Enhancing Care for Diverse Communities: The Role of Community Health Workers

The 2020 U.S. Census revealed that the United States is more racially and ethnically diverse than ever before. Nevertheless, the field of palliative care, like other medical disciplines, lags significantly behind this demographic landscape. For example, data shows that only 4.5% of hospice and palliative fellows identified as Black, compared to 12% of the overall US population. Systematic studies have found improved partnership and participatory decision-making in care delivery with racially concordant clinicians, which is especially important when facing a serious illness.

Studies show that the lack of diversity among U.S. clinicians may contribute to adverse outcomes for Hispanic, Black, and other populations. In addition to potential communication challenges arising from cultural and linguistic differences, these communities may lack trust in the health care system perpetuated by discriminatory medical policies and practices.

Equity in health care—including diversity among health professionals—is a complex and multifactorial problem, and no single ‘solution’ can resolve current-day inequities. However, strategies that improve racial concordance between patients and professionals are an avenue to deepen trust and improve communication within historically oppressed patient populations.

One such strategy is the Community Health Worker (CHW) model, which has garnered significant recognition for its progress towards health equity. Per the American Public Health Association (APHA), a CHW is “a frontline public health worker who is a trusted member of and/or has a close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health care providers and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”

CHWs may also be called “lay workers,” “promotores de salud,” “patient navigators,” “community liaisons,” or “peer coaches.” CHWs complement medical care delivery; with their connection to the community, CHWs can help bridge the divide between the medical system and marginalized communities.

Incorporating CHWs into health care is not new. CHWs have been a rallying voice within the APHA since the 1970s but have recently garnered increased support and attention due to their positive impact on health equity.

CHWs and social workers have distinct yet complementary roles in supporting patients with serious illness. Some responsibilities that CHWs can fill are often excluded from health care delivery, including:

• Bridging communication between patients and their social workers, nurses, and/or physicians.
• Supporting outreach and education within specific communities (e.g., promoting health literacy, increasing the use of preventive services, and explaining the myriad social services offered by social workers).

While CHWs play an invaluable role in providing emotional support for patients and families, social workers bring the essential skills of counseling, navigating family dynamics, overcoming obstacles, and much more. CHWs improve the efficiency and effectiveness of social work by explaining its role, “translating” its benefits to improve engagement, and ensuring follow-up with community services.

Racial and ethnic congruence with the communities CHWs serve affords them an unparalleled understanding of cultural, linguistic, and social nuances, facilitating enhanced community engagement. In recent times, hospitals and Federally Qualified Health Centers (FQHCs) have hired CHWs as formal employees—and in 2010, the Bureau of Labor Statistics added CHW as an occupational code. Some colleges now offer CHW certification and training programs similar to public health curricula.

Given the diversity of a CHW’s educational background, working environment, and specialty of the employer, scopes of work may vary. Using job descriptions from various FQHCs, we compiled a list of three common CHW job duties performed in patients’ homes, social settings, or both:

• Patient-Clinician Liaison: CHWs use their community’s cultural and linguistic characteristics, ensuring that health care information is communicated effectively and understood.
• Resource Navigation: CHWs help individuals navigate the health care system by explaining and connecting them to medical professionals, specialists, screenings, and social services based on their needs.
• Health Education and Promotion: CHWs provide education on health topics, disease prevention, nutrition, hygiene, and other wellness practices to individuals and communities. They help people understand and adopt healthy behaviors in alignment with their preferences.

An expanding body of research underscores the CHW’s effectiveness in aiding populations that underutilize palliative care. A study published in 2014 found that after adding CHWs to a patient-centered medical home in the South Bronx, New York:

• Emergency department visits fell by 5%
• Hospitalizations dropped by 12.6% among patients with chronic health issues
• There was a net savings of $1,135 per patient
• There was a net savings of $170,213 annually generated by each CHW

An earlier use of CHWs occurred at Harlem Hospital Center, where they supported Black women when accessing mammograms and early treatment opportunities. The CHWs helped to nearly double the five-year breast cancer survival rate in that neighborhood. More recently, CAPC completed a scan of interventions to improve care for Black patients and families facing serious illness and identified at least 19 interventions across 15 states using CHWs. The impact of these included improved advocacy for evidence-based care and increased:

• Understanding of illness and trajectory
• Family discussions and goal alignment
• Understanding of palliative care
• Understanding of hospice
• Completion of advanced directives
• Emotional support/reduce stress

Having discussed the diverse applications of CHWs, how does a palliative care team finance a CHW? It is crucial to develop a customized approach to financing that aligns with your palliative care team's specific requirements. If your team does not have the resources to hire a dedicated CHW, explore partnerships with state or community-based programs staffed by CHWs, who may extend support to patients in your shared service area. Also, many state and local government websites maintain online registries or networks where you can identify alternative avenues of support for your patients.

Additionally, teams with limited financial resources can pursue grant funding opportunities to initiate a CHW program, particularly if it would improve access to populations proven to be underserved by palliative care. Several private foundations and states endorse these program initiations due to their positive impact on advancing health equity. If you choose this route, ensure a sustainable plan is in place beyond the grant period, possibly through hospital leadership’s commitment to ongoing salary support or funding through a specific value-based program.

The 2024 Medicare physician fee schedule makes some Medicare reimbursements for patient navigation services available.

Lastly, if your team has the resources to integrate CHWs, you may be able to improve the overall efficiency and effectiveness of your interdisciplinary team (IDT), expanding revenue in excess of the additional salary costs. The first step that you would take is to ensure that there is a clear understanding of the CHW’s scope of practice and role compared to the other positions on the IDT.

Dr. Nathan Goldstein did this for the outpatient program at Mount Sinai Hospital in New York City. During an IDT retreat, his team set aside time to discuss the roles and specific responsibilities of each team member—including CHWs. They made sure to address the scope of practice and existing legal boundaries. They also discussed which responsibilities belong to the social worker and which would be appropriate for the CHWs, given the inevitable overlaps. Mapping this out helped his team identify where the overlaps lay and where handoffs should occur.

While the CHW model is impactful, it is not without its own challenges. There is no standardized pay for CHWs, and many are often paid lower wages compared to other health care workers with similar levels of responsibility. This can be seen as a reflection of the undervaluation of their work. Additionally, low wages can make it difficult for sustainable living, leading to high turnover and reducing the quality of care provided to the patient.

Moreover, many health care organizations require a bachelor's or master's degree for CHW roles, creating a barrier for job candidates from underserved communities. With the escalating costs of college education, many people with limited financial resources find it nearly impossible to attain advanced degrees. That said, if you are hiring a CHW, consider removing the educational requirements from the job description to ensure that candidates from the underserved community of focus are not screened-out of the application process.

Community Health Workers are an effective solution to the challenges posed by a growing health care workforce shortage, an increasingly diverse patient population, and the rise in health care costs. Incorporating CHWs offers a unique opportunity to expand your team’s reach in effective and more cost-efficient ways. If your organization has outpatient and community-based programs, consider adding CHWs to the team.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.