Community Health Workers at UH a Vital Part of Comprehensive Care

A visit to the doctor, a physical therapy appointment or a stay in the hospital are three everyday healthcare encounters – but they’re by no means the only ones. A definition of healthcare befitting today’s modern world includes a sizeable variety of other services.

Here at UH, we embrace that expanded definition, leaning in on access and empowerment. Every day, we help patients secure the medical guidance they need, provide education about how they can follow health recommendations and live a healthy lifestyle and connect people with resources in the community, with the goal of promoting their overall health. ‌

And while our whole UH team shoulders responsibility for this holistic approach, much of this effort comes from one talented group -- our amazing Community Health Workers (CHWs).

A small but mighty cadre of dedicated professionals, these trusted members of their local communities serve as an important liaison between all of us on the clinical side at UH and the people we serve. Most work out of our Accountable Care Organization. They offer a practical, down-to-earth approach, working to provide vital health information and acting as a conduit for crucial support services available from our community partners – work that has a measurable impact on people’s everyday lives.

‌You find them embedded all around UH. At the UH Rainbow Ahuja Center for Women and Children, for example, CHWs help lead the acclaimed CenteringPregnancy^® prenatal care program, which just celebrated its 15th anniversary at UH. During two-hour sessions, each woman individually sees a provider, then the women reconvene as a group to discuss timely topics in their lives. And it gets results: Moms who participate in Centering are more likely to breastfeed, have lower rates of preterm birth and lower rates of low birthweight babies. CHWs at the UH Rainbow Ahuja Center are also instrumental in providing services through Rainbow Connects, a program that links patients and families to valuable community resources. From helping to troubleshoot a utility disconnection to providing needed diapers for a young family or helping a mom navigate the process when her child tests positive for lead, UH CHWs employ their trademark compassion and savvy to help others on a daily basis.

At our UH Wellness Centers in Bedford, Richmond Heights and Glenville, the story is much the same – but tailored for local needs. CHWs collaborate with their clients to complete a comprehensive review that identifies which of the person’s needs are going unmet – whether it be dental care or housing or food or transportation. They then connect with community partners to determine how these needs can be met — often bringing health and wellness resources directly to the Wellness Center, where people already gather. By connecting with local organizations and stakeholders, the CHW helps make Wellness Center programs accessible directly within the community. Sometimes the problem is finding a new primary care provider – an issue the CHW is ideally equipped to solve. One important note: These interactions with community members are not one-off events. Our CHWs provide ongoing support, advocacy and follow-up for their clients, ensuring that community members are empowered to take charge of their health and well-being going forward.

‌CHWs at UH also offer valuable support in more clinical settings, from provider’s offices to even certain Emergency Departments.

In select pediatric offices and UH Rainbow Babies & Children’s EDs, they’re an integral part of the statewide Outcomes Acceleration for Kids (OAK) Learning Network, which seeks to accelerate improvements in care. There, our CHWs do crucial work -- helping young patients improve their asthma medication use, arranging follow-up care after an ED visit for mental health or substance abuse reasons, getting patients the care they need for sickle cell disease and helping make sure kids see a doctor regularly for necessary preventive care. In the EDs at UH Cleveland, UH Ahuja and UH Parma medical centers, the CHW dives deep to get a complete picture for each patient, gathering information from the care team, the electronic medical record and conducting an in-depth conversation to assess the needs that can impact health, such as food, lack of transportation and others. Does the patient have a primary care provider? Do they know how to use MyChart? It’s the CHW’s job to know – and help make it so. Patients being discharged after a hospital stay are also assessed for whether they can benefit from the services of a CHW, especially those with chronic disease and multiple comorbidities deemed high risk.

This service continues to demonstrate strong demand and measurable impact across the system. In addition to CHWs embedded at multiple UH locations, the program serves as a centralized hub for referrals from key areas such as Women’s Health, Home Health, Healthy at Home Virtual Clinic, Rainbow Pediatrics and Primary Care. The CHW team manages an average of 15–20 referrals per day, reflecting both the need and trust in this resource.

The CHW team handling these referrals plays a critical role in addressing social determinants of health by connecting patients with transportation support, food resources, utility assistance and primary care linkage. By closing these essential gaps, the program not only improves patient outcomes but also strengthens care coordination, reduces barriers to care and enhances overall system efficiency.

‌In some cases, our CHWs also actually travel to people’s homes to provide care navigation and support.

That’s the case with our ACHIEVE GreatER project, funded with an $18.2 million grant from the National Institutes of Health and led by Sanjay Rajagopalan, MD, Chief of the Division of Cardiovascular Medicine and Chief Academic and Scientific Officer of UH Harrington Heart & Vascular Institute; as well as the Herman K. Hellerstein, MD, Chair in Cardiovascular Research. The project’s ambitious goal is to lessen disparities in heart disease in Cleveland and Detroit and improve outcomes, using CHWs to deliver risk screenings, advice and support on site where people live. The idea is to build trust with those who may feel they have been marginalized or are distrustful of the healthcare industry.

Four years and 200 patients into the project, it’s clear it’s working. Results show that ACHIEVE GreatER’s CHWs have resolved 98% of participants’ identified social needs. What’s more, 80% of these same people have lowered their blood pressure, and several have lowered their “bad” cholesterol and A1C levels and weight. Average weight loss for the participant group is 18 pounds.

Alyssa Myers is a great example of what this program has achieved. The 55-year-old small business owner and mom of five had persistent dizziness and headaches – conditions she thought she just had to live with. But it turned out her headaches were being caused by high blood pressure measuring 155/110 — stage 2 hypertension — putting her at increased risk for heart disease and stroke. Through regular meetings with her UH CHW, Kimberly Nicholson, who helped her get the medical care she needed, Alyssa now has blood pressure that’s down to almost normal, and her headaches and dizziness have subsided. Technology also played a role, with Kimberly coaching Alyssa on how to effectively use a scale and watch, as well as blood pressure and air quality monitors to help achieve better health.

“Alyssa and I meet month to month,” Kimberly says. “We go over her data, we go over smart goals that she set, things that she would like to do to help better her lifestyle and reduce her numbers and live a healthier life.”

‌That’s the whole idea – working one-on-one to help people live better lives. Whether in people’s homes, in the community or one of our healthcare facilities, one thing now seems crystal clear.

The personal touch of a CHW is an essential part of healing. We’re so proud of their work at UH.