Community Health Workers

Community Health Workers (CHW) play an important role in the identification, prevention, and risk management associated with Chronic Kidney Disease (CKD). 

For decades, primary care has nationally served as the front line of the American health care system, but access to a regular, high-quality source of affordable primary care is not equal for all Americans. For large portions of society, geographic, social, financial, and other issues create high barriers to health care. Social factors that inhibit access to quality care, including preventive care, are called social determinants of health (SDOH). Studies suggest these factors account for 80 to 90 percent of an individual’s health ¹, and often involve limited access ² to:

• Social and economic opportunities.
• Social supports and resources such as quality schools and quality housing.
• Neighborhood and workplace safety.
• Healthy food, clean air, and safe water.

These social factors create barriers to care and weaken trust in the health care system. In surveys and studies, physicians say they do not have the time or “sufficient staff support to address patients’ social needs — such as access to nutritious food, transportation assistance and adequate housing — even though these needs are as important to address as medical conditions." ³

Community Health Workers, on the other hand, are experts at managing SDOH. They specialize in bridging people and communities to health care services. Community health workers have or build in-depth awareness of local community assets and trusted resources. Their cultural competency and frequently their language skills help build trust, and they employ a network of both traditional and nontraditional resources to connect people to the right care at the right time and in the right place. 

Chronic kidney disease (CKD) is a serious public health burden that Community Health Workers can effectively address. 90% of people with CKD don’t know this silent condition is ushering them to heart disease, kidney failure and death. And most do not know they are even at risk of CKD. 

But community health workers can raise awareness of risk factors – such as hypertension and diabetes – and connect people to proper testing, diagnosis, and care including:

• CKD screening- risk assessment/risk score and scheduling clinician follow-up
• Post COVID kidney assessment
• Blood pressure or diabetes screening and management
• Address social determinants of health – Food access/food insecurity, transportation, and access to care/insurance.
• Patient education- awareness, early CKD management, lifestyle change/healthy behaviors, treatment options for ESKD
• Care coordination – primary care and specialists, transplant evaluation process

As part of the National Kidney Foundation’s initiative CKDintercept, engaging Community Health Workers to help increase rates of diagnosis and proper disease management is a critical path to ensure high risk communities are not left behind.