Interdisciplinary Care Teams, Patient Navigators, and Community Health Workers

These models focus on the use of interdisciplinary care teams, patient navigators, and community health workers (CHWs) to help address social determinants of health (SDOH) in healthcare settings.

Community Health Workers and Patient Navigators

Community Health Workers (CHWs) are non-clinical public health workers who often live and work in communities that they are very knowledgeable about. CHWs are also sometimes called community health advisors, lay health educators, or promotores de salud. CHWs help to connect individuals with healthcare services and decrease barriers to care. A CHW serves in a distinct role from other healthcare professionals, and patient navigation may be one component of a CHW's responsibilities. Patient navigators, also known as patient advocates, help guide patients through the healthcare system and provide support in an effort to improve follow-up and adherence. Patient navigation was originally designed as a way to help decrease disparities in cancer care.

Most patient navigator and CHW models employ people from the community. As a result, these navigators and CHWs are better connected to the patient populations and understand community-level barriers, facilitators, and other social factors that may impact a patient's ability to access healthcare. CHWs and patient navigators may provide transportation for patients to get to doctors' offices and may also provide informal counseling and social support, which can improve patient outcomes.

CHWs are often used in healthcare systems in several ways:

As direct members of the healthcare delivery team
As a patient navigator connecting people with needed services
To offer screening and health promotion activities
To provide outreach and assistance with enrolling in benefits
In an organizing capacity and as a patient advocate

There is some evidence to suggest that the use of CHWs and patient navigators can increase overall access to healthcare. There is strong evidence showing that patient navigators can improve rates of cancer screening, especially breast cancer screening. CHWs have been identified as a promising practice for addressing SDOH in rural and frontier communities by increasing care coordination and linking populations to healthcare and other social services. CHWs have also been found to improve management of chronic diseases as well as decrease barriers for patients trying to access different health services. For more information about how CHWs can improve health and well-being in rural communities to address SDOH, see the Rural Community Health Workers Toolkit.

Health Extension Agents

Health Extension is based on the Cooperative Extension Service model that aims to connect communities with healthcare services by leveraging resources and local knowledge through universities and other local organizations and agencies. Health Extension Rural Offices (HEROs) began as a model to link University Health Extension Offices with rural, underserved communities to leverage extension resources to improve local health and well-being. HEROs were developed in rural New Mexico to help residents navigate health services and connect them with care. HEROs have been found to be a promising approach to address SDOH and improve health for residents in rural New Mexico. HERO agents work to build community capacity and connect with different sectors to provide local communities with extension resources and services focused on improving health. Agents can connect communities with services such as healthcare, education, and career opportunities.

Interdisciplinary Care Teams

Interdisciplinary care teams, also known as multidisciplinary care teams or community care teams (CCTs), are teams of healthcare providers that work to address multiple patient needs. The services offered to patients through interdisciplinary care teams might include:

Financial services
Transportation
Food/nutrition services
Housing
Care management
Social services

These teams look different depending on location, and often include both clinical and non-clinical providers, such as CHWs and patient navigators. Regional Health Connectors (RHCs) program is another approach that has been successful at connecting rural patients with clinical and non-clinical services. RHCs work to connect healthcare clinics with other community groups and organizations that can help address SDOH. RHCs develop relationships between the different service providers to improve coordination of care. Additional information about patient navigation, care coordination, and community care team approaches to improve health and well-being to address SDOH can be found in the Rural Care Coordination Toolkit.

Examples of Programs that use Interdisciplinary Care Teams, Patient Navigators, and CHWs to Address SDOH

The Community Caring Collaborative (CCC) in rural Maine provides support to families and children in an effort to address SDOH and reduce health disparities. One CCC-developed program is called Nurse Bridging. This program uses a nationally recognized promising approach that connects high-risk families with a specially trained nurse or an Infant and Family Support Specialist (IFSS) to navigate prenatal health services. Participants are women with high-risk pregnancies and families with infants with special needs, including babies born with Neonatal Abstinence Syndrome. The IFSS can accompany families to medical appointments, connect them with eligible benefits and services, provide in-home assessments, and provide other needed social support services.
Community Outreach and Patient Empowerment's (COPE) Training and Outreach program trains CHWs to serve residents in the Navajo Nation. Doctors, local trainers, and COPE staff develop and deliver trainings on topics including childhood obesity prevention, diabetes in pregnancy, and congestive heart failure. Navajo CHWs employed through COPE are known as Community Health Representatives (CHRs). CHRs are members of the community where they work, speak both English and Navajo fluently, and must have special certifications to practice in their community. These Navajo CHRs partner with tribal leaders to provide culturally-tailored healthcare information to the Navajo communities.
Kentucky Homeplace is a CHW program founded in 1994 to address health disparities in the Appalachian region of Eastern Kentucky. The program trains CHWs from the community to connect residents with services such as chronic disease self-management, reduced cost medications, help with enrolling in insurance programs, eye and dental exams, and care coordination, among others.
The Health-able Communities Program used CHWs to address healthcare needs and SDOH in remote and frontier areas of rural Idaho. This program, led by several organizations who partnered together to address issues related to poor health outcomes and limited access in the region, used CHWs connected with the community to provide direct healthcare services to residents as well as connect them with social services. The CHWs also worked on community improvement efforts, such as creating trails to increase walkability and physical activity.

Implementation Considerations

The American Academy of Family Physicians (AAFP) proposes several key steps to addressing SDOH as a team-based approach in primary care settings. These steps can apply in both rural and urban healthcare settings and should be adapted to fit the community to ensure a focus on health equity:

Building an understanding of the local community
Gaining knowledge about SDOH and how social factors impact health
Addressing implicit bias and working as a team to address SDOH
Focusing on the importance of health literacy

Most reimbursement is only provided for these services when the CHW or patient navigator works under the supervision of a clinical healthcare provider. As a result, in order to implement programs that use these models, communities may need to seek additional funding outside of Medicaid and Medicare payments.

Finding and recruiting CHWs and patient navigators in the same community where they live can be difficult. Since CHW programs use different curriculum and training materials, there may be a lack of standardization. Another challenge for CHWs working with rural patients is connecting them to specialty medical services which may require travel outside of their community. Many rural areas are designated as Health Professional Shortage Areas (HPSAs), meaning that there are low numbers of certain types of healthcare providers available to treat patients who need their services. In 2019, 62.9% of primary medical HPSAs and approximately 61% of mental health HPSAs in the U.S. were located in rural areas. This may result in patients having to travel long distances from home to get care. The significant distances between providers can make it difficult to connect people with healthcare and social support services. CHWs may need additional resources to help connect patients with transportation services and other types of care coordination to overcome some of these barriers.

For additional implementation considerations for using CHWs to address SDOH and other care coordination techniques, see Implementation of Community Health Worker Programs and Implementation Considerations for Care Coordination Programs.

Program Clearinghouse Examples

Resources to Learn More

Addressing Social Determinants of Health Through Community Health Workers: A Call to Action
Document
Policy brief with evidence-based recommendations to support the implementation of CHW models to help address SDOH and reduce health disparities in communities.
Author(s): Damio, G., Ferraro, M., London, K., Perez-Escamilla, R., & Wiggins, N.
Organization(s): Hispanic Health Council, Southwestern AHEC
Date: 1/2018

A Framework for Educating Health Professionals to Address the Social Determinants of Health
Document
Report presents a framework for understanding SDOH and how to educate health professionals in an effort to address SDOH.
Organization(s): National Academies of Sciences, Engineering, and Medicine
Date: 2016

Health Extension Toolkit
Website
Toolkit that describes the model of Health Extension and provides detailed information for states, academic health centers, FQHCs, and others who want to implement this model to improve the health and well-being of rural communities.
Organization(s): The University of New Mexico Health Sciences Center

Promoting Policy and Systems Change to Expand Employment of Community Health Workers (CHWs)
Document
Audio transcript describing official CHW definitions, common CHW roles and functions, employment settings and challenges, and models of care.
Organization(s): Centers for Disease Control and Prevention