Bridging the Gap: The Vital Role of Community Health Workers in Transforming Care
A community health worker (CHW) is someone who works directly with the community to support their health and well-being. Because they are part of the community and deeply connected to it, people trust them. This trust helps CHWs bridge the gap between the community and health or social services, making it easier for people to access care and ensuring the services are delivered in a way that respects their culture and needs.
Over time, the duties of CHWs have evolved. Years ago, they mainly helped social workers and nurses who could not get in touch with members. Over time, CHWs mastered the tools to locate members in need and now complete home visits and non-clinical assessments. They also counsel members to accept case management and have added non-clinical member education and nursing-facility transitions to their duties.
CHWs are vitally important in rural and frontier areas. Effective CHWs are those who are familiar with the local customs and community resources. They play a key role in areas with limited healthcare services, delivering culturally appropriate health and prevention education. CHWs guide members through the healthcare and social-services systems, enabling nurses and social workers to focus on practicing at the top of their licensure.
In larger cities, CHWs can see more members in a day than their counterparts in frontier areas where they have much longer travel times between facilities and member homes. Rural members have a harder time finding community resources, primary care physicians, specialty physicians, dental and vision providers and transportation without a long drive. CHWs can assist members to find the closest providers to their area.
We all know that delivering healthcare means more than doctor visits and medication. For example, nutrition is foundational to everyone’s health, and CHWs are often called upon to connect members to food assistance and other social resources. It’s rewarding to see the difference these efforts make in the lives of members.
One such member, “Mike,” recently moved from a nursing facility to his own apartment. He was delighted to be living on his own, but he had some challenges that a CHW was able to help him address. Although he didn’t live far from the local supermarket, his unexpected expenses had left him with little money for food. A CHW delivered a food box to him and connected him with a nearby resource for additional help.
As an added bonus, the CHW also was able to enrich and simplify his life. She helped him access a streaming service so he could watch TV without having to go to the apartment lobby.
Today’s CHWs also provide care coordination for members in long-term care facilities, which can be especially difficult in rural and frontier areas. When members desire to transition to the community from a long-term care facility, a “pod group” made up of social workers and CHWs research and brainstorm solutions to support members’ best health outcomes and life satisfaction.
Transitioning from a nursing facility to the community in rural areas presents unique challenges due to factors such as geographic isolation and fewer available resources. Understanding these obstacles and tailoring solutions to the rural context is critical for ensuring a successful transition.
One particularly challenging example involved a member in her 30s. She had impaired balance, limited mobility, weakness and paraplegia but overcame physical health barriers to successfully move back to the community from a nursing home. It took her a year to be ready to move into a wheelchair-accessible housing community, but she is thriving today, thanks to the help of a team that included CHWs and social workers.
In conclusion, community health workers are invaluable assets in the healthcare system, especially in underserved areas where access to care and resources can be challenging. Their ability to build trust, navigate complex systems and address non-clinical needs ensures that individuals receive holistic support. By connecting people to vital services and fostering independence, CHWs not only improve health outcomes but also enhance the quality of life for those they serve. Their dedication and resourcefulness demonstrate the profound impact that compassionate, community-centered care can have in transforming lives.
is the senior manager of care coordination for Sunflower Health Plan, a Centene Corporation company. Sunflower is a managed care organization in Kansas that serves members in the state’s KanCare Medicaid program, as well as members in Medicare Advantage and the Health Insurance Marketplace.
She has managed a caring team that includes Community Health Workers since 2011. Sunflower’s program has changed over time to empower these CHWs to do more to improve the lives of members. Sunflower requires its CHWs to be certified by completing the Kansas Department of Health and Environment-approved community health worker training. This training helps equip them to understand and resolve the complex challenges of Sunflower’s membership.
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