Tackling social determinants of health outside the hospital walls

It was clear the 63-year-old Irving man at a Baylor Scott & White community clinic needed help — and that his diabetes wasn’t the only problem at hand. Clinic personnel noted that he seemed disconnected with the outside world and lacked social support.

Concerned, one of the clinic’s community health workers asked if she could visit him at home to see if he needed anything to help him stay healthier. He declined her help. Why?

“I’m a hoarder,” he said.

This man’s story is not unique. Healthcare providers are finding it increasingly important to address lifestyle factors and barriers outside of the hospital that influence a patient’s health and wellbeing.

Community health workers, or CHWs, are integral in doing so. Community health workers have emerged as cost-effective medical team members who work with patients and caregivers to improve the health of “frequent flyers” — patients who habitually visit emergency rooms and fill hospital beds.

CHWs help patients with nonmedical needs by connecting them with community resources and providing social support. Integrating social and medical care helps reduce overall healthcare spending by decreasing hospitalization rates and empowering patients to take charge of their own health. Baylor Scott & White Health has employed community health workers since 2005.

Related: Addressing the social determinants of health

The role of patient-centered medical homes

The Baylor Scott & White HealthTexas Provider Network operates seven patient-centered medical homes dedicated to the holistic care of uninsured patients. The community clinics address key chronic disease management and social needs through an integrated care team model that focuses on behavioral health and medication management. The clinics are located near Baylor Scott & White Health hospitals in Dallas, Fort Worth, Irving and Carrollton.

In these patient-centered medical homes, community health workers are integral members of the care teams. They encounter significant social barriers among the populations they serve, including:

• Nearly 3 out of 4 patients lack basic knowledge of how to control their chronic conditions
• About 2 out of 3 patients suffers from food insecurity
• More than half of patients lack transportation for medical visits
• More than 1 out of 4 patients are socially isolated

By addressing these social and resource needs, community health workers have been able to reduce hospital readmissions for high-risk patients by one third.

By addressing these social and resource needs, community health workers have been able to reduce hospital readmissions for high-risk patients by one third.

According to a 2017 study, patients who received support from community health workers had 30 percent fewer hospital admissions in one year and saw reductions in cigarette smoking, obesity, diabetes severity and mental illness. Researchers estimated that CHWs provide an annual return on investment of $2 for every dollar invested.

Life-changing intervention where it’s needed most

Community health workers typically work with patients in the clinics but ask patients if they can visit them at home if they sense there is something amiss in addition to their medical problem. Missed doctor appointments are a common trigger.

“The main goal of home visits is to re-engage patients with the clinic,” said Karla Alvarado, manager of community care navigation for HealthTexas Provider Network Community Care Clinics. “We do a social visit. We make sure they can get transportation, help paying bills or getting food. We connect them with community resources. These CHWs are working magic.”

Related: Bridging the gap between healthcare and faith

Community health workers have been part of healthcare worldwide for decades. They generally are not trained as doctors or nurses. They often are recruited directly from the communities they serve with the goal of helping individuals navigate the healthcare system, manage chronic illnesses more effectively, and access preventive care.

They often work with people in impoverished communities who lack access to quality healthcare, lack the means to pay for healthcare, do not speak English fluently, or have cultural beliefs, values and behaviors that differ from those of the traditional U.S. healthcare system. The result is that CHWs help health systems become more culturally appropriate and relevant to those they are seeking to reach.

Let’s revisit the earlier scene of the Irving “hoarder.”

The concerned community health worker navigator kept in touch with the patient until he eventually allowed her to visit his home after six months of contact. She didn’t expect to see any drastic needs. Perhaps he needs a microwave, she thought.

According to a 2017 study, patients who received support from community health workers had 30 percent fewer hospital admissions in one year and saw reductions in cigarette smoking, obesity, diabetes severity and mental illness.

But that wasn’t the problem. During her home visit, she found out that he didn’t have food. The navigator arranged to have him approved for the Supplemental Nutrition Assistance Program. She also helped him get Social Security disability benefits. The man also lacked a phone. The only way clinicians could communicate with him was by mail or getting him into the clinic. Fortunately, the navigator was able to secure him a cellphone.

“Now, he has food and can communicate with the world,” Karla said.

And his hoarding was not a problem during the home visit.

“He was a very organized hoarder,” Karla said. “He organized his model car collection by driver, model and serial number. I want him to come organize my house.”

For this man and many others with similar stories, community health workers are providing life-changing — and often life-saving — intervention outside the hospital walls.

Find out more about this and other community initiatives empowering healthier individuals and stronger communities.