With current trends in legislation around the delivery of patient care, the role of a community health worker (CHW) is gaining growing and much deserved attention. However, a system needs to be built for any CHW program to be successful and sustainable. This article describes a unique approach to community health work at the Massachusetts General Hospital Chelsea HealthCare Center where a well-integrated CHW model provides support for everyone involved in patient care: patients, providers, the community at large, and the internal CHW staff.

We report an unusual congenital cardiac anomaly consisting of a downward displacement of all leaflets of both atrio-ventricular valves. In addition to these changes, an atrial septal defect of the secundum type was noted. In light of the extreme rarity of this interesting anomaly complex, we reviewed the literature and compare the morphologic features of the present case with classic Ebstein's anomaly. (Jpn Heart J 36: 119-125, 1995) arise from the annulus fibrosus but instead from the ventricular wall caudal to the atrio-ventricular ring. Ebstein's anomaly accounts for less than 1% of all heart malformations.1) In this case report we describe a lesion which, in addition to the usual Ebstein's anomaly, showed an almost mirror image type of change on the left side of the heart. The heart demonstrated situs solitus using the standard morphological criteria for defining the laterality (sideness) of the heart chamber walls.1) Patent foramen ovale, or atrial septal defect, is associated with classic Ebstein's anomaly in approximately 80 per cent of the cases.1) In our case, an atrial septal defect of the secundum type was demonstrated at time of postmortem examination. This is the third case report in the literature that describes a bilateral anomaly and the first of bilateral anomaly and atrial septal defect. CASE REPORTThis female fetus, delivered prematurely, was the product of a second preg-

IntroductionDespite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic.MethodsWe collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing.ResultsVisit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses.ConclusionsVisit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates.