On a recent Monday, Sandy Guzman, a community health worker in rural Oregon, drove to visit a patient in her 60s in a small city called The Dalles.<\/p>\n
The patient lived alone, and \u201creally struggles with social isolation,\u201d Ms. Guzman said. After a serious fall and subsequent surgery, the woman was using a wheelchair. She confided that she would like to attend services at a church down the road but had no way to get there and did not want to seem \u201ca bother.\u201d<\/p>\n
\u201cWe called the pastor to see if there was someone who could pick her up\u201d on Sundays, Ms. Guzman said. And there was.<\/p>\n
The next day, Ms. Guzman visited a woman with heart failure who required constant oxygen. She lives in \u201cless than ideal housing,\u201d with no kitchen and only a plug-in heater for warmth.<\/p>\n
\u201cWe were trying to figure out if she qualifies for HUD housing or assisted living,\u201d Ms. Guzman said. \u201cWe spent a lot of time talking about the options and came up with a game plan.\u201d<\/p>\n
Wednesday\u2019s schedule included a 20-mile drive to Hood River to see an 81-year-old woman whose partner of nearly 40 years was contending with a serious cancer. Ms. Guzman, who speaks to her in Spanish, found her distraught at the possibility of losing him.<\/p>\n
Ms. Guzman had arranged for the woman to begin seeing a therapist to help her through the crisis \u2014 no minor achievement. But on this visit, \u201cI just handed her tissues and tried to give words of comfort,\u201d she said. \u201cHonestly, sometimes just sitting and listening\u201d is the best response.<\/p>\n
A community health care worker, the American Public Health Association says<\/a>, is a \u201ctrusted member\u201d of a local community or someone who has \u201can unusually close understanding\u201d of it, enabling the worker to serve as intermediary between patients and the health care system.<\/p>\n These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics reports about 65,000<\/a> of them, which the National Association of Community Health Workers says is probably an underestimate.<\/p>\n That partly reflects the difficulty of counting workers who go by a variety of names \u2014 community health educators, outreach specialists, promotores de salud \u2014 and operate under different state regulations, sometimes with no licensure or certification required.<\/p>\n What they have in common is that \u201cthey talk like the people they work with,\u201d said Sam Cotton, who directs the curriculum for several such programs at the University of Louisville in Kentucky.<\/p>\n With shortages of health care professionals and an aging population, \u201cthere\u2019s a lot of momentum for this,\u201d she said.<\/p>\n In Oregon, for example, five rural clinics employ community health workers, who become state-certified after completing 90 hours of online training, through a program called Connected Care for Older Adults. A sixth clinic employing a community health worker operates in neighboring Washington.<\/p>\n Their frail patients are struggling. \u201cThey can\u2019t drive, so they can\u2019t get to a grocery store and shop,\u201d said Dr. Elizabeth Eckstrom, the chief of geriatrics at Oregon Health and Science University, who helped oversee the program\u2019s start in 2022. \u201cThey\u2019re not taking their medications, either for cognitive reasons or because they can\u2019t get to a pharmacy.\u201d<\/p>\n Few have completed an advance directive, specifying the care they want \u2014 or don\u2019t want \u2014 if they suffer a health crisis.<\/p>\n Connected Care\u2019s community health workers tackle many of those not-exactly-medical problems \u2014 from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to work with each patient, usually during home visits.<\/p>\n They help coordinate follow-up appointments. They administer cognitive and mental health screenings and watch for use of too many medications, entering their observations in the patients\u2019 electronic health records.<\/p>\n \u201cIt\u2019s like being the eyes and ears for the doctors, to see what\u2019s happening outside the 20 minutes they get to spend with patients,\u201d said Ms. Guzman, whose work has ranged from ordering a bath mat to reporting suspected financial abuse.<\/p>\n In a study of Connected Care patients<\/a> (average age: 77), a subsample found substantial decreases in emergency department visits and hospitalizations among those served by community health workers.<\/p>\n More extensive research, not yet published, supports that finding, Dr. Eckstrom said.<\/p>\n \u201cE.D. visits cost thousands, and hospitalizations are tens of thousands,\u201d she pointed out. The cost per patient for the 90-day program is $1,500. Its workers earn $25 an hour, a fairly typical wage, and receive full employee benefits.<\/p>\n Dr. Manali Patel, an oncologist at Stanford University, found similar benefits and cost savings for older patients with advanced cancer<\/a> in a clinical trial at the V.A. Palo Alto Health Care System.<\/p>\n \u201cLots of people were passing away in the I.C.U.,\u201d she recalled. \u201cIf we\u2019d asked, they probably would have wanted to be at home.\u201d Oncologists, she added, are \u201cnotoriously bad at engaging in and documenting those conversations.\u201d<\/p>\n But when a lay health worker made regular phone calls to help patients understand their options, discuss their preferences with their care team and file advance directives, the results \u2014 published in JAMA Oncology in 2018 \u2014 were \u201cvery dramatic,\u201d Dr. Patel said.<\/p>\n More than 90 percent of the participating veterans had their goals documented in their records compared with less than 20 percent of the control group. The lay worker\u2019s patients had significantly fewer emergency room visits and hospitalizations, and were more likely to enroll in hospice care.<\/p>\n Dr. Patel and her co-authors have gone on to document the benefits of lay health workers, the term they used, in undertaking other tasks in other settings.<\/p>\n In oncology clinics in Arizona and California, for instance, two bilingual lay health workers made regular phone calls to cancer patients<\/a> over age 75 to assess symptoms like pain, nausea, breathlessness and depression.<\/p>\n Alerting the health care teams to these patients\u2019 problems substantially reduced their emergency department use and hospitalizations, and the cost savings averaged $12,000 per patient.<\/p>\n \u201cThis low-tech, human-administered intervention reaped huge dividends,\u201d said an editorial accompanying that study<\/a> in the medical journal JAMA.<\/p>\n \u201cCommunity health workers should be part of every health care team,\u201d Dr. Eckstrom said. \u201cThey support the patient in ways the medical system just can\u2019t, no matter how hard we try.\u201d<\/p>\n One obstacle to expanding their use, however, is unstable funding.<\/p>\n In 2024, Medicare began covering some community health worker services, but not all. (The costs of driving 30 miles to remote homes, for example, are not reimbursed.) Medicaid coverage is piecemeal, reimbursing for some services in some states and not others.<\/p>\n \u201cA lot of community health worker roles rely on short-term grants,\u201d said Neena Schultz, a director of the National Association of Community Health Workers. \u201cSustainability is something we talk about every day.\u201d<\/p>\n