Community Health Workers: From Bench to Bedside to Curbside
Georgia CTSA Community Health Worker and Morehouse School of Medicine (MSM) faculty member, Gail McCray, MA, CHES teaches freshman medical students every Wednesday at the Thomasville Heights Boys and Girls Club. As part of the service learning component of the medical school curriculum, MSM freshman spend one semester completing a community assessment and a second piloting health solutions in the community - all the while tutoring elementary, middle, and high school students weekly for the year. Photo Credit: Bryan Meltz
Community Health Workers (CHWs) are known by many names, including community health representatives, outreach workers, community health advisors, patient navigators, peer counselors, promotoras de salud, and in-between people. These trusted individuals are well-trained frontline health workers with great understanding of the community they serve, many of whom come from the same community or have some strong cultural or professional ties there. Through this relationship, they serve as the intermediary between a specific community and the health and social services that provide them care. They aim to improve the cultural competence of those providing service, increase the quality of care, and decrease healthcare costs. Through outreach, care coordination, community education, informal counseling, social support and advocacy, CHWs are able to reduce health disparities and increase health literacy and self-sufficiency on both an individual and community level – empowering both for better health. Community Health Workers involved in research are able to increase the capacity of individuals and communities to appreciate and be full participants in biomedical research in an effort to have better health outcomes.
Gail G. McCray, MA, CHES, is a program manager in the Prevention Research Center, Department of Community Health and Preventive Medicine at Morehouse School of Medicine. Since 2000, she has been involved in the training and deployment of CHWs across the state of Georgia. With the initial curriculum designed for CHWs focused on cancer control, and then expanded to a competency-based curriculum across chronic disease areas, including hypertension, diabetes, asthma, and cardiovascular diseases. In the Georgia Clinical & Translational Science Alliance (Georgia CTSA) Community Engagement Research Program (CERP), she recruited, trained, and employed CHWs in a health literacy program for the unemployed called Health Works! Through CERP, CHWs were also hired to implement an evidence-based research program in colorectal cancer screening. CERP trains and employs CHWs in other programs, including e-HealthyStrides and diabetes control. “We want to see the best science applied to everyday practice,” said McCray. Currently, she is a faculty member at Morehouse School of Medicine, a Certified Community Health Educator, an advisory board member of Georgia’s Cancer Survivorship Connection, recently retired as the first co-chair of the Cancer Patient Navigators of Georgia (CPNG) – sponsored by the Georgia Society for Clinical Oncologists and Georgia CORE (Center for Oncology Research and Education) – and an avid supporter of Community Health Workers and their path to credentialing in the state of Georgia.
The Georgia CTSA is a collaborative effort between Emory University, Morehouse School of Medicine, Georgia Institute of Technology, and University of Georgia which aims to improve the way biomedical research is conducted and disseminated throughout the city and across the country. The consortium is funded through the National Center for Advancing Translational Sciences, one of the National Institutes of Health’s Clinical and Translational Science Awards (CTSA). The collaborators share a common vision to translate laboratory discoveries into treatments for patients, engage communities in clinical research efforts, and train the next generation of clinical investigators.
After college, McCray learned first-hand the value of community-based participatory research (CBPR). She worked with a clinical trials program in hypertension at Emory University’s School of Medicine, going into communities around Grady Memorial Hospital, educating and enrolling people into research trials. Her involvement with this five-year multi-center trial also led to a change in the definition of hypertension from 160/95 to 140/90. The current definition of hypertension is now less than 120/80. “People being involved is key. Patients and families can accelerate the research process of bringing the latest science to the community by being involved from the beginning – including creating research questions and conducting research,” said McCray. To that end, through CERP, McCray supports the training of community partners in research and health promotion areas.
Community Health Workers
Being a Community Health Worker means operating as a connector or a bridge builder. They are well-trained and can spend more time with patients than other health professionals in a medical environment “This workforce seeks to resolve any barriers to care for communities and individuals and lessen the probability of people falling through the gaps in healthcare,” said McCray. Critical to this is the attention paid to relationships – McCray has an interest and investment in bringing the local community and the medical/health/research community together by translating “medical-ese" to everyday language for community residents, engaging community members as research partners, working as “in-between" people – between community/individuals and healthcare professionals, and disseminating the findings of research to wider audiences – to “end-users” or the curbside.
“Research can be seen as something to fear in many underserved communities – they feel used by researchers, in large part due to the history of poor ethical practices and lack of respect for people, citing examples like the Tuskegee Syphilis Experiment and Henrietta Lacks,” said McCray. “Since the 1970s, there are many safeguards in place by the federal government to protect people from questionable research. This includes Institutional Review Boards (IRBs), at all institutions, to review research to protect humans in research.” In order to rebuild trusting relationships in these communities, McCray stresses that anyone working as a Community Health Worker must remain engaged. “Consistency is of the utmost importance – in order to create change, CHWs and researchers must stick around, ask the people what they want from research projects, conduct prior community assessments, and be careful to share the progress and results of any research with the community,” said McCray.
CHWs are often found in underprivileged, marginalized communities where many people have limited resources, lack access to quality healthcare and the means to pay for healthcare, do not speak English fluently, or have cultural beliefs, values, and behaviors different from those of the dominant Western healthcare system. CHWs help patients overcome these obstacles by accompanying them through treatment, and monitoring needs for food, housing, and safe water. Through the establishment of a trusting relationship with their clients, they are able to bridge the gap between the clinic and the community. In this manner, CHWs help translate new treatments to patients and become more culturally relevant and appropriate to the people the healthcare systems are serving and can motivate patients to remain in compliance to recommended medical treatment plans, and reduce healthcare costs by decreasing the number of Emergency Room visits, return hospitalizations and need for later stage disease treatment. CHWs work in communities, clinics, and in hospital settings to help patients and families navigate the increasingly complex medical system. In medical settings, there are Nurse Navigators, Social Worker Navigators, as well as Lay Navigators. “This model is seen more in cancer care at this point, and their support is needed across disease and socioeconomic groups,” said McCray. CHWs are essential members of the healthcare team along the continuum of care – from prevention to post diagnosis to rehabilitation.
She emphasizes this continuum of care as “bench to bedside to curbside,” the last of which is a CHW’s strong suit. In research, CHWs serve an important role. They can help basic scientists communicate outcomes of their bench research to communities. They better support the recruitment of community residents and patients to clinical trials. Finally, the translation of medical research involves dissemination of research results back to the communities. This is similar to the translational research spectrum, truly translational science in action – moving basic science, to discovery, to clinical trials, to patients/communities – to improve health outcomes.
CHWs spend time in and with communities, community leaders, community-based and faith-based organizations in meetings and activities – becoming familiar with community dynamics. Included in the many roles of CHWs are translational research activities and recruitment for clinical trials. They develop health education and training opportunities in grant writing, evaluation, and output. McCray reports, networks, and shares CHW efforts with the local, statewide, and national level audiences at conferences and through publications.
Community Benefit
Seeing success is McCray’s favorite part of her job, as there is a certain satisfaction and gratification that comes from seeing individuals and communities make an impact and a difference in their own lives. “More equal patient/family-provider relationships create a respect and better communication across disciplines of CHW, community, and healthcare provider,” said McCray. To her, these partnerships and collaborations represent important shifts in healthcare – from the patient as a passive recipient of doctors' orders to an active partner and participant in informed decision-making about their care and bringing solutions to the community through research participation. Researchers must engage community partners early in their research process to help communicate research progress so that the results do not stay within the confines of a lab – and Georgia CTSA can help.
The most pressing needs for her community are all related to chronic health issues – diabetes, cancers, HIV/AIDS, hypertension, violence prevention. Solutions include a partnership to effectively address health literacy, tobacco use, diet, physical activity, and access to healthcare. More creative ways to address poverty and violence are needed and more mental health resources are essential. McCray is also working with individuals in the community to get grant funding for their own research. CERP/ACTSI and its academic partners and community partners offer grant writing training series to improve skills in that area. With the annual Community Health Forum sponsored by CERP/ACTSI, there are many educational resources all in one place. McCray wants even more networking for these individuals, providing them the opportunities to achieve and bridge the gap among community, healthcare, and academic institutions.
This job is not always easy, many challenges revolve around resource allocation, as not all are consistent and reliable. Even listening to the community can be difficult at times, as there is a certain pressure on the CHW to devise a strategy to address the problem directly. These problems though are very small in comparison to the potential payout for a Community Health Worker, getting medical teams to realize their value, and empowering patients to reach their health end goals.
CERP supports community-university research partnerships by connecting existing academic community research programs, transforming research from a scientist-subject interaction to a more equitable partnership, and training investigators in principles of Community-based Participatory Research (CBPR).