The New Front Line of Public Health

When Stephanie Brown, a community health worker (CHW) affiliated with a large health care system in Baltimore, sat across from her new client, she thought she’d be teaching the elderly woman to prepare a checklist of questions for her doctor.

Instead, the woman nervously admitted that her biggest concern was a waterline break in her house. She and her husband had no money to fix it, so they’d spent weeks wading through standing water. Even worse, they had no clean drinking water.

Brown juggled phone calls and emails with agencies across the city to secure repair funds and get a crew out to the couple’s house.

Coordinating home repairs may seem far afield from the typical health care job description, but for CHWs, doing the job well means taking a 360-degree view of a patient’s health. That includes the safety of her home; her ability to travel to a doctor’s office; and even her state of employment or financial security.

As Dwyan Monroe, who runs community health worker initiatives at the Institute for Public Health Innovation, a Washington, D.C. nonprofit, explains: “CHWs are informal counselors … and [help] address the social barriers to care, such as access to healthy foods; transportation to appointments; and connecting to social or environmental services that help people with day-to-day survival.”

It’s a job that dovetails with the health care industry’s increasing emphasis on public health, a shift promoted in no small part by the Affordable Care Act (ACA). The ACA has provisions that promote preventive care and better health access and quality, and seek to alleviate disparities, particularly within urban and rural populations.

The U.S. Bureau of Labor Statistics (BLS) puts the number of CHWs nationwide at 48,000 and the mean annual wage at $40,000. Job growth within the field is expected to be higher than average from 2014 to 2024. According to the BLS, these jobs are held overwhelmingly by women, and women of color are well represented. U.S. News and World Report ranks the job 18th on its list of 25 Best Social Services Jobs.

The election of Donald Trump—who turned “repeal and replace” into a campaign-trail slogan—has launched a flurry of questions about the future of health care. Whatever the ACA’s fate, there is a real chance that grant funding for the research and outreach programs that often employ CHWs will be curtailed.

However, Monroe doesn’t read doom in the tea leaves. “There’s been a growing [contingent] within the health profession supporting a more tailored and patient-centered approach, even before the ACA was adopted,” she says.

Research indicates that including CHWs in treatment teams leads to better long-term outcomes and lower health costs—the kind of results any politician would love to talk up on Sunday morning TV.

Erica Shelton, an assistant professor in the Department of Emergency Medicine at the Johns Hopkins University School of Medicine in Baltimore, has received funding from the Gordon and Betty Moore Foundation for a study using CHWs. The goal is for patients who frequent the emergency room to overcome barriers to the preventative and follow-up care that can help them stay out of the ER. Shelton hopes evidence-based studies like hers will encourage hospital and insurance administrators to consider formally integrating CHWs into the everyday health care team.

Shelton says one of the benefits of hiring CHWs is that, “as members of the communities they serve, [they] speak in a voice familiar to patients.” When she’s interviewing CHWs, she’s looking for “excellent communication skills; knowledge of the community, [and] not just knowledge of the physical neighborhoods, but knowledge of community coalitions and leaders as well; and the ability to engage patients in meaningful conversation.”

The role appeals to “natural helpers,” in Monroe’s words, who are interested in the altruistic aspects of health care and its overall job stability without the expensive and time-consuming schooling required to become a doctor, registered nurse, or nurse practitioner. CHW training programs generally cover certain health care laws; how to conduct home visits and prepare proper documentation; the ins and outs of working on a clinical care team; and how to be an effective advocate, among other topics.

Often, the employer will cover the cost of these trainings. “So, the training is paid for, the workforce is [expanding], and [CHWs] are starting to move up in livable wages,” Monroe explains. “You have people from the community who want to work in a health profession, but couldn’t afford school, now getting an opportunity.”

These skills can be stepping stones to positions in case management or social work, or, in Monroe’s case, as a trainer. Like Brown, Monroe was a CHW in Baltimore; she now serves as a personal mentor and “provid[es] technical assistance to organizations who are looking to bring [in] community health workers as a part of their infrastructure.”

Monroe teaches the higher-ups in health care how to leverage CHWs’ unique expertise and experience to benefit public health. Sometimes, the latest technologies simply can’t compete with the personal touch that CHWs provide.

This intimacy—the freedom to meet in a client’s home, or over a cup of coffee at the local fast-food joint—is a huge part of what drew Brown to the job. She left an unsatisfying call center gig three years ago and has never looked back, even when her new work has brought her into contact with people who’ve suffered from addictions and despair.

“We can relate, and the patients know that,” she says. “A majority of us do come from the community. [So] we look at the patients as equals.”