Community Health Workers Generate Value at Health Systems and Hospitals. Here's How.

At Cedars-Sinai Health System, community health workers are addressing patients' social drivers of health and impacting key metrics such as readmissions.

Cedars-Sinai Health System is generating positive outcomes with its community health worker program.

The primary role of community health workers is helping health systems and hospitals address their patients' social drivers of health. Unmet social needs such as food insecurity, housing instability, and transportation barriers impact clinical outcomes and key healthcare organization metrics such as hospital readmissions.

At Cedars-Sinai, community health workers are fully integrated and embedded in clinical care teams across several service lines, including emergency medicine, primary care, inpatient care teams, and outpatient clinics.

"Our community health workers are full-time staff, so they are not volunteers or contracted with community-based providers. This helps ensure accountability and the sustainability of our workforce," says Kathryn Hren, LCSW, MPH, director of the Community Connect Program at Cedars-Sinai. "They are not an adjunct service—they are directly part of our care teams."

Data indicates that community health workers at Cedars-Sinai are having a positive impact.

In the past year, the community health workers have served more than 2,000 patients, and 62% of those patients were successfully connected to services or resources for their unmet social needs. The national benchmark is about 57%.

Survey data shows patients have a high satisfaction rate in their engagement with community health workers, with 90% of patients who respond to the surveys saying they have strong satisfaction with their community health workers.

The community health workers are also moving the needle on key health system metrics, according to Hren.

"We look at data for appropriate utilization of healthcare services as well as engagement with primary care services," Hren says. "We see a promising pattern that patients who engage with our community health workers have a decrease in avoidable healthcare service utilization."

From the CMO perspective, Cedars-Sinai's community health workers help patients who are overwhelmed by navigating their healthcare and provide patients with support for issues that their clinical team cannot provide, according to Richard Riggs, MD, senior vice president of medical affairs and CMO of Cedars-Sinai Medical Center.

"Community health workers add value by connecting patients to social services for food, housing, and transportation while also helping them follow through on appointments and care plans," Riggs says. "By addressing these broader needs, they reduce unnecessary hospital visits, improve long-term outcomes, and ensure health systems are delivering care that truly meets patients where they are."

At Cedars-Sinai, community health workers are particularly helpful for serving the Medicare fee-for-service population, which has 35% of patients above the age of 80 and 40% of patients who are dual eligible for Medicare and Medicaid, Riggs explains. Community health workers can help ease common frustrations such as scheduling confusion, insurance, or how to access follow-up care. They also address practical barriers such as trouble managing medications.

"With their hands-on guidance, patients feel less overwhelmed and more supported in navigating both the health system and the everyday challenges that affect their health," Riggs says.

Community health workers at Cedars-Sinai are generating value for patients by addressing social needs and helping patients stabilize their lives after a hospital stay, according to Riggs.

"When social barriers are reduced, patients are better able to attend follow-up visits, fill prescriptions, and engage in ongoing care," Riggs says. "That stability translates into fewer avoidable readmissions and better long-term health outcomes, demonstrating how meeting social needs directly supports recovery."

Richard Riggs, MD, is senior vice president of medical affairs and CMO of Cedars-Sinai Medical Center and Cedars-Sinai Marina del Rey Hospital. Photo courtesy of Cedars-Sinai Health System.

How community health workers can address social needs

Although Cedars-Sinai social workers and clinical staff conduct routine social drivers of health assessments of patients, community health workers conduct a second round of assessments, Hren says.

"Sometimes, patients do not feel comfortable disclosing their needs to their clinical care team," Hren says. "So, once a patient is referred to a community health worker, they will do their own assessment of social drivers of health to make sure that we are not missing anything."

The next step is for community health workers to engage with patients to make sure they understand how they can address the identified needs.

"This includes insurance benefits, connecting to a community-based partner, and applying for public benefits," Hren says. "Community health workers provide education to help patients understand their options."

Cedars-Sinai's community health workers spend a lot of time hand holding patients to make sure they get connected to the social services they require, according to Hren.

For example, if a patient is at home and does not have access to a computer or Internet access to complete an application for Medi-Cal enrollment, a community health worker will go to the patient's home with a computer and hot-spot Wi-Fi to complete the enrollment application.

At Cedars-Sinai, the key differentiator between the community health worker role and a nurse or other roles is that community health workers can build a high degree of trust with patients because they can spend more time with patients than most clinical team members can spend, Hren explains.

"The interaction between community health workers and patients is not limited to one encounter—community health workers continue to work with patients in an environment that is comfortable for the patients such as home visits or meeting at a coffee shop," Hren says. "There are continuous phone calls and check-ins to encourage patients to engage in services and understand the resources that are available."

Kathryn Hren, LCSW, MPH, is director of the Community Connect Program at Cedars-Sinai Health System. Photo courtesy of Cedars-Sinai Health System.

Advice for other health systems

Health systems and hospitals that are interested in launching community health worker programs should start small and scale a program intentionally, according to Hren.

"For example, you can start a community health worker pilot in one service line, get data from the service line that shows the impact and value of community health workers, then expand intentionally to specific patient demographic groups or to patients with chronic illnesses," Hren says.

If funding is a barrier to starting a community health worker program, there are philanthropy dollars and grants that can support these programs, Hren says.

Finally, a health system or hospital must make sure that there is buy-in for a community health worker program among senior leadership and frontline clinical staff, Hren explains.

"You should avoid siloing community health workers and make sure they are part of the care team," Hren says.