Early in her career as an RN at a North Carolina-based hospital, Margaret Rudisill saw firsthand the importance of cultural, social and economic factors in managing chronic illness. Rudisill — now a Performance Improvement (PI) program director at Vizient — helped in the hospital's development of programs and screenings to educate and support individuals diagnosed with diabetes and/or at a high risk of stroke.
Despite the comprehensive nature of the work, the programs initially failed to attract patients.
The key to success, the team eventually realized, was to embrace a community health worker (CHW) model. Community health workers are lay members of the community who work with their local health care systems in urban and rural environments and typically share ethnicity, language, socioeconomic status and life experiences with the community members they serve.
In the 25 years since Rudisill's involvement in her hospital's chronic disease management programs, the importance of the CHW model has grown substantially, with many healthcare organizations viewing it as a leading outreach tool for at-risk patients.
"Intentionally developing and embracing the CHW model allows us to tap into the wealth of knowledge and expertise that exists within communities," said Rudisill, who in her role at Vizient develops and facilitates collaboratives with hospitals across the U.S. on some of the most pressing issues in healthcare. "CHWs serve as trusted advocates and resources, empowering individuals to take control of their health and navigate healthcare services effectively. By integrating CHWs into healthcare teams, we can enhance patient engagement, improve health outcomes and reduce healthcare disparities."
Here, she looks back on her hospital's development of diabetes- and stroke-focused educational programs and how the CHW model led to greater success.
How did you first become interested in new ways to address chronic disease management?
Nearly three decades ago, I became deeply concerned about the impact of chronic diseases on individual health. As a nurse in a rural community with high rates of diabetes and strokes, I believed that healthcare could do better in addressing these challenges. Our community, located in the stroke belt, received a request from physicians seeking assistance with managing the diabetes population that could, in turn, impact stroke incidence. This marked the beginning of a transformative journey that continues to benefit our community to this day.
In 1995, chronic disease management was not a top priority for everyone. The CFO of our hospital had financial obligations to meet, and admissions for heart failure, strokes and diabetes were financially rewarding. Although the financial perspective may have been unfavorable, our CEO at the time recognized the importance of supporting efforts to improve the health of individuals living with chronic diseases, even in the face of reduced revenue.
How did your organization strategize its approach to chronic disease management and what positive outcomes did you see?
We focused our initial efforts on diabetes. Following the guidelines provided by the American Diabetes Association (ADA), we developed a program curriculum to inspire behavioral changes in individuals diagnosed with this disease. The program offered education, clinical support and assistance in modifying behaviors. Participants attended weekly sessions where their weight, blood pressure and blood sugar levels were monitored. While the group classes were conducted, another clinician reviewed the participants' individual logs and provided written feedback. The program quickly gained success, and word spread rapidly. We soon found ourselves with a significant number of participants who were keen to learn how to live healthier lives and gain a better understanding of their disease.
From the outset, we recognized the importance of tracking outcomes. We discovered significant improvements in overall HgA1c, blood pressure and cholesterol levels among program participants.
After a few years, we began analyzing additional data. To our delight, we found that if a program participant was admitted to the hospital, their length of stay (LOS) was at least half a day shorter than that of the general population. We attributed this finding to their enhanced knowledge about their disease and ability to advocate for themselves. It was a significant achievement and a testament to the effectiveness of our program. Encouraged by this success, we were then approached to expand our offerings into other areas.
How did you expand your focus on diabetes to other chronic disease and what were the results?
Further analysis of community data revealed a significant opportunity to decrease stroke-related mortality rates in our community. This finding reinforced our commitment to continuously improve and expand our programs to address the specific health needs of our community members.
Due to North Carolina's central location in the Stroke Belt, there was a strong interest at the state level to address strokes. In collaboration with leading medical centers, community leaders and healthcare providers, the North Carolina Stroke Association was formed. One of its key initiatives was the development of a stroke screening process to identify individuals at high risk of developing a stroke.
The stroke screening assessment was designed to be comprehensive, covering various aspects of health. It included measurements of lipid levels, HgA1c levels, weight, blood pressure, waist/hip circumference, and a survey to gather information about lifestyle choices such as smoking and exercise. Participants moved through different stations, where a team of nurses, nurse assistants, dietitians and pharmacists conducted the necessary assessments. Once the screening was complete, participants received counseling from a clinician on ways to reduce their risk of stroke as well as awareness of signs and symptoms of a stroke.
Despite the seemingly complex process, it took roughly eight minutes to complete the screening, which was free and offered strategies to decrease stroke risk factors.
Although there were many benefits to these screenings, it appears your organization initially struggled to attract participants. What were the challenges you noted?
One of the first screenings we held was at a local church within a vulnerable population, and there were no participants. Recognizing the need to build trust within the community, the team approached the church secretary and asked for her participation. As she went through the screening process and endorsed it, word spread among the church members, leading to increased participation.
This experience highlighted the importance of cultural sensitivity and understanding. The team realized that there was significant mistrust among the African American population toward medical professionals, particularly those who were white. However, by actively engaging with community members and addressing these concerns, the program gained momentum. This was 25 years ago, before the widespread recognition and utilization of community health workers. The team's experience led to the development of our own model, which involved partnering with individuals from the community to conduct screenings in various areas. This approach proved successful, and the program flourished as a result.
What was the impact of embracing a community health worker model?
The stroke death rate in the community began to decline significantly. People not only modified their behaviors to decrease their risk of stroke but also became more proactive in seeking medical attention at the first signs of a stroke. This timely response made them eligible for receiving tPA (tissue plasminogen activator), a medication that can reverse stroke symptoms and save lives. At one point, our small community had one of the highest rates of tPA administration in the country, leading to a substantial decrease in stroke-related deaths. These efforts gained national recognition and played a significant role in driving improvements in stroke prevention and treatment throughout North Carolina.
The experiences we had over 25 years ago serve as a powerful reminder of the significant impact that cultural factors can have on a person's health. Although we did not set out with the intention of developing a formal CHW model at the time, our journey naturally led us to morph into a model that continues to make a positive difference in the health of the communities we serve.
The lessons we learned from engaging with diverse communities highlighted the importance of recognizing and addressing cultural barriers to healthcare. We realized that trust and understanding were crucial in establishing effective relationships with individuals and communities, particularly those who have historically harbored mistrust toward the healthcare system. By actively involving community members in our efforts and valuing their perspectives, we were able to build strong connections and improve health outcomes.
In the years since, how have you seen the importance of a CHW model evolve and how do you see it continuing to evolve?
Today, the need for intentional development and implementation of the CHW model is more critical than ever. Community health workers play a crucial role in bridging the gap between healthcare providers and underserved communities. They possess a deep understanding of the cultural, social, and economic factors that influence health and can effectively navigate the complexities of the healthcare system. By leveraging the unique skills and perspectives of CHWs, we can overcome barriers to care, improve health literacy, and address the constraints faced by hospitals and healthcare systems.