Community Health Workers: A Scalable, Proactive Approach to Care

The challenges in delivering effective healthcare and social support are constantly evolving. We often focus on medical treatments, but increasingly, we recognize that true health begins in our communities, shaped by factors like stable housing, nutritious food and reliable transportation. Addressing these social determinants of health (SDOH) is complex, and traditional clinical models alone can’t always reach deep enough.

This is where Community Health Workers (CHWs) step in as a proven, human-centered bridge. They are frontline workers, often from the communities they serve, who connect individuals with the healthcare and social services they need. This short-term intervention has been shown to delay or altogether prevent the need for expensive long-term support.

At CICOA, our CHW program is a key growth opportunity within our “CICOA Reimagined” strategic plan. We believe that investing in and scaling CHW programs is not just about doing good; it’s a smart, essential strategy for the future of health and social care, improving outcomes and building a more resilient community.

The Strategic Value Proposition of CHWs

Community Health Workers fill critical gaps that traditional healthcare often misses. They go beyond the clinic walls to address the non-medical factors that powerfully impact a person’s health – whether it’s finding stable housing, securing food or arranging transportation for medical appointments.

Our own Director of Community Health Programs, McKenzie Reed, once worked with an elderly man who was frequently hospitalized due to loneliness and anxiety. By connecting him with a volunteer senior companion, McKenzie helped reduce his hospital visits from every two months to just once in six months. This isn’t just a win for the client’s well-being; it’s a significant reduction in costly hospitalizations for the system.

From a business perspective, CHW programs deliver real value. National studies show compelling returns on investment. For example, a study published in Health Affairs found that for every dollar invested in a CHW intervention, Medicaid payers saw an average return of $2.47 within the fiscal year. This highlights how CHWs are a cost-effective way to deliver essential health and social services. They reduce expensive emergency room visits and hospital readmissions, while improving chronic disease management. Beyond cost savings, CHWs actively reduce health disparities by improving patient engagement, adherence to care plans and health literacy, particularly for marginalized populations. This aligns directly with the strategic priorities of “CICOA Reimagined,” enabling us to achieve measurable results and deliver cost-effective, high-impact services.

CICOA’s Approach: Scaling for Impact

CICOA has a long history of community-based care, making us uniquely positioned to lead in the CHW space. We launched our CHW initiative in April 2022 with a grant from Purdue University’s Center for Health Excellence, Quality and Innovation (CHEQI) that provided certifications for three CHWs. Our CHWs often live in the communities they serve, sharing similar backgrounds, languages or experiences with their clients, which builds a crucial level of trust.

For the first two years of CICOA’s CHW program, these team members were embedded into our Flourish Care Management teams, focusing on care transition support for individuals after discharge from the hospital, emergency department or rehab facility. For up to 90 days, CHWs supported clients with regular phone calls to screen for social determinants of health and proactively address barriers that could impede their ability to continue living in their community of choice.

The impact in just the first two years of the program was clear for CICOA clients:

• 2,080 unique clients served through nearly 3,000 care transitions and over 6,500 total interactions.
• A 64% decrease in hospitalizations after CHW intervention (average of 1.3 hospitalizations in the 3 months before intervention dropped to 0.4 in the 3 months after).
• A 30.5% increase in clients who understand their medications.
• A 12.9% increase in clients reporting they never felt worried, tense, or anxious.
• An 8.1% decrease in clients lacking access to healthy food.

decrease in hospitalizations after CHW intervention

An evaluation of our CHW program by Purdue University’s Center for Community Health Workforce Development Institute (CHWDI) found that for every $0.10 invested per client daily (the average cost of the intervention), both emergency and inpatient admissions decreased, which demonstrates its cost-effectiveness in preventing more expensive care.

These outcomes were so encouraging that we knew we had to figure out a way to leverage our data-driven approach to scale for real impact.

Daily cost per client in the CHW care transition program

Starting in June 2024, in partnership with IMPaCT Care, one of the leading evidence-based CHW interventions in the country, CICOA CHWs began expanding their reach to include individuals in the community who are at high risk of eventually needing long-term services and supports, through factors such as recent falls, chronic illness, lack of primary healthcare and other SDOH factors. In addition, we moved from telephonic support to weekly in-person visits to build more meaningful connections. The goal of these two strategic steps is to delay or prevent the individual’s need for more intensive and costly long-term support.

Our CHWs navigate a wide range of challenges, often with profound personal impact. For instance:

• They’ve helped clients secure permanent housing after months of instability.
• They’ve gone grocery shopping with an individual on a new diabetic diet, offering practical support and encouraging them to try new foods.
• One CHW successfully advocated for a client in a wheelchair to get to a crucial doctor’s appointment when her building’s elevator was broken and unaddressed, ensuring she received necessary medical care.
• Another CHW assisted a client in obtaining new IDs and insurance cards, unlocking access to vital services like Medicaid and transportation.

Today, we have nine certified CHWs receiving referrals from all CICOA programs, as well as 14 community partner organizations, many with on-site CHWs, including hospitals, meal sites and shelters. This highlights our commitment to building a deeply integrated and effective social care ecosystem together.

Collaboration for Collective Impact

The true power of Community Health Workers is unleashed through partnership. For healthcare systems, payers and other social service agencies, collaborating with CHW programs like CICOA’s offers significant advantages:

• For Healthcare Systems and Hospitals: CHWs improve discharge planning, reduce readmissions, and enhance patient satisfaction by ensuring a seamless transition home and addressing factors that often lead to re-hospitalization.
• For Health Plans and Payers: By promoting better health management and reducing costly acute care utilization, CHW programs lead to lower overall costs and improved quality measures.
• For Other Social Services: CHWs act as expert navigators, connecting individuals to a wider array of resources and avoiding duplication of effort, resulting in more holistic client support.
• For Employers and Faith Communities: By supporting individuals and families with complex social needs, CHWs can contribute to a more stable workforce and stronger communities.

Looking Towards a Healthier Future

Community Health Worker programs are not just an emerging trend; they are a fundamental shift in how we deliver effective care for those with the greatest need. They bridge gaps, build trust and address the very real social challenges that impact health, leading to better outcomes for individuals and significant cost savings for our healthcare system.

As a core part of “CICOA Reimagined,” our CHW program embodies our commitment to innovation, growth and continuous improvement. We are dedicated to leading this area, driving financial health for our organization and robust well-being for our community. We invite other business leaders and policymakers who share our vision for a healthy, supported community to connect with us. Let’s explore how we can collaborate to deliver impactful outcomes and build a brighter future for those we serve.

Related blogs:
A New Chapter Begins: CICOA Reimagined
Expanding Our Reach and Sustaining Impact with Private Pay Solutions

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Lisa Schneekloth

As President & CEO of CICOA, Lisa Schneekloth’s vision is shaped by more than 15 years of experience within the organization, from direct client support to establishing robust compliance standards. Driven by a commitment to excellence and innovation, she collaborates with the community to expand CICOA’s impact and ensure individuals have the opportunity to live their lives to the fullest.