On a recent Monday, Sandy Guzman, a community health worker in rural Oregon, drove to visit a patient in his 60s in the small city of The Dalles.
The patient lives alone and “really suffers from social isolation,” Guzman said. The woman was in a wheelchair after a severe fall and subsequent surgery. She confessed that she wanted to attend a church service nearby, but didn't have the means to get there and didn't want to be seen as a “trouble.”
“I called my pastor to see if he had someone to pick me up,” Guzman said Sunday. And there it was.
The next day, Guzmán visited a woman with heart failure who required constant oxygen. She lives in “less than ideal housing,” with no kitchen and the only warmth she gets from a plug-in heater.
“We were trying to determine if she was eligible for HUD housing or assisted living,” Guzman said. “We spent a lot of time thinking about options and coming up with a game plan.”
Wednesday's schedule included a 20-mile drive to Hood River to visit an 81-year-old woman whose partner of nearly 40 years is battling severe cancer. Guzman, who spoke to him in Spanish, appeared distraught over the possibility of losing him.
Guzman had arranged for the woman to see a therapist to help her overcome the crisis. This was no small accomplishment. But on this visit, “I just tried to give her tissues and say some comforting words,” she said. The best answer is, “To be honest, sometimes I just sit and listen.”
According to the American Public Health Association, a community health worker is a “trusted member” of the community, or someone who has an “unusual close understanding” of the community, and can serve as an intermediary between patients and the health care system.
These workers have been working since the 1960s, especially in rural and low-income areas. Now, that number is increasing. The Bureau of Labor Statistics reports about 65,000 of them, but the National Association of Community Health Workers says this is likely an underestimate.
This partly reflects the difficulty in counting workers who go by various names, such as community health educators, outreach specialists, and salud facilitators, who operate under different state regulations and, in some cases, do not require licenses or certifications.
What they have in common is that “they talk like the people they work with,” says Sam Cotton, who directs the curriculum for several similar programs at the University of Louisville in Kentucky.
“There's a lot of momentum behind this” due to a shortage of medical professionals and an aging population, she said.
For example, in Oregon, five rural clinics employ community health workers. They earn state certification after completing 90 hours of online training through a program called Connected Care for Seniors. A sixth clinic employing community health workers is operating in nearby Washington.
Frail patients are suffering. “They can't drive, so they can't go to the grocery store or go shopping. They're not taking their medications, either for cognitive reasons or because they can't go to the pharmacy,” said Dr. Elizabeth Ekstrom, director of geriatric medicine at Oregon Health and Science University, who helped oversee the program's launch in 2022.
Few people have advance directives that specify the care they want or don't want in the event of a health crisis.
Connected Care's community health workers tackle many non-medical issues, from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to attend to each patient, typically during home visits.
It will help you schedule follow-up appointments. They perform cognitive and mental health screenings, monitor excessive medication use, and enter their observations into patients' electronic health records.
“It's like being the doctors' eyes and ears and seeing what's going on outside of the 20 minutes they spend with their patients,” said Guzman, whose job ranges from ordering bath mats to reporting suspected financial abuse.
A study of connected care patients (mean age: 77) found that the subsample experienced significant reductions in emergency department visits and hospitalizations for patients served by community health workers.
Dr. Ekstrom said more extensive research, which has not yet been published, supports that finding.
“Emergency room visits cost thousands of dollars, and hospitalizations cost tens of thousands of dollars,” she noted. The cost per patient for the 90-day program is $1,500. The company's employees make $25 an hour, a fairly typical wage, and receive full benefits.
Stanford University oncologist Dr. Manali Patel found similar benefits and cost savings for older patients with advanced cancer in a clinical trial at the Veterans Affairs Palo Alto Healthcare System.
“Many people were dying in the ICU,” she recalled. “If we had asked, they probably would have stayed home.” Oncologists are “notoriously bad at participating in and documenting these conversations,” she added.
But when lay healthcare providers called patients regularly to help them understand their options, discuss their preferences with their care team and submit advance directives, the results were “very dramatic,” Dr. Patel said, published in 2018 in JAMA Oncology.
More than 90 percent of participating veterans recorded their goals in their records, compared to less than 20 percent of the control group. Patients in the general workforce had significantly fewer emergency department visits and hospitalizations, and were more likely to enroll in hospice care.
Dr. Patel and his co-authors continue to document the benefits for lay health workers (as they used the term) when taking on other jobs in other settings.
For example, at oncology clinics in Arizona and California, two bilingual general health care workers regularly called cancer patients over the age of 75 to assess symptoms such as pain, nausea, shortness of breath, and depression.
By alerting the medical team to these patient issues, emergency department utilization and hospitalizations were significantly reduced, resulting in an average cost savings of $12,000 per patient.
“This low-tech, human-administered intervention yielded significant benefits,” said an editorial accompanying the study in the medical journal JAMA.
“Community health workers should be part of every health care team,” Dr. Ekstrom said. “No matter how hard we try, they support patients in ways that the health care system cannot.”
However, one obstacle to expanding its use is the instability of funding.
In 2024, Medicare began covering some community health worker services, but not all. (For example, the cost of a 30-mile drive to a remote home is not reimbursed.) Medicaid coverage is tiered, with some services reimbursed in some states and not in others.
“Many of the community health worker roles rely on short-term grants,” said Nina Schultz, director of the National Association of Community Health Workers. “Sustainability is something we talk about every day.”
The group and other supporters are seeking more state and federal funding. The new federal Rural Health Transformation Program, which allocates $10 billion a year, will include some funding for community health worker programs, but cuts to state Medicaid budgets could more than offset those gains.
However, grants funding connected care for older adults will continue. Guzman, who is employed by the nonprofit clinic One Community Health, continues to make the rounds.
This is one of my recent victories. A patient in his 60s who had just lost his wife and was struggling financially because his wife had no income, lost his home and was sleeping in his truck. Through another patient, Guzman learned of an unused RV whose owner was willing to donate it.
Widowed, she now lives comfortably in a park in a mobile home.
“I feel safe” in a patient's home, Guzman said. “They feel comfortable talking about things. They don't have to rush things. They build relationships and feel like they have someone to advocate for them.”
New Old Age is produced through a partnership with. KFF Health News.
