The role of health care workers in chronic disease management

Effective chronic disease patient management is possible when a strong medical service team is in place comprising social workers and community health care workers.

Such a team can improve the quality of chronic care for low-income people. Social workers can train and supervise community health care workers, provide them with adequate resources, and link them to physicians. Such teamwork will make it easier to identify and serve members of the community who need chronic care services and directives.

From the community

A community-based health care worker is an individual who promotes health or nutrition in the community to which he or she belongs. These workers are not required to hold advanced degrees, and they work under the supervision of a licensed medical social worker. Because they are a part of the community, these health care workers can easily communicate with patients and monitor their conditions. Having a community health care worker is vital for improving patient health outcomes, especially for low-income patients who have limited access to healthcare services and information.

Educating the community

Community health care workers are in the position to provide health education to low- income communities. They can share linguistically and culturally appropriate information to patients so that they can better understand their chronic diseases. They can correct misinformation and challenge long-held false medical beliefs. Community health care workers are also there to provide coaching and encouragement for maintaining good health practices within the community.

Linking patients and providers

Patients from low-income communities have less access to technology and this can hinder making and keeping communication with providers. Here is yet another valuable function of the community-based health care worker: Community health workers strengthen the communication and coordination between patients and physicians. They can conduct regular home visits to monitor progress of treatment and report the information to the provider. They can coordinate schedules and remind patients not to miss their appointments.

Government incentives

The government is aware of the benefits of utilizing the community health care workforce to improve health outcomes through patients' chronic disease management. Section 5313 of the Patient Protection and Affordable Care Act of 2010 is entitled, "Grants to Promote the Community Health Workforce." By providing financial resources, the government encourages health care providers to recruit, train, and compensate community health care workers who can provide much needed help to the medical team.

Evidenced-based benefits

Community health care workers have been shown to deliver evidenced-based success in improving chronic disease management for low-income patients. At Children's Hospital Boston, a program that focused on utilizing community health care workers reduced pediatric asthma-related emergency visits by 64%. The program was also shown to significantly reduce hospital costs. The success of the program was directly related to the output of community health care workers who educated patients and their families about asthma triggers, reminded them about appointments, and monitored the progress of their treatment plans. They also helped improve access to healthcare by linking patients with government programs for issuing them bus fare.

Healthcare providers would do well to utilize the community health care worker system, especially since government funding and evidence-based information are available to assist.

After graduating from Yale with a B.A. in Economics, Richard Kimball Jr. spent over two and a half decades advising healthcare organizations on strategy and capital structure and leading and building both early stage and more established businesses. Rick started at Morgan Stanley and rose to Managing Director. More recently he was Chief Strategy & Growth officer at Accretive Health. Rick is a Trustee of The Brookings Institution, a Fellow in Stanford University's Distinguished Careers Institute and a member of the World President's Organization. Rick is currently CEO of HEXL, a population health management start up. Learn more about Rick Kimball by visiting his Wiki and blog

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