How Community Health Workers are Bridging Health Care Gaps

 
When a person visits their primary care physician at Virginia Mason Franciscan Health (VMFH), the health and wellbeing of the individual is the physician's primary focus. They aim to care for the whole person and understand all factors impacting their health, but up until recently, many of these factors are out of the medical care team’s control.

According to the Centers for Disease Control and Prevention (CDC), social determinants of health (SDOH), such as food insecurity and housing instability, often impact health outcomes that fall outside traditional medical care. Recognizing this gap, VMFH has implemented a vital new role: the community health worker.

“What I think is unique is how we are addressing gaps that are non-health care related but greatly impact a patient’s treatment plan,” said LuzMarina Tejada, who leads the community health worker program at VMFH.

These factors include things like being able to afford medication, access to transportation, and/or housing stability.

“Things that affect you day to day, we care, and we are here to help,” said Tejada.

The position was created in 2022 as a pilot program. Community health workers were first placed in Tacoma and Burien. Today, 30% of VMFH primary care clinics have a community health worker to assist the needs of patients that fall outside of the scope of primary care physicians and clinic staff.

Embedding community health workers in primary care is part of a CommonSpirit program called Total Health Road Map. Funding and support from CommonSpirit helped implement the program in the Puget Sound.

When an individual checks in for their appointment at their primary care clinic, they are given an optional simple one-page screener. Questions include things like: Have you worried that your food would run out before you got the money to buy more? Did you skip medication to save money? Are you worried about physical or emotional safety?

If they indicate they have a need, a community health worker is alerted, and they will then follow up with the patient.

“We meet the patient where they are and advocate for them at whatever level is needed,” said Tejada. “We have a very unique role within the health care team. We touch every aspect of the patient’s life.”

Tejada worked as a registered nurse in care management for 28 years before starting her role as the director of care coordination.

“I loved providing bedside care when I first started as a nurse,” she said. “But I really wanted to advocate for my patients in a more global way.”

One day, Tejada overheard a conversation between her nurse manager and another individual discussing care management. They were discussing a new role that would focus on addressing social determinants of health.

“I stopped immediately and said, ‘I want to do that,’” Tejada said. “They took a chance on me, and that’s how I started.”

The team of community health workers are passionate about the impact they make in a patient’s life.

“I offer emotional support, listen to concerns, and connect patients with community resources like food banks, housing assistance, and mental health services. I also try to create a bond of trust; I hear personal stories about their lives and help facilitate growth and solutions to their needs,” said Carrie Pieszak, a community health worker located at Franciscan Medical Clinic Port Orchard.

Other community health workers said they have worked with community organizations and local resources to help patients find housing, flee domestic violence, and coordinate food delivery.

“Having the ability to directly connect people in our community with vital resources and support often bridges those gaps in health care access,” said Pieszak. “When I hear someone cannot make it to an appointment because they do not have transportation, I can help them navigate that issue and they can get to see their primary care physician.”

Not only do patients express gratitude and appreciation for the role of community health workers, but physicians and nurses do as well.

“Our community health care program and its talented staff have been a terrific addition to our ambulatory team over the last year,” said Christopher Quarles, MD, a board-certified family medicine physician at VMFH. “They allow us to address patient's social health issues and resource needs in a timely manner. Many of our patients have benefited from their care, compassion and coordination. In short – our community health workers make us a more complete health care team.”