Integrating community health workers into medical homes

Elizabeth A Rogers, Sarah Turcotte Manser, Joan Cleary, Anne M Joseph, Eileen M Harwood, Kathleen T Call

Research output: Contribution to journalArticlepeer-review

32 Scopus citations


PURPOSE Though evidence supports the value of community health workers (CHWs) in chronic disease self-management support, and authorities have called for expanding their roles within patient-centered medical homes (PCMHs), few PCMHs in Minnesota have incorporated these health workers into their care teams. We undertook a qualitative study to (1) identify facilitators and barriers to utilizing a CHW model among PCMHs in Minnesota, and (2) define roles played by this workforce within the PCMH team. METHODS We conducted 51 semistructured, key-informant interviews of clinic leaders, clinicians, care coordinators, CHWs, and staff from 9 clinics (5 with community health workers, 4 without). Qualitative analysis consisted of thematic coding aligned with interview topics. RESULTS Four key conceptual themes emerged as facilitators and barriers to utilizing a CHW model: the presence of leaders with knowledge of CHWs who championed the model, a clinic culture that favored piloting innovation vs maintaining established care models, clinic prioritization of patients’ nonmedical needs, and leadership perceptions of sustainability. These health care workers performed common and clinic-specific roles that included outreach, health education and coaching, community resource linkage, system navigation, and facilitating communication between clinician and patient. CONCLUSIONS We identified facilitators and barriers to adopting CHW roles as part of PCMH care teams in Minnesota and documented their roles being played in these settings. Our findings can be used when considering strategies to enhance utilization and integration of this emerging workforce.

Original languageEnglish (US)
Pages (from-to)14-20
Number of pages7
JournalAnnals of family medicine
Issue number1
StatePublished - Jan 1 2018

Bibliographical note

Publisher Copyright:
© 2018, Annals of Family Medicine, Inc. All rights reserved.


  • Community health workers
  • Health workforce
  • Medical home
  • Primary care


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