Caring for people with complex medical and social needs requires a holistic person-centered approach that recognizes non-medical factors such as housing, transportation, food insecurity, and social supports. To help patients address these underlying needs, many provider organizations are tapping the unique skill set of community health workers (CHWs). CHWs typically have shared lived experience and a first-hand understanding of the cultural and community norms of the populations they serve. As such, they are able to build relationships with patients based on mutual understanding and respect and help them navigate complex health and social service systems to access necessary care and services.
Heidi Behforouz, MD and Clemens Hong, MD, MPH provide technical assistance to sites participating in the Center for Health Care Strategies’ (CHCS) Transforming Complex Care initiative, made possible through support from the Robert Wood Johnson Foundation. Drs. Behforouz and Hong understand the importance of integrating CHWs into care teams and have been collaborating in this work for 12 years. The two cofounded Anansi Health, a nonprofit technical assistance institute that promotes best practices for incorporating CHWs into care teams. Currently, they both work for the Los Angeles County Department of Health Services’ Care Connections Program and Whole Person Care Program, both of which use CHWs to help care for the county’s sickest, most at-risk patients. CHCS recently spoke with Drs. Behforouz and Hong to learn about their experiences in training, supervising, and integrating CHWs into complex care teams.
Q: Which kinds of trainings for CHWs have you found most useful?
A: One of the most important trainings for CHWs is motivational interviewing, which helps build the patient and provider relationship through clear communication, active listening, and goal setting. This type of training gives CHWs tools to help patients acknowledge unhealthy behaviors and increase self-management to facilitate behavior change. We also recommend harm reduction and trauma-informed care trainings to help CHWs understand the relationship between trauma and conditions like substance use disorders, eating disorders, depression, and anxiety. While most training typically occurs prior to a CHW working with patients, training should be ongoing so CHWs are continuously learning and enhancing their skills.
Q: What should be done to ensure CHWs’ safety?
A: CHWs spend a lot of time in the field and working within the patient’s home, so training should emphasize safety, especially assessing the safety of a patient’s home, the severity of a situation, and how to handle an emergency. CHWs should be trained on how to set clear and respectful boundaries, because delivering care in the home can blur the lines between personal and professional. Prior to working with a new patient, we suggest that CHWs complete a consent to care form that lets the patient know that they are responsible for the CHW’s safety while in their home. We also recommend extensive role playing and regularly scheduled supervision with feedback to help CHWs practice and perfect their skills.
When CHWs first start working, they should be paired with another CHW to serve as a “buddy” during home visits. Eventually, they will each work independently, but for all home visits, they should “check-in” and “check-out” with their buddies via text messaging. We recommend giving all CHWs laminated emergency information cards so they have necessary numbers and hotlines in hand at all times.
Q: What kind of supervision and support should be provided to CHWs?
A: In our experience, social workers are ideally equipped to supervise and support CHWs, particularly as they may experience vicarious trauma as well as burnout and compassion fatigue. CHWs should receive monthly or twice monthly 1:1 supervision with their social worker supervisor to review cases, discuss priority actions, and encourage self-care. We hold monthly case conferences that provide an opportunity for collaboration, reflection, and shared learning to address the variety of situations that arise in the field. We also hold morning “huddles” and afternoon “cuddles,” providing an opportunity to build team culture. During the huddles, the care team establishes a plan for the day and discusses patients who require extra time and assistance. The cuddles, which take place at the end of the workday, offer CHWs a chance to debrief, ask questions, and problem-solve difficult situations.
Q: What are your top recommendations for integrating CHWs into care teams?
A: When incorporating CHWs into care teams, it is critical that there is a clear vision for how these new care team members will be effectively integrated into the clinical workflow. Part of this is making sure that there is clarity around what they are accountable for, what their value add is, and to whom they are reporting to meet their identified objectives. Once the role of the CHW is elucidated, supervisors and clinical leadership should take the time to train members of the care team (e.g., nurses, social workers, clerks, etc.) on the role of the CHW, so they are aware of their role and responsibilities. This will also help care team members understand the purpose of a CHW, so they do not feel burdened or their work threatened. Finally, supervisors should actively work to preserve the role of the CHW. Being mindful of the prominence of their being in the community and the idea that their main locus should be the patient home (not the telephone or office) is key to making sure their role is preserved. This advocacy and support from supervisors will also help CHWs feel comfortable negotiating their role with other members of the care team.
Q: What are key considerations for determining CHW caseloads?
A: The number of patients a CHW manages depends on: (1) the complexity of the patient population; and (2) the skill-level of the workforce. Since patients with many medical, social, and emotional needs will require more of a CHW’s time, if patients are more high risk, the CHW caseload should be lower. Conversely, if care teams are more experienced and interdisciplinary, the CHW can typically manage a greater caseload. Having a social worker, community resource specialist, and/or case worker on a team helps “lighten up” the CHW’s work, allowing CHWs more time to focus on the accompaniment and home visitation aspects of their work.
Q: What advice would you give to complex care providers for sustaining CHW programs?
A: There are two key parts to sustaining successful CHW programs. The first is maintaining leadership buy-in by making the business case for CHWs. While financial outcomes may not be achievable, particularly during the initial program phases, providers should consider other potential evaluation outcomes including health and health care delivery metrics, self-reported health, utilization (e.g., primary care, behavioral health, and emergency department), patient and provider satisfaction, and medication adherence.
The second and critical part to sustainability involves taking care of your workforce. No program — especially complex care management programs that are both emotionally and time intensive — can survive without engaged employees who feel respected and valued. CHWs should be supported in their current roles and have the opportunity to advance their careers. This can be accomplished by integrating wellness through huddles and cuddles, having an open door policy for supervisors, and creating flexibility in scheduling so CHWs can accommodate continuing education.