Why we need to support community health workers

They address non-medical issues affecting patient health

MEDICAL VISITS are rarely straightforward. Add factors such as poverty, chronic stress, complex medical issues, functional impairment, and barriers to material needs, and caring for one’s well-being becomes exponentially more layered and challenging.

A community health worker is a human service worker who supports individuals and families in navigating systems, advocating for their needs, and building relationships that foster social-emotional well-being. In the context of the medical home and integrated behavioral health care settings, community health workers are increasingly becoming a fixed part of the care team, addressing many of the non-medical issues that impact health. Unfortunately, the presence of community health workers on care teams is not yet supported by a sustainable payment system, nor by widespread understanding of what the profession entails.

The Affordable Care Act recognizes poverty, housing, and food access as critical social determinants of health and has in fact implemented screeners at medical visits to collect data on these life domains to track their impact on overall health. Community health workers are hired to address those very issues; their efforts must garner the financial and professional respect that match the gravitas of what they do.

Wanda Resto is a community health worker at Greater New Bedford Community Health Center who has been working in the medical field and living in the New Bedford area for over 20 years. Wanda works on a multi-disciplinary team of community health workers, behavioral health clinicians, and primary care providers in the pediatric department at the New Bedford health center as part of TEAM UP for Children, a pediatric-integrated behavioral health initiative. She works with a specific pediatrician daily, which allows her to get to know this doctor’s patient panel and work style intimately. She scrubs the schedule a day in advance and calls families to complete a questionnaire that highlights concerns about a child’s developmental or mental health prior to their visit – one of the new virtual workflows designed to limit the amount of time a patient spends in the clinic during the COVID-19 pandemic.

During this initial phone conversation, Wanda notes the family’s concerns, ranging from developmental issues to challenges navigating the school system to food scarcity. At the New Bedford facility, the percentage of families reporting food insecurity reached 22 percent during the COVID-19 pandemic.

Wanda and two of her colleagues share an office, which enables them to learn from each other’s communication styles in real time by overhearing interactions with families. “We’ll say to each other, ‘I like how you asked that question, let me try that,’ or, ‘do it like this instead,’” says Wanda, adding that they’re careful to present information in a way that is culturally informed.

If a concern is raised on the phone, Wanda makes herself available during that family’s appointment to be called for a warm hand-off, defined in integrated care as a direct connection with another member of the team during a patient’s visit. Sometimes these warm hand-offs involve a referral to early intervention services or scheduling a meeting with the child’s school. In other cases where there are not specific action steps, Wanda will call the family periodically to check in, creating an on-going relationship where the family knows they can reach out with questions, needs, or concerns. On an average day, Wanda interacts with 12 to 15 families, both on the phone and in person.

“Completing a referral is not just about sending someone to see a specialist,” says Lissette Blondet, executive director of the Massachusetts Association for Community Health Workers. “It’s about collaborating with the patient or client so that they see the benefit of going to that appointment. Community health workers are critical in making this link, particularly among ethnic groups who might be hesitant, because they are able to provide coaching, translation, and depth that support the client’s grasp of a complex medical system.”

Blondet contends that community health workers save costs. People are more likely to share their concerns when they feel comfortable, resulting in more efficient and productive medical visits. “If you go to a primary care visit and don’t feel comfortable and only ask one third of what you were supposed to ask – that means two more primary care visits to maybe get to the problem,” says Blondet. “So if we created an environment to maximize the visit, which includes CHWs, the system would save a lot of money.” We cannot underestimate the impact of cultural brokering on the efficiency of the system.

Wanda recently completed Massachusetts’ community health worker certification, which requires 4,000 hours on the job, but her life experience represents far more than that. “When I took the classes, I realized I’ve been a community health worker since I was born.” Reflecting on her upbringing in Puerto Rico, where her family would collect and distribute clothing and food donations to neighbors, she says, “My family [members] are community health workers. My family’s been feeding people. As I’m listening to the classes, I’m like, ‘my grandmother is a community health worker.’”

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It is the community health worker’s role in behavioral health, though, that is most often overlooked, according to Blondet. “It’s not therapy but it’s coaching at its best,” says Blondet. “Community health workers embody behavioral health integration – they deliver services with that understanding and that trauma-informed approach because they have walked those shoes. They have lived in those neighborhoods that are disproportionately impacted by COVID, by food deserts, and by poverty.”

Given how critical this work is, why does it continue to be so under-valued? We know that many patients would fall through the cracks without the efforts of community health workers. As our understanding of whole health broadens, so too should care teams and payment systems to value those community health workers who have been doing this work all along. Whether by reimbursing for their services under our current fee-for-service model or shifting toward a system that incorporates them into a collaborative and value-based care model, community health workers are an integral part in the push toward more client-focused, holistic healthcare delivery. They are the safety net, and it would not be possible to create an equitable health system without them.

Grace Riordan is the communications and policy coordinator for TEAM UP for Children at Boston Medical Center. Sonia Erlich is a licensed mental health counselor who provides patient care at DotHouse Health Center in Dorchester and serves as manager of clinical role development for TEAM UP for Children at Boston Medical Center.