Community health workers, lay people who live in the community they serve and understand the challenges of the people who live there, can teach at-risk patients how to navigate the healthcare system, help them obtain community services, and support them in overcoming obstacles to care.

  • The concept of community health workers is gaining ground as healthcare payers move toward basing reimbursement on quality and hospitals assume risk for patient outcomes after discharge.
  • Case managers should familiarize themselves with community organizations that offer care coordination and partner with them to ensure that at-risk patients avoid unnecessary hospitalization and ED visits.
  • For a community health worker program to be successful, providers must plan the process carefully, clearly delineate the roles and responsibilities, and hire people with good communication skills and who relate well to others.

New reimbursement models and increased financial risk for hospitals make it imperative for case managers to work even harder to ensure that patients have what they need to be safe and follow their treatment plan after discharge.

Making follow-up calls, setting up primary care appointments, and scheduling home health visits all help, but they are short-lived. Some patients have needs that go beyond a telephone call or a few visits from a home health nurse.

Hospital stays are episodic and about 10% of patients who return to the community cannot manage independently, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts. Home care is one solution, but the visits don’t last forever, and the at-risk patients will need continued support after home care ends, she adds.

Navigating the healthcare system is challenging for everyone, but it’s particularly difficult to understand for patients who are uninsured, undocumented, living in poverty, and/or have limited proficiency in English, says Patricia Peretz, MPH, lead for the Center for Community Health Navigation at New York-Presbyterian Hospital.

That’s where community health workers can be helpful, she says.

Community health workers (CHWs) live in the communities in which they work and understand the culture, language, and the challenges of the people they support, says Jill Feldstein, MPA, chief operating officer for the Penn Center for Community Health Workers at the University of Pennsylvania Health System.

“Hospitals and other clinical providers are now being held responsible for the health outcomes of their patients, but the social determinants of health have a tremendous direct impact on these health outcomes,” says April Hicks, MSW, chief operating officer of the Community Health Worker Network of NYC. “Clinicians are not trained or equipped to address these barriers, but community health workers are. That is precisely where they live and work. They help address the root causes that are creating barriers to improving health outcomes.”

Community health workers share life experiences with the patients they assist, which allows them to form relationships more quickly and easily, Feldstein says. “Because of the shared life experiences, patients are more likely to tell them what is going on in their lives,” she adds.

Community health workers are uniquely positioned to build trusting partnerships, Peretz says. “They can be the voice of the community in clinical settings and bridge gaps in care,” she adds. (For details on New York-Presbyterian’s two community health worker models, see related articles in this issue.)

When case managers make follow-up telephone calls to patients, they receive a limited amount of information and never know if they are getting the whole story, says Donna Zazworsky, RN, MS, CCM, FAAN, principal of Zazworsky Consulting in Tucson, AZ.

“Telephone calls rarely uncover all the issues a patient is facing — they aren’t addressed and the patient’s condition worsens. Someone who visits patients in the home gets a much better picture of the patients’ condition and the obstacles the patients face,” Zazworsky says.

Home health nurses may be in the home for 30 minutes at a time for a few weeks. Physicians typically spend as little as 10 minutes with patients, Hicks points out. “That’s not enough time to build the trust needed to help some at-risk patients overcome the obstacles to receiving care,” she says.

Patients see community health workers in the grocery store, in the park, in church, or other places in the community, Hicks points out. “They know them and trust them. They let them into their homes and tell them things they would never tell a provider in an office,” she adds.

Many hospitals have a transitional case manager who touches base with patients by telephone, Cesta points out. This works with lower-risk patients, but high-risk patients may need more support. Community health workers are part of the neighborhood and spend time with patients in their home, which makes a big difference, she adds.

“There is a difference between making a referral and ensuring that the connection actually happens. The community health workers make sure appointments are scheduled, go to them with patients, answer questions, and make sure the visit goes well and the patient understands everything,” Feldstein says.

The community health worker model lends itself to healthcare reform and innovations in how care is provided, Hicks says.

“Community health workers are the wave of the future. People are recognizing their value in helping at-risk people stay healthy in the community. The hope is that as we continue to think differently about how to care for people, healthcare providers will be able to appropriately and effectively integrate community health workers into the continuum of care,” she adds.

“Community health workers are someone that patients are familiar with, whom they trust, and who they are likely to listen to. They go into the home and can see the conditions in which the patient lives and get a firsthand impression of the family dynamics and the patient’s support,” she says.

Hicks recounts reports from CHWs who worked in a program designed to teach parents how to care for their children’s teeth. But, the CHWs reported that they seldom were able to immediately address oral health because the parents had so many pressing issues.

“Oral health wasn’t relevant or a priority when they are concerned with feeding their family or having a job. This is the difference between program goals and individual goals. CHWs help bridge the gap in these goal differences and help systems better engage and support client needs,” Hicks says.

The parents asked for help finding a job, getting their utilities reconnected, or finding a food pantry so they could feed their families, Hicks says. “They were burdened with so many other complexities and realities that they couldn’t work on oral health. These are the social determinants of health. CHWs are not clinical and while they may be working in programs addressing chronic illness and clinical issues, they are addressing root causes. CHWs learn firsthand about what these people are facing in a way that other providers cannot,” she says.

People want other people to like them and think highly of them, so they aren’t likely to discuss their status or living situation with authority figures like physicians or case managers, Hicks says. “Community health workers are in the community and in people’s homes and they see the issues that need to be addressed,” she says.

The concept of community-based care coordination is not new, but the idea is beginning to gain traction as reimbursement shifts to value-based payment, Cesta says.

“The healthcare industry is starting to realize that we have to address costly at-risk patient populations. If we don’t stay on top of them and support them in the community, they are likely to be problematic and detrimental to the hospitals’ bottom lines,” Cesta adds.

At-risk patients may be people with chronic conditions who aren’t managing themselves well, people who have behavioral health issues, and many who also have a clinical condition, elderly patients who need help with activities of daily living, or other patients who just can’t manage without assistance, Cesta says.

Hospitals need to hand off their at-risk patients to someone in the community who can help them overcome the obstacles to care, Cesta says.

Studies in the 1990s pointed out the advantages of having case management in the community to help patients avoid readmissions or ED visits after discharge, Cesta adds.

“But without financial incentives, providers were not interested in reducing readmissions. We’ve been waiting for reimbursement to catch up with the idea. Now with bundled payments, the Centers for Medicare & Medicaid Services’ readmission reduction program, and accountable care organizations, we’re almost there,” she says.