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Integrating Community Health Workers into Primary Care Practice

A Resource Guide for HCH Programs

Community Health Worker
1: CHWs and HCH
4: Training CHWs
2: CHW Roles and Responsibilities
5: Supervision of CHWs
3: Hiring CHWs
6. CHW Integration and Support

Consider CHWs an extension of care that can be present with clients in their day-to-day lives. There are likely gaps in care that exist because of a lack of resources, staff time, etc. Once gaps are identified, consider the ways in which a CHW can close those gaps. What does the organization need from a CHW? Does the organization need CHWs to help clients who are having difficulty making it to specialty appointments, who are inappropriately utilizing the Emergency Department, struggling with medication management, having trouble understanding what benefits they are eligible for, or all of the above?

Once the role of the CHW is identified, the next step is ensuring the organization’s workforce has a comprehensive understanding of the role of the CHW. The work of a CHW may be perceived as an overlap of what is already being provided by social workers, case managers, and/or nurses. Staff members need to be adequately trained on the scope of the CHW position and the many ways in which the CHW role compliments and enhances the work already being done. In order for CHWs to be successfully integrated into a program, there must be institutional support for the position.[i]



Clinician’s response to CHWs: Stories from the field

“What happened because of this project is we were able to show the clinic staff and management that there really is a place and a benefit for CHWs within our system. Now we are able to show all the great things that can happen when you have a CHW as part of your team. From a long term perspective, I think that’s the best outcome we’ve had. Providers really appreciate being able to do a little bit more if they know a patient is struggling with one of their recommendations or following a certain plan. The provider can connect them with the CHW to follow up on specific issues and help them when they are outside of the clinic. In the past when a provider gets labs back that are alarming or they need to make a referral and they can’t find a particular client, they would make phone calls and then send a letter. If we couldn’t get a hold of them then we just couldn’t get a hold of them, we didn’t have the resources to do anything else. Now, when those urgent things come up or we know someone needs to get to a specialty appointment and needs support to get there or they won’t go, then the providers can call on the CHWs to either go out and find the individual or help individuals get to appointments. The providers were really excited when we made this a more formal process. Often times the providers feel like they can’t do much else for their patients outside of the four walls and they worry about them. They really want to help but they themselves can’t go out and find them.”

CHWs and Care Teams

Team based care is widely recognized as critical to achieving the Triple Aim of CMS – improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. CHWs can be vital members of these teams. As part of a care team, CHWs work alongside other providers (medical providers, social workers, case managers, etc.) to integrate and coordinate client care.[ii]

The relationship a client has with a CHW may be different than the relationships with other health care providers. Clients may feel as though they can be more honest with their CHW. When CHWs are integrated into care teams with their client’s providers, the honesty between a CHW and their client can translate into the clinic being able to provide services to individuals in more holistic and effective ways.

A case study done in the South Bronx, New York and highlighted in the Journal of Ambulatory Care Management chronicled one clinic’s successful integration of CHWs into the practice. The case study highlights the meaningful impact a CHW’s perspective can bring to a care team.

They can transform the way that health care team members view patients by correcting misunderstandings and providing context for patient behaviors. Health care providers value the ability of CHWs to connect with patients, overcoming the linguistic, cultural, economic, and other barriers that they are unable to transcend. The incorporation of CHWs into the care team allowed for the team to better engage patients who experienced the greatest barriers to care. Through full integration with the care team, CHWs helped identify ways in which the care team could become more patient-centered. Thus, it was not simply the addition of the CHW, but the transformative nature of the collaboration between CHWs and other members of the care team, that allowed this practice to improve its outcomes for the most vulnerable patients.[iii]


“CHWs bring a perspective to the table that sometimes the business or administrative side of the clinic does not always see. They can offer some good suggestions on policies, procedures, and workflow. They can offer insight on how some things that make sense on the business side may be taken differently by clients and may cause unintentional problems.” ~ Supervisor

Building a supportive HCH environment

In order for a CHW to serve in the role successfully, the HCH clinic needs to be considerate of the realities of their day-to-day work. Here are a few items to consider as an agency develops a plan for integrating a CHW into its practice:

  • It is important to be flexible. A CHW working with high needs clients will probably not fall into a 9:00am to 5:00pm model. The day depends on what is happening with their clients and unfortunately it can be hard to predict what will come up with a client who may frequently be in chaos or crisis.
  • If the clinic has a dress code, be considerate of what clothing would be most appropriate for the CHW when they are out in the community.
  • It is imperative to make a plan for transportation prior to hiring a CHW. Transportation was a barrier for almost all of the programs that participated in the National HCH Council’s project. Think critically about how the CHW is going to help clients get to and from appointments.
  • Be open to suggestions from the CHW. Clients may share more information with their CHWs than their medical providers. Additionally, the lens through which a CHW sees the HCH clinic may provide insight and feedback not previously considered. [iv]

Establishing Peer Support for CHWs

Peer support can be deeply meaningful as a form of ongoing support for CHWs. The unique experience CHWs have in their work, walking the line between maintaining their status as trusted members of the homeless community while simultaneously serving as professional staff members of the HCH clinic, is one that is best understood by other CHWs in the field. Having a cohort of CHWs who meet regularly to share their challenges, provide each other support, celebrate success, and participate in shared learning is an effective way to institutionalize support for CHWs. Unfortunately, for many HCH programs, having more than one or two CHWs is a luxury they cannot yet afford. In situations such as these, encourage the CHW to engage with the local and/or state CHW associations. Involvement in these organizations will connect the CHW with other CHWs in the area for networking and support.



As part of the National HCH Council’s project, all 15 CHWs convened during interactive online trainings, monthly calls, and at in-person conferences. Many of the CHWs were the only CHW in their agencies; some were the only CHWs in their communities. Having a cohort of CHWs doing similar work and negotiating similar challenges was incredibly beneficial. They were able to lean on each other for support, reach out to one another for advice, and hold each other accountable. “The fact that they were able to do it together and they had a larger peer group was the most important. Friendships were developed and support was given that was really helpful, especially in the beginning when the case managers and medical providers were a bit slow in understanding their role and what they brought to the table. They had each other as peer support.” ~ Supervisor

Peer Support Resources for CHWs

American Public Health Association: Community Health Workers

APHA Facebook

Alaska Community Health Aide Program

Arkansas Community Health Worker Association

California Association of Community Health Workers

Chicago CHW Local Network

Maine Community Health Worker Initiative

Massachusetts Association of Community Health Workers

Florida Community Health Worker Coalition

Michigan Community Health Worker Alliance

Oregon Community Health Workers Association

Penn Center for Community Health Workers

Minnesota Community Health Worker Alliance

CHW Network NYC

Community Health Worker Texas

Association for Utah Community Health

Washington Community Health Workers Network

Arizona Community Health Workers Association

Indiana Community Health Workers

Community Health Workers Institute of New Jersey

Community Health Worker Association of Rhode Island

Additional Resources

InFocus: Integrating Community Health Workers into Care Team

Community Health Worker Integration into the Health Care Team Accomplishes the Triple Aim in a Patient-Centered Medical Home


[i] Paradis, R. and Phalen, J. (January 2015). How Community Health Workers Can Reinvent Health Care Delivery in the US. Retrieved from:

[ii] Clary, A. (November 2015). Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers. National Academy of State Health Policy. Retrieved from:

[iii] Mayer, M. (March 2014). How One Medical Practice Integrated Community Health Workers into the Health Care Team. Retrieved from:

[iv] The Common Wealth Fund. (December 2015). InFocus: Integrating Community Health Workers into Care Teams. Retrieved from:

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