The Importance of Collaboration Between Community Health Workers and Clinical Care Teams

TON - February 2021 Vol 14, No 1
Director, Ambulatory Care Management Saint Joseph Health System/Select Health Network, Mishawaka, IN

Helping patients with cancer achieve optimal health status can present special challenges when their basic needs such as food security, housing, and transportation are not being met. If patients experience such social influencers to health, they will often forgo healthcare or become noncompliant with treatment due to lack of resources. Implementing a community health worker program to complement clinical care can provide compassionate care for the most vulnerable patients and lead to improved outcomes.

Addressing Health Inequities

The United States, despite ranking among the 10 richest countries in the world per capita, experiences sizable health disparities among its citizens that are rooted in social, economic, and environmental factors.1 Social influencers to health are typically the factors that cause health inequities in the community. The circumstances that lead to these social influencers of health are the conditions in which the individuals exist, and the lack of resources needed to live healthy lives and seek appropriate medical care.

On average, there is a 15-year difference in life expectancy between the most advantaged and disadvantaged citizens in our country.1 Patients with social influencers to health experience more adverse outcomes from chronic disease, and preventive screenings in this population are often lacking. Racial and ethnic minorities, the medically underserved, and those with low socioeconomic status also have higher rates of cancer in the United States,1 and disparities in cancer treatment and long-term survivorship remain an issue.

Creating a community health worker program for the most vulnerable patients in society can be an effective solution to these problems. Empathic, caring, compassionate, and culturally sensitive, community health workers are trusted members of the community who act as advocates for underserved members. They assist patients with health system navigation, care coordination, and access to community resources.

However, community health workers are often challenged when they encounter clinical situations in the field because they are nonlicensed, nonclinical individuals and cannot make clinical judgments or decisions. Teaming the community health worker with a clinical care manager can provide the resources needed to address unexpected clinical issues. This model also builds a strong, comprehensive team among the community health workers, care management nurses, healthcare providers, pharmacists, and other team members, bridging gaps in care.

As part of a team, when community health workers encounter a clinical issue, they have an immediate resource with whom to discuss the situation. The community health worker and clinical care team member can work together to assess the patient’s condition and provide an appropriate plan of care. By addressing social influencers to health, the clinical care team is able to support the Institute for Healthcare Improvement’s Triple Aim of better health outcomes, greater patient experience, and lower costs.2 The patients benefit from a greater experience by becoming decision makers in their own healthcare and having an advocate to help them with clinical as well as social issues.

Overcoming Barriers to Success

Although proper implementation of a community health worker program can set the stage for long-term success, integrating clinical and nonclinical team members can present challenges if there is not a clear understanding of the community health worker’s role. The members of the clinical team need to respect the knowledge of the community health workers and be willing to mentor without “taking over.” Educating staff on the unique contributions a community health worker makes to the team improves acceptance. Defining the scope of work for community health workers ensures they are working within their area of expertise. An essential, cohesive partnership between the community health workers and the clinical care team results in a constant flow of bidirectional information. Success of the program relies on the ability to integrate community health workers and clinical staff within the clinic.

Before implementing a community health worker program, financial costs must be taken into consideration. Some state Medicaid programs offer reimbursement, but few third-party payers reimburse for community health workers. Although many community health worker programs receive financial support through grants, this cannot be guaranteed. Continued funding will be a challenge if funding is dependent on grants. Because grants are often short-term, and sustainability is expected at the end of the grant, there must be a long-term financial strategy. Financial success will need to be realized through utilization metrics, compliance, and overall cost of care. But, ultimately, the benefits of a community health worker program often outweigh the cost.

By bringing together community health workers and clinical care teams to provide the resources needed to take care of the vulnerable patients, the solution not only addresses the Triple Aim, it also helps reduce workforce burnout. Providers have an avenue to refer their high-risk patients and ensure that the whole patient—mind, body, and spirit—is addressed. Once patients have their basic needs met, they can engage in decisions affecting their healthcare, which can lead to improved quality of life and clinical outcomes.


  1. Daniel H, Bornstein SS, Kane GC; for the Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168:577-578.
  2. Institute for Healthcare Improvement. The IHI triple aim. Accessed November 9, 2020.

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