Growing Together: Reimagining Health Care with CHWs

As defined by Texas Health and Human Services Commission: A community health worker (CHW) is a person who, with or without compensation is a liaison, and provides cultural mediation between health care and social services, to the community. 

At Baylor Scott & White Health, CHWs are trusted members of the community who have a close understanding, of the ethnicity, language, socio-economic status, and life experiences of the community served. Besides assisting people in gaining access to needed services, CHWs also build individual, community, and system capacity by increasing health knowledge and self-sufficiency. One of the ways the hospital uses CHWs is to enhance care coordination. CHWs improve health outcomes, access to care, help control costs of care, and address social determinants of health by providing support and counseling, addressing barriers and increasing use of services, establishing connections and providing education, and strengthening care. 

As the CHW staff grew, Baylor Scott & White Health developed a CHW Development Council. The purpose of the council is to:

- Demonstrate & educate on clinical, patient, quality, and cost-effectiveness of CHWs

- Help grow CHW role

- Ensure support of CHW staff

- Be a model organization for utilization & outcomes related to CHWs

The History

Baylor Scott & White Health reimaged health care by building a pathway for growth for their CHWs. With over 100 CHWs on staff, its the national leader in the use of CHWs in health care. It began in 2007 with only 1 CHW for a Diabetes Equity project to 4 in Community Care Navigation in 2010/2011, prompting the creation of other positions. In 2018, Baylor Scott & White Health has over 100 CHWs with various titles and roles, providing them with potential advancement opportunities. 

CHW ROLES at Baylor Scott & White Health

Baylor Scott & White Health's CHWs are spread out across many different programs:

Community Care Navigation CHWs

The Baylor Scott & White Community Care Clinic utilized embedded, bi-lingual medical assistants trained as CHWs within the patient-centered medical homes. The clinic leveraged CHWs to assist unfunded, referral clinic patients by providing care, managing their long-term conditions and minor illnesses, as well as connecting them to social and health system resources in the clinic. CHWs have connected patients to primary care, decreased readmissions, and therefore provided Baylor Scott & White Health a greater cost-savings per patient.  

Primary Care Connection CHWs

CHWs assist emergency department patients with finding a physician who can manage their long-term conditions and minor illnesses. Helps to reduce patient readmissions to the ED, improve overall hospital costs, and patient outcomes by connecting patients to a medical home, medical specialist and community resources in the emergency department. Figure 3 and Figure 4 show a decrease in utilization rates since the start of this program:

**Utilization calculated using number of actual patient encounters for identical time periods 90 days before and 90 days after Primary Care Connection involvement**

Chronic Disease Education CHWs

Chronic Disease Educator CHWs provide culturally appropriate, patient-centered, self disease management education, support and services for those with diabetes, asthma, heart failure and COPD. All 5 clinics who participated in this program met the BMI screening goal and adhered to the program guidelines. Out of the those, 3 met the enrollment and the A1c goal.

Every 1% drop in HbA1c can reduce the risk of microvascular complications by 40% and death by 21%

Additionally, in partnership with the North Texas Food Bank (NTFB) and several of the Baylor's Community Clinics, CHWs with the Chronic Disease Education program screened patients for food insecurity and referred them to NTFB's Food 4 Health. NTFB provides these patients with fresh produce and other nutritious nonperishable food items twice a month for six months or every week for three months at participating clinics. Each clinic can enroll 15 – 20 patients per session. In addition to the food, patients receive recipes, food education and other incentives like cutting boards or potholders.

BSW Health and Wellness Center CHWs

The Baylor Scott & White Health and Wellness Center (BSW HWC) at Juanita J. Craft Recreation Center offers comprehensive health and wellness services with an emphasis on access to care, health education, nutrition and physical activity. The Center is a model for population health, community collaboration and innovation all aimed at meeting the healthcare needs of our neighbors

PEERS (Promotion, Empowerment, Education, Resources, Support) CHWs are part of Baylor Scott & White Health'faith-based community service model that support the BSW Health and Wellness Center. They provide needed education and support for the South Dallas Community regarding overall health, prevention and care management. In the past five years, the program had reduced emergency department visits by 17% and inpatient admissions by 37%. 

Healthy Cities, a free 10-week community-based chronic disease management program coupled with a healthy eating program, formed through partnerships between the City of Dallas, Dallas Park and Recreation, United Way of Metropolitan Dallas, and Baylor Scott & White Health. It is delivered at City of Dallas Park and Recreation Centers in three targeted zip codes in Dallas.

Trained CHWs use multiple teaching and coaching techniques to develop healthy behaviors in community members through the weekly classes. There are both English and Spanish speaking classes available. Key program initiatives include a six-week Stanford Chronic Disease Self-Management Program, a four-week healthy eating boot camp, recreation and physical activity, and text reminders about the program, resources and health tips.

During the four-week healthy eating boot camp, participants are provided the supplies for fix meals per week, less any meats. This will include fresh fruits and vegetables. Research has shown that regular consumption of fruits and vegetables are associated with a reduced risk of many chronic diseases, including heart disease, and may be protective against certain types of cancers.

This program is different than other chronic disease management programs in the ways Baylor Scott & White Health is incorporating technology through the leadership of CHWs. CHWs bring the shared expertise of being a community member and knowledge in managing chronic diseases, text alerts, integration with community partners to connect participants to services that address social determinants of health, such as access to fresh fruits and vegetables and physical activity.

Innovative Care Team CHWs

CHWs at Baylor Scott & White Health are also part of an innovative multidisciplinary coordinated care team model that includes social workers, pharmacy team members, and a chaplain. This team providers high-risk Medicare patients support, prevention, and wellness in outpatient settings. 

Being a CHW with the Innovative Care Team means being a personal health coach provide education on chronic diseases, assist patients with meal planning, providing exercising tips and useful educational handouts to help patients get a better understanding. I help ensure that our patients have a better understanding on the instructions given by their provider, to answer any questions they might have, and safeguard that there’s an open line of communication between patient, provider, and myself

-Community Health Worker

As part of this intervention, CHWs did the following:

1. CHWs called patients four times a week to establish goals of care and inform patients and families of care locations outside the emergency department, such as urgent care, retail clinics, after hours care units and same day appointments.

2. Medication reconciliation.

3. Connected patients and families to community resources.

As seen below in Figure 3, since the start of this intervention in September 2017, the ED utilization rate at Baylor Scott & White Health has decreased significantly:

Annual Wellness Visits CHWs

Patients sometimes don't see the purpose of annual wellness visits. They often feel they already have too many appointments, don't have reliable transportation to attend appointments or don't trust the process.

Upon attending CMS education classes on annual wellness visits, CHWs developed scripts on how to best communicate the importance of annual wellness visits to patients. Since then, patients have been more willing to actively make and attend appointments. Below are outcomes from this initiative:

Table 1: Annual Wellness Visits Outcomes

Home Visits CHWs

Home Visit CHWs cover more than a patient’s medical issues – they address everything else that is affecting a patient’s overall well-being from social isolation, to food insecurity, transportation needs, providing other resources such as needed commodities, or even medical equipment.

Many recently discharged patients above the age of 50 years old are at high-risk for 30-day readmission and isolation when unsupervised by the Transitional Care Team post-discharge. To reduce readmission rates of these patients, Care Navigator and Chronic Disease Educator CHWs visit these patients to support their needs, including connecting them to community resources, referring them to doctors, dieticians, respite care, etc., and ensuring the delivery of required medical equipment to manage a patient's health. From November 2017 to April 2018, the initiative reached out to 55 patients. Out of those, 30 of them participated and only 6 patients were readmitted within 30 days of discharge. Through this intervention, 13 patients were connected to food sources, 54 referrals were administered and 76 medical equipment items were delivered to patients.  

CHW Home Visit Impact – A Patient Success Story

“Mr. M” was referred to the Home Visit program due to missed appointments. The CHWs scheduled a home visit to meet with Mr. M in person and when they arrived, Mr. M was dressed in his best and was excited to receive company. The CHWs discovered that Mr. M no longer felt comfortable traveling by bus to get to his appointments because his vision decreased. He felt depressed and isolated because he is often alone – his adult son works long hours far away from home, and Mr. M can no longer visit a local park he frequented due to his visual impairment. With the help and direct support of the home visit CHWs, Mr. M received cataract surgery in both eyes, decreased his AbA1c, and continues to be a patient at the Baylor Scott & White Community Care Clinic in Fort Worth.

Home Health Care CHWs

To decrease the number of Medicare patients using home health for more than 120 days, Baylor Scott & White Health's CHWs worked with physicians to evaluate patients need for home health care, reduce or eliminate automatic renewals of home health care and identify in-network home health care services.  From June to September 2017, 405 patients completed a home health questionnaire. This process identified 14 patients capable of possible discharge from home health care. Out of the 405 patients, CHW addressed the socio-economic needs of 364 patients, as seen in Table 2.

Table 2: Social Needs Addressed by CHWs

Other Initiatives

CHWs that also serve as pharmacy technicians who perform medication reviews and refer patients to the pharmacist for interventions. These medication reviews are performed prior to a patient’s appointment at two of Baylor Scott & White Health's clinics. Since March 2016, 8,395 discrepancies in medications were discovered and documented, with at least three discrepancies per patient. Additionally, the electronic health record lacked information on 6,345 medications patients reported taking. This initiative helped rectify patient records in the EHR system, reducing discrepancies over time. Baylor Scott & White Health is developing other pharmacy initiatives to establish standardization around proper use of medications around anti-depressants, hypnotic drugs, depression and chronic insomnia. 

Additionally, Baylor Scott & White Health identified a correlation between the increase in falls and use of ED with increased use of Zolpidem (Ambien)/hypnotic drugs. The hospital developed guidelines on the use of hypnotic drugs, and are currently launching a sleep hygiene campaign with the support of community health workers. 


Baylor Scott & White Health and Bell County, Texas partnered on a community-based community health workers program that provides medical support to individuals in underserved areas of Bell County. To keep the county's residents healthy, the CHWs navigate health care benefits, refer patients to in-house direct care services such as immunizations, vision, dental, family planning, and refer patients to other social needs services identified through assessments. The participating CHWs are co-managed by the health system and the county. They float to multiple care locations in the county and provide both in-person and remote support to patients. 


Baylor Scott & White Health is exploring innovative ways to help the underserved patient population access primary care and specialty care they need to maintain their health status, and overcome barriers such as cost of service, time needed for appointments and lack of transportation. 

Baylor Scott & White Health plans on introducing care providers and underserved patients to low-cost, accessible, digital tools to access health care effectively. This community-based care approach of utilizing telehealth tools to expand the capacity of care teams can engage the community while providing access to clinical care and chronic disease education through convenient, connected and conducive care that fits various lifestyles. This approach also allows individuals from the community to access health care service the same way a commercially insured patient would.

The combined impact of a Community Health Worker as a technology conduit, who can engage and educate patients on the actual use and value of technology with a clinician and case managers from partnering community organizations, will be the major first step in providing health care to an underserved community. Baylor Scott & White Health's goal is to improve access to high-need specialty care services, meet the unique needs of patients by providing resources and education needed to adapt and improve health outcomes, and potentially avoid disease-related complications through access to “virtual encounters”.

Contact Information:

Ashley Rodriguez

 Community Health Worker System Manager