CMSA Today - Issue 4, 2017 - 16

C O L L A B O R AT I V E C A R E

COMMUNITY
HEALTH WORKERS:

A KEY ROLE ON THE COLLABORATIVE CARE TEAM
BY MARY BETH NEWMAN, MSN, RN-BC, CCM, CHCQM

T

here is relentless change
happening today across the full
continuum of healthcare; new
models of healthcare delivery
and reimbursement are
evolving rapidly. Affected practice settings
include accountable care organizations
(ACOs), integrated health delivery systems
and population health management
models of coordinated care with valuebased (outcomes-driven) reimbursement,
and they all rely on effective identification,
engagement and care coordination of
patients at risk for adverse outcomes, both
to achieve improvements in clinical outcomes
and reduced cost of care.
However, there are additional factors that
need to be considered in these models when
they serve vulnerable populations such as
the economically disadvantaged, racial and
ethnic minorities, the uninsured or underinsured, low-income children, the frail elderly,
the chronic mentally ill and the homeless.
For these populations, it's absolutely critical
to incorporate a community-based focus to
effectively address the many social determinants of health that are key drivers of health
inequities and disparities in care.
Community health workers are the ideal
members of the collaborative care team to
help achieve this critical need in vulnerable
populations and underserved communities.
Case managers and other members of the
collaborative care team need to understand
the role and functions of the community
health worker (CHW) to fully appreciate the
value CHWs bring to the team and to the
patients they work with.
16

CMSA TODAY

Issue 4 * 2017

WHO ARE COMMUNITY
HEALTH WORKERS?
Healthcare professionals are often surprised to learn that community health workers have been around for many years! In
fact, CHWs have a "long and proud history
of accomplished service" in reaching underserved populations within communities that
typically have both complex medical and
social needs (Phalen & Paradis, 2015).
CHWs are non-clinicians and do not provide clinical care. They are not physician or
nurse extenders, but rather have a unique
specialized role that is best described by the
American Public Health Association's policy
statement on CHWs (APHA, 2009):
* CHWs are front-line public health workers
who are trusted members of and/or have
an unusually close understanding of the
community served.
* This trusting relationship enables CHWs
to serve as a liaison/link/intermediary between health/social services and
the community.
* CHWs seek to facilitate access to services
and improve the quality and cultural competence of service delivery.
* CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range
of activities such as outreach, community
education, informal counseling, social
support and advocacy.
CHW ROLES AND FUNCTIONS
CHWs work in a wide variety of settings
along the care continuum, including public health organizations, healthcare clinics,

medical offices, hospitals, managed care
organizations, schools and community centers. CHWs most commonly focus on helping
patients manage chronic diseases, encouraging preventive healthcare and ensuring
healthcare access.
Since CHWs generally live in the communities where they work, they are highly tuned
into the social context of the community.
Thus, they are uniquely qualified to be connectors to the community and link patients
to resources and networks (Brownstein &
Hirsch, 2011).
The roles and activities of CHWs are
focused on meeting the unique needs of
patients within their communities and the
goals of the organizations within which they
work. Generally, these include:
* Creating connections between vulnerable
populations and healthcare systems;
* Ensuring cultural competence among
healthcare professionals serving vulnerable populations;
* Providing culturally appropriate health
education on topics related to chronic
disease prevention, physical activity and
nutrition; and
* Advocating for underserved individuals
and communities.
The CHW serves as an integral member
of the healthcare team by supporting the
team's patient-centered goals and interventions. For example, CHWs:
* Support individualized goal-setting, implementation of self-management plans and
long-term self-management support;
* Help patients navigate healthcare systems
(for example, by providing assistance with



Table of Contents for the Digital Edition of CMSA Today - Issue 4, 2017

President’s Letter
Association News
CMSA Conference Supporters
CMSA Corporate Partners
Case Management at the Helm of Diverse America
Community Health Workers: A Key Role on the Collaborative Care Team
Ticket to Work: Strategies for Case Managers Who Face Work-Disrupting Disabilities
For Case Managers, Success Requires Mastering Today’s Challenges
Using a Patient Engagement Strategy to Help Care Managers Educate Patients at the Right Time—Before It’s Too Late
Index of Advertisers
CMSA Today - Issue 4, 2017 - Intro
CMSA Today - Issue 4, 2017 - cover1
CMSA Today - Issue 4, 2017 - cover2
CMSA Today - Issue 4, 2017 - 3
CMSA Today - Issue 4, 2017 - 4
CMSA Today - Issue 4, 2017 - 5
CMSA Today - Issue 4, 2017 - President’s Letter
CMSA Today - Issue 4, 2017 - 7
CMSA Today - Issue 4, 2017 - Association News
CMSA Today - Issue 4, 2017 - 9
CMSA Today - Issue 4, 2017 - CMSA Conference Supporters
CMSA Today - Issue 4, 2017 - CMSA Corporate Partners
CMSA Today - Issue 4, 2017 - Case Management at the Helm of Diverse America
CMSA Today - Issue 4, 2017 - 13
CMSA Today - Issue 4, 2017 - 14
CMSA Today - Issue 4, 2017 - 15
CMSA Today - Issue 4, 2017 - Community Health Workers: A Key Role on the Collaborative Care Team
CMSA Today - Issue 4, 2017 - 17
CMSA Today - Issue 4, 2017 - 18
CMSA Today - Issue 4, 2017 - 19
CMSA Today - Issue 4, 2017 - Ticket to Work: Strategies for Case Managers Who Face Work-Disrupting Disabilities
CMSA Today - Issue 4, 2017 - 21
CMSA Today - Issue 4, 2017 - 22
CMSA Today - Issue 4, 2017 - 23
CMSA Today - Issue 4, 2017 - 24
CMSA Today - Issue 4, 2017 - For Case Managers, Success Requires Mastering Today’s Challenges
CMSA Today - Issue 4, 2017 - 26
CMSA Today - Issue 4, 2017 - 27
CMSA Today - Issue 4, 2017 - Using a Patient Engagement Strategy to Help Care Managers Educate Patients at the Right Time—Before It’s Too Late
CMSA Today - Issue 4, 2017 - 29
CMSA Today - Issue 4, 2017 - Index of Advertisers
CMSA Today - Issue 4, 2017 - cover3
CMSA Today - Issue 4, 2017 - cover4
http://www.nxtbook.com/naylor/CMSQ/CMSQ1118
http://www.nxtbook.com/naylor/CMSQ/CMSQ0417
http://www.nxtbook.com/naylor/CMSQ/CMSQ1417
http://www.nxtbook.com/naylor/CMSQ/CMSQ0317
http://www.nxtbook.com/naylor/CMSQ/CMSQ1317
http://www.nxtbook.com/naylor/CMSQ/CMSQ0217
http://www.nxtbook.com/naylor/CMSQ/CMSQ1217
http://www.nxtbook.com/naylor/CMSQ/CMSQ0117
http://www.nxtbook.com/naylor/CMSQ/CMSQ1117
http://www.nxtbook.com/naylor/CMSQ/CMSQ0416
http://www.nxtbook.com/naylor/CMSQ/CMSQ1416
http://www.nxtbook.com/naylor/CMSQ/CMSQ0316
http://www.nxtbook.com/naylor/CMSQ/CMSQ1316
http://www.nxtbook.com/naylor/CMSQ/CMSQ0216
http://www.nxtbook.com/naylor/CMSQ/CMSQ1216
http://www.nxtbook.com/naylor/CMSQ/CMSQ0116
http://www.nxtbook.com/naylor/CMSQ/CMSQ1116
http://www.nxtbook.com/naylor/CMSQ/CMSQ0415
http://www.nxtbook.com/naylor/CMSQ/CMSQ1415
http://www.nxtbook.com/naylor/CMSQ/CMSQ0315
http://www.nxtbook.com/naylor/CMSQ/CMSQ1315
http://www.nxtbook.com/naylor/CMSQ/CMSQ0215
http://www.nxtbook.com/naylor/CMSQ/CMSQ1215
http://www.nxtbook.com/naylor/CMSQ/CMSQ0115
http://www.nxtbook.com/naylor/CMSQ/CMSQ1115
http://www.nxtbook.com/naylor/CMSQ/CMSQ0414
http://www.nxtbook.com/naylor/CMSQ/CMSQ1414
http://www.nxtbook.com/naylor/CMSQ/CMSQ0314
http://www.nxtbook.com/naylor/CMSQ/CMSQ1314
http://www.nxtbook.com/naylor/CMSQ/CMSQ0214
http://www.nxtbook.com/naylor/CMSQ/CMSQ1214
http://www.nxtbook.com/naylor/CMSQ/CMSQ0114
http://www.nxtbook.com/naylor/CMSQ/CMSQ1114
http://www.nxtbook.com/naylor/CMSQ/CMSQ0413
http://www.nxtbook.com/naylor/CMSQ/CMSQ1413
http://www.nxtbook.com/naylor/CMSQ/CMSQ0313
http://www.nxtbook.com/naylor/CMSQ/CMSQ1313
http://www.nxtbook.com/naylor/CMSQ/CMSQ0213
http://www.nxtbook.com/naylor/CMSQ/CMSQ1213
http://www.nxtbook.com/naylor/CMSQ/CMSQ0113
http://www.nxtbook.com/naylor/CMSQ/CMSQ1113
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0412
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1412
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0312
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1312
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0212
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1212
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0112
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1112
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0411
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1411
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0311
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1311
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0211
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1211
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0111
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1111
http://www.nxtbookMEDIA.com