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Community Navigators: Extending Care into the Neighborhood

Community health workers (CHWs) have been a vital part of our workforce for decades. Yet only recently has their contribution received full attention and scrutiny, with HHS defining their work as key to eliminating disparity, and PPACA recognizing them as part of the workforce. Various definitions for CHWs exist along with many models (paid, unpaid, stipended, working with a team, or solo).

The American Public Health Association defines the CHW role as a frontline public health worker who serves as a liaison between health/social services and the community, while building individual and community capacity within a broader community-based health system. Core competencies for CHWs include communication, interpersonal skills, knowledge base, service and care coordination, capacity-building, advocacy, teaching, organization, cultural competency and outreach, and enrollment. It is estimated that there were about 121,000 CHWs in 2005, a 41% increase from 2000. While older models placed CHWs in community as somewhat isolated ‘outreach’ workers, more recently the trend is for CHWs to be integrated into the more traditional ‘clinical’ healthcare team.

From Health System Learning Group (HSLG) Monograph p. 59-60. Prepared for the shared learning for use at Strategic Investment in Shared Outcomes: Transformative Partnerships between Health Systems and Communities. Washington D.C. April 4, 2013, p. 59, 60.

Community Navigators Promising Practices

CORE Health, as part of Spectrum Health’s Michigan’s Healthier Communities Programs, is providing a management solution for underserved populations diagnosed with chronic disease through its innovative RN/CHW team approach for home visitation.  Targeting maternal and child health, hypertension, diabetes, nutrition and healthy lifestyles in schools, hospitals and communities, the strategy demonstrated an ROI of $1.68 dollars saving per dollar spent in a 3 year analysis.

Boston Children’s Hospital Community Asthma Initiative (CAI) produced a reduction of 65% in ED visits, and 81% in hospitalizations by incorporating home visits by nurse case managers who specializing in asthma.  CAI staff get a birds-eye-view of potential household triggers, while improving communication between patients and their caregivers.

Columbia St. Mary’s Hospital’s Urban Wellness Initiative identifies Church Health Liaisons (CHLs) to coordinate congregational based programs that bridge hospital resources to church congregants.   They have screened more than 8,000 people and provided disease management services to 1,000. Outcomes show that 71% of participants had reduced their blood pressure, cutting their risk of death by 32%, of heart failure by 56% and of stroke by 44%.

Health Leads recruits and trains college students— Health Leads Advocates – to walk side by side with patients and connect them with basic resources including food, heat, and other critical needs that can affect their health.  Founded by a team from Boston Medical Center, Health Leads has connected over 25,000 patients to critical services while training future health leaders to incorporate public health issues into their clinical practice.

Methodist Le Bonheur’s Congregational Health Network is a volunteer- based program which relies on over 550 unpaid trained CHWs in over 512 Memphis area churches to work with 10 hospital-based, paid employee ‘navigators’ , to help patients in and out of the hospital system. Readmissions rates declined by 20% for CHN members and early savings of over $8,000 per capita on total hospital charges. See also Sojourners Magazine, The Power of Partnership, August 2102; Salon.com, It really does take a village: How Memphis is fixing healthcare, Sep 3, 2013

Washington Heights/Inwood Network Asthma Program (WIN) New York, NY- Bilingual Community Health Workers serve as the single point of contact for families who require comprehensive asthma education, support, and multiple referrals for services such as housing, immigration, and mental health.  After 12 mo., ED and hospitalization rates decreased by more than 50% and school absenteeism by 30%.

henry ford win networkHenry Ford Health System’s, WIN Network (Women- Inspired Neighborhood Network, formerly Sew Up the Safety Net for Women and Children) joined Detroit partners (including competing health systems) in a community wide effort to address the health disparities impacting infant mortality.  Program relies on CHW staffing and “high tech/high touch” social marketing decrease infant mortality.

Henry Ford Health System, Cost Savings/Cost Avoidance (CS/A) Tool demonstrates impact of Faith Community Nurses (FCNs) on health outcomes.  The CS/A tool developed by the team at Henry Ford Macomb Hospitals demonstrates the impact of interventions by FCNs and their health ministry teams on health outcomes.

University of New Mexico, School of Medicine’s  Project ECHO—(Extension for Community Healthcare Outcomes) leverages teletechnology to train primary care doctors and community health workers in rural and underserved areas to effectively treat chronic, common and complex diseases and monitor treatment outcomes.

The Wake Forest Baptist Medical Center’s FaithHealth NC is training nearly 270 environmental services workers at Wake Forest Baptist as community liaisons to help them connect both on the job and in the community with people that FaithHealthNC is trying to reach.

Inova Health System, Promotores De Salud PerinatalThe Promotores de Salud Perinatal Community Outreach Program of Inova Health System was created to bridge the existing gap between the Latino/Hispanic community and the health system.  Promotores are trained in the basics of prenatal care- the importance of folic acid, signs and symptoms of preterm labor and best practices for infant sleep.  They also serve as advocates for their community, and link pregnant women and new mothers to patient centered medical homes.