Community Health Workers as Patient Navigators
Thursday, August 16, 2012
Posted by: Joy Ingram
Kelly Volkmann, Health Navigation Program Manager, Benton County Health Services
Case Study: Carmen
Carmen, a 67-year-old Latina woman who speaks and reads only Spanish, was recently diagnosed with diabetes in Mexico. In early 2012, she moved to Benton County to live with her adult children and subsequently established care at Benton County Health Services. Carmen has low health literacy, which affects her understanding of how to manage her diabetes, including how and why to monitor her glucose levels, and the relationship between glucose, eating, exercise and medication. As a result, she was checking her blood glucose sporadically, had readings ranging from 58 to 500, and was reluctant to take insulin or other prescribed diabetes medication. Carmen also reported to her primary care provider (PCP) that she did not feel like she was healthy, which made her feel sad, depressed, and a burden to her adult children.
As part of the standard diabetes education protocol, Carmen attended the diabetes education classes provided by the local hospital. Unfortunately, the classes were taught in English, using telephone interpretation for Spanish speakers. Moreover, the traditional classroom lecture style did not increase Carmen’s understanding of her disease. Finally, although Carmen had an adult daughter-in-law who attended her medical appointments with her, this was not the daughter she lived with, so care plans and medication changes developed during a provider appointment needed to be explained again to the family who provided Carmen’s daily care. This extra communication often resulted in missing or inaccurate information, which decreased the likelihood that Carmen would be able to adhere to her care plan.
Community Health Workers and the Patient-Centered Primary Care Home
If you work in a Community Health Center, it is likely that you are familiar with patients who, like Carmen, struggle to manage their chronic disease. At Benton County Health Services (BCHS), we have learned that Community Health Workers (CHWs) are very effective in helping patients with complex conditions improve their disease self-management and adhere to their treatment plan.
This article will give you a brief overview of Community Health Workers, their unique characteristics, what roles or duties they can perform, how they fit into a patient-centered primary care home (PCPCH), and how they can benefit your patients and your agency.
Community Health Workers and Patient Navigators
Community Health Workers (CHWs), also called lay health advisors, promotores/as, or health promoters, have a long history of providing culturally and linguistically appropriate care to a wide variety of communities and sub-populations. CHWs usually share similar characteristics and “life experiences” with members of a particular community, such as language, culture, and/or socio-economic circumstances. They may themselves have a chronic disease or mental health concern, or have experienced the issue from the perspective of a family member. Above all, CHWs are trusted members of the community they serve and, as such, are able to establish relationships, increase communication, and act as cultural brokers between the community and the health care system.
Traditionally, non-clinically trained CHWs have been used primarily in an outreach capacity, providing topic-specific health education, community advocacy and empowerment, resource and social service connection and referral, and coordination of community events such as health fairs and screenings. Perhaps most importantly, the CHW’s unique understanding of the challenges facing their community allows them to function as “barrier busters” to help community members appropriately access and utilize health care services.
More recently, patient navigators, also called health navigators, are workers trained to help patients “navigate” their way through the complex and fragmented health care system. They offer a range of services, such as providing social service and resource information, assisting with health and insurance forms, finding transportation alternatives, and making a connection to specialty health care. While navigators act as thoughtful and informed guides through the often confusing and overwhelming maze of health care services, their roles typically do not encompass health promotion, education, disease self-management coaching, individual and community advocacy, and health equity.
Although there is no requirement that a patient navigator be a community health worker, it could be argued that the best navigator will also be a CHW. The personal characteristics of a CHW may more readily facilitate a trusting relationship and an open dialogue about the barriers and challenges preventing patients from receiving the health care they need. Knowing and understanding those barriers will enable the CHW to help the patient navigate the system and receive those services. In addition, a CHW brings to the role of navigator the understanding of the importance of patient advocacy and empowerment in improving an individual’s ability to manage their health.
CHWs and Health Care Reform
In March 2012, The Oregon Senate passed Senate Bill 1580, which provides legislative approval of the Oregon Health Authority’s proposal for Coordinated Care Organizations (CCOs), Oregon’s equivalent of Accountable Care Organizations, or ACOs. The Bill itself contains guidelines for the development of CCOs and their coordination of care for members of Oregon’s Medicaid program, the Oregon Health Plan (OHP). Language in the Bill specifically calls for the use of “non-traditional health workers” such as community health workers, peer wellness specialists, and personal health navigators to be part of the member’s care team to “provide assistance that is culturally and linguistically appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services.” (Senate Bill 1580, Section 5-c)
As health care reform and legislation call for more involvement of CHWs within a patient-centered primary care home (PCPCH) setting, there is an increasing need to understand the depth and breadth of the potential roles that a CHW can perform.
CHWs as Health Navigators: Benton County Health Services
Within a PCPCH, Community Health Workers can provide a continuum of services, such as increasing access to and utilization of health care services, system navigation, insurance and health plan outreach and enrollment, assistance with financial eligibility, appointment scheduling, interpretation, transportation assistance, chronic disease self-management education and coaching, care coordination, and providing input and insight into care plans.
In 2012, Benton County Health Services (BCHS), an integration of the Benton County Public Health Department and the Community Health Centers of Benton and Linn Counties (CHC), achieved “Tier Three Patient Centered Primary Care Home” recognition at all four clinic sites. At BCHS, Community Health Workers have been working as health navigators since 2008. In that time, the program has grown from one CHW working with the primary care team to six CHWs providing a continuum of services spanning from inside the clinic as an integral member of the primary care team to outside the clinic working on community advocacy, empowerment, and policy. (See Diagram 1: CHW Continuum of Services)
CHW as a Clinical Health Navigator
At BCHS, one of the CHWs functions in the role of a “clinical health navigator.” In this position, the CHW does more than system navigation, care coordination, and telephone follow-up, but also provides chronic disease self-management education and support, nutrition and exercise coaching, patient advocacy, and enhanced communication between patient and provider team. Because of the increased trust that a CHW may have with a patient, he or she may have increased access to important health information that a patient may be reluctant to share with the provider. In addition, a CHW – who by definition is from the community they serve – understands and can effectively address the barriers that may be getting in the way of successful adherence to a care plan.
An important aspect of the clinical health navigation position is the partnership between the navigator/CHW and the Registered Nurse Care Coordinator (RNCC). The CHW works closely with the RNCC, who guides care coordination activities and acts as the clinical resource for the CHW. Working together, the RNCC and the CHW provide a holistic, wraparound approach to clinical case management and robust self-management education and support for their patients. In order to keep care team members informed, all RNCC/CHW activities are documented in the patient’s health record.
Patient care teams at BCHS have begun working with the CHW and RNCC to provide case management and disease self-management support for patients with chronic disease and complex conditions.
Conclusion: Carmen and the Community Health Worker
Concerned that the traditional diabetes management strategies were not working with Carmen, the PCP asked the care team’s Community Health Worker to begin diabetes self-management education and support with Carmen. The CHW, who has received training in chronic disease and diabetes self-management, motivational interviewing, teach-back methods, and low literacy educational techniques, began working with Carmen and her extended family to assure that everyone assisting with Carmen’s care understood and agreed to the care plan. The CHW, who is herself bilingual and bicultural, was able to meet with the family on an independent, flexible basis, which allowed her to meet directly with the daughter who was the main caregiver. In addition, the CHW’s shared language and cultural understanding allowed her to quickly build trust with Carmen and her family and address dietary needs and requirements in ways that were acceptable to Carmen. Working with Carmen and her daughter, the CHW also created a language- and literacy-appropriate glucose monitoring system that Carmen could understand and use by herself, and referred them to a Tomando Control de su Salud workshop, where they learned about chronic disease self-management.
In her role as clinical health navigator, the CHW also functioned as a cultural broker by explaining to the care team the difficulties that Carmen was having in adhering to her care plan and working with them to look for alternative solutions. In conversations with Carmen and her family, the CHW had gained valuable information about the circumstances that led to Carmen’s relocation to Oregon and the family dynamics that were affecting her health. Sharing this information with the care team significantly improved the communication and understanding between the care team, Carmen, and her family. As a result of working with the CHW, her PCP, and her care team, Carmen now reports that she feels better and has greater confidence in her ability to manage her diabetes, which is evidenced by an improved stability in her daily blood glucose readings and a decrease in her HbA1c from 9.7 to 7.6 in 3 months. The CHW continues to follow up with Carmen on a bi-monthly basis, reviewing glucose levels, ensuring that Carmen is administering the appropriate amount of insulin throughout the day, and evaluating Carmen’s confidence in her ability to manage her diabetes. When news of a dental van became available, the CHW immediately contacted Carmen to get her one of the limited appointments. Although scheduling Carmen with a dentist was not part of the care plan nor a referral from the PCP, the CHW, in her role as navigator, proactively ensured that Carmen had access to this important health maintenance service.
CHWs as members of the primary care team
As highlighted in the brief case study of Carmen, a Community Health Worker as an integral member of a primary care team can significantly benefit the patient and the care team in a number of ways. By building a trusting relationship with the patient, A CHW can increase meaningful communication between the care team and the patient, recognize and address barriers to care that may not be visible to the care team, improve coordination of care, and improve the likelihood that your patients will understand, engage in, and adhere to their care plan.
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