COMMUNITY HEALTH WORKER (CHW) models have gained popularity with health care and social services systems over the past decade as a way to better meet different communities' needs (Lau et al., 2021). These models center around the importance of the CHW, defined by the American Public Health Association (2009) as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served” (para 4). Beyond this, however, CHW models can take a variety of forms, with CHWs embedded in health systems or health plans, health or social services agencies, community-based organizations, or other nonprofit organizations, and serving as health educators, advocates, and navigators (Malcarney et al., 2017). This flexibility is critical to their success, as community needs differ and a one-size-fits-all approach does not work across diverse organizational contexts or populations served (Chaidez et al., 2018).
Previous research has demonstrated these programs' positive impacts on both clients and the organizations employing CHWs. Through the development of trusted relationships between CHWs and clients, CHW programs have increased access to preventive health care by facilitating insurance enrollment (Perez et al., 2006), improved chronic disease management (Mistry et al., 2021), reduced use of acute health care (Enard & Ganelin, 2013), and connected clients to social services and supports such as housing or food assistance (Freeman et al., 2020). Previous research on the benefit of CHW programs to the organizations employing the CHW has focused primarily on return on investment and shown positive financial returns in various CHW models (Berkowitz et al., 2018; Campbell et al., 2015; Felix et al., 2011; Kangovi et al., 2020; Redding et al., 2015).
There has been less research, however, on the impact of CHW models in building relationships between organizations, although this is a critical component of CHW models that focus on interorganizational care coordination. For example, through a multistate survey of 265 CHWs, Allen et al. (2015) found that the majority of CHWs cited networking with other CHWs and with non-CHW organizations as key supports for their role. In focus groups among executive directors and supervisors from organizations employing CHWs, Rahman et al. (2021) identified that the success of interorganizational referrals was often reliant on the relationships and knowledge of individual CHWs or their supervisors.
This study aims to begin addressing this gap in the literature by exploring the impact of a specific CHW model on the ecosystem of medical and social services organizations in Southwest Washington. The Southwest Accountable Community of Health (SWACH), an Accountable Community of Health created under Washington State's 1115 Medicaid demonstration waiver, has implemented the Pathways program to address the region's siloed health care and social services systems. Pathways is an evidence-based approach to care coordination in which CHWs, hired and supported by Coordinated Care Agencies (CCAs), help program participants identify social and medical needs and then support them in addressing those needs through semistructured pathways (Pathways Community HUB Institute, 2019). We interviewed CCA staff, including CHWs and their supervisors, to explore their experiences with this program and understand the role they play in multidimensional organizational relationships in the region.
The present study was part of a larger research effort that evaluated the implementation of the Pathways program in Southwest Washington. This qualitative study examined the experiences of staff implementing the program, who worked either directly with participants or in managerial roles. Semistructured interviews were used to collect these experiences. All study protocols were approved by the Providence St. Joseph Health Institutional Review Board.
Interviewees were recruited from the 3 CCAs that had been implementing the Pathways program since its 2019 launch in Southwest Washington; one CCA that no longer participated in the program and 7 CCAs that joined following the program's launch were not included. At least one CHW, one CHW direct supervisor, and an executive-level staff member were interviewed at each CCA. CHWs were included if they had worked in the Pathways program for at least 6 months, for supervisors if they oversaw Pathways staff, and for executive-level staff if they were familiar with the Pathways program. The research team worked with SWACH and each CCA to ensure that the appropriate staff participated in interviews based on the inclusion criteria. Once interviewees were identified, the research team conducted all recruitment.
Thirteen semistructured individual interviews were conducted in October and November 2020. Trained research team members conducted the interviews, which ranged in length from 30 to 60 minutes, and were conducted by phone due to the COVID-19 pandemic. Unique interview guides were developed for each of the 3 organizational roles, but all guides centered on program perceptions, participant and organizational support, and experiences working during the COVID-19 pandemic (see Supplemental Digital Content Text file, available at: https://links.lww.com/JACM/A117, which demonstrates the interview questions asked to each role type). All interviewees provided verbal consent, and no incentive was offered for participation.
Interviews were audio recorded, and transcriptions were coded using ATLAS.ti version 9. One interview was not recorded at the interviewee's request; in this case, detailed notes were used in the analysis. A thematic analysis approach was used to code and analyze the interview data (Braun & Clarke, 2006; Guest et al., 2012). The codebook was developed through a collaborative process between 2 research team members who used a mix of inductive codes that emerged when reviewing a subsample of interviews and a priori codes from the interview guides. During regular analysis meetings, the research team iteratively updated the codebook using a consensus-based decision-making process, which ensured reliability and supported the creation of use cases and definitions for all codes that were then applied across all transcripts. Codes were then analyzed to identify emergent patterns and themes across interviews.
Seven CHWs, 3 supervisors, and 3 executive-level staff members were interviewed across organizations that were diverse in structure, size, services provided, and geography served. But regardless of interviewee role or organizational context, the major theme that emerged from this study was the importance of multidimensional organizational relationship building by CHWs and supported by other staff members within the Pathways program to meet participant needs. Relationship building encompassed both establishing new relationships and strengthening existing relationships created by CHW supervisors and executive staff, and while relationship building was largely positive, it was not without challenges. Three distinct relationship types were identified through these interviews: (1) between CCAs and external organizations; (2) between CCAs; and (3) within each CCA. These 3 types of relationships are described in more detail in the following text, followed by 3 relationship-building challenges.
Between CCAs and external organizations
Interviewees viewed building out a network of relationships with external organizations (eg, health care and behavioral health providers, school districts, food pantries) as an essential aspect of their work that required a significant amount of time and energy. CHWs and supervisors were the CCA staff primarily involved in external relationship building, which included educating other organizations about the program and exploring ways their organizations could work together. For some CCAs, relationships were initiated by supervisors, who conducted initial outreach to describe the program and the value of collaborative relationships. CHWs then further strengthened and solidified these relationships through their day-to-day work with participants. In other cases, CHWs initiated new relationships with external organizations to ensure that external organizations were aware of their services and gain familiarity with the services provided by others in the region. One CHW discussed the process of building external relationships as follows:
We've been encouraged from the beginning of this program to reach out to make connections with other agencies. Reach out and make connections with all different programs and get to know people in the community so that you have a good working relationship with people in the community and different agencies. (CHW 1)
Benefits of relationship building
Pathways participants have varied and complex needs, and strong relationships with a variety of external organizations ensure that CHWs can more comprehensively address those needs. Once relationships with external organizations were established, staff from these organizations referred participants into the Pathways program, which increased program enrollment and the program's potential impact. These relationships also supported direct contact with the individuals served by external organizations, who reached out directly to CCAs after seeing flyers posted in external organizations' facilities or talking with staff about the program.
Furthermore, CCA staff reported that successfully meeting participant needs through these relationships led to a greater sense of trust, mutual understanding, and deeper commitments to shared visions between organizations. Organizational trust then led to a further increase in referrals from external organizations, which were often bidirectional, both from external organizations to CCAs and from CCAs to external organizations. A supervisor described the connection between organizational trust and referrals as follows:
It takes a little bit of time to get outside community partners to really trust the program, but I think it took off as expected, where it took a few referrals before people really understood how helpful it can be. Now I don't think we have a problem getting referrals. We definitely have some community partners that are referring quite regularly. (Supervisor 1)
While the Pathways program's role of developing and maintaining relationships was characterized positively in most interviews, this view was not unanimous. One of the executive team members noted that their organization already had established community connections and was able to generate referrals outside of CHWs' work and their involvement in the Pathways program.
According to staff, the program's design supported relationship building between CCAs and these relationships were then put into practice through CHWs' day-to-day work with participants. The entity that coordinates the Pathways program, SWACH, supported relationship development between CCAs by hosting regular trainings for CCA staff; helping to coordinate the transfer of participants between CCAs; and maintaining a shared data system that allowed for communication between CHWs. Hosting monthly meetings for CCA staff was a prime example of how SWACH helped foster these relationships according to interviewees. These meetings provided space for CHWs and supervisors to receive training and discuss their current work collectively and then break out by role. Although not all CCA staff members communicated outside of the monthly meetings, these sessions provided participants with insight into how other organizations approached their work and what resources existed that they might not be utilizing. The value of these regular meetings was described as follows:
I do love the fact that we do get to meet once a month with the other [CCAs] that [SWACH is] managing or working with. Working with those [CHWs] has been really, really valuable. Getting that feedback and understanding just how other organizations are [...] navigating what's going on. (CHW 2)
Benefits of relationship building
Established relationships between CCAs supported program enrollment by ensuring that participants were matched with the most appropriate CCA. For example, when multiple CCAs operated in the same county, CHWs and their supervisors worked to make sure that participants were enrolled with the CCA best suited to meet their needs. In other cases, CHWs contacted other CCAs if a participant should be enrolled elsewhere based on where they lived. One supervisor described how these relationships support enrollment in the following way:
We tried to work really closely with them [another CCA] to ensure that the clients that they were getting were appropriate for their organization as well as the clients that we got referred were appropriate for [our CCA]. (Supervisor 2)
Similarly, relationships between CCAs supported communication when participants moved counties to minimize possible service disruption. CHWs and supervisors noted that a shared data system played an important role in supporting the seamless transfer of participants between CCAs:
Say they're in [one county], they're moving to [another county] or to [another], we're able to transfer them with ease. We're able to communicate with other CHWs if we have questions. (CHW 3)
Communication between CCAs happened not just when participants enrolled or relocated but also when CCA staff needed support brainstorming or problem-solving challenging situations. CHWs recognized that each CCA had its own specialty and reported that they contacted one another for advice based on those areas of expertise. While they would often first look to their immediate coworkers for ideas, CHWs described finding it helpful to know they had colleagues at other CCAs that they could turn to as additional resources:
We have different agencies which is great ... they have more experience because that's the field of their work. Us, we're medical, and then they help us with the homeless population. [...] If we are struggling helping a client with housing, then there is those organizations that are part of the team [of CCAs] that we could reach out and ask for more guidance or assistance. (CHW 4)
Within each CCA
Within individual CCAs, staff reported increased communication with other departments through CHWs' work, particularly within CCAs with numerous departments or locations. Intraorganizational relationships were supported through supervisor outreach to other departments and by Pathways staff making announcements at morning huddles where a variety of providers regularly convened. CHWs further developed relationships through ongoing conversations, which helped solidify the presence of Pathways and its potential utility in other providers' minds. One CHW described the different ways in which relationships within the organization were built:
Making ourselves known in our particular clinic and attending those [morning meetings] is something huge, because people start their day with the information of like, “Hey, remember, [we're] the Pathways Program.” Sometimes our supervisor hops on with the provider, they kind of let them know about the program. Just word of mouth literally within the [CCA] clinic about the program has been also a big one. (CHW 5)
Benefits of relationship building
Intraorganizational relationships were seen as directly benefiting participants. By better understanding the other services that participants received and how they engaged with those CCA services, CCA staff were better able to meet participant needs and provide more holistic care. One CHW summarized how participants benefited as follows:
More than likely, our clients are working with other people in the agency, because we all have different roles. [...] Really, we can all sit down and be like, “Okay, this person is this, is at this place, this is how they're feeling.” We can really help get wraparound care. I'm not talking medical care; I'm talking about personal wraparound care. (CHW 6)
CCA staff reported that internal relationship building benefitted the entire organization by allowing providers and specialists with more extensive professional training to focus on their areas of expertise, as CHWs worked with participants to coordinate their care rather than having specialized providers attempt to do so. An executive team member explained how intraorganizational relationships benefited both participants and providers, and the role of CHWs in the process:
When you have a therapist not trained in case management [...] they can't get all the necessary work done. It's hard to progress in therapy without all those social needs also being addressed [...]. With Pathways they can say, you do this and I will do this. In therapy, they then focus on what they can do best. The same goes for medical providers. They are able to do what they are trained to do and what they can best help clients with. (Executive staff 1, summary statement)
Furthermore, one CCA adopted an approach to care coordination modeled on the Pathways program across its organizational programming, which was inspired, in part, by CHWs' work and their success engaging with providers and participants to meet their needs.
CCA staff reported differing views about the extent to which CHWs' work benefited their entire organization. Some staff members felt that CHWs made it more likely that participants and their families would establish with a primary care doctor or behavioral health provider at their CCA, which would make them less likely to visit the emergency department when urgent needs arose. Other staff members felt that the Pathways program had not yet created or demonstrated savings for their organization or the larger health care system.
Challenges to relationship building
While the Pathways program relies on relationships that are built and strengthened by CHWs between and within organizations to meet participant needs, CHWs have had to navigate obstacles when developing these relationships. The COVID-19 pandemic, geographic context, and staffing have all posed significant challenges, which are described in more detail as follows:
The COVID-19 pandemic acted as a stress test on organizational relationships that had been built by CHWs up until March 2020. CCA staff reported differing perceptions about the pandemic's impact on their ability to connect with other organizations and CCAs. While some expressed fear that they lost the momentum they had been building with external organizations up to that point, others believed that COVID-19 had created a sense of solidarity between organizations, mutual understanding of one another's struggles, and that they worked together more closely in the resource-scarce environment created by the pandemic. CHWs saw particular value in regular communication with other CCAs, so they could collaborate and share strategies with each other:
There's constantly new information out there of somebody who is doing something new or [...] different. It's been really important that we all communicate with each other [between CCAs] about what's happening in our different communities. (CHW 7)
While there were differing views of the pandemic's impact on relationship building between organizations, staff reported working more closely with internal departments to meet with participants. This was done to ensure participant needs were met while still complying with pandemic-related policies, such as organizational regulations and external public health measures.
Working in rural areas presented 2 CCAs with unique challenges to relationship building. In some cases, rural CCA staff reported that external organizations simply did not exist for them to build relationships with, and in other cases, CCAs had to work with spatially distant organizations due to local resource scarcity. This preexisting lack of resources was further exacerbated by COVID-19, as already limited public transportation routes and shelters closed.
Given this reality, rural CCA staff were particularly aware of the importance of maintaining and strengthening relationships with the limited number of external organizations that did operate in their communities. Even when these relationships were imperfect, they were important to preserve, as one executive team member explained:
We are in a really small community and we don't have a lot of options for service providers, so it's really important to maintain relationships with the service providers that we do have. [...] Because you can't go somewhere else [...] you really have to work to maintain the relationship. Even if it's not good, you have to do the best that you can to make it good. (Executive staff 2)
Further complicating matters, the resources and trainings provided to CHWs during regular Pathways meetings were often incongruous with the experience of rural CCA staff. For instance, SWACH encouraged CHWs to reach out to external organizations that simply did not exist in rural areas or that were not operating due to COVID-19. One CHW explained this as follows:
A lot of the things that we're covering in that particular meeting really do serve the [urban] area. They don't work in the small towns. We're talking about certain services that just simply don't exist here. It's great to have the information, but I'd say about half the time [...], some of the information is not really useful [...] I think it is just simply because we do live in such a rural area that sometimes the long list of resources, they just don't apply to us. (CHW 1)
CHWs are the CCA staff most likely to regularly interact with other organizations and departments when working with participants, and these regular interactions with CHWs are vital to maintaining relationships as they increase the program's visibility and perceived value. CHW turnover can negatively impact the relationships that CHWs have developed, as new staff must reestablish trust with other organizations and departments. Inadequate compensation, insufficient staffing, and high stress levels were reported as contributing to CHW dissatisfaction. As one CHW stated:
We're getting paid as someone who supports the caseload versus someone who holds a caseload. Sorry. I hope that would be more recognized [organization]-wide as the position that we actually do, because we're doing the job of two people. (CHW 5)
Supervisors and executive team members were particularly aware of the additional stressors placed on CHWs by COVID-19 and the importance of CHW retention. One executive team member described this challenge:
We really tried to prioritize self-care and making sure that staff were aware that we are all experiencing the same thing, we all know how difficult it is, we all have our kids home from school. Do your best, but at the end of the day, we're in a new world, so don't beat yourself up if you didn't meet what you thought you needed to meet that day. (Executive staff 2)
Even as the COVID-19 pandemic, geographic context, and staffing have presented significant challenges, CHWs have played a fundamental role in establishing and strengthening relationships between and within organizations; without CHWs playing this crucial role, the Pathways program would be unable to function as envisioned.
The present study explored the role of CHWs in developing organizational relationships to meet participant needs within Pathways, a care coordination program in Washington State. Through interviews with program staff, the study found that CHWs built and furthered multidimensional organizational relationships to meet the complex needs of participants. These relationships occurred between and within the organizations participating in the program, as well as with external organizations in the region. However, these relationships can be fragile and potential relationship challenges were also identified, including the COVID-19 pandemic, geographic context, and staffing.
Although this study focused on one program in one state, the study's lessons learned may be useful to other care coordination programs that center the role of CHWs within diverse organizational networks. To ensure such programs' success, organizations employing CHWs need to provide CHWs with the necessary supports to develop and sustain relationships, such as setting aside scheduled time for outreach. Our results suggest that a supportive infrastructure, such as the Pathways program, can increase organizational capacity to provide this support. Along with addressing the challenges identified here, successful CHW-driven programs require appropriate compensation, program funding, training to support CHW core competency development in areas such as relationship building, supervision, and access to other resources such as local and national professional networks, as previous research has identified (Bukach et al., 2017; Findley et al., 2014; Miller et al., 2021; Payne et al., 2017; Rosenthal et al., 2018). These considerations are especially important in times of crises, such as the COVID-19 pandemic (Peretz et al., 2020; Rahman et al., 2021), when health disparities deepen and organizations increasingly rely on CHWs for continued community outreach and care coordination.
Relationship development hinges on regular communication. CHWs play a central role in facilitating communication between and within organizations in service of participants, but shared data systems can further support relationship building. While only mentioned for relationships between CCAs, shared data systems can support relationships with external organizations and within organizations by facilitating trust, communication, and knowledge sharing between diverse care team members, as previous research demonstrates (Gill et al., 2020; Poku et al., 2019; Reinschmidt et al., 2017). Shared data systems may also help address relationship-building challenges identified in this study. During crises, they can support the provision of timely information and resources. In rural contexts, they can facilitate communication between spatially distant organizations. Increased connectivity and community provided by shared data systems may also reduce staffing challenges related to stress and burnout.
This study has several limitations. First, our sample was limited to CCAs who were active since the Pathways program's launch; organizations that had ended their participation or joined after the program's launch may have different experiences not represented here. Second, study participants were limited to CCA staff actively employed during the study period and may not represent the views of former staff, or the experiences of staff of all racial, ethnic, and gender identities who work in CHW-driven programs. Third, all interviews were conducted in 2020 as COVID-19 cases were surging; responses to the pandemic might have been at the forefront of study participants' minds and been shared in place of their overall program experiences. Finally, this study is limited to CCA staff perspectives; program participants may have different experiences navigating the care coordination ecosystem. A forthcoming study that explores how program participants experience the Pathways model will complement this research.
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