Role of Community Health Workers for Clinical Systems: The Mississippi Delta Clinical Community Health Worker Initiative

Issues: The clinical community health worker (CCHW) model emphasizes the importance of integrating CHWs as integral members of a clinical team. Although the CCHW model has been used in public health over decades, there is limited data on how CHWs impact clinical outcomes in rural settings.  

Description: Eight clinical sites in the Mississippi Delta agreed to refer patients to the CCHW Initiative program.  Patients were selected based on diagnosis of uncontrolled hypertension, or diabetes, dyslipidemia.  The CHWs visited patients in their homes within 7 days of referral, quarterly, and as needed. The CHWs addressed the patient’s basic healthcare needs by conducting chronic disease self-management workshops, teaching proper techniques for BP and hemoglobin A1C measurement, and encouraging compliance.

Lessons learned:  The Community Health Worker must reside in and be knowledgeable of the community they serve.  Patient participation and retention in the program was higher, when clinic providers played an active role in program recruitment and referral.  Communication with providers is key.  When CHWs found elevated BP and glucose measures at the time of the home visit, they notified providers so that emergency appointments could be scheduled.  The CHWs participated in regular meetings with clinic staff to inform providers of the status of the patient visits.   

Recommendations:  CHWs may be useful in clinical and community settings to bridge the relationship between health care systems and patients, facilitate access to services, perform informal counseling on self-management skills, and improve ABCS health outcomes in rural settings.