Community Health Workers

Baylor Scott & White Health integrated Community Health Workers (CHW) in the care team to help patients navigate the health care system, facilitate self-management of chronic diseases, and connect patients to primary care homes. CHWs’ cultural humility and competence allow them to gain a greater understanding of their patients, who may not seek out or continue with complex care or treatment. How does this build trustworthiness? CHWs act as trusted peers for patients, increasing their comfort with and understanding of their care, and enhancing their willingness to communicate their needs and concerns.

How It Works

At Baylor Scott & White Health System, community health workers (CHWs) are members of interdisciplinary teams that include social workers, nurses, pharmacists, physicians, and sometimes chaplains. Teams are dedicated to subcategories of patients, including Medicare beneficiaries, individuals with chronic conditions, and individuals encountering social needs. CHWs work with patients to navigate the healthcare system, facilitate self-management of chronic diseases, and connect patients to primary care homes. They enhance care coordination by providing direct patient engagement and support, addressing barriers to care through social resource connections, & provide education to help strengthen care.

CHWs have the ability to meet patients where they are (physically and emotionally) as a trusted peer, often with lived experience. CHWs are viewed as fellow members of the community with whom patients can be open and honest. Typically, CHWs wear plain-clothes, even in a clinical environment – this helps the patients to see CHWs like themselves. Some CHWs conduct home visits to physically meet the patients where they are – this helps to further address any unidentified social needs that patients may have. Their cultural humility and competence allow them greater understanding through high-touch, low-volume interaction with patients who may not seek out or continue with complex care or treatment.  This is in contrast to physicians who may operate at a high-volume, low-touch clinical pace. CHWs often follow-up through phone calls or other outreach for patients to confide in them their struggles, misunderstandings, and any confusion about their complex and chronic health issues. Bi-lingual support can be critical to patients that may be fluent enough in English to answer questions with a simple yes or no, but may not be fluent not enough to ask questions of their own or have health literacy issues that have not been identified by other care team members

Skills and Competencies

CHWs have several competencies such as:

  • Interpersonal Skills – including motivational interviewing;
  • Service Coordination Skills – developing networks to address social and economic needs;
  • Communication skills – use rapport-building tactics and skills such as teach-back to ensure the patient understands what a physician, nurse, or social worker has told them;
  • Capacity-Building Skills – facilitate support groups;
  • Teaching Skills – methods that promote learning and positive behavior change; &
  • Knowledge Base on Specific Health Issues.

Please note this is not an all-inclusive list – there are many more competencies and skills CHWs utilize to build trust.


CHWs have been recognized and utilized in various settings across the country since the 1970’s. The use of this role is arguably an emerging opportunity for many organizations that serve high-needs, high-risk, or complex patients.


While this program has not published evidence on the use of CHWs, there are many evaluations and case studies published by other community-based and health care organizations. Studies have demonstrated that use of CHWs can:

  • Improve process measures in diabetes, mental healthcare, asthma, and others;
  • Reduce hospital readmissions; and;
  • Lead to reduce total cost of care.


The use of CHWs is scalable and is used in multiple care settings both clinical-facing and community-facing as a community-level engagement and investment strategy, for patient engagement purposes, and in care team development.