Insightful Interventions: CHWs Using Data to Drive Change
Community health workers (CHWs) are the unsung heroes of public health, deeply embedded in the communities they serve. CHWs are diverse and dynamic, spanning a variety of healthcare settings such as within managed care organizations, medical provider centers, and non-profit community-based organizations. Each CHW brings their unique expertise, passion, and focus, whether it’s improving maternal health, managing chronic diseases, or promoting mental health awareness. Within healthcare teams, their roles may be non-clinical; however, they serve as integral members of the multi-disciplinary care teams to support specialized populations.
Relying on their lived experiences, CHWs—referred to as “feet on the street” or care extenders—use their expertise to connect with individuals. They might also be known as care team members, social support team members, or care support specialists. The unique skills and experience of CHWs set them apart from others on the care team, enabling them to strategically support key team functions and cater to specialized populations.
THE POWER OF PERSONAL CONNECTION
One of the most powerful attributes that sets CHWs apart is their lived experience and ability to connect on a personal level with the people they serve in the very communities where they live and work. Their intimate, deep-rooted understanding of local cultures and challenges qualifies them to address the specific needs of their communities. CHWs are not just health workers; they are trusted neighbors, friends, and advocates who people turn to in times of need. This established trust allows CHWs to effectively bridge gaps in healthcare and enables CHWs to effectively advocate for equitable access to the support and resources patients need, regardless of background, circumstances or resources.
THE INTERSECTION OF CHWS AND DATA
Typically, the focus of CHWs aligns with direct and supportive care for at-risk populations. However, a deeper opportunity lies in exploring the trends and outcomes of the CHW interventions, especially with specific population needs. One way that CHWs can spot health trends for at-risk groups within their communities is through a combination of organizational and public data sets. Organizations may have their own unique data sets and assessments to interpret CHW interventions—such as service, program utilization and community needs—and provide visualizations about the individuals they serve. Public data sets are also vital to expand the understanding of the communities, providing valuable points of reference for validating hypotheses.
To give you a better idea, here are four examples of public data supportive of CHW initiatives:
- Healthy People 2030: A federal initiative that sets data-driven objectives to improve health and well-being across the United States. It offers data on a wide range of health indicators, helping CHWs identify and address health disparities.
- March of Dimes: “Nowhere to Go: Maternity Care Deserts Across the US.” This report uses data to highlight counties across the United States that lack adequate access to maternal health services, offering critical data support to CHWs focused on maternal health outcomes and interventions.
- Community Health Rankings: County Health Rankings & Roadmaps
- Social Vulnerability Index (SVI): Published by the Centers for Disease Control and Prevention, the SVI uses data from the U.S. Census to determine the social vulnerability of each census data track, allowing CHWs to effectively identify communities that may require additional support.
Integrating organizational and public data sets is crucial for CHWs to effectively identify and support at-risk populations. By leveraging both types of data, CHWs can develop focused, measurable programs that address specific health trends and needs within their communities. For example, Community Health Needs Assessments conducted by organizations leverage qualitative interviews and focus groups from within the community alongside quantitative elements that capture not only demographic information but also access to services such as healthcare providers per capita, distance to healthy food, and transportation. This dual approach enhances the accuracy of identifying at-risk groups and broadens the scope of intervention strategies, ensuring a comprehensive and informed response to community health challenges.
Imagine the impact when CHWs can pinpoint exactly where to direct their initiatives, thanks to the rich insights from both organizational and public data. It is like having a detailed map guiding them to the heart of the issues, allowing them to make a real difference in the lives of those who need it most.
DATA-DRIVEN ADVOCACY
How does access to data extend to community resource availability and further support public health initiatives?
One core responsibility of CHWs is advocating for resources to meet the demands of the at-risk populations they serve. By using data to identify areas with the greatest need, CHWs can advocate within their organizations and broadly in the community that resources are allocated equitably, providing essential health services to those who need them most. When there is a disparity of resources, data-driven advocacy empowers CHWs to make a compelling case for funding and support, highlighting the specific needs and challenges of their communities.
This approach not only helps secure necessary resources, but it also fosters a sense of urgency among stakeholders to prioritize the health needs of at-risk populations within the community. With accurate and comprehensive data, CHWs can paint a vivid picture of the health landscape, making it clear where interventions are needed and why. This, in turn, builds stronger support networks, drives meaningful change, and improves health outcomes for the entire community. Integrating data into their work underscores the importance of evidence-based practices in achieving sustainable health outcomes.
GATHERING INSIGHTS: HOW CHWs COLLECT DATA
CHWs not only serve on the front lines of health support and data utilization, but they also play a crucial role in data collection, which is essential for understanding and addressing community health needs. Here are four examples of how they gather data:
- Surveys and Questionnaires: Conducting non-clinical surveys and assessments to gather information on health behaviors, needs, and outcomes. Standardized screening tools such as the Accountable Health Communities Health Related Social Needs and PRAPARE provide a point-in-time assessment for identifying individuals’ critical social health needs.
- Interviews and Informal Conversations: Collecting qualitative data through one-on-one interviews and informal conversations provides deeper insights into health challenges and perceptions. These can occur through direct support of individuals or with community leaders in development of population health programs.
- Community Observations: Observing community environments and behaviors allows CHWs to gather environmental data that might not be captured through surveys or interviews. This includes noting the availability of healthy food options, safe transportation resources, and other social determinants of health.
- Collaboration with Healthcare Providers: Working closely with healthcare providers to access medical records and other health data ensures a comprehensive understanding of health status and challenges. This collaboration is multifaceted and may involve accessing electronic health records, data sharing and integration, and collaborative multi-disciplinary team meetings to discuss social and environmental factors affecting health.
It is important to recognize that dependence on data has its own limitations, and we have a responsibility to guard against unconscious biases. Biases can negatively impact our credibility, leading to disparities in health outcomes and a lack of trust in the interventions implemented.
CHARTING THE FUTURE
As we look to the future, the transformative power of data for CHWs becomes even more apparent. Data can help inform the training needed, such as advanced health education, data management skills, and technology use, which are becoming increasingly important to support the unique challenges of the populations they serve. Training in data analysis and interpretation empowers CHWs to make informed decisions and advocate effectively for their communities. Community engagement efforts can be strengthened by building trust, staying connected and transparent with community members, and using data to show the effectiveness of health programs and interventions. Building strong networks with local organizations and stakeholders and sharing data insights can establish valuable private-public partnerships. And don’t forget about feedback! Setting up ways to receive feedback— through both qualitative and quantitative data—ensures health services meet their needs and preferences.
It’s not just about numbers; it’s about shaping policy and public health strategies to drive real, scalable change. This allows CHWs to tackle emerging health issues and respond to potential crises promptly. But the magic of data does not stop there! Data is essential for evaluating the effectiveness of health programs, ensuring they meet community needs. By focusing on these areas and leveraging data, we can significantly enhance the future of community health work, leading to better health outcomes and more resilient communities.
DISCLAIMER
Please note that depending on federal budget changes, programs referenced in the article may or may not have the most up-to-date information.
REFERENCES
March of Dimes. (2024). Nowhere to Go: Maternity Care Deserts Across the US. https://www.marchofdimes.org/maternity-care-deserts-report
Office of Disease Prevention and Health Promotion. (2020). Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030
United States. Agency for Toxic Substances and Disease Registry. Geospatial Research, Analysis & Services Program. (2020). CDC Social Vulnerability Index: A tool to identify socially vulnerable communities. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/111729
University of Wisconsin Population Health Institute. (2025). County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/
https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2021.674858/full
https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.12657
https://www.urban.org/invest-data-capacity/stories-field/advocacy-and-policy-change-data
https://www.chcs.org/media/SDOH-Complex-Care-Screening-Brief-102617.pdf
https://www.cms.gov/priorities/innovation/media/document/ahcm-screeningtool-companion
, MSW, LCSW, clinical strategy & practice lead, Humana, Inc., is a Licensed Clinical Social Worker with 20+ years of experience as a social worker. Her career has spanned leadership, direct service as a care manager and private practitioner. Christine’s background encompasses community focused care delivery and managed care organizations. She has deep experience in care management operations and strategies for promoting health equity. Christine’s current scope of work supports the enablement of equitable population health innovation through the development of clinical products. Christine resides in Florida.
, MSHAN, BA, CCM, population health manager, Humana Healthy Horizons in Kentucky, heads a dedicated team of community health workers, focusing on addressing health-related social needs and improving health outcomes. With nine years at the company, she has participated in both member-facing and leadership roles. Driven by a specialized interest in data-driven outcomes and equitable healthcare access, Alyssa consistently applies her expertise to advocate for her team and member populations. Alyssa resides near Cincinnati, Ohio.
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