Transforming primary care with Community Health Workers

Richmond Clinic staff volunteering at a COVID-19 vaccination clinic
Community Health Worker Jorge Gonzalez (left), took his role even further and was trained to administer the COVID-19 vaccine. He has participated at the vaccine clinics at the Richmond Clinic and other OHSU sites across the metro area. Also pictured: Ayana Johnston, Richmond Clinic CFO (now Family Medicine Director of Finance) and Valerie Cecil, FNP, Richmond Clinic PCP.

In July of 2018, OHSU Family Medicine at Richmond hired the first Community Health Workers (CHW) within OHSU with the objective of supporting Richmond Clinic’s patients in addressing their healthcare needs in a way very different from how we typically addresses health — by focusing on addressing social needs.

Patrick Maloney, a CHW at Richmond Clinic, shares:

A Community Health Worker is someone who often works as a liaison between medical settings and social services with the goal of improving a person's overall health outcomes. The idea is that a person’s health outcomes include social factors outside of the clinical setting such as access to food, affordable housing, transportation, etc. A CHW can help provide tools and resources to reduce barriers, advocate for community needs, and aid in navigating complex health systems.”

Community Health Workers are trusted members of their communities who typically have lived experience or at least an in-depth understanding of oppressed and marginalized identities. They are experts in resource navigation and have significant experience in outreach, advocacy, and community connection. CHWs certified as Traditional Health Workers are trained in a variety of areas in community health; research also shows the role has significant impact on health outcomes, works to eliminate health disparities, and can help reduce cost as well (CDC).

The three CHWs at Richmond Clinic serve our patient population in a way vastly different from our other care team members. Community Health Workers typically do not meet their patients in the clinic, but rather in the community where they can provide support — such as a food bank, the social security office, a housing agency, or even their local library or community center. The ability to connect with patients offsite does more than allow the CHW to meet patients' needs — it allows for a healing connection with the healthcare system for many who have been harmed by it. By providing a person-centered intervention that is focused on the patient’s needs and objectives, CHWs enable those who have experienced harm within the healthcare system to have a healing relationship with a member who understands and validates their experience.

In the process implemented at Richmond Clinic the provider or clinician doesn’t refer a patient to a CHW and there is intentionality behind this design — we want to ensure that we are not being prescriptive in ‘referring’ a patient to a CHW, but rather allowing the patient to retain control by determining if they want support with their social needs. For a patient to engage with a CHW, they would need to screen positive on a social needs screener and request support with that need.

The Richmond Clinic screens for social needs via a one-page screener administered at each visit with a primary care provider. If a patient elects to receive help with a concern they’ve selected on the screener, they will be connected with a CHW. The Community Health Worker will do a further, conversation-based assessment with the patient to determine what help they would benefit from and how to support them in accessing resources. CHWs can have a one-time interaction with a patient, work with them over a few months, or even have long-term, ongoing relationships — all of this is dependent on the patient’s need and desired level of connection.

Aside from one-on-one connections, resource navigation, and help accessing the support patients need to be healthy, CHWs also play a variety of other roles at Richmond Clinic when it comes to social determinants of health interventions. Like much of our work, the efforts of the CHWs at Richmond Clinic have changed drastically since the pandemic began and continue to evolve. Prior to the emergence of COVID-19, CHWs at Richmond Clinic coordinated programs such as healthy cooking classes, holiday gift donations to patients, writing workshops focused on healing and building community, as well as CSA Partnerships for Health, our onsite prescription veggie program that occurs each week during the summer.

Just like many people experienced when the pandemic began, adapting quickly was key; much of the Community Health Workers’ efforts changed overnight. CHWs started working from home. Meeting in the community paused — even CSA Partnerships for Health moved to a delivery service. As Richmond Clinic’s CHW Jorge Gonzalez puts it:

As Community Health Workers at the OHSU Richmond Clinic during the pandemic, we have supported [the entire state via] the OHSU COVID Connected Care Center (C4) as well as our own clinic’s patients who have tested positive for COVID-19 or have been asked to quarantine. In addition, we have created workflows to make person-centered outreach to patients who test positive for COVID-19. We have provided social resources to patients, which range from setting people up with temporary shelter at hotels, dropping off cleaning supplies at patients’ homes, and directing patients to Community Based Organizations (CBO) that provide wrap around services like rental and utility assistance, and food deliveries.”

Most recently, the team has been working to ensure our communities are vaccinated, particularly those who experience the deepest health disparities. With the release of the COVID-19 vaccines, we advocated for primary care clinics within the OHSU system to be able to administer them. Through the CHW team’s initial efforts to help schedule appointments using the mass vaccine websites during the initial release of vaccines, we quickly discovered that these options were simply inaccessible to many of our patients, especially those without access to technology, transportation, or those who are homebound. 

Additionally, we discovered that many patients declined to get the vaccine at a mass vaccination event and informed us they would prefer to receive it from their primary care office. After the Richmond Clinic started its vaccine clinic, the CHWs have continued to center equity by doing targeted outreach to BIPOC communities, LGBTQIA+, and older populations which may be more at risk of barriers in receiving the vaccine or who have experienced harm in the healthcare system and may benefit from more support. While doing outreach calls, CHWs also help patients schedule transportation to appointments, help dispel any myths about the COVID-19 vaccine, and find vaccine options that fit with our patients’ schedule and needs.  

In summary, Community Health Workers have had a significant impact at Richmond Clinic: on our outlook on how to serve patients, in addressing their social needs, and most recently, in playing key roles in our COVID-19 response. A variety of evidence supports the effectiveness of Community Health Workers, but the intangible piece that we have recognized at Richmond Clinic is the transformation in how we can support patients in a person-centered way given the lived experience, expertise, and community-based nature of CHWs. Not only do CHWs provide care to patients using the specific lenses they possess, but they also impact the way we provide primary care as a whole by centering patient-driven solutions to focus on addressing the root causes and barriers that exist in achieving health.

Jorge Gonzalez, BS, THW
Community Health Worker

Patrick Maloney, BA, THW
Community Health Worker

Lia Sebring, BS
Social Determinants of Health Coordinator

Jennifer Schlobohm, MSW, LSCW
Behavioral Health Supervisor

Interested in learning more about Community Health Workers or becoming a CHW? Check out the Oregon Community Health Workers Association!