This document discusses the role of community health workers (CHWs) in geriatric care. It begins by defining CHWs according to the American Public Health Association as frontline public health workers who serve as liaisons between health services and their communities by providing outreach, education, informal counseling, social support, and advocacy. The document then outlines key strengths of CHWs for geriatric care like developing trust with patients, addressing social determinants of health, and providing social support. It explores roles for CHWs in chronic disease management, care transitions, falls prevention, and senior centers. Studies show CHWs have potential to reduce costs and hospital readmissions when utilized in these areas.

1. Carl H. Rush, MRP
Project on CHW Policy & Practice
University of Texas – Houston,
Institute for Health Policy
Community Health Workers:
Key Assets in the Future of
Geriatric Services
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2. Topics: CHWs in geriatric care
Getting on the same page: definitions
Key strengths of the CHW
CHW roles in key geriatric issues
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3. Definitions: what is a CHW?
GETTING ON THE
SAME PAGE
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4. What’s your definition of CHW?
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5. Community Health Worker Definition
American Public Health Association (1)
• The CHW is a frontline public health worker
who is a trusted member of and/or has an
unusually close understanding of the
community served.
• This trusting relationship enables the CHW
to serve as a liaison/link/intermediary
between health/social services and the
community to facilitate access to services
and improve the quality and cultural
competence of service delivery.
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6. Community Health Worker Definition - APHA (2)
•The CHW also builds 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.
APHA Policy Statement 2009-1, November 2009
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7. Key strengths of the CHW
for geriatric care
Develop and maintain trust, rapport and candor
with patients and families
Work directly with social determinants and inform
clinicians of their importance
Connect patients with non-medical resources
Provide informal counseling and social support:
home visiting and extended listening
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8. CHWs are playing new roles in geriatric care
 Vital support to self-management of chronic
conditions
 Supporting home-and community-based long term
care
 Making care transitions more efficient and effective
(reducing inpatient readmissions)
 Falls prevention
 The “utility infielder” in senior centers and senior
housing
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Versatile and adaptable
CHW roles in CDM

10. Shifting Tasks to the CHW
16
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11. 8
Case Manager RN/CHW Model
Patient Experience - CHW
Weekly to Monthly visits
■ Data collection – VS, foot check, self
report
■ Goals using Motivational Interviewing
■ Education
■ Referrals – community connections
■ Self-Efficacy
Patient Centered - Address barriers
of equity and access3/24/15 11
www.spectrumhealth.org/healthiercommunities

12. Cost Efficiencies – Right Place Care
14
Diabetes
Only
Heart
Failure
Only
Heart
Failure
AND
Diabetes
Usage Rate
BEFORE Core
Health
8.5% 38.2% 38.2%
Usage Rate for
Core Health
Experience
3.1% 10.2% 9.3%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
Hospital Admissions
Diabetes
Only
Heart
Failure
Only
Heart
Failure
AND
Diabetes
Usage Rate
BEFORE Core
Health
16.4% 31.1% 31.1%
Usage Rate for
Core Health
Experience
12.0% 11.0% 11.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Emergency Department Visits
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13. 3/24/15 13
CHWs at Work:
Home- and
Community-based
Care

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CHWs in home-and community-based care
Complement rather than overlap roles of home
health aides
Connecting to community resources
Providing caregiver support
Arkansas “Community Connectors”
• 5-year Medicaid waiver demonstration in 3 counties
• Net return to the State of 3:1 in reduced overall cost of care
• Being expanded statewide
Felix HC, Mays GP, Stewart MK, et al. The care span: Medicaid savings
resulted when community health workers matched those with needs to
home and community care. Health Affairs. 2011;30(7):1366-74.

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CHWs showing potential in
Care Transitions

16. CHWs contribute the essence of the
“warm handoff”
Supporting patient and family in hospital and
home setting
Coaching on understanding of discharge
instructions
Follow-up visits on treatment adherence,
appointments
Connecting to non-medical services
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Recent results are encouraging
Philadelphia RCT study showed CHW-driven follow-
up led to significant reductions in long-term
readmission rates
• Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, Shannon
RP, Long JA. Patient-Centered Community Health Worker Intervention to
Improve Posthospital Outcomes: A Randomized Clinical Trial. JAMA Intern
Med. Published Online: February 10, 2014.
KentuckyOne Health’s 9-month pilot program
showed 19% readmission for intervention group vs.
41% for comparison group
• http://www2.massgeneral.org/disparitiessolutions/z_files/Summary_DLP%2
0cost%20analysis_Final.pdf

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CHWs showing potential in
Falls Prevention

19. Potential for CHWs in falls prevention
CHWs have demonstrated success with home
assessments, medication reconciliation, basic
screenings
Texas A&M has a falls prevention curriculum for
CHWs developed with UNC Chapel Hill PRC
http://nchwtc.tamhsc.edu/fall-prevention-curriculum/
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CHWs can be based in
Senior Centers and
Senior Housing

21. Potential for CHWs in non-medical settings
CHWs can offer resource referral, classes,
eligibility/enrollment services, and address barriers to
access
Sustainable financing may be available thru diverse
sources in models like the Community HUB/Pathways
HUD has been expanding efforts to station CHWs;
affordable housing developers like Mercy Housing and
Local Initiatives Support Corp. are interested
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22. Thank you!
Carl H. Rush, MRP
(210) 775-2709
carl.h.rush@uth.tmc.edu
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