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.
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
- Food/nutrition services
- 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.
Hidalgo Medical Services provides comprehensive medical and social
support services to families living in rural and frontier areas of southern New Mexico. It employs CHWs to
connect patients to these services. CHWs work with
families in their home to identify solutions to potential challenges that might prevent them from
receiving the care they need to decrease health disparities. They also connect families with community
resources including parent education classes, chronic disease management, help with signing up for health
insurance and other support services, and even offer a program that provides books for young children. One
of the CHW programs previously implemented by Hidalgo Medical Services, LA VIDA (Lifestyle and Values
Impacting Diabetes Awareness), specifically targeted improving diabetes-related health outcomes and
improving access to healthy foods for participants.
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.
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
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
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
Social Determinants of Health Through Community Health Workers: A Call to Action
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
Framework for Educating Health Professionals to Address the Social Determinants of Health
Report presents a framework for understanding SDOH and how to educate health professionals in an effort to
Organization(s): National Academies of Sciences, Engineering, and Medicine
Health Extension Toolkit
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
Organization(s): The University of New Mexico Health Sciences Center
Promoting Policy and Systems Change to
Expand Employment of Community Health Workers (CHWs)
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