Over the course of her 30-year career, Dr. Tina Castañares has worked as a primary care clinician at three of Oregon’s migrant health centers. An original member of the Oregon Health Services Commission, Dr. Castañares assisted in the pioneering, priority-setting work that helped create the Oregon Health Plan. She also served as the National Ombudswoman for Farmworker Health to the U.S. Assistant Surgeon General for 11 years, was a member of the national Board of Trustees of the American Hospital Association and was a member of the Board of Directors of the Northwest Health Foundation. She has taught and lectured nationally and internationally about resource allocation, Latino and immigrant health, palliative and end-of-life care, bioethics, community health workers, upstream public health and health care reform.
I was a latecomer to medicine. After being educated by a progressive order of Catholic nuns, I had a strong foundation in social justice. This led to my first career working in a “war on poverty” program where I saw vast disparities firsthand. You can’t turn your back on that kind of thing.
Several years later, I began my medical career working at a health care practice with patients that were almost exclusively from minority populations. Health disparities were in front of me all of the time. For two years, almost half of my patients were H’mong refugees from Southeast Asia and there was not much information available about their background. I knew nothing about the profound life experiences that led to their presence in my community, and our clinic and other agencies sorely lacked interpreters. I was working in a profession with so many advanced tools and treatments, but my service was not as effective as it could be because I couldn’t communicate well with my patients. I couldn’t even properly say, “Good morning.” And most of all, I didn’t understand their culture and background.
Through this experience, I realized one major obstacle to addressing health disparities – I didn’t have all of the answers. I needed help. Now, after 25 years working closely with Community Health Workers (CHW), I know that they have many of the answers. It’s a life-changing realization, and I believe that the entire health care system would shift toward equity if CHWs were meaningfully and more widely used.
“Community Health Worker” has become a term referring to a myriad of job and volunteer titles that span the care continuum. In my own Federally Qualified Health Center, we employ and call them “community health promoters” (Promotores de Salud). CHWs, in general, serve in educational, advocacy and health care roles. These roles range from promoting outreach campaigns, to screening for medical and oral health, to helping people navigate the health care system, to bridging cultural gaps between providers and diverse communities. CHWs can have an enormous impact by addressing health literacy challenges and confer cultural competency in completely unique ways if properly supported by their managers and supervisors.
At my health center, we are unusual in that we also rely heavily on what we sometimes call “Clinical Community Health Workers” (CCHW). They perform all of the functions of a CHW, but they also work as members of the primary care team and as skilled care coordinators in specialized programs aimed at vulnerable populations, including farm workers, patients with diabetes, pregnant women and their newborns, and others. Our three longest-running programs focus on maternity needs, overall wellness (nutrition, physical fitness, and stress reduction) and diabetes control. Backed by trained medical staff, the CCHWs act as case managers, teachers, home visitors, lifestyle coaches, lay nutritionists and more. They empower patients to take control of their health.
Every time patients in the perinatal or diabetes program see their primary care provider, they also have an appointment with their CCHW. In one instance, an elderly woman with diabetes was teetering on the edge of dialysis. We learned through her CCHW, who visited her at home, that she wasn’t using her insulin properly because she was nearly blind and illiterate. The CCHW educated the patient’s granddaughter so that she could help her grandmother properly adhere to her medication.
CHWs are able to dig a little deeper and understand the personal needs in the home. They can identify, and sometimes even prevent, unwarranted medical visits and consequences for those “frequent fliers” who undergo so much suffering and who account for so many health care dollars. We in the health care system can tinker all we want, measuring metrics or hospital readmission rates, but what would really make a difference would be to connect with people effectively – emotionally and through education.
One thing I like to say is that CHWs are “high touch.” I think the United States health care system is predominately “high tech.” CHWs, if selected properly, largely share native language, socioeconomic status and life experiences with the people they serve. They have an investment in and connection to the community. They serve as a communication bridge between patients and providers, helping build trust and producing better health outcomes. We need high touch in addition to high tech.
Today, many people are learning about CHWs, but they’re not always learning what’s correct. CHWs should be recruited to serve their peers in their own communities, in a social justice framework; trust will develop only when those elements are in place.
Trust is what’s really needed to achieve the outcomes we desire in health care. We need to bridge the gap between communities that don’t trust the health care system and its providers. CHWs do just that. They help vulnerable populations navigate the care continuum successfully, which is something the best technology can’t do alone.