Community Health Workers will Save Us All

Photo by Tim Mossholder on Unsplash

I am perched on the exam table wrapped in a paper gown, waiting for my first appointment with a new primary care provider. The nurse is typing into my chart very quickly, her long nails clicking loudly on the keys. I am cold in that gown, and visibly shivering. I don’t think anyone notices. I am new to the city and shopping for a medical home — with very little consumer information to go off of, I choose a provider off the list my new insurance company provides based on distance from my house.

The nurse flies through the screening questions as if there is a bonus for speed. I feel like I’m in that American Gladiators game where the Gladiators shoot tennis balls out of the gun at the contestant. The nurse barely looks up from the screen as she peppers me with questions like:

“Do you have enough food?”

“Are you afraid of being fired?”

“Can you pay your rent or mortgage?”

I respond with one-word answers: “Yes, no, yes.” I give these answers because the truth is too complicated, and I know we don’t have time to dig into why I have a good, full-time job, and life still feels like it’s draining my bank account dry every month. This nurse’s role is not to help me unpack why I’m always afraid of being fired, even when I know I am doing just fine.

“Last question,” she says, “do you feel safe at home?”

And this time, I pause. I sort of freeze. There is a movie montage playing in my head of my home life, highlights and lowlights, memories I had shoved away. She looks at me for the first time, raises an eyebrow. I stutter, “um… yes… yah, totally,” and she sighs in relief.

“Good,” she says, “that’s a lot easier.”

All care providers operate within a healthcare system that incentivizes efficiency. Appointments are overbooked to make sure that the day is full after the inevitable cancellations. A little extra time with your first patient in the morning can snowball into super-late appointments later in the day, affecting your patient satisfaction and the quality of care. There is little incentive baked in to take your time, get to know your patients, and calmly listen as they tell you about their life.

Even if we know that empathy and connection are at the heart of competent care (as I wrote about here), there is only so much one physician, one nurse or one case manager can do. Think about the people you turn to for guidance on the day-to-day. Do you choose them because they always have all the “correct” answers? Do you prefer them because they dole out accurately calculated, always-sound advice? Likely not. You feel drawn to them because they listen, because they challenge you to find answers and because they make you feel heard and known.

Enter the Community Health Worker (CHW for short). Employing CHW’s is not a new concept; the idea of communities coming together to lift the health of others in the absence of reliable medical care is a practice as old as the human race. The modern evolution of the role of a CHW is rooted in social justice. You can read an excellent timeline of CHW’s in the US here and get more definition of CHW responsibility here.

CHW’s are an integral part of a holistic healthcare system rooted in trust, empathy, and equity. Randomized trials like this one find high returns on CHW investment for health outcomes and costs of care. Early findings on CHW’s effectiveness in managing chronic conditions, prenatal and postpartum health, and supporting healthy lifestyles — coupled with funding from the Affordable Care Act — led to a massive influx of CHW’s in care settings.

To support CHW’s, those who hire them must ensure that this critical workforce has the tools they need to succeed. The results of a CHW intervention are highly contextual.

You can not just embed a CHW in your care setting with minimal infrastructure and expect miracles to happen.

At mySidewalk, we think a lot about how our tools can best support the healthcare system’s reimagining. If CHW’s are essential, then it’s our responsibility to make sure that our solutions are useful.

GIF Courtesy of the Antelope Valley CHNA powered by mySidewalk and co-created by Community Health Workers

Here are three things we’ve noticed in our work that can be the difference between a successful CHW program and a not-so-great one:

1. A good CHW program is also a workforce development program. Many CHW’s we have trained in our platform lack experience in data science. CHW training programs typically focus on the patient experience (for good reason!) and provide a crash course in disease management, cultural competency, and privacy laws. The best CHW programs we’ve seen include skill-building that is ongoing and rooted in the advancement of the CHW’s career. Training in public speaking, policy advocacy, data visualization, and data storytelling should all be part of a comprehensive approach to CHW enablement.
2. Everyone respects CHW’s as part of the care team. Have you ever showed up to a new job on day one and felt like nobody knew you were coming, and nobody knew what work you were supposed to do? We’ve all been there. In the most successful clinical settings, we see CHW’s valued by physicians, nurses, and office staff as experts in their own right. Even outside the doctor’s office, we are impressed by how our clients engage CHW’s in community health improvement. Many of our customers employ CHW’s as street intervention specialists trained to de-escalate conflict. Others leverage CHW’s as peer educators deployed to prevent postpartum depression among first-time moms and advocate for equitable health policies designed to support moms and babies. In California, CHW’s are even shaping the very definition of a healthy community through their mySidewalk training and the co-creation of neighborhood health equity assessments.
3. Recruiters don’t tokenize or simplify CHW’s. The most successful CHW programs are set up for success before the CHW’s enter the building. Recruitment for CHW’s should be intentional and thoughtful. The best CHW programs are community-owned; communities that feed CHW’s into the system are the same communities that benefit from their hard work. Healthcare systems must engage folks from day one. Communities are complex, and we can’t reduce an ideal CHW to one or two demographic characteristics. Just because someone hires a CHW from a Latinx neighborhood doesn’t mean they reflect the average resident. Our partners regularly use the mySidewalk platform to explore neighborhoods and understand whom they should recruit. Is a Latinx neighborhood majority Mexican? What’s the English literacy level? How long have those born in another country been in the United States? What job sectors are present, and are they well paid? Are jobs in this community dangerous? These types of questions help set the stage for optimal concordance between the patient and the CHW.

I never went back to that American Gladiator primary care office. The physician wasn’t warmer than the nurse, so I chalked it up to office culture and tried again. I eventually found a fantastic PCP who was kind, thoughtful, and brilliant — she felt like a confidante, and I could open up to her and her staff in a way I hadn’t before. What they couldn’t handle in-office, they referred to other providers who shared their vibe.

We all have to stop and recognize that medical care — no matter the type — can be an intimidating, scary experience. The best care comes when the patient feels like they have a team behind them and possess the confidence to make the healthiest decisions.

CHW’s are the not-so-secret magic that completes the team.