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Community Health Workers Are Vital to a Connected Community of Care

Analysis  |  By Estefania Salazar Contreras  
   April 06, 2023

The Dallas-based Parkland Center for Clinical Innovation saw great success with its Accountable Health Communities (AHC) program, thanks to the participation of community health workers (CHWs). 

Editor's note: Estefania Salazar Contreras is the advisory service ops manager at the Parkland Center for Clinical Innovation (PCCI), an affiliate of Parkland Health in Dallas.

Community health workers (CHWs) were found to be one of the critical elements that supported the Parkland Center for Clinical Innovation’s (PCCI) successful five-year implementation of the US Centers for Medicare & Medicaid Services' Accountable Health Communities (AHC) model in Dallas County, Texas.

PCCI and its provider partners and community-based organizations supporting the Dallas AHC model offered innovative and highly effective new technologies and methods to help address health-related social needs (including food, housing, transportation, utilities, and interpersonal safety) of Medicare and Medicaid beneficiaries in Dallas County. But the glue to the entire process was the human touch delivered by CHWs who worked with the program participants every day through a process called 'navigation.'

The work itself was not unique to the program. CMS requires AHC awardees to screen and identify high-risk beneficiaries with health-related social needs (HRSNs) and provide them with active navigation services consisting of referrals to aligned CBOs, accompanied by monthly follow-up calls for up to 12 months or until the documented HRSNs are successfully addressed. CMS provided specific methods, goals, and even scripts for this work.

But what we didn’t count on was the impact of our CHWs in delivering compassionate support to those who were not expecting it but were incredibly grateful to receive it.

The Ideal Beneficiary Screening Setting

A key factor in a successful outreach program such as this is to have the 'Ideal Screening Setting.' When we began implementing the AHC program, we thought we could include screening for HRSNs in outpatient clinical site encounters. However, our CHWs and team realized that screening in outpatient clinic waiting areas was not ideal for the beneficiaries, who were waiting to see a physician or financial department advisor. In addition, because we did not have a private space for conducting the screening, there were concerns that others could hear the conversations with the CHWs. As a result, this process yielded a low rate of completed screenings, making it nearly impossible to meet our CMS navigation targets. 

We decided to change our approach to conduct screenings in Emergency Departments. While this yielded a slight increase in the number of completed screenings, the numbers were still not sufficient to meet CMS targets. It's no secret that EDs are extremely busy, and CHWs wanted to be respectful of the clinical staff who had other, more pressing priorities. It was also difficult to get participation from individuals who were focused on more immediate health needs or in pain.

With these lessons learned, we shifted to a telephonic post-clinical-visit screening intervention. Our CHWs could screen beneficiaries through a phone call within five days of their inpatient, ER, or outpatient encounter. PCCI’s data scientists helped make this engagement possible by generating daily beneficiary eligibility call lists for the CHWs. The beneficiaries could communicate in the language of their choice, and could even request a call-back if they did not feel comfortable answering the screening questions at the time of the initial call. This process was the 'Ideal Screening Setting,' and it allowed PCCI to not only meet, but ultimately surpass, CMS navigation targets.

What Successful Outreach Looks Like

Once an eligible beneficiary completed the screening and interview, the CHW provided a list of referrals to CBOs best suited to meet the beneficiary’s needs (help with food, rent, or transportation). Referrals for each beneficiary were based on the CHW’s personal knowledge of available local resources.

The outreach didn’t end with one screening or referral. Following a two-week referral follow-up, the CHWs contacted the beneficiary monthly to determine if any additional referrals were needed, as well as to assess the status of the beneficiary’s experience with the resource list and referrals. If a beneficiary was unsuccessful with a specific CBO, the CHW offered additional guidance or a new referral. This proved beneficial, as beneficiaries often reported new needs not identified during the initial screening stage.

The CHWs had to overcome a number of obstacles, especially the pandemic. Many CBOs limited or changed their hours or even closed unexpectedly. Our CHWs found themselves driving by CBOs to check on their availability while updating the program’s network on the CBOs’ status. This speaks to the dedication and passion our team had in making sure the program participants were well cared for and received the most up-to-date and accurate information.

Additionally, with the help of PCCI’S data scientist, they were able to create a daily automated case management report that identified which beneficiaries needed to be prioritized in the CHW’s caseload and weekly workflow. This enabled CHWs on the team to maintain a caseload of about 200-250 beneficiaries at any one time. Because they were consistent with their monthly follow-ups, the CHWs  developed a rapport with beneficiaries, making it easier to learn of concerns or additional needs.

Some of the most pressing concerns outside of CMS' five core HRSNs (food, housing, utilities, transportation, and interpersonal safety) are affordable child-care, baby supplies such as formula and diapers, and medical equipment. These additional needs are incorporated into our CBO directory.

The consistency of our outreach made it possible to conclude that it takes, on average, about 93 days or 4 telephone contacts to be able to resolve a need. During the pandemic we also noted that the CHW phone calls with beneficiaries were longer, especially for those who did not have any family or friends to count on or had to isolate because they were at high risk of infection. This truly speaks to the power of human impact and the willingness of the CHW team to go above and beyond for the beneficiaries they served.  

Human Touch is Still the Best Human Service

The results of the program speak to its success in very meaningful ways. For example, the results showed that actively navigated individuals saw a greater decrease in ED visits than those in a comparable control cohort, and they also had a statistically significant reduction in average ED utilization, both while actively navigated and in the 12 months after navigation. They also demonstrated a greater likelihood to seek and keep scheduled outpatient visits compared with the control cohort. These results were included in our manuscript in NEJM Catalyst titled "The Dallas Accountable Health Community: Its Impact on Health-Related Social Needs, Care, and Costs."

These results offer our community greater cost savings and lead to a healthier community, especially for those who are considered the most at-risk. In addition, a survey of participants on their perspectives and experiences yielded these comments:

  • “It helped me out in so many ways with my first baby. As moms we think everything will be easy, but there was so much I didn’t know about that helped me.”
  • “It made a big difference for me both emotionally and with my physical needs like food and bills. To know Parkland cares about us means so much!”
  • “It was nice to hear that there was help. I didn't feel alone.”

A highlight from this survey is the value that participants placed on the connection with their CHWs, underscoring the importance of the human touch in improving the health and well-being of those most at-risk. For our team of CHWs, the positive data and cost savings are great, but their pride comes from knowing they have helped to provide meaningful compassion, care, and support to people who needed it the most.

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“A highlight from this survey is the value that participants placed on the connection with their CHWs, underscoring the importance of the human touch in improving the health and well-being of those most at-risk”


Community health workers were integral to the success of the Accountable Health Communities model overseen by the Parkland Center for Clinical Innovation (PCCI).

The Dallas-based project was one of 28 developed and shepherded by CMS across the country, aimed at addressing critical gaps between clinical care and community services in underserved communities.

CHWs helped to establish and keep the connection between participants and care providers and helped steer participants to available resources. 

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