Community Health Worker and Community Paramedic Models for Chronic Disease Management

Community engagement and social supports are important components of chronic disease management. Community health workers (CHWs) and community paramedics can mitigate barriers to accessing chronic disease care in rural areas by providing services within the patient's community, like at the local library, YMCA, community center, or home.

In this model, CHWs provide chronic disease management by helping address individual- and community-level factors affecting chronic disease care and outcomes. CHWs are also known as lay health advocates or promotores(as) de salud (CHWs in Spanish-speaking communities). CHWs can be paid professionals or volunteers. They provide culturally appropriate services, patient advocacy, education, and mentorship.

CHWs possess characteristics similar to the populations they serve. These characteristics include, for example, common language, ethnicity, socio-economic status, values, and experiences. Because of their similarities with the community, CHWs can develop trusting, one-on-one relationships with patients.

CHWs provide a range of services with the goal of reducing barriers to care in underserved populations, including rural communities. In addition to providing clinical care, CHWs can also connect patients to resources to address social determinants of health or health inequities. For more information on how rural communities can use CHWs to improve health outcomes for chronic diseases, see the Community Health Workers in Rural Settings topic guide. For more information on developing a rural CHW program, see the Community Health Worker Toolkit.

Similar to CHWs, paramedics and emergency medical technicians (EMTs) can serve as a bridge between the patient and provider. Community paramedics can provide medical services in the patient's home, facilitate telehealth visits in areas with limited internet access, and connect patients to CHWs for additional support. In-home care facilitates a whole-person approach and allows community paramedics to consider other factors that impact chronic health management like home safety, food access, and environmental concerns. To learn more about paramedicine, see the Rural Community Paramedicine Toolkit.

Examples of Rural Programs Using CHWs or Community Paramedics for Chronic Disease Management

A New Approach to Diabetes Navigation in Rural Appalachia is a program designed to improve health outcomes (for example, glycemic and blood pressure control, depressive symptoms, diabetes distress, quality of life) and lower healthcare expenditures for children and adults with diabetes in rural southeastern Ohio. The program includes three arms: 1) Child Diabetes Navigation, 2) Community Health Workers, and 3) Peer Support. Each arm addresses the high-risk social determinants that contribute to health disparities in the rural Appalachian region of southeastern Ohio. This program expands access to care, supports enhanced care coordination, and lowers barriers to diabetes management.
Vivir Mejor! is a culturally competent health education program. The 13-week curriculum delivers weekly education classes and supplemental physical activity sessions to participants. Education classes are delivered by promotoras, with trained and certified instructors providing physical activity sessions. The Mariposa Community Health Center (MCHC) developed the program to help address the high prevalence of chronic disease in rural Hispanic/Latino populations near the U.S.-Mexico border. The program initially provided diabetes prevention education and has expanded to include cardiovascular disease prevention.
Project REACH, at Intermountain Health Care, is a community paramedicine and a care coordinator project. It provides services for Cassia County residents with heart disease and chronic lower respiratory disease. When a resident presents with either of these chronic conditions at Cassia Regional Hospital, Family Health Services Corp., or South Central Public Health District, they are referred to the Project REACH coordinator, who links them to appropriate services. The hospital's electronic health records flag emergency department visits, and if a resident qualifies the resident is referred to the program.
The Great Mines Health Center Washington County Mobile Integrated Healthcare Network (MIHN) uses skilled paramedics to provide chronic disease management care and treatment in patients' homes. These EMS clinicians provide physical and medical assessments, take vital signs, provide preventive and post-discharge care, offer in-home lab draws and point of care lab testing, and facilitate telehealth appointments.
Abbeville County Emergency Management Services implemented the Abbeville Community Paramedicine program in rural South Carolina with the goal of reducing hospital readmissions for patients who frequently used the emergency department and had at least one chronic disease. Services delivered by the program's community paramedics included home- or community-based non-emergency care, like monitoring blood pressure and medication adherence, connecting patients to other providers or community resources, and clarifying discharge instructions.
The Health-able Communities Program works to expand healthcare access to rural communities in Idaho. The program created a hybrid CHW role, based on their review of existing, evidence-based CHW models, to supplement traditional healthcare delivery services. The program's CHWs lead chronic disease self-management programs, conduct disease screenings, and offer general health and wellness education. These CHWs are also able to receive referrals from medical providers and community members.

Implementation Considerations

It may be important for patients to see healthcare providers with shared social, cultural, and economic characteristics. CHWs and community paramedics are examples of healthcare providers who are members of the population served and can more easily build trust and rapport with patients.

When implementing a CHW model for chronic disease management, rural communities should ensure that CHWs work as part of a team. Successful programs integrate CHWs into an existing care team and clarify their specific role within that team. It is also important to ensure communication across the patient's care team, so that all providers, including the local hospital, primary care, and other healthcare providers, are aware of changes in the patient's health status, hospital admissions, and updated prescriptions.

CHWs and community paramedics have varying certification requirements and training considerations. Trainings may cover topics including soft skills, technical skills, techniques, and knowledge of specific health conditions. These skills can be taught through interactive trainings, team-based exercises, mentoring, or experiential learning.

There may be opportunities for reimbursement for CHWs and community paramedics. Programs using volunteers who are not eligible for reimbursement can find other ways to recognize volunteers (for example, an awards ceremony) when monetary incentives are not available.

To learn more about CHW implementation considerations, see Implementation of Community Health Worker Programs.

To learn more about Community Paramedicine implementation considerations, see Implementation Considerations for Establishing a Rural Community Paramedicine Program.

Program Clearinghouse Examples

Resources to Learn More

Emergency Medical Services (EMS) and Community Paramedicine
Website
Offers adopted and implemented evidence-informed policy resources related to EMS and community paramedicine in the U.S.
Organization(s): Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention

An Emerging Model for Community Health Worker-Based Chronic Care Management for Patients with High Health Care Costs in Rural Appalachia
Document
Reports on a community health worker-based care model implemented in rural Appalachia to improve patient outcomes and lower costs for high-risk diabetes patients.
Author(s): Crespo, R., Christiansen, M., Tieman, K., & Wittberg, R.
Citation: Preventing Chronic Disease, 17
Date: 2/2020

MIH-CP Program Toolkit
Website
Supports healthcare services delivery using mobile integrated healthcare-community paramedicine (MIH-CP). Provides a variety of resources, tools, and informational videos for training community paramedics and for implementing an MIH-CP program.
Organization(s): National Association of Emergency Medical Technicians