Whole Health: Primary care and the role of Community Health Workers — by Carlos Roberto Jaén

A recent report by the National Academies of Science, Engineering, and Medicine (NASEM), described a vision, goals, and recommendations for achieving “whole health” in the United States and internationally. I, along with several other Primary Care centers Roundtable colleagues, were members of the NASEM committee that prepared the report. We defined “whole health” in the following way:

Whole health is physical, behavioral, spiritual, and socioeconomic wellbeing as defined by individuals, families, and communities. To achieve this, whole health care is an interprofessional, team-based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. It aligns with a person’s life mission, aspiration, and purpose.

 The committee identified five “must-have” elements for an effective whole health care system. The system must be: (1) people-centered, (2) comprehensive and holistic, (3) upstream-focused, (4) accountable and equitable, and (5) grounded in team well-being.

 Health coaches, peer support specialists, community health workers, and care coordinators all play an integral role in a whole health approach.

Colleagues and I recently published work, based in our urban safety net primary care practice in San Antonio, Texas, that demonstrates the role of community health workers in helping people advance towards whole health.

In what we call the “Nosotros” approach (the “we” approach), community health workers worked with patients as part of a multidisciplinary primary care team. The community health workers developed trusting relationships with patients and helped the primary care team to better understand patients’ stories of vulnerability and their social context. With this understanding, community health workers helped patients identify their goals, navigate their health care, and connect to community resources. Community health workers assisted patients to help answer four questions: 1) What do we want?, 2) Why do we want it?, 3) What do we do?, 4) What do we get? These questions guided a tailored course of action for achieving the desired outcomes that were specific to an individual, both in terms of their life’s mission and aspirations and in terms of health care.

Community health workers fostered measureable and long-lasting improvements in diabetes self-management among patients, most of whom faced significant historical disadvantages. After 12 weeks of working with a community health worker, 32% of patients displayed greater motivation for self-care and improved skills for self-management. Importantly, repeated measurement over 4 years showed superior HbA1c reduction (better control) in this group of motivated patients. Rates of emergency department visits and hospital visits were also lower.

Our work shows that practice-based community health workers are an important part of high-performing interprofessional teams. Community health workers can engage patients and help them identify and advance their self-management goals in the context of formidable social disadvantages. They helped our primary care practice build relationships with patients that fostered comprehensive and holistic care.

 As they work together, the interprofessional teams and their patients develop a critical awareness of the structural barriers they face to improve and promote whole health. With shared understanding, together they can craft innovative approaches to address these barriers.

One important aspect of this is ensuring that interprofessional teams represent the populations they serve with respect to cultural characteristics, socioeconomic status, and shared life experiences. Such teams will be more likely to exhibit enhanced patient communication, better patient satisfaction, and improved clinical outcomes.

 There is no doubt that the community health workers in our safety net clinic contributed to our patients’ whole health.

 “Community Health Workers as Trust Builders and Healers: A Cohort Study” https://www.annfammed.org/content/20/5/438.   

 Bob Ferrer and Carolina Gonzalez Schlenker are Co-Directors of the Centers and key developers of what we call the “Nosotros” Approach.