Member of Care Delivery Team Model

In this model, community health workers (CHWs) collaborate with or work alongside medical professionals on a clinical care team. Research has demonstrated the effectiveness of engaging CHWs on clinical care teams to promote and increase cancer screenings, improve blood pressure and cholesterol to prevent cardiovascular disease, and prevent and manage diabetes.

CHWs may work in a variety of practice settings, such as Federally Qualified Health Centers, Rural Health Clinics, primary care offices, dental practices, and pharmacies. CHWs may also conduct home visits, working with medical professionals. In this model, the members of the care delivery team will differ across practice settings. Depending on the setting, clinical staff such as pharmacy technicians or paramedics may be cross trained as CHWs to meet patient needs. This approach was used in one rural community, where CHWs were placed in a pharmacy to support medical professionals with chronic disease management and improving health outcomes.

CHWs may conduct a range of activities when collaborating with medical professionals, such as physicians, nurses, and others, including:

Health services, such as measuring vital signs, disease screenings, body mass index (BMI) screenings, chronic disease self-management, or first aid care
Education, such as medication counseling and providing health and nutrition information
Advocacy and assistance, including patient navigation to help patients access health services and coordinate care
Other basic services

CHW programs using this model may also integrate a more holistic approach or a medical home model. Within a medical home, CHWs may work alongside a care team comprised of physicians, nurse practitioners, and allied health workers to deliver a range of services, including navigation, outreach, education, or referrals.

Examples of Rural Member of Care Delivery Team Models

Community Connections of the Northeastern Vermont Regional Hospital (NVRH) integrates CHWs into a team of healthcare professionals, including physicians, nurses, behavioral health specialists, chronic care coordinators, and dietitians. CHWs help patients access resources, link them to health and social services, and provide coaching, among other support.
The Community Health Worker-based Chronic Care Management Program is an effective model for CHW-delivered chronic care management, implemented in three Central Appalachian states. The program enrolls patients with diabetes, heart disease, and chronic obstructive pulmonary disease. CHWs work with a mid-level provider and a nurse. CHWs conduct home visits and help patients with their self-management goals, medications, and other social needs. Patients in the program have improved health outcomes and the program has had an annual cost savings of $384,000.
The Corewell Health Start Now Program is a 12-month program for rural populations with chronic diseases in Michigan. Nurses and CHWs work together to conduct home visits to help patients manage their chronic disease.

Implementation Considerations

When seeking to integrate CHWs into clinical healthcare teams, it is essential to create a clear plan. This includes identifying the specific roles and responsibilities of the CHW and how their work is related to the work of other members of the care team. Other implementation considerations for this model address integration, funding, and liability.

Integrating CHWs into the care delivery team. Programs may experience barriers integrating CHWs into the care delivery team. Some providers may be less willing to work with CHWs, particularly if they do not recognize the value of CHWs to the care delivery team. Successful integration relies on communication and collaboration. One strategy for achieving this is by co-locating CHWs and members of the care delivery team. The more deeply integrated CHWs are, the more providers understand CHW activities and roles.

Funding. A major consideration for implementing this model is identifying a funding source. Funding for incorporating CHWs into care-based teams can come from grants, but increasingly, states are aligning CHW activities with opportunities for reimbursement in medical settings. In some states, reimbursement for CHW services is provided by Medicaid programs. In other states, private health plans have begun reimbursing for CHW services or using teams of in-house CHWs. Healthcare providers may also develop other internal financing strategies to support CHWs. For more information on funding, see Funding and Sustainability Strategies.

Liability. Rural programs should have clear protocols in place for CHW activities to mitigate potential liability issues. This includes, for example, acquiring insurance to protect the organization and its CHWs. For more information on liability, see Legal Considerations for Community Health Worker Programs.

Program Clearinghouse Examples

Resources to Learn More

Integrating Community Health Workers into Complex Care Teams: Key Considerations
Document
Discusses the elements of maximizing the impact of CHWs within a healthcare setting including recruiting and hiring, training and career advancement, team integration, and support and retention.
Author(s): Lloyd, J. & Thomas-Henkel, C.
Organization(s): Center for Health Care Strategies, Inc
Date: 5/2017