I want to discuss a model for supporting vulnerable and underserved patients that integrates the Community Health Worker (CHW) as a critical role. I’ll start with the story of a patient I met too late.
It was a hot summer day in Arizona, where temps can easily reach over 98 degrees on average. A table and three chairs were stationed out front of a small trailer home. My visit with the patient would take place in those chairs because it was cooler outside. There was no running water or air conditioning in the home, and the trailer was so cluttered, there was hardly room to walk through it.
My patient was in his 80s. We were meeting that day because his doctor was concerned that he was not checking his blood sugar levels regularly. He had Type 2 diabetes, hypertension and a host of other illnesses.
As I conducted the visit, the patient was mostly silent. His wife did most of the talking. She explained that her husband didn’t trust anyone, particularly when it came to medical professionals. She said it hurt his fingers when he checked his blood sugar, and he just didn’t want to do it.
I learned that a neighbor down the road would occasionally bring them water, and that the patient’s wife would walk to the grocery store for supplies because they had no vehicle.
And then, she shared one of the biggest obstacles to her husband’s care. She was embarrassed to admit to me that she couldn’t read. She said all the papers and instructions they received overwhelmed her, so she would just stash them in drawers. Given that English was not their first language, there were both language and literacy barriers occurring here, in addition to significant social barriers. After my visit, I followed up with their provider and explained this patient needed a higher level of care. With these discoveries, we were able to get the couple access to food resources, and we found a caregiving agency that would pay their neighbor for helping more regularly with daily needs, including driving the patient to doctor appointments.
The patient’s physician knew the couple had limited resources, but did not have full visibility into the extent of those limitations. And, the physician had no visibility at all into the patient’s mistrust of the healthcare system, fear of being deported and lack of basic necessities to support their daily care.
In our current healthcare system, there are many individuals like this patient, who are aging at home and being undone by a range of social determinant of health (SDoH) challenges. Their care teams are often unaware of what’s happening outside the clinical setting and the basic needs that aren’t being met. Meanwhile, there are countless community organizations, programs and resources available to help patients. But patients need guidance to know how to find them, and often basic awareness to know how to ask for help in the first place. That’s where an integrated model of care with a CHW at the center of it can change the narrative. CHWs are trained to uncover and address barriers that negatively impact a patient’s health and care.
We are seeing the rise of the CHW as a profession, as several states now offer certification of this role. The challenge is that many CHW programs are still either in pilot phase or are nonprofit efforts. CHWs can play an absolutely pivotal role in patient care, which is why they are most effective when integrated into a care team that regularly engages the patient in the home.
It’s obvious we must do more to connect the dots for vulnerable patients who have SDoH needs. We’ve also established the value of the CHW as a resource that can make a huge difference for these individuals. But how do we better integrate CHWs into the care team to maximize their impact?
The first step is assessing whether there are non-clinical obstacles to the patient’s health. Completing SDoH assessments during patient visits is vital to understanding specific needs. To build off the initial assessment, a CHW can engage the patient in their home.
In the home environment, the CHW will gain additional insight on the areas of need identified in the assessment. And, because a CHW is someone who is part of the patient’s community, patients are often more comfortable speaking about non-clinical challenges with them. So, the CHW becomes a great bridge back to better care for the patient.
Working as an integrated part of the patient’s care team, a CHW can help build an action plan to address the needs uncovered in the assessment and home visit. This includes helping the patient get back to a place where they can more fully participate in existing care plans issued by the primary care physician.
As part of the action plan, patients can be connected to multiple community resources to help navigate barriers to care. These resources are available in most cases. It’s just a matter of helping patients find the right fit and take the right steps to engage.
Finally, measuring the effectiveness of the action plan is important. We need to know whether care gaps have been closed and whether SDoH needs have been effectively addressed. Based on these findings, with the help of a CHW at the core of the team, the value of the program can be quantified and opportunities for improvement addressed.
I still vividly remember sitting outside in the heat, listening and uncovering what my patient and his wife really needed. What if a thorough SDoH assessment had been completed prior to my visit to help his entire care team fully understand the obstacles he was facing? What if someone like me had engaged with him earlier, set an action plan and helped his family make connections to community resources? What if we had helped him get back on a healthier track and surrounded him with the right kind of support? It’s likely he would have been in better health overall and avoided unnecessary complications.
I am thankful for the advancements we are making in primary care today, specifically for models like Emcara Health, where we are integrating CHWs into the care team and bringing support to patients in their homes. Every time we bridge a gap, fill a need or lend a hand, we are making a difference. Every patient we touch is one more person who gets a chance to live a happier, healthier, longer life.
Lead National, Community Health Worker
As National CHW Lead and Senior Manager, Susie Martinez leads the Social Care Center of Excellence at Emcara Health. A fierce and compassionate advocate for breaking down the social barriers to a person’s health and well-being, Susie started her career as a Community Health Worker (CHW) in 2014 at Valle del Sol Community Health Center, an integrated healthcare organization with a focus on behavioral health for adults and pediatrics. Susie joined Emcara Health as a CHW in 2018, connecting patients to resources one-on-one and shaping the company’s approach to social care delivery. Susie earned an Associate of Arts degree in Psychology & Behavioral Science from Imperial Valley College and a Bachelor of Arts degree in Liberal Studies from Arizona State University.