In Worcester, community health workers provide critical care and trust — while facing an uncertain future.
A woman who regularly visits the Family Health Center of Worcester continues to suffer from hypertension. Her blood pressure fluctuates dangerously, and she struggles to take medicine as prescribed.
In a conversation over the phone, her community health worker determined that her depression and anxiety have made it hard to manage her medications on her own. She lives alone. Only her son and a friend occasionally check in on her. Sometimes she doubts whether she takes too much medicine to feel better. The patient receives one-on-one assessments so that she will feel more secure about taking medication properly.
Community health workers help address a variety of health issues, from connecting expectant mothers to providers to finding therapists or group counseling for patients with substance use disorders. They also help address social conditions that have an impact on health, such as housing and food access.
Currently, CHW services are not reimbursed by MassHealth or commercial health insurance. Hospitals, community health centers and community-based organizations rely on unstable grant funding to hire CHWs.
By the end of a grant cycle, “they are terrified that they will be unemployed in a month,” said Lissette Blondet, the executive director of the Massachusetts Association of Community Health Workers. Massachusetts has approximately 3,000 CHWs, according to the association.
Legislation aims to stabilize the workforce
A bill proposed by Rep. Marjorie Decker, D-Cambridge, and Sen. Robyn Kennedy, D-Worcester, would require public and private health insurers to cover the costs of services provided by CHWs. Supporters believe the proposal would strengthen the workforce that serves the most vulnerable patients and reduce health care costs by preventing avoidable hospital visits.
The bill remains under consideration after a hearing in September.
Massachusetts formally launched a CHW certification process in 2018. Currently, CHWs may apply for certification by either completing the required 4,000 hours of work experience or completing 2,000 hours plus a training program in core competencies and specialty health topics.
Trust built through community connections
CHWs’ understanding of the disparities and insecurities in their communities — from language barriers to prejudice against immigrants in the health care system — has prepared them to build connections with underserved patients. Due to recent immigration raids, patients sometimes feel afraid to answer phone calls from health centers but will respond to a CHW they know and trust, Blondet said.
This trust, however, has to be built on consistent, long-term service.
“It is so absurd to lose a workforce that has prepared for a long time, who has the skills, education, the trust, the presence in the community,” she added.
Lessons from the pandemic and looming coverage losses
Kennedy, who sponsored the bill, said the issue came to her attention during the pandemic, when CHWs shared accurate information about COVID-19 vaccines and made sure people got vaccinated.
Securing funding for CHWs, Kennedy said, is an investment in the health care system that will result in better outcomes for residents. In light of federal cuts to Medicaid, it is also a strategic move to save the state money in the long term.
“Instead of getting access to primary care to treat a cold, they were then waiting till that cold turned into pneumonia and going to the emergency room,” she said. “That was not just again devastating for their health care, but it was also incredibly costly to the overall system.”
Up to 300,000 Medicaid recipients in Massachusetts could lose coverage over time due to federal policy changes, the state estimates. They might struggle to seek affordable primary care. This will place a greater burden on CHWs at community-based organizations to provide basic services, such as vaccinations and health screenings, said Taylor Rich, a project manager at Partners In Health overseeing CHW workforce development programs.
“There are a lot of times that we focus on crisis intervention,” Rich said, “and CHWs address those upstream health effects. So sometimes their work goes unacknowledged because people can’t see the longevity of it over time.”
Language and culture as essential tools
CHWs’ cultural and linguistic expertise is an important asset as they serve patients using a community-based approach, said Olga Valdman, the executive director and a physician at Worcester RISE for Health, a nonprofit that provides health care services to refugees and immigrants.
RISE currently has seven CHWs providing services such as behavioral health care, prenatal care and education about the U.S. health care system. The organization tries to match each patient it serves with a CHW who speaks their language if they have limited English proficiency, Valdman said.
Valdman has seen how language, knowledge and transportation barriers affect patients’ health outcomes. Even taking time off work can be a challenge, especially for those who work multiple jobs.
“People cannot risk jeopardizing their jobs,” she said. “So they always prioritize that over their health.”
Meeting patients where they are
“We have to first acknowledge that, and understand, and be empathetic,” Valdman said. CHWs play an important role in identifying why a patient is unable to keep appointments, looking for flexible solutions such as making appointments after hours and making follow-up phone calls to check in.
A CHW who speaks the same language or comes from the same culture as their patients can build a trusting relationship in a way that health care providers are unable to.
“That trust is critical in health care,” Valdman said. “As a physician, I see all the time that the mistrust, the not knowing what to say, what not to say, not being sure, being shy, being worried about being judged. All of these things hold our patients back and prevent them from being able to share critical information that will influence our ability to care for them.”
An uncertain future for a vital role
While CHWs face different responsibilities and situations, one goal is consistent: meeting people where they are. CHWs try to recognize the unexpressed needs of patients by reading their body language or tone of voice, making sure these needs are seen, said Harvard Thompson, senior director of CHW training at the Center for Health Impact.
Thompson highlighted how CHWs work with patients who have behavioral health issues. Because of the stigma around therapy, some patients are hesitant to meet with a therapist. Speaking with a CHW first avoids the label associated with therapy and makes patients more comfortable about being referred to a therapist.
When funding runs out, CHWs are often the first people to be laid off, Thompson said. Reimbursing CHWs would allow employers to incorporate their work into internal budgets instead of hiring them only when grants are available, he said.
“It just takes redesigning the system,” he said. “And it can ultimately be effective.”
