Delivering Whole Person Care through a Community Health Worker-led Community-Clinical Linkage Model

Benita Arokiaraj, MPH

Cardiovascular heart disease (CVD) remains the leading cause of death in the United States, primarily due to key risk factors such as high blood pressure. High blood pressure or hypertension, often called a “silent killer”, disproportionately affects communities that are medically underserved and negatively impacted by social drivers of health. There is a widely recognized gap in the coordination between healthcare systems and communities and a critical need for a model that links patients to medical or community resources. 1 This is where Community Health Workers (CHWs) play an important role.

CHWs are frontline public health workers who are trusted messengers of and/or have a close understanding of the community served.1 By sharing a similar socioeconomic background with patients, CHWs can build a great rapport and translate public health information into lived experiences. CHWs also build individual and community capacity by increasing health knowledge and navigating barriers that impact patient outcomes.

There is strong evidence that demonstrates CHW interventions improve hypertension and CVD outcomes by enhancing blood pressure screening, coordinating healthcare workers to connect patients through referral care, motivating healthy behaviors, addressing barriers to hypertension medication adherence by adopting culturally appropriate education methods, and cost-effectively expanding care outside of traditional settings.3,4 While there is increased awareness that establishing strategic relationships with CHWs and healthcare teams will support the delivery of whole person care, barriers exist in the effective and successful integration of CHWs into healthcare settings. The barriers include, but are not limited to, recruitment strategies, lack of comprehensive/specialty training and certification, supportive supervision, career progression, and limited use of implementation theories and frameworks to study and evaluate CHW interventions in healthcare settings.4,5,6

One way of uniting clinical care delivery and community resources is by establishing a community care hub. Community care hubs are community-centered entities that support a centralized network of community-based organizations to work in tandem with healthcare organizations to address health-related social needs. 7 These hubs help coordinate administrative functions between the health and social care sectors.

With the greatest hypertension and CVD burden concentrated in the southeastern states, the Constellation Community Care Hub is uniquely positioned to create an effective community-clinical linkage to support efficient patient navigation in the arena of cardiovascular health. The Constellation Community Care Hub is a centralized, bi-directional, closed-loop referral hub that allows providers to refer patients to meaningful resources and communities to have input into the organization and management of health care delivery. Staffed by CHWs, the Hub will engage referred clients to understand their social needs and make appropriate referrals to address them to make a difference in their health care and outcomes.

For more information, contact regionalcollab@constellationqh.org 

1. Lohr, A. M., Ingram, M., Nuñez, A. V., Reinschmidt, K. M., & Carvajal, S. C. (2018). Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review. Health promotion practice, 19(3), 349–360. https://doi.org/10.1177/1524839918754868
2. American Public Health Association. (2025). Community Health Workers. Retrieved from https://www.apha.org/apha-communities/member-sections/community-health-workers.
3. Allen, C. G., Brownstein, J. N., Satsangi, A., & Escoffery, C. (2016). Community Health Workers as Allies in Hypertension Self-Management and Medication Adherence in the United States, 2014. Preventing chronic disease, 13, E179. https://doi.org/10.5888/pcd13.160236
4. American Heart Association. (2018). The Importance of Community Health Workers for CVD Prevention and Treatment. Retrieved from https://www.heart.org/-/media/Files/About-Us/Policy-Research/Policy-Positions/Access-to-Healthcare/Community-Health-Workers–Policy-Brief–July-2018.pdf?sc_lang=en.
5. Ignoffo, S., Margellos-Anast, H., Banks, M., Morris, R., & Jay, K. (2022). Clinical Integration of Community Health Workers to Reduce Health Inequities in Overburdened and Under-Resourced Populations. Population health management, 25(2), 280–283. https://doi.org/10.1089/pop.2021.0376
6. Allen, C. G., Barbero, C., Shantharam, S., & Moeti, R. (2019). Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings. Journal of public health management and practice : JPHMP, 25(6), 571–580. https://doi.org/10.1097/PHH.0000000000000846
7. U.S. Department of Health and Human Services. (2023). Community Care Hubs: A Promising Model for Health and Social Care Coordination. Retrieved from https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf