Factors affecting a patient’s overall well-being, such as social isolation, food insecurity and transportation needs are addressed by Baylor Scott & White Health community health workers, who are deployed out into the community in a home visit program.

Baylor Scott & White Health works closely with community health workers to best serve high-risk patients and underserved communities

by David Buice, Special Contributor | June 27, 2019

Navigating the complexities of the American healthcare system can be challenging, and those challenges are only compounded by factors such as limited income, a lack of reliable transportation, advanced age and various health infirmities. For those living in underserved areas of the D-FW metroplex, it can feel insurmountably difficult to get the essential medical care they need.

Baylor Scott & White Health patient “Mr. M.” knows these challenges all too well. Having poor eyesight, a high A1C level and an understandable reluctance to use public transportation, Mr. M missed several much-needed medical appointments. Help came, however, from two Baylor Scott & White Health community health workers (CHWs) who made a series of visits to his home.

The community health workers helped bring Mr. M’s A1C level under control and eventually arranged for him to have cataract surgery. Thanks to their intervention, Mr. M is now a patient at the Baylor Scott & White Health Community Care Clinic in Fort Worth, where he receives the regular medical care he needs.

Mr. M’s case is just one example of the many ways in which Baylor Scott & White Health’s community health workers help thousands of vulnerable individuals living in North and Central Texas secure medical assistance outside of emergency departments and hospitals.

The Community Health Workers program began in 2006 with just a single CHW who was responsible for promoting diabetes education in underserved communities. Today, over 100 CHWs are employed and perform a wide spectrum of activities in the community, making Baylor Scott & White Health a national leader in the use of CHWs to improve the health and well-being of vulnerable communities.

Securing certification

There are two ways in which Baylor Scott & White Health’s CHWs can secure certification from the Texas Department of State Health Services (DSHS), and both are challenging. One option is the “experiential path” that requires the candidate to have logged at least 1,000 cumulative hours of community health work services — either paid or volunteer — in the last six years and to have those hours verified by both a supervisor and the DSHS.

The second option requires the candidate to attend a 160-hour training course covering the competencies required by the DSHS for certification. These competencies include an understanding of the basic principles of verbal and non-verbal communication, sensitivity, honesty, empathy and respect, along with the ability to identify challenges and barriers and utilizing skills such as motivational interviewing to encourage and empower patients and members to set attainable health goals they can manage. CHWs use their learned teaching skills to promote health education and positive behavior change.

State certification of CHWs lasts for two years, with 20 hours of continuing education required for renewal.

Once certified, Baylor Scott & White Health’s CHWs strive to address the social determinants of health among traditionally underserved communities with the ultimate goal of reducing emergency room visits and hospital readmission rates.

Primary Care Connection CHWs

Primary Care Connection CHWs play a crucial role in reducing emergency department visits and hospital readmissions by helping emergency department patients find a primary care physician to manage their minor illnesses and long-term health conditions.

On average, Primary Care Connection CHWs have linked about 70 percent of their patients to primary care providers, leading to a substantial drop in readmission rates among traditionally underserved members of the population. As these patients bond with primary care providers who can treat both minor and long-term health issues, readmission rates at Baylor Scott & White Health facilities have decreased by 65 percent in Dallas and by up to 63 percent at others.

Chronic Disease Education CHWs

Chronic Disease Education CHWs work at several Baylor Scott & White Health community care clinics providing disease management education and other services for patients suffering from diabetes, asthma, heart failure and COPD. These CHWs also screen for food insecurity and, where appropriate, refer patients to organizations such as the North Texas Food Bank to help them receive much-needed food assistance.

Community Care Navigation CHWs

Community Care Navigation uses bilingual CHWs to bridge the gap between the hospital and medical home for chronically ill, uninsured patients. These CHWs help patients with appointment scheduling, medication access, transportation and completion of forms. On average, Community Care Navigation CHWs connect 70 percent of the referred patients they receive to a primary care provider.

Home Visit CHWs

Beyond the Baylor Scott & White Health emergency departments and clinics, a chronic disease CHW and Community Care Navigator CHW are deployed back out into the community in a home visit program. Home visit CHWs are trusted members of their communities with a keen understanding of the ethnicities, languages, socioeconomic status and life experiences of the individuals they serve.

In pairs, home visitation CHWs reach out to isolated and high-risk patients and provide valuable information to help them manage chronic conditions such as diabetes. Home visitation CHWs also address other factors affecting the patient’s overall well-being, such as social isolation, food insecurity and transportation needs.


PEERS (Promotion, Empowerment, Education, Resources, Support) CHWs, placed at the Baylor Scott & White Health and Wellness Center, play a vital role in providing the Southern Dallas community with education and support related to overall health, disease prevention and care management. In the past five years, this program has reduced emergency department visits by 17 percent and inpatient admissions by 37 percent.

A digital future

While the Community Health Workers program has accomplished much to bridge the gap between hospital and primary care providers and chronically ill, high-risk and uninsured patients, there’s still plenty of work to be done.

In the future, Baylor Scott & White Health intends to provide both community health workers and underserved patients with low-cost digital tools that will help patients access healthcare more effectively. Using technology to connect CHWs and patients to clinicians and case workers will be a major step forward in providing improved healthcare to underserved communities in North and Central Texas.

For more information about the latest advances in patient care and the many services Baylor Scott & White Health provides its patients, check out their blog at https://scrubbing.in/.

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