Community Health Workers at the National Kidney Foundation of Michigan
The National Kidney Foundation of Michigan (NKFM) has built a strong track record as a “catalytic” organization that provides innovative, community-focused interventions that improve the system by which at-risk individuals within a community are identified and connected to appropriate health care and social services. NKFM is viewed as a respected convener of public and private stakeholders to identify local needs and create appropriate interventions and services, including using Community Health Workers (CHW) to ensure at-risk individuals receive needed evidence-based health and social services. The NKFM has a 20+ year history of utilizing CHWs to deliver exceptional value by providing assistance in appropriate care transition services and evidence-based chronic disease self-management support in health care and community settings.
NKFM’s capacity in implementing systems change with the goal of improving health outcomes in underserved populations utilizes support from both community partners and CHWs. Sustained successes are exemplified by the Coalitions for Healthier Communities project funded by Office on Women’s Health (OWH), the Reducing Diabetes Disparities in Vulnerable Populations project funded by CDC, and the Lay Health Advisors project funded by the Division of Transplantation. Initiatives have embraced prevention-oriented models focused on disproportionate racial/ethnic health problems by supporting a systems approach to addressing health problems needing more intensive management, including efforts to increase awareness of the problems, improve cultural competency in care, and improve health outcomes for underserved populations.
A key to past success has been strategic collaborations with organizations across multiple sectors at both the state and local levels that are well-versed in the factors that shape health behaviors and address the many challenges in achieving effective strategies to produce better health outcomes and reduced costs. For example, from 2007-10, NKFM worked with community partners to train 352 CHWs to deliver the Stanford Chronic Disease Self-Management Program, which resulted in 2,765 people receiving self-management education in communities with high diabetes prevalence. During that same period, a similar CHW effort resulted in 16 sites to deliver Enhance Fitness, a low-cost evidence-based physical activity program held in locations in underserved communities, with 64 trained instructors and ~1,500 individual participants. In 2010, 138 NKFM-trained peer mentors had 1,615 personal contacts with Medicaid-covered kidney patients and their families.
Studies show that CHWs improve health outcomes, particularly in low-income populations, when they participate in disease prevention and chronic disease management models, such as diabetes and cardiovascular disease. Studies show that CHWs reduce health care costs by decreasing ambulatory care sensitive emergency room visits, hospitalizations including admissions and readmissions, and by improving individual and community capacity to understand their condition and utilize health care services appropriately. CHWs also work in a wide range of community resource development, community organization and policy change initiatives.
Community Health Workers are involved in a number of programs at the NKFM: