Regional One Health’s Community Health Workers Program helps patients access medical care and resources for social needs like housing, food, and transportation.
CHWs are required to have lived experience, which means they have personally overcome the type of challenges their patients are facing.
The program earned accreditation from the Tennessee Community Health Worker Association, a recognition of the fact that it meets rigorous quality standards.
Regular medical care is key to good health – but so are food, housing, transportation, and other social factors. Regional One Health’s Community Health Worker (CHW) Program recognizes that reality and is making a positive impact by reaching patients right where they are.
Megan Williams, director of complex care, said the CHW team sees patients in Regional One Health’s primary care practices and specialty clinics including internal medicine, orthopedics, and surgery. The program recently earned accreditation from the Tennessee Community Health Worker Association (TCHWA), a recognition that Regional One Health meets rigorous standards in training, program effectiveness, and patient support.
“Our Community Health Workers are people with lived experience who are helping patients with their health care needs and connecting them to resources in our community,” Williams said. “They help patients navigate the health care system, promote preventative care, and address social determinants of health by connecting patients with community resources.”
Where many other complex care programs have specific criteria for patients to meet in order to be enrolled, the CHW model simply requires a patient to show a need in a social domain like housing, transportation, food, utilities, childcare, or interpersonal safety.
“We take any patient who needs help,” Williams said.
Carmen Thompson, program supervisor, said all patients in Regional One Health’s outpatient clinics, inpatient areas, and emergency department are screened by nurses or medical assistants for social determinants of health. If a domain is flagged for a patient in one of the clinics CHWs cover, they schedule an appointment to meet with the patient.
“We meet them right where they are. We bring them help, and we bring them hope,” Thompson said. “We find out what they need, what they’re struggling with, and what’s important to them.”
Linda White, program supervisor, said the process starts with a conversation.
Community Health Workers connect patients with medical care and support for social needs like housing, food, and transportation.
“We get their history from childhood to where they are now. We talk about their goals, and we talk about things like what makes them happy and what they’re afraid of,” she said. “From that we can develop a snapshot that includes what’s important to that patient and what they want to work on. With that information, we create goals and supply them with resources.”
The team helps the patient access providers and medications to manage chronic conditions and improve their health. They also connect the patient to organizations to address their social needs.
“We’re partnering with local organizations, so all of the resources are community-based,” White said. “We supply the patient with resources, and the patient follows up with the resources. Every week we call the patient to check on their progress.”
CHWs can access a resource databank right in their digital patient records system and refer the patients directly through the portal. “We can text it to them, email it, print it out. It’s easy to get the information to the patient, and it’s very accessible for them,” Thompson said.
Each patient starts with a three-month program, but it can be extended as needed and patients can re-enroll at any time.
Williams said one of the most unique aspects of the program is that CHWs are required to have lived experience with the situations they address.
She said lived experience is defined as “personal, direct involvement and knowledge gained from their own encounters and choices, rather than knowledge acquired through second-hand sources. It encompasses the individual’s subjective understanding, feelings, and interpretations of events, experiences, and the world around them.”
White said that concept has helped Regional One Health build an exceptional team.
Regional One Health’s Community Health Workers Program is accredited by the Tennessee Community Health Worker Association (TCHWA), a recognition that it meets rigorous standards in training, effectiveness, and patient support.
“We look for people who have overcome difficult times in their own lives and are ready to help others do the same,” she explained. “That helps Community Health Workers relate to the patients and make a connection, and that connection starts the patient on their journey to better health.”
The program is getting positive responses from patients, Thompson said.
“We try to be personal with patients and let them know we’ve been where they are. Being able to relate to patients lets them know they’re not alone,” she said. “When you’re sincere and let them know you can help, most patients have a sense of relief, and they’re happy to work with us.”
The successful model recently helped Regional One Health gain TCHWA accreditation, which is based on a multi-month process that included a site visit to review adherence to standards including training, support, evaluations, development, scope of work and more.
“Achieving this accreditation reflects our deep commitment to holistic, person-centered care, where the needs of patients beyond medical are addressed,” said Susan Cooper, senior vice president and chief integration officer. “Our CHWs work tirelessly to bridge gaps in care, build trust, and empower patients to take charge of their health. This recognition affirms that our efforts are making a real difference.”
Thompson said she looks forward to helping more patients access the support they need.
“The most important thing is making sure everybody knows there’s somewhere they can turn,” she said. “There are so many people who don’t know about the program and don’t know that there are resources. We’re right here and ready to help!”