryland AHEC Program at the University of Maryland School of Medicine Department of Family & Community Medicine

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.

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Caring as Communities Podcast: Caring and Advocating for Provider Mental Health (Part 2)


Learn the mental health challenges faced by nurses and physicians across the country—including burnout compassion fatigue, and moral injury—following the COVID-19 pandemic with the country’s leaders in provider health research and advocacy.

Special Guests:

Bernard Chang, MD, Ph.D., FACEP and Vice-Chair of Research and Associate Professor of Emergency Medicine at Columbia University Irving Medical Center

Lisa Wolf, Ph.D., RN, CEN, FAEN, and Director, Emergency Nursing Research at the Emergency Nurses Association.


Dr. Enrique Enguidanos, CEO, founder, and practicing ED physician for Community Based Coordination Solutions

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.


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CEO Dr. Enrique Enguidanos to present at the 2021 American Public Health Association Conference


The American Public Health Association’s 2021 Annual Meeting and Expo will take place Oct. 24-27. The 2021 theme is “Creating the Healthiest Nation: Strengthening Social Connectedness.”

On October 27th, Dr. Enguidanos will be co-presenting COVID Response from Multiple Perspectives with the Cuban Society of Public Health, offering contrasting perspectives on the challenges faced in Cuba and the United States related to the management of COVID-19. Dr. Enguidanos will be presenting “An Overview of the U.S. COVID Experience.”

The purpose of the quarterly dialogues is to examine key public health issues in both Cuba and the U.S.  Through the leadership of their respective national associations (Cuban Society of Public Health and the American Public Health Association), the intent is to carry these conversations to the state/local level and engage with stakeholders who are critical to carrying out this work.

Co-organizers: Cuban Society of Public Health (SOCUSAP), Pennsylvania Public Health Association (PPHA), Public Health Management Corporation (PHMC) and American Public Health Association (APHA)


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Caring As Communities Podcast Episode 16: Addressing Social Determinants Through Technology Solutions (Part Two)

Health IT Solutions are becoming an increasingly integral component of organizational efforts to address social determinants of health.

Join us in part two of a special series with health IT leaders as we talk with Point Click Care Chief Medical Officer- Benjamin Zaniello, M.D., M.P.H.- about utilizing technology to connect individuals with the community resources they need.

A practicing Infectious Disease physician, Ben is also a technologist at heart, focused on healthcare innovation for Population Health and the transition to value-based care for all patients. His passion for care transformation comes from firsthand experience. Most recently Ben worked at Providence St. Joseph Health, as their Chief Medical Information Officer in Population Health.

Dr. Zaniello continues to practice medicine, focusing on Utah’s high-risk populations. His undergraduate work was at Stanford (in Architecture, German, and Computer Science) but he returned home to his native Kentucky for medical school at the University of Kentucky College of Medicine. He did his Internal Medicine residency at Weill Cornell Medical Center and Infectious Disease fellowship at the University of Washington where he also received his Master’s in Public Health.

This episode is available on Apple PodcastsSpotify, Google Podcasts & Buzzsprout.

Read More | Posted In: model of care, Podcasts

Webinar: Enhancing care coordination across the continuum: A guidebook to reducing readmissions


Tuesday, September 21st, 2021 | 12:00 PM – 1:00 PM CT

Readmissions are a significant driver of healthcare costs and inefficiencies, accounting for $26 billion per year across the U.S. Join our CEO Enrique Enguidanos as he sits down with fellow physician thought leaders to discuss challenges and strategies to reduce ED readmissions. Hosted by Becker’s Healthcare. Register here!

Becker’s Healthcare is the go-to source for healthcare decision-makers and one of the fastest-growing media platforms in the industry. Through print, digital and live event platforms, Becker’s Healthcare equips healthcare leaders with the information and forums they need to learn, exchange ideas, and further conversations about the most critical issues in American healthcare

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CBCS is excited to be featured on Population Health Learning Network


Enrique Enguidanos, MD, FACEP, MBA, CEO and founder of Community Based Coordination Solutions discusses how CBCS is rethinking the complex engagement model

It was the tenth time Mary had presented to the emergency department (ED) suicidal and intoxicated after trying to subvert her depression with alcohol. This time, a caring bystander had called 911 as they saw her laying on the sidewalk mumbling and the ambulance had brought her to the one place that was open after hours—the ED.

Mary’s story is not unique; research shows that roughly one in four Americans suffer from a diagnosable mental illness. When complicated by other psychosocial conditions such as substance abuse, homelessness, or chronic medical conditions, our country’s medical care system can be disheartening to navigate.  All too often, this leads to poor preventative care and eventually higher incidences of crisis events such as Mary’s. One term used to describe patients at such risk is “complex care patients.” Our current system of care for complex care patients isn’t working; a new approach is needed—one that accounts for these conditions and better leverages in-person connection to address them.

Read the full article here.

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Caring As Communities Podcast Episode 15: Addressing Stigmas in Healthcare

Stigmas promote feelings of isolation, unworthiness, and unwelcomeness, leading to discomfort and distrust. Yet they are a common reality in healthcare—especially for patients with social determinants of health, chronic conditions, or addictions. Drs. Stephen Anderson, FACEP, and Donald Stader, FACEP, join Jeneen Skinner of the Camden Coalition to discuss how we can reduce these stigmas in our workplaces.

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.



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Caring As Communities Podcast Episode 14: Engaging Patients with Complex Care Needs

It’s the Caring As Communities Podcast’s one-year anniversary, and Dr. Enrique Enguidanos steps away from the role of host and instead shares his own insights after over a decade of dedicated work in the complex care space. Tune in as he shares key strategies for engaging patients with complex care needs by working in tandem with community resources.

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.




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Improving outcomes through patient engagement
Keeping healthcare personal, scalable, and affordable with the CBCS direct patient engagement program

Trent was a Vietnam War veteran with diagnosed type 2 diabetes, PTSD, and acute schizophrenia who was seen frequently at the hospital with primary complaints of heart failure. When multiple tests showed that Trent’s heart was healthy, but that he was experiencing regular panic attacks, an onsite social worker sat down with him to explain that there are resources available to support veterans like him. However, even with those resources, Trent was unable to get the care he needed.

To get appropriate help, Trent needed to arrange transportation to and from the VA home—which required not only money to pay for the fare, but a phone to look up bus schedules or call for a ride. Trent also felt anxious visiting the home, unsure of who he would meet there or what he would experience. He would have to test his physical abilities to travel safely (especially in the winter when ice increased his risk of fall) and navigate new organizations with which he was unfamiliar. All of this became overwhelming—leading Trent and many others to stay at home, avoid connecting with key resources, and ultimately struggle with unmanaged conditions.

Changing this narrative starts with direct, personal, and supportive patient engagement programs that are designed to help individuals like Trent navigate the healthcare landscape, receive support during crisis moments, and ultimately connect with key community resources to improve their quality of life.

Step one: Supporting complex care patients in navigating the healthcare landscape

According to a recent study published by the Agency for Healthcare Research and Quality, merely five percent of the U.S. population accounts for over fifty percent of total healthcare spending—and one percent accounts for roughly twenty percent of healthcare spending. Of this spending, it is estimated that anywhere between 10 to 30 percent of this cost is avoidable—just factoring in high-cost utilization alone.

So why the high costs?

Patients with comorbid physical and behavioral health conditions require complex care that can seem impossible to manage—especially when current data shows that 30 percent of complex care individuals are homeless, 40 percent have some form of mental disorder, and 50 percent have significant forms of substance use disorder. As a result, many of these individuals struggle to know where they can turn for the care that they need and, like Trent, resort to an ED visit—knowing that it will be open and that they must be seen.

The CBCS direct patient engagement program works to address this gap, supporting those complex care patients where traditional care coordination programs have failed and providing assigned peer community workers who can help them navigate the healthcare system.

With the direct patient engagement program, workers reach out proactively to patients who are struggling—leveraging email, phone calls, texts, and in-person visits to connect with these individuals and work with them on achieving better care plan adherence. Whether that means helping the patient call and schedule appropriate follow-up appointments, going over medication instructions to make sure the individual understands the directions, or simply being the person who is willing to go with a patient to an exam to ensure they have transportation, language translation services (if needed), or other support, the engagement builds trust with the assigned peer—and rebuilds trust in a system that has traditionally overlooked these individuals or let them down.

Step two: Connecting with patients during moments of crisis

The peers assigned through the direct patient engagement program are available 24/7, allowing them to be there with the patients when the patient needs them most—reducing barriers to care and connection.

CBCS leverages existing shared community health information exchanges (HIEs) to receive real-time notifications whenever a patient presents at the hospital during a crisis, has a change in care plan, or needs other follow-up. By receiving updates in real-time, community workers can respond to immediate needs—providing ongoing, local, empathetic support to help rebuild that patient trust and ensure a smoother transition post-hospital discharge to post-acute, outpatient, MAT, or other follow-up care.

This 24/7 accessibility is key to successful engagement, as studies show that individuals with recurrent ED utilization are more common during evening and night shifts. This means that a majority of complex patients who would benefit from case management are presenting when there are no social workers or on-site community resources available, missing that opportunity for engagement and connection.

Ensuring that individuals will not only have someone available whenever crisis moments hit but have someone available who knows them personally and understands their circumstances becomes critical for improving transitional care and preventing future acute care utilization. As such, patients enrolled in the CBCS direct patient engagement program see an average reduction of $40K in acute care costs annually.

Step three: Bridging the gap between individuals and the communities ready to support them

The National Academy of Medicine suggests that medical care accounts for a mere 10-20 percent of a patient’s outcomes. That means it is not enough to provide quality medical care in traditional brick-and-mortar clinics, but that community resources are necessary to support these individuals in addressing social determinants that act as barriers to better health.

Encouragingly, the resources are out there. In fact, in the past year, multiple large-scale efforts have been made to strengthen community resources for marginalized patient populations, including:

  • $130 million from UnitedHealth and UnitedHealth Group to improve access to healthcare and housing for underserved populations—including a $5 million grant for addressing mental health
  • $50 million from Anthem to improve health equity
  • $25 million to address health equity and racial inequities

In other words, our communities are ready to support these individuals in addressing social determinants and improving their quality of life. However, even with the financial support, much of the U.S. is still struggling to move the needle in these communities.

Why? Because there remains a disconnect between these community resources and the individuals they were created for.

Erine Gray, CEO, and Founder of Aunt Bertha—a health IT platform that specializes in connecting individuals with community resources—explains:

“Just getting someone enrolled into a public benefit program, like SNAP, like Medicaid, like TANF, is incredibly challenging, and it requires a lot of policy knowledge… It was not that long ago that people would have to take the day off work and find childcare for their kids just to renew their food stamps or other public benefits. We need to build more dignity into the process of enrolling individuals to receive these benefits.”

CBCS brings together community resources for the most high-risk, complex care patients—with community workers who are trained to support individuals in connecting with public benefits and local and national nonprofits. In addition, these workers use immediate access funds—available through the direct patient engagement program—to meet emergent needs, such as transportation costs home from the hospital, dinner for a patient’s children, or adequate clothing to stay dry and warm during a recovery.

When these immediate funds are paired with community resources, they work together to streamline support efforts, reduce duplication of efforts between organizations, and ultimately ensure each individual has what is needed to be healthy and thrive.

Conclusion: We have all the pieces

At almost $12K spent per year per person on healthcare, and an average annual expenditure of $116,331 for those with complex conditions, the solution to improving care is not in getting more. It is connecting more.

As more organizations learn to invest both money and time into supporting complex care patients like Trent with direct patient engagement programs, the return on those investments is steep: millions of dollars in cost savings for payers, ED and opioid use reduction for patients, and better alignment and satisfaction for the communities as a whole.

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Caring as Communities Podcast: Addressing Social Determinants with Technology Part One

HealthTech is paving the way for addressing social determinants of health through a myriad of platforms, software, and more. Join us as we talk with health IT industry leader, Erine Gray—CEO and founder of Aunt Bertha—in this tech series and get insights for reducing gaps in care.

Erine Gray has been working on business and technology consulting projects for more than 15 years and is the Founder and CEO of Aunt Bertha. Aunt Bertha’s mission is to make human service program information more accessible to both people and programs. 

Prior to founding Aunt Bertha, he directed more than 60 employees within a project responsible for administering the application process for the Texas Health and Human Services Commission. At the Commission, he delivered more than 40 software and operational improvement projects that saved more than $5 million dollars annually in operating expenses. Erine studied public policy at the LBJ School of Public Affairs at the University of Texas and has a BA in Economics from Indiana University. He’s a 2019 TED Senior Fellow.

This episode is available on Apple PodcastsSpotify, Google Podcasts & Buzzsprout, which provides a full transcript of this podcast as well.

Read More | Posted In: model of care, News, Podcasts