This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

Community health worker (CHW) Aleea Swinford says she looks at health as "not only physical and mental."

"Sometimes people just need support," says Swinford, who works for Ingham Health Plan Corporation's Pathways to Better Health program. "Clients tell me, 'What would I do if you hadn't been in my life? Nobody else took the time to pay attention and listen.' I am really teaching patients how to advocate for themselves."

Swinford is one of Michigan's many CHWs – professionals who provide culturally aware peer support, connections to community resources, and care coordination for often vulnerable clients. CHWs' specific duties vary widely, but Swinford works with adult clients who have chronic illnesses, supplementing their treatment by connecting them to basic needs like food, housing, clothing, and transportation. Although her job can be very stressful, Swinford says the rewards are worth it.

"When people can't meet their basic needs, they can't focus on their health or get to the doctor. They end up needing high-cost care at the emergency room," she says. "Meeting their basic needs is a foundation for them to make their own healthcare a priority instead of worrying about what will there be to eat for dinner tonight."

A cultural bridge

CHWs connect the dots to make truly integrated care happen, and data has proven that their role improves outcomes. They meet directly with clients, mainly in their homes, and may coordinate care among various providers or help connect clients to basic needs. They most often live in the communities they serve and share similar backgrounds with the clients they assist. Deidre Hurse, interim executive director of the Michigan Community Health Workers Alliance (MiCHWA), says those clients are often among Michigan's most vulnerable residents, including people with chronic illness and Medicaid recipients.

"The crux of CHW work is relationship," Hurse says. "They use the relationship they have with their community to foster an environment where clients can successfully address social determinants of health (and) things that happen outside of the health clinic – things like homelessness, inadequate food, (or) being in a domestic violence situation. These things ... have a huge impact on clinical outcomes."

Deidre Hurse, interim executive director of the Michigan Community Health Worker Alliance.

Each CHW program has unique characteristics. Some CHWs may engage in general education and outreach at schools. Some may make home visits to pregnant and new mothers. Others may focus on services for clients with specific illnesses like HIV or diabetes.

"They are that cultural bridge," Hurse says. "They provide culturally appropriate coordination to clients navigating the system."

At the state level, the Michigan Department of Health and Human Services' (MDHHS) MiCare Team includes CHWs as part of a program serving 2,374 residents. They address those social determinants of health impacting Medicaid clients. CHWs may arrange transportation to medical appointments, find housing resources, or direct people to medical services they were unaware of.

"CHWs play a strong role in knowing what services are available. When a Medicaid beneficiary needs those services, they help to connect them," says Jackie Prokop, director of MDHHS' program policy division. "If you have a CHW who can address those social determinants of health, that has a positive impact on outcomes. We have found that CHWs really have played a very important role in helping people."

CHWs and an escape from domestic violence

As a CHW in MHP Salud's Amigas de Lenawee Moviéndose Adelante program in Lenawee County, Maricruz Moya works hard to support Latinx women survivors of sexual assault and intimate partner violence. A national nonprofit administering CHW programs for more than 35 years, MHP Salud's model includes community outreach to provide information and combat stigma, community-based support groups, and identifying and training community leaders to educate their communities and lead support groups when the program ends.

Moya strives to build relationships with the women she serves. Cultural norms and fears inflamed by immigration policies add many layers of difficulty to her role.

"The population I work with can be very challenging," she says. "Speaking their language is very important. As a CHW, I am open to give information. Once they know what's going on, they are more open to talk about what's happening to them."

Maricruz Moya.

After assaults, Moya says many Latinx women don't want to go to the hospital, don't have insurance, or don't have a primary care provider. In addition to connecting them to the medical care they need, Moya facilitates an eight-session support group to address survivors' mental health. Sessions address what a healthy relationship looks like, building self-esteem, self-care, and making jewelry, which the participants can sell.

"This helps them learn independence. Survivors (often) have no job, no income. It's very difficult. They can't leave their perpetrator," Moya says. "One of the main roles of the CHW is to serve as a bridge. I can't provide everything they need, but I can help them make the connection with services."

Funding and certification for the future

Not all Michigan CHWs have the same training. MiCHWA offers a voluntary CHW certification process that requires mastery of a 120-hour curriculum. Over 560 CHWs who have completed this process are listed on the MiCHWA registry. However, agencies and health systems are not required to hire certified CHWs. CHWs in Michigan earn an average of $15.15 per hour, 6% below the national average.

Hurse believes the future of CHWs depends on the state mandating CHW certification and finding stable funding that includes more Medicaid dollars and private insurance coverage.

"Most of the CHWs in this state are still funded under grants," Hurse says. "While the state does recognize that CHWs are important, the funding necessary to really sustain the number of CHWs needed to be effective isn't there. So most organizations (employing them) have to rely on grant funding that isn't sustainable."

Loss of funding has put some successful models on hold. When funding was available, the Michigan Public Health Institute was engaged as an anchor organization overseeing the Michigan Pathways to Better Health initiative, which established care "hubs" within three high-need Michigan counties: Ingham, Saginaw, and Muskegon. These hubs served as entry points for community residents who were enrolled in Medicare or Medicaid, lived with two or more chronic conditions, and had unmet health and social service needs, with CHWs working to address those needs.

But the Saginaw Community Care HUB is now on hold, and the Ingham County CareHub has been dissolved, due to funding issues.

"We wish we were viable. We're on pause," says Colleen Sproul, director of enhanced health and integration for the Saginaw County Community Mental Health Authority. "Even though the outcomes were remarkable, very dynamic and impactful, the community itself could not seem to come up with funding. And for the hospitals, it just wasn't deemed a priority."

Muskegon, the only active hub remaining in the State, has benefited from funding by the state of Michigan's State Innovation Model (SIM). SIM was created to test and implement an innovative model for delivering and paying for healthcare. SIM utilized a $70 million award from the Centers for Medicare and Medicaid Services to test and implement an innovative model for healthcare delivery and payment.

"(Michigan's) SIM projects were set up with the purpose of transforming the payment system for services, and hubs were one of the many mechanisms to improve people's health and access to care," Sproul says. "SIM funding is coming to a close, so any hub models will be looking for sustainability."

Sproul cites the State of Ohio Medicaid Health Plan's successful funding of certified hubs using the CHW model — and hopes the state of Michigan will support a similar funding model in the future. She and Hurse agree that these programs improve the effectiveness of healthcare delivery, result in better patient outcomes, and provide cost efficiencies across the board.

"The data that we've received demonstrates that quality care is the future of healthcare in our country," Hurse says. "We have to be open to (paying for) quality rather than number of visits. CHWs help the issue of quality. They can help to articulate the story of the patient in a way where providers can give best treatment."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.

Deidre Hurse photos by Mike Naddeo. Maricruz Moya photo courtesy of Maricruz Moya.