Growing Together: Reimagining Health Care with CHWs

This story was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

As defined by Texas Health and Human Services Commission: A community health worker (CHW) is a person who, with or without compensation is a liaison, and provides cultural mediation between health care and social services, to the community. 

At Baylor Scott & White Health, CHWs are trusted members of the community who have a close understanding, of the ethnicity, language, socio-economic status, and life experiences of the community served. Besides assisting people in gaining access to needed services, CHWs also build individual, community, and system capacity by increasing health knowledge and self-sufficiency. One of the ways the hospital uses CHWs is to enhance care coordination. CHWs improve health outcomes, access to care, help control costs of care, and address social determinants of health by providing support and counseling, addressing barriers and increasing use of services, establishing connections and providing education, and strengthening care. 

As the CHW staff grew, Baylor Scott & White Health developed a CHW Development Council. The purpose of the council is to:

  • Demonstrate & educate on clinical, patient, quality, and cost-effectiveness of CHWs
  • Help grow CHW role
  • Ensure support of CHW staff
  • Be a model organization for utilization & outcomes related to CHWs

The History

Baylor Scott & White Health reimaged health care by building a pathway for growth for their CHWs. With over 100 CHWs on staff, its the national leader in the use of CHWs in health care. It began in 2007 with only 1 CHW for a Diabetes Equity project to 4 in Community Care Navigation in 2010/2011, prompting the creation of other positions. In 2018, Baylor Scott & White Health has over 100 CHWs with various titles and roles, providing them with potential advancement opportunities.

CHW ROLES at Baylor Scott & White Health

Baylor Scott & White Health's CHWs are spread out across many different programs:

Community Care Navigation CHWs

The Baylor Scott & White Community Care Clinic utilized embedded, bi-lingual medical assistants trained as CHWs within the patient-centered medical homes. The clinic leveraged CHWs to assist unfunded, referral clinic patients by providing care, managing their long-term conditions and minor illnesses, as well as connecting them to social and health system resources in the clinic. CHWs have connected patients to primary care, decreased readmissions, and therefore provided Baylor Scott & White Health a greater cost-savings per patient.

Difference in Hospitalizations + ED Visits


Usual Care


% Change


Total 30-days4.77.5-2.8-37.60.37
Total 60-days8.114.9-6.8-45.40.12
Total 90-days10.521.6-11.1-51.50.03
Total 6 months32.633.7-1.2-3.50.87
Total 1-year59.060.5-1.4-2.40.88

Cost Savings from Prevented Readmissions


Lower 95%CI

Upper 95%CI

6 months2($12,040)
Total 1-year0$760

Primary Care Connection CHWs

CHWs assist emergency department patients with finding a physician who can manage their long-term conditions and minor illnesses. Helps to reduce patient readmissions to the ED, improve overall hospital costs, and patient outcomes by connecting patients to a medical home, medical specialist and community resources in the emergency department. Figure 3 and Figure 4 show a decrease in utilization rates since the start of this program:

**Utilization calculated using number of actual patient encounters for identical time periods 90 days before and 90 days after Primary Care Connection involvement**

Chronic Disease Education CHWs

Chronic Disease Educator CHWs provide culturally appropriate, patient-centered, self disease management education, support and services for those with diabetes, asthma, heart failure and COPD. All 5 clinics who participated in this program met the BMI screening goal and adhered to the program guidelines. Out of the those, 3 met the enrollment and the A1c goal.

"Every 1% drop in HbA1c can reduce the risk of microvascular complications by 40% and death by 21%"

Additionally, in partnership with the North Texas Food Bank (NTFB) and several of the Baylor's Community Clinics, CHWs with the Chronic Disease Education program screened patients for food insecurity and referred them to NTFB's Food 4 Health. NTFB provides these patients with fresh produce and other nutritious nonperishable food items twice a month for six months or every week for three months at participating clinics. Each clinic can enroll 15 – 20 patients per session. In addition to the food, patients receive recipes, food education and other incentives like cutting boards or potholders.

BSW Health and Wellness Center CHWs

The Baylor Scott & White Health and Wellness Center (BSW HWC) at Juanita J. Craft Recreation Center offers comprehensive health and wellness services with an emphasis on access to care, health education, nutrition and physical activity. The Center is a model for population health, community collaboration and innovation all aimed at meeting the healthcare needs of our neighbors

PEERS (Promotion, Empowerment, Education, Resources, Support) CHWs are part of Baylor Scott & White Health's faith-based community service model that support the BSW Health and Wellness Center. They provide needed education and support for the South Dallas Community regarding overall health, prevention and care management. In the past five years, the program had reduced emergency department visits by 17% and inpatient admissions by 37%.