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Diabetes and chronic kidney disease (CKD) are two of the most serious health issues facing Bexar County, Texas. One in seven adults has diabetes, which may lead to CKD. About 30 people out of 100,000 die of CKD in Bexar County.
People who have diabetes or are at-risk for CKD may have a hard time managing their disease because of unmet health-related social needs. Addressing social needs can help prevent or slow the progression of diabetes. Some of these needs are having a stable place to live, a steady job and a primary doctor who can help manage their journey through the health care system.
To meet these social needs, the Bexar County Community Health Collaborative is building the Grow Healthy Together Pathways Community HUB. This model connects community members to resources that help address their health and social needs. It is the first model of its kind in Texas.
In this model, a Community Health Worker (CHW) uses a survey to gauge each individual’s needs. This helps the CHW find the most important risk factors to work on first. The CHW then works to connect the client with resources until all needs are met.
The CHW uses a digital tablet to record each attempt at reaching the client, home visit and step taken to help the client. This data will help show the number of people who report having CKD and/or diabetes, and the progress made in meeting their health-related social needs.
Data collection also helps to track the hard work of CHWs, as well as information about the services available in the community. The data will also show the hurdles to connecting people to services and what resources the community still needs.
The Bexar County Community Health Collaborative is launching this model with funding from Blue Cross and Blue Shield of Texas. The project began in March and will grow over the next year.
To learn more about the Grow Healthy Together Pathway Community HUB, you can contact the Bexar County Community Health Collaborative at healthcollaborative.net or 210-481-2573. You can also follow them on Facebook, Instagram and Twitter.
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