Advancing health equity is not only a core value of the Alameda Health System (AHS), it’s also a collective passion for our community health outreach workers (CHWs) who play a critical role in the health and well-being of our highest-risk patients and underserved communities.
“I know it’s my life’s purpose to make a difference in people’s lives,” said Saundra Mercado, community health outreach worker in care management and member of the High Utilizer Team (HUT). “It’s a privilege to serve each patient by meeting them where they are and connecting them to the specific community resources needed for the best possible outcomes.”
Mercado shared that many AHS patients in historically marginalized neighborhoods face barriers to living healthy lives because of little or no access to healthy food, safe housing, reliable transportation and other social determinants of health.
These social and economic obstacles can keep patients from receiving preventative health care services including regular wellness visits, screenings and immunizations. In addition, they can often lead to the over-utilization of the system’s emergency department (ED).
At AHS, two of our 48 CHWs are members of the High Utilizer Team (HUT) and serve as a bridge between patients, providers and community partners. CHWs help patients to better manage their health so they can eliminate unnecessary visits to the ED. Approximately 88% of our current CHW workforce are solely dedicated to caring for our high risk and complex patients.
Mercado shared that connecting her patient, Star (name has been changed to protect privacy at patient’s request), to local community resources has reduced her high utilization of the ED to virtually zero visits. The services allowed Star to get off the streets of Oakland where she was sleeping outdoors and into a safe place where she felt safe to focus on her physical and mental health.
Now off the streets, Star is receiving both primary care and behavioral health services and is now medication compliant. In addition, she has been matched to multiple permanent housing options and is awaiting approval for what she calls her ‘forever home.’
“Saundra has been there every step of the way this past year,” said Star. “Without ever judging me for my situation, she has provided me with endless encouragement, advocacy and love which I appreciate so much.”
CHWs are trained to help patients like Star with both preventative health care needs and health-related social needs. As trained health educators, CHWs help patients through coaching and goal setting to improve their health and ability to self-manage chronic health conditions such as diabetes, asthma, heart disease substance use and behavioral health disorders.
In addition, they can also assist in finding and applying for specific community programs and services tailored to a patient’s needs including housing, clothing, financial assistance, low and no-cost transportation services, daycare, substance use programs and Medi-Cal benefits.
One of the most important ways CHWs are helping patients attain their optimal level of health and wellness is by helping them to navigate our health care system so they can receive the right care at the right time.
Irvin Servellon, community health outreach worker in complex care management at Eastmont Wellness is not only helping patients stay healthy, he’s improving their overall experience at AHS. He shared that he recently worked with a patient who had lost faith in the health care system and was struggling. She had a complex history of chronic conditions that included diabetes, hypertension, hyperthyroidism, anxiety, dementia and depression.
Servellon began by building his patient’s trust and advocating for her at medical appointments. “Eventually I was able to help her find her own voice, stand in her truth and advocate for herself,” Servellon said. “She once told me that she was proud of the person she had become and it was incredibly touching and meaningful to know that I could help make that happen.”
Creating these critical relationships with patients is integral to AHS’s whole-person approach to health care and illustrates the important role CHWs play as trusted partners in the lives of their patients and the community. It also highlights an opportunity for expanding the CHW program at AHS to ensure more patients can benefit from the personal support and services it provides.
“Our CHWs represents an invaluable resource that when fully leveraged has the capacity to reduce health inequities through health education, patient navigation and care coordination,” said Lilly MacRae, RN, PHN and the director of community health. “They are passionate individuals who are devoted to serving their community and I’ve seen firsthand the impact they have on our patients and their total health.”