Partnering with Community Health Workers: Empowering Key Health Mediators in Chronic Care Management

Cynthia Orofo, BSN, RN

For most nurses, the path to innovation is natural but not linear. Nurses in general, especially since the start of the COVID-19 pandemic, have been innovators at the bedside, in the community, and in every care area they reach.

As an ICU nurse working during the height of the pandemic, I and other nurses had to constantly innovate to provide optimal care for patients. And as public health nurses, we had to skillfully navigate the strains of the pandemic on dynamic social and health needs to keep communities supported. With the COVID-19 pandemic exposing health care inequities and putting stress on the fractures in our health system, I realized it was necessary to create a program for the collective care of minoritized folks.

Meeting a Gap in Traditional Health Care Delivery

Culture Care Collective is a hybrid health support program (face-to-face and via an interactive digital app) where community health workers (CHWs) are integrated into clinical care teams to coordinate care for minoritized groups in order to increase access to socially supportive health care at low costs.

The program’s multi-phase care model enables the delivery of coordinated care to minoritized clients with chronic conditions. The CHW coordinates with other members of the multidisciplinary care team and with the client to establish a targeted and tailored care plan with the client at its center. The client is then immersed in social support, care coordination, and advocacy led by the CHW and guided by clinical professionals.

The program strives to improve the health and social capital of minoritized communities, optimize the patient journey, increase cultural awareness of health systems, decrease readmissions, and expense, and reduce health care disparities.

The Journey to Innovation

I have had the great privilege of exploring several areas of nursing through clinical practice and research. From the ICU to a mobile health van, I learned that innovation is essential to effective and equitable care delivery. Marrying the two domains of public health and critical care has been a passion of mine since my work as a doctoral student to developing this program. I knew it was necessary to create a program like Culture Care Collective for people who need help navigating health and social services. And I didn’t want to wait until the end of my PhD journey to build something that impacts change.

Culture Care Collective was created through an unconventional partnership between a nurse and an engineer, united by our shared West African roots and appreciation for community health work. We intentionally bring a high impact, community empowered care model and supportive technology to the forefront of clinic-based health care, powered by our personal and professional experiences. My innovation journey allowed me to fully appreciate the power of multidisciplinary collaboration to drive health innovation.

The Problem

Due in part to a lack of tailored health care and education, minoritized communities often face challenges when trying to manage their health care. This leads to poor health outcomes that contribute to disparities.

Clinicians have an important role in empowering patients to gain and maintain control over their health and decision-making. However, limited physician time, as well as lack of integrated technology, severe nursing shortages, and patient-clinician cultural discordance all widen health disparity gaps that health care organizations in the U.S. are challenged to fill with its current care models.

Community health workers, who have typically worked outside traditional health care to support minoritized populations, have recently been integrated into patient care beyond community-based interventions as a novel solution to addressing disparities. And though an expanding body of research highlights their function as key health mediators within hospital-based care, meaningful partnerships with CHWs are untapped in our complex health system.

How is this work innovative and necessary for the nursing profession?

Demands on the public health system, such as the COVID-19 pandemic, reinforced inequity-fed disparities among minoritized groups. As we emerge from the COVID-19 pandemic, worsening clinical staffing shortages are straining health care workers. CHWs, as formidable and trustworthy health mediators, can fill these gaps by providing social needs screening and tailored health education. This supplements holistic care efforts by health care workers and reduces inefficiencies in care.

What advice did you receive that really helped you?

“Never discount the power of community.” I learned this in from my public health professor in nursing school. Although there has been a historic separation of traditional medicine and community in the U.S. health system, community-clinical linkages and clinically integrated CHWs offer a unique impact on chronic disease management and health care delivery overall.

What advice do you have to offer?

You are always in the best position to innovate. Don’t wait for the perfect conditions.