Role of Community Health Workers for Clinical Systems: The Mississippi Delta Clinical Community Health Worker Initiative
Description: Eight clinical sites in the Mississippi Delta agreed to refer patients to the CCHW Initiative program. Patients were selected based on diagnosis of uncontrolled hypertension, or diabetes, dyslipidemia. The CHWs visited patients in their homes within 7 days of referral, quarterly, and as needed. The CHWs addressed the patient’s basic healthcare needs by conducting chronic disease self-management workshops, teaching proper techniques for BP and hemoglobin A1C measurement, and encouraging compliance.
Lessons learned: The Community Health Worker must reside in and be knowledgeable of the community they serve. Patient participation and retention in the program was higher, when clinic providers played an active role in program recruitment and referral. Communication with providers is key. When CHWs found elevated BP and glucose measures at the time of the home visit, they notified providers so that emergency appointments could be scheduled. The CHWs participated in regular meetings with clinic staff to inform providers of the status of the patient visits.
Recommendations: CHWs may be useful in clinical and community settings to bridge the relationship between health care systems and patients, facilitate access to services, perform informal counseling on self-management skills, and improve ABCS health outcomes in rural settings.
Learning Areas:Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Identify potential challenges of implementing the clinical community health worker model in low-resource, rural communities. Discuss strategies for implementing and sustaining a clinical community health worker program in low-resource, rural communities.
Keyword(s): Chronic Disease Management and Care, Community Health Workers and Promoters
Qualified on the content I am responsible for because: I have been in public health for over 15 years, working on programs to prevent and control child abuse, injuries, infectious diseases, and chronic diseases such as diabetes, heart disease, stroke, and cancer. In my current role, I am responsible for leading community, regional, statewide efforts to combat chronic disease.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.