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Arizona
Mariposa Community Health Center,
Center of Excellence in Women's Health[1]
Location: Santa Cruz County,
Arizona
Services provided by CHWs: Goal
is to improve the health and social well-being
of women. Strategy for achieving the goal
and objectives is a strong linkage between
clinic services and health promotion efforts.
CHWs deliver health education, and work
on community mobilization through neighborhood-based
outreach to engage women, in partnerships
and collaborative efforts in order to
reduce health disparities and increase
access to care. Information is available
in Spanish and services are free. Baby-sitting
and transportation assistance are also
provided to decrease barriers of access
to care. Plans for the replication of
some programs developed in the Center
of Excellence in Women's Health are under
way at the El Rio Community Health Center
in Tucson, Arizona.
Arizona Health Start[2]
Location: Statewide
Services provided by CHWs: Lay
health workers provide education, support,
and advocacy services to pregnant and
postpartum women and their families. Nurses
and social workers provide oversight as
families receive home visits and case
management services. Families are monitored
through the enrolled child's second year
of life. Goals of the program are to prevent
low birth weights in infants, to increase
care for high-risk pregnant women, to
ensure that every child in the program
is appropriately immunized and has a medical
home, to provide health education to women
and their families on topics ranging from
prenatal care to proper child care and
safety, and, finally, to screen for early
identification of developmental delays
and make appropriate referrals. According
to the Web site, 39 community health workers
completed 9,718 visits during 2004 (average
of 4.5 visits per client) and documented
that 94 percent of two-year old children
had been properly immunized.
Luchando Contra el SIDA, Campesinos
Sin Fronteras (CSF)[3]
Location: Yuma County, Arizona
Services provided by CHWs: Volunteer
promotores provide information,
counseling, and referrals on HIV/AIDS
and other sexually transmitted diseases.
Promotores go into the fields with
the farmworkers, facilitate the community's
linkage with local social service and
health programs, and perform follow-up
for the services provided. All outreach
and education, including content of presentations,
literacy level, and language, is sensitive
to farmworkers' working conditions and
culture. Promotores have also been
able to mediate for the health care system
to assist farmworkers with HIV counseling
and testing services, scheduling appointments,
facilitating transportation, as well as
translation and buffering costs. In addition,
they contact and refer farmworkers at
high risk for HIV infection for HIV counseling
and testing. Promotores have developed
innovative ways to educate the community,
including a play on HIV/AIDS, two fotonovelas
that discuss the importance of condom
use, and an appealing distribution of
condoms inside of paper flowers.
Massachusetts
Action for Boston Community Development,
Inc. (ABCD, Inc.);[4]
two programs highlighted: Entre
Nosotras (Between Us) and Boston
Family Planning
Location: Boston, Massachusetts
Services provided by CHWs:
Entre Nosotras:
A community-based peer educator program
takes place in locations like beauty salons
and private homes; provides risk reduction
education about reproductive and sexual
health, domestic partner violence, and
healthy relationships to Latina women
between the ages of 18 and 45. The program
used both paid and volunteer staff as
part of the peer network.[5]
Boston Family Planning: Trained
reproductive health and sexuality educators
hold workshops and programs for women,
teens, men, and parents in community settings.
They provide sexual health education and
counseling as well as promote informed
sexual and reproductive choices. The family
planning community outreach initiatives
included outreach education in schools,
faith-based programs, prisons and pre-release
programs, community agencies, and after-school
programs.
The Bowdoin Street Health Center
Location: Dorchester, Massachusetts
Services provided by CHWs: In
the past, CHWs worked as generalists,
acting as links for the neighborhood population
to various city services. A change from
the generalist model occurred when funding
streams changed roles and functions (grants
were now issue-oriented). Several of the
CHWs worked in individual specialty health
areas: a childhood obesity program with
an objective of involving youth in sports
and increasing their physical activity;
an environmental justice and safety program,
visiting auto shops in the area and working
with employers on workplace safety; and
an initiative involving local schools
to reach at-risk children and families.
In addition, some of the workers at the
Bowdoin Street Clinic were called CHWs,
outreach workers, or family advocates.
The Bowdoin Street Clinic had five CHWs,
a family advocate for domestic abuse clients,
a family planning/tobacco outreach worker,
and two other outreach workers funded
through a recent diabetes prevention and
management grant. Clients served by the
diabetes outreach workers were identified
through the clinic as either having diabetes
or being at risk for developing diabetes.
CHWs made home visits to these patients.[6]
Two of the CHWs at the clinic remained
in generalist roles working on a range
of issues from public safety to community
organizing. A main objective of CHWs at
the clinic was to assure that each client
had a primary care medical provider who
was accessed regularly either at the Bowdoin
Street Clinic or elsewhere. Outreach workers
participated in family outreach days and
health fairs.
The Boston Housing Authority (BHA)
Location: Boston, Massachusetts
Services provided by CHWs: Residents
from housing developments throughout the
city were able to take part in the Resident
Health Advocate (RHA) program. Objectives
of the program were to provide intensive
training[7]
for health advocates, to create linkage
between residents and the health resources
in the community, and to foster both individual
and public health prevention and wellness.
RHAs created and distributed health materials,
scheduled meetings with community organizations
and tenant groups, accomplished some surveying
of tenants for needs assessments, and
participated in information sharing and
referrals for individual residents in
their assigned housing development.[8]
RHAs also attended appointments for social
or health services with residents[9]
and assisted families in obtaining appropriate
health resources through health education
and referrals during their six- to eight-month
commitment.[10]
The outreach activities of the RHAs included
participation and planning for community
events (similar to block parties), which
were scheduled throughout the summer,
and traveling community health fairs.
This provided the RHAs with visibility
in their communities of interest.[11]
Massachusetts Department of Public
Health (MDPH), program highlighted:
Refugee and Immigrant Health Program[12]
Location: Statewide
Services provided by CHWs: The
current refugee program was based in the
Massachusetts Bureau of Communicable Disease
Control. The program continued to utilize
an international model using indigenous
health workers whose focus included management
of tuberculosis (TB) and Hepatitis B,
and HIV and STD education, management,
and prevention. After screening and identification
of newly arrived immigrant and refugee
populations, community outreach educators
(COEs) employed by the program worked
with local public health nurses from the
city or town in which the case was managed
to assure that identified refugees were
treated. The nurse provided needed clinical
services and the COEs offered education,
translation, and other needed services.
COEs followed those who were served until
the prescribed course of treatment was
completed. Services provided by the COEs
in the immigrant and refugee program were
generally health focused.[13]
COEs acted as both navigator and interpreter.
Community outreach educators in the program
including workers who spoke Vietnamese,
Cambodian, Laotian, Haitian Creole, Spanish,
Arabic, Somali, French Swahili, Liberian,
Russian, Ukrainian, Bosnian, and Moldavian.
North End Outreach Network (NEON)[14]
Location: Springfield, Massachusetts
Services provided by CHWs: Community
health advocates (CHAs) performed door-to-door
outreach in one or two assigned geographic
zones.[15]
Each CHA was also assigned a school in
the neighborhood and worked with the youth
and families from that school. If a child
was truant, the school would make a referral
to NEON. The CHA would then visit the
family to discover if any assistance was
needed and to address the importance of
school attendance. Although the original
purpose of the organization was to improve
health outcomes in the neighborhood, the
organization had taken a wraparound approach
to its mission. NEON was interested in
all elements that made a family healthy,
strong, and secure including education
and literacy, employment, housing, public
safety, and anything that would stabilize
the neighborhood. Until recently, CHAs
worked alone, but they were now required
to work in pairs. CHAs were expected to
be in the field at least four hours each
day making connections with families,
building trust, doing informal assessments,
and discussing services available in the
community. Once the connection with NEON
had been made, CHAs followed families
to assure appropriate referrals to agencies
were made and services were provided.
CHWs developed caseloads of families that
were visited repeatedly. Most clients
were found through community outreach,
but some were walk-ins to the NEON offices.
Many patients referred to the health clinic
and became the outreach arm for a wide
variety of community agencies.
HealthFirst Family Care Center[16]
Location: Fall River, Massachusetts
Services provided by CHWs: Each
CHW was employed to promote the health
center and its programs through attendance
at community events such as health fairs.
These workers also made educational presentations
about the clinic and its services to church
groups, other clinics, and to hospitals.
In addition to providing community outreach,
the interpreter/outreach worker also worked
as a patient navigator for some clients,
accompanying them to medical appointments.
The outreach workers were liaisons between
the clinic and the community whose primary
function was advocacy and education about
the health clinic so that community residents
would come to the center. The WIC community
coordinator in the clinic was trilingual
in Spanish, Portuguese, and English and
recruited women from the community to
the WIC program.
Beth Israel Deaconess Hospital[17]
Location: Boston, Massachusetts
Services provided by CHWs: Community
resource specialists were employed as
patient navigators, targeting breast cancer
and prostate cancer patients, to help
clients navigate the health care system
through all stages of care.[18]
Community outreach at public events such
as health fairs was also a strategy for
recruiting patients to the program. Community
resource specialists were hospital-based
and traveled to patient homes only on
rare occasions. Resource specialists acted
as liaisons between the community and
the hospital linking patients to both
health and community services. They negotiated
transportation, housing, insurance, food
stamps, and clothing for patients. There
was no time limit on length of service,
and a patient received help from the resource
specialist as long as required. Resource
specialists carried caseloads of 20 to
25 patients at any time and touched on
every kind of health issue. Although their
work was primarily one on one, the resource
specialists worked as part of clinical
teams that included physicians, nurse
practitioners, and nurses as well as social
workers, physical therapists, and occupational
therapists.
New York
Health Plus[19]
Location: Brooklyn, New York
Services provided by CHWs: Patients
were helped through the health care system
and were provided community education
and target information about immunization
and prenatal care. There was a focus on
advocacy, patient empowerment, and health
translation services. CHWs represented
23 different cultures and spoke 16 different
languages (all were fully bilingual) including
Creole, Russian, Chinese, Spanish, Albanian,
Polish, Urdu, Nepalese, Arabic, and Korean,
among others.
Community Action for Prenatal Care
Initiative (CAPCI or CAPC), programs
highlighted: CAPCI programs in the South
Bronx and Buffalo
Location: Vary, see below
Services provided by CHWs: Model
of delivery varies with each coalition.[20]CAPCI
Program in the South Bronx: Bronx
Lebanon Hospital manages the CAPCI program
in the South Bronx and contracts with
15 local community-based organizations
to provide intervention, education, and
referral services in a seven ZIP Code
area for pregnant women at high risk for
HIV and HIV transmission to their newborns.
The 38 outreach workers in the program
are employed by the various contracting
community organizations. Clients are often
women with histories of substance abuse,
mental illness, incarceration, prostitution,
or developmental disabilities who are
provided with intensive intake, referral,
and follow-up services. The program works
with 11 hospitals and health centers in
the Bronx. CAPCI Program in Buffalo,
New York: Is housed with other member
programs of the Buffalo Prenatal-Perinatal
Network, sharing office and administrative
resources with the Community Health Worker
Program, the Healthy Families America
Program, the Buffalo Home Visiting Program,
and the Lead Safe Interim Housing Program.
The program targets at-risk women in specific
ZIP Codes for street outreach and home
visiting. Outreach workers were employed
directly by the Buffalo CAPCI Program,
although referrals were made after intake
to a number of community provider organizations.
The CAPCI Program collaborates with the
Erie County Department of Health, Hispanics
United, the Women's Health Peer Initiative,
Group Ministries, Kaleida Health, and
other local agencies and health providers
to link at-risk women to prenatal care.
The program operates a 24-hour hotline
and completes intakes on more than 200
women each year. There is a large Latino
population in the catchment area as well
as some refugee settlements including
Somalian immigrants. The program also
has a 12-member consumer advisory group.
Church Avenue Merchants Block Association
(CAMBA)
Location: Brooklyn, New York
Services provided by CHWs: Provided
health education and outreach services
to improve residents' access to primary
care.[21]
Currently, CAMBA has two home visiting
programs with a maternal and child health
focus (MCH); one is a Healthy Families
America Program and the other is a Community
Health Worker Program funded by the New
York State Department of Health.[22]
Both employ home visitors focused on better
health outcomes for families. CHWs do
street outreach in local businesses such
as beauty salons. Once identified, clients
complete an assessment and intake process,
and help build action plans for their
families. Workers accompany clients as
needed to obtain public assistance or
food stamps, etc. Home visiting is an
important part of the MCH programs as
it permits the client to share problems
with the workers. Depending on the program
in which they are enrolled, clients receive
services prior to birth and for a year
or longer after birth.[23]
Oak Orchard Community Health Center[24]
Location: Brockport, New York
Services provided by CHWs: Bilingual,
bicultural health promoters were recruited
from a migrant community to work with
migrant Mexican farmworkers in three counties
designated as Health Professional Shortage
Areas in upstate New York. With funding
from the New York State Department of
Health, the program used a mobile van
to transport health providers and promoters
to migrant camps. Workers were trained
over a two-month period in basic health
management, screening, and treatment.
The curriculum also covered issues such
as domestic violence, parenting skills,
lead screening, nutrition, substance abuse,
prenatal care, as well as Medicaid eligibility
and application. The success of health
promoters with respect to a TB program
in the mid-1990s was attributed to the
good relationships of the health promoters
with the target community, their concerted
efforts to reach all migrant workers,
and the ability of the promoters to work
with the clinical health care team.[25]
Texas
Gateway to Care (also a certified
CHW training institution)
Location: Houston, Texas
Services provided by CHWs: Navigators
were responsible for helping people find
and understand how to use a "Health
Home." They performed a combination
of services associated with case management,
such as outreach, eligibility determination,
health promotion, referral, advocacy,
and facilitation of service coordination.
Navigators provided "cultural linkages
between communities and health care providers."
Explicit goals were to encourage individuals
to seek services "at the lowest level
of care," utilize services that "promote
health and prevent disease," and
improve patient-provider communication,
as well as reduce inappropriate emergency
room visits. Navigators were also responsible
for assisting individuals in obtaining
non-health care services and development
of family preventive care plans.
Migrant Health Promotion, REACH
2010 Promotora Community
Coalition Model[26]
Location: Rio Grande Valley (Cameron
and Hidalgo Counties), Texas
Services provided by CHWs: REACH
2010 Promotora Community
Coalition Model: Promotores
supported changes in physical activity
as well as improved nutrition that helps
to control or prevent Type 2 diabetes.
Three settings in which promotores
performed their work were: schools, clinics,
and colonias. School-based promotores
conducted group education sessions and
one-on-one encounters regarding diabetes,
nutrition, and physical activity. They
also met regularly with school-based teams
to assess and implement changes with respect
to physical activity, nutrition, and diabetes
education among students. Clinic-based
promotores conducted periodic home
visits with current diabetic patients
and educated the patients' family/friends
with respect to diabetes, nutrition, and
physical activity. Community-based promotores,
those working in the colonias,
conducted home visits to educate the community
about diabetes, nutrition, physical activity,
and health/social services; provided training
to residents about healthy cooking; and
organized monthly community meetings to
identify and implement system changes
that supported healthy lifestyles.
De Madres a Madres[27]
Location: Houston, Texas
Services provided by CHWs: The
focus was on perinatal health and facilitating
the application process for Medicaid eligibility.
CHWs promoted mother-to-mother support
for at-risk, predominantly Hispanic women,
children, and families through education
and self-empowerment. CHWs encouraged
women to seek prenatal care, and home
visits to pregnant mothers occurred at
least once per month. Infants and children
were followed by CHWs until the age of
three on a monthly basis.
CHRISTUS Spohn Health System
Location: Nueces County, Texas
Services provided by CHWs: CHWs
were assigned to one of three settings:
the emergency department (ED), hospital
floor, and primary care center. The emergency
department-based worker used "patient
satisfaction techniques" to establish
a relationship with patients and arrange
a follow-up visit to educate them about
alternative options to the emergency room.
Program descriptions noted that follow-up
care was generally needed after an ED
visit and that this intervention promoted
continuity of care. Benefits to Spohn
were evident in that emergency department
staff requested expansion of the program.[28]
Hospital floor CHWs again focused primarily
on patient satisfaction and seeing that
all patient needs were met. The CHW linked
the patient to the "appropriate problem
solver," which was equivalent to
becoming an internal advocate (as other
CHWs are advocates with agencies outside
of their own). The CHW offered "a
theoretical companion from the emergency
room to the unit and on to the family
health center, their source of primary
care." The workers based in the primary
care center had some home visiting roles,
but mainly focused on medication compliance.
Center-based workers also spent the first
hour of each morning and afternoon taking
vital signs in order to help the care
team get the center's workflow started
efficiently. There was a core of common
tasks for each of the three CHW models.
All were expected to make phone contacts
with certain groups of patients: the previous
day's patients in the emergency room,
no-shows, and frequent fliers. Part of
the common role of all three types of
worker was internal referrals. All three
settings for the community health workers
placed relatively low emphasis on home
visits as a technique.
City of Fort Worth Public Health
Department[29]
(also a certified CHW training institution)[30]
Location: Fort Worth, Texas
Services provided by CHWs: CHW
duties included home visits, data collection,
assistance in planning, investigation
of resident concerns, articulation of
community needs, and increasing collaboration
between the department and community agencies.
According to the City's Web site, the
benefits of CHWs were not isolated from
those of the rest of the team, but included
"determining the impact of health
care activities on the overall health
status of the community by collecting
statistical data and helping to assure
the quality of services." Examples
of other CHW activities were social service
evaluations, following up on elevated
blood lead levels, assisting families
in obtaining preventive services, arranging
for interpreters and transportation, assisting
in planning programs and interventions,
and serving as a voice for residents and
acting to decrease health disparities.
A more recent initiative of the Outreach
Teams was the Congregational Health Promoter
Program, which educated residents to be
volunteer "health promoters"
based in faith communities. Following
standardized training, volunteers worked
to identify health needs of their communities
and find resources to meet those needs,
which might involve setting up a health
screening through the local hospital district
or an immunization event for seniors to
receive flu shots.
[1] United States-Mexico Community Health
Workers Border Models of Excellence, Transfer/Replication
Strategy. Mariposa Community Health Center
of Excellence in Women's Health Model,
Santa Cruz County, Arizona. El Paso (TX):
United States-Mexico Border Health Commission,
2004.
[2] Office of Women's
and Children's Health - Health Start [Internet].
Phoenix (AZ): Arizona Department of Health
Services, Division of Public Health Services;
2006 [updated 2006 Sep 13/cited 2006 Oct
9]. Available from http://www.azdhs.gov/phs/owch/healthstart.htm.
[3] United States-Mexico
Community Health Workers Border Models
of Excellence, Transfer/Replication Strategy.
Luchando Contra el SIDA Model,
Somerton, Arizona. El Paso (TX): United
States-Mexico Border Health Commission,
2004.
[4] Health Programs.
[Internet] Boston (MA): Action for Boston
Community Development, Inc.; 2005 [updated
2006/cited 2006 Sep 29]. Available from
http://www.bostonabcd.org/programs/health-programs.htm.
[5] CHW National Workforce
Study Interviews (CHW/NWSI) (2006).
[6] Ibid.
[7] Resident Health
Advocate Program [Internet]. Boston (MA):
Boston Housing Authority; 2000 [cited
2006 Nov 08]. Available from http://www.bostonhousing.org/detpages/deptinfo139.html.
Note: Participants in the program train
on many topics, including: health assessment
models, leadership skills, cultural competence,
outreach education, navigating the health
care system, asthma, first aid, nutrition
for life, mental health, depression, stress,
and STDs.
[8] CHW/NWSI (2006).
[9] Ibid.
[10] Resident Health
Advocate Job Description. Boston (MA):
Boston Housing Authority, 2005; Resident
Health Advocate Recruitment Flyer "Attention
BHA Residents." Boston (MA): Boston Housing
Authority, 2006.
[11] CHW/NWSI (2006).
[12] Refugee and Immigrant
Health Program [Internet]. Jamaica Plain
(MA): Massachusetts Department of Public
Health; 2002 [cited 2006 Nov 08]. Available
from http://www.mass.gov/dph/cdc/rhip/wwwrihp.htm.
[13] Ibid.
[14] CHW/NWSI (2006).
[15] Services [Internet].
Springfield (MA): North End Outreach Network;
1996 [cited 2006 Nov 08]. Available from
http://www.neonprogram.org/html/services.html.
Note: According to the Web site, there
were 10 zones with one community health
worker per zone.
[16] CHW/NWSI (2006).
[17] Ibid.
[18] Multicultural
Cancer Task Force [Internet]. Boston (MA):
Beth Israel Deaconess Medical Center;
[cited 2006 Nov 08]. Available from http://www.bidmc.harvard.edu/display.asp?node_id=743.
[19] CHW/NWSI (2006).
[20] Ibid.
[21] Walker MH. Building
Bridges: Community Health Outreach Worker
Programs. New York (NY): United Hospital
Fund of New York; 1994.
[22] Community Health
Worker Program [Internet]. Albany (NY):
New York State Department of Health; [updated
2004 Jun/cited 2006 Nov 08]. Available
from http://www.health.state.ny.us/nysdoh/perinatal/en/chwp.htm.
Note: There are 23 Community Health Worker
Programs across the State, according to
the New York State Department of Health
Web site.
[23] CHW/NWSI (2006).
[24] Poss JE. Providing culturally competent care: is there a role
for health promoters? Nurs Outlook 1999;
47 (1):30-6.
[25] Poss JE, Rangel
R. A tuberculosis screening and treatment
program for migrant farmworker families.
J Health Care Poor Underserved 1997; 8
(2):133-40.
[26] United States-Mexico
Community Health Workers Border Models
of Excellence, Transfer/Replication Strategy.
REACH 2010 Promotora Community
Coalition Model, Rio Grande Valley in
Texas. El Paso (TX): United States-Mexico
Border Health Commission, 2004.
[27] De Madres a Madres
[Internet]. Houston (TX): de Madres a
Madres, Inc.; [cited 2006 Nov 08]. Available
from http://www.demadresamadres.8m.com/.
[28] Rush CH. Conversation
with: Bert Ramos (Director CHRISTUS Spohn
Family Health Center- Westside). 2006
May 01.
[29] Neighborhood Outreach
Teams Fort Worth Public Health Department
[Internet]. Fort Worth (TX): City of Fort
Worth, Texas; [updated 2006 Jun 29/cited
2006 Nov 08]. Available from http://www.fortworthgov.org/health/OR/.
[30] As of June 2006.
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