HealthConnect Referrals

Southwest Washington Accountable Community of Health (SWACH) is excited to partner with PeaceHealth to help further support unhoused or housing insecure individuals in our community. As an agency, SWACH is dedicated to providing the infrastructure and support to address health-related social needs that individuals may have in Clark, Klickitat and Skamania Counties. Our work relies heavily on partnership and cross-sector expertise, which connects community members to services and support across multiple sectors like housing, behavioral health, primary care, and more. This referral network is built on the HealthConnect Hub, SWACH’s community hub.

HealthConnect Hub

HealthConnect Hub is a Care Coordination Hub of Southwest Washington (including Clark, Klickitat, & Skamania County) Partners. Community-based care coordination is a partnership among health care providers, clinics and hospitals, pharmacists, mental health professionals, community services and other professionals working together, sharing resources and offering support, to provide client-centered, coordinated care.

HealthConnect Pathways

HealthConnect Pathways is a community-based care coordination model that the HealthConnect Hub utilizes. This model is centered around risk factors, translated into “Pathways”, that pose barriers to individuals achieving positive health outcomes.  Through an initial risk assessment, Community Health Workers can work with clients to identify individualized pathways to be completed and develop a plan to address them.

Suzanna is one of the CHW’s in the PATCH project with an incredible experience in care coordination.

HealthConnect Pathways is a unique way to provide community-based care coordination.

SWACH Referral Form

The “HealthConnect Hub PeaceHealth Southwest Referral Form” is used to refer PeaceHealth patients to SWACH for care coordination related to their care and discharge as part of the PATCH project.

The following programs are a part of the HealthConnect Hub and a variant of the HealthConnect Pathways program:

  • The Community Assistance Referral and Education Services (CARES) Program is run through Clark Cowlitz Fire Rescue (CCFR). This program hopes to reduce dependency on emergency services for non-emergency needs. This program brings together EMS services, community-based care coordination, education, and the effective use of resources to improve population health. A team consisting of a community paramedic and social worker connects with community members with identified needs and uses SWACH’s HealthConnect platform to link individuals to the appropriate services for their situation.

    Referral expectations and information

    Primary Reason for Referral: Short-term, post-hospital follow-up; Transition of care support.

    Response Time: Contact will be made within 48 hours of referral, Monday through Friday.

    Location of Follow-Up: Contact and follow-up will occur in the community. There is opportunity to meet in the hospital, as needed.

    Hours of Operation/Availability: Monday through Friday, 8:00 am to 6:00 pm. Closed Holidays

  • Is a pilot project between PeaceHealth Southwest and SWACH which aims to connect our unstably housed or houseless patients with one of Share’s Community Health Workers to increase support and aid in transitional care. The goal is for the patients to connect with Community Health Workers while still hospitalized, allowing for an opportunity of rapport building and care coordination. *Referrals should be made early in a patient’s hospital admission to allow for community health workers to respond and connect with patients prior to discharging.

    *Phase one of this pilot is accepting referrals from the Mother Joesph Building, floors 2, 3 and 4; There will be an announcement when this pilot will expand to other parts of the hospital*

    Referral expectations and information

    Primary Reason for Referral: Patient experiencing unstable housing or houselessness.

    Response Time: Contact will be made within 48 hours of referral, Monday through Friday.

    Location of Follow-Up: Initial contact and introduction while patients are admitted in the hospital. Can make contact in the community as needed.

    Hours of Operation/Availability: Monday through Friday, 8:00 am to 5:00 pm. Closed Holidays.

  • Community Health Workers from other SWACH partner agencies, that utilize the Pathways model and are funded through the HealthConnect Hub.

    Referral expectations and information

    Primary Reason for Referral: Support with long-term social needs.

    Response Time: Contact will be made within 72 hours of referral, Monday through Friday.

    Location of Follow-Up: Contact and follow-up will occur in the community.

    Hours of Operation/Availability: Monday through Friday, 8:00 am to 5:00 pm. Closed Holidays.

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