Community Health Workers As Members of the Health Care Team

In our community, one-half of local residents are foreign-born, one in four households are linguistically isolated, and one in three families live below the poverty level. Despite proximity to a large academic medical center, gaps in culturally appropriate care and related supports often lead to significant health risks for community residents and compromised quality of life for their families. 

In August 2010, a hospital-community care coordination program partnered with 6 community based health practices to bring community health workers into Patient Centered Medical Homes (PCMHs), where they could provide culturally-sensitive support and education on-site to patients with pediatric asthma or adult type 2 diabetes. The CHWs, who are based in local community-based organizations, use a peer-based approach to ensure that key health messages are understood, to identify obstacles that impede disease management, and to reinforce self-management goals. Those patients who are struggling to manage their chronic disease are often referred to a year-long, CHW-led care coordination program in which they receive intensive education and support over the course of 1 year. After the education sessions, the CHWs communicate with health care team members and relevant information is added to the patient’s electronic medical record.  In addition, CHWs participate in weekly multidisciplinary meetings during which they share their unique perspective, including findings associated with visits made to the patient’s homes.  To date, CHWs have supported 3311 patients in the practice settings. Feedback from other members of the health care team suggests that CHWs are considered valuable members of health care team and are seen as especially skilled in identifying key obstacles associated with disease management.