Community Health Workers (CHWs) are trusted members of their communities who share similar backgrounds with the people they serve. In partnership with health care consumers, clinicians and other providers, CHWs play a pivotal role in reducing health disparities and helping community members to better manage their health. At Make the Road New York (MRNY), a community-based organization with offices in New York City, Long Island and Westchester County, we run a CHW training program, from which graduates enter into jobs in the health care field. Over the years, some CHW graduates have been hired at MRNY to implement projects focused on improving health outcomes for immigrant families in our communities.

Through New York State’s Delivery System Reform Incentive Payment Program (DSRIP), MRNY has expanded its CHW project’s reach. MRNY is an active partner in the One City Health Performing Provider System (PPS), which is the largest Performing Provider System in New York City. The One City Health PPS is sponsored by NYC Health + Hospitals, the nation’s largest municipal health care system. MRNY, along with other community-based organizations, receive funding to support a community health worker asthma project, in which hospitals and clinics refer patients with high rates of asthma to our CHWs. The CHWs then follow up with the patients to set up a home visit. CHWs are welcomed into families’ homes as trusted community members, helping bridge the health system with the community.

During the home visit, the CHW listens to the patient and family about experiences with asthma while conducting an intake interview. The CHW then carries out an asthma control test, provides asthma education, and reinforces the Asthma Action Plan (AAP) set forth from the provider. The CHW also reviews medication with the family, provides general medication education and refers the patient to a doctor, if needed. The CHW completes an environmental assessment with the family to identify asthma triggers in the home and refers the family to services to help remedy the household environmental factors that may include mold remediation and integrated pest management services. The CHW is responsible for ensuring that the family is connected to wrap-around services such as health insurance, food stamps, housing assistance, legal and other services. Through regular follow-ups, CHWs develop relationships with families, while helping them to manage their asthma.

Here is one exemplary success story. Carmen Garcia, one of MRNY’s CHWs, had a home visit with the mother of Kelly, a 10-year-old girl with asthma, for the first time in April 2017. Carmen observed that they were not using the medicine as directed, and offered one-to-one education about following the AAP and explained the difference between controller and rapid-relief medicine. The child’s mother had been resistant to giving her child the asthma medications because she was worried about them interfering with another epilepsy medicine. Carmen helped reassure the family about the safety of the medications and the need to follow the treatment plan. She also pointed out the mold and pest asthma triggers in their home, but the family initially declined a referral for  Integrated Pest Management (IPM) services. However, after a second visit, the family agreed to start using IPM and were able to eradicate the cockroaches in their apartment, as well as make repairs that helped remediate mold. After her third visit, Carmen saw that the family had taken her advice in storing stuffed animals and toys, another possible trigger, away from the child’s bed. The continuity of such repeated follow-ups with trusted community members prove effective in helping families to make the environmental changes that support their children’s health, while building their trust with the health care system, and helping them to advocate for themselves.

The Affordable Care Act has generated increased interest in CHWs as catalysts of disease prevention and promoting healthy behaviors, and to help manage health care costs in low-income and immigrant communities. MRNY’s CHW training program is replicable and scalable across state lines. CHWs know their communities assets and needs, as well as how best to communicate with them. They are an invaluable resource to our communities and should be lifted up as health systems are transformed.

Rebecca Telzak, Director, Health Programs and Amy Richards, Health Programs staff
Make the Road New York