On a recent Monday, Sandy Guzman, a community health worker in rural Oregon, drove to visit a patient in her 60s in a small city called The Dalles.
The patient lived alone, and “really struggles with social isolation,” Guzman said. After a serious fall and subsequent surgery, the woman was using a wheelchair. She confided that she would like to attend services at a church down the road but had no way to get there and did not want to seem “a bother.”
“We called the pastor to see if there was someone who could pick her up” on Sundays, Guzman said. And there was.
The next day, Guzman visited a woman with heart failure who required constant oxygen. She lives in “less than ideal housing,” with no kitchen and only a plug-in heater for warmth.
“We were trying to figure out if she qualifies for HUD housing or assisted living,” Guzman said, referring to the federal Department of Housing and Urban Development. “We spent a lot of time talking about the options and came up with a game plan.”
Wednesday’s schedule included a 20-mile drive to Hood River to see an 81-year-old woman whose partner of nearly 40 years was contending with a serious cancer. Guzman, who speaks to her in Spanish, found her distraught at the possibility of losing him.
Guzman had arranged for the woman to begin seeing a therapist to help her through the crisis — no minor achievement. But on this visit, “I just handed her tissues and tried to give words of comfort,” she said. “Honestly, sometimes just sitting and listening” is the best response.
A community healthcare worker, the American Public Health Association says, is a “trusted member” of a local community or someone who has “an unusually close understanding” of it, enabling the worker to serve as intermediary between patients and the healthcare system.
These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics reports about 65,000 of them, which the National Association of Community Health Workers says is probably an underestimate.
That partly reflects the difficulty of counting workers who go by a variety of names — community health educators, outreach specialists, promotores de salud — and operate under different state regulations, sometimes with no licensure or certification required.
What they have in common is that “they talk like the people they work with,” said Sam Cotton, who directs the curriculum for several such programs at the University of Louisville in Kentucky.
With shortages of healthcare professionals and an aging population, “there’s a lot of momentum for this,” she said.
In Oregon, for example, five rural clinics employ community health workers, who become state-certified after completing 90 hours of online training, through a program called Connected Care for Older Adults. A sixth clinic employing a community health worker operates in neighboring Washington.
Their frail patients are struggling. “They can’t drive, so they can’t get to a grocery store and shop,” said Elizabeth Eckstrom, chief of geriatrics at Oregon Health & Science University, who helped oversee the program’s start in 2022. “They’re not taking their medications, either for cognitive reasons or because they can’t get to a pharmacy.”
Few have completed an advance directive, specifying the care they want — or don’t want — if they suffer a health crisis.
Connected Care’s community health workers tackle many of those not-exactly-medical problems — from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to work with each patient, usually during home visits.
They help coordinate follow-up appointments. They administer cognitive and mental health screenings and watch for the use of too many medications, entering their observations into the patients’ electronic health records.
“It’s like being the eyes and ears for the doctors, to see what’s happening outside the 20 minutes they get to spend with patients,” said Guzman, whose work has ranged from ordering a bath mat to reporting suspected financial abuse.
In a study of Connected Care patients (average age: 77), a subsample found substantial decreases in emergency department visits and hospitalizations among those served by community health workers.
More extensive research, not yet published, supports that finding, Eckstrom said.
“ED visits cost thousands, and hospitalizations are tens of thousands,” she pointed out. The cost per patient for the 90-day program is $1,500. Its workers earn $25 an hour, a fairly typical wage, and receive full employee benefits.
Manali Patel, an oncologist at Stanford University, found similar benefits and cost savings for older patients with advanced cancer in a clinical trial at the Department of Veterans Affairs’ Palo Alto Health Care System.
“Lots of people were passing away” in the intensive care unit, she recalled. “If we’d asked, they probably would have wanted to be at home.” Oncologists, she added, are “notoriously bad at engaging in and documenting those conversations.”
But when a lay health worker made regular phone calls to help patients understand their options, discuss their preferences with their care team, and file advance directives, the results — published in JAMA Oncology in 2018 — were “very dramatic,” Patel said.
More than 90% of the participating veterans had their goals documented in their records compared with fewer than 20% of the control group. The lay worker’s patients had significantly fewer emergency room visits and hospitalizations and were more likely to enroll in hospice care.
Patel and her co-authors have gone on to document the benefits of lay health workers, the term they used, in undertaking other tasks in other settings.
In oncology clinics in Arizona and California, for instance, two bilingual lay health workers made regular phone calls to cancer patients over age 75 to assess symptoms like pain, nausea, breathlessness, and depression.
Alerting healthcare teams to these patients’ problems substantially reduced their emergency department use and hospitalizations, and the cost savings averaged $12,000 a patient.
“This low-tech, human-administered intervention reaped huge dividends,” said an editorial accompanying that study in JAMA.
“Community health workers should be part of every healthcare team,” Eckstrom said. “They support the patient in ways the medical system just can’t, no matter how hard we try.”
One obstacle to expanding their use, however, is unstable funding.
In 2024, Medicare began covering some community health worker services, but not all. (The costs of driving 30 miles to remote homes, for example, are not reimbursed.) Medicaid coverage is piecemeal, reimbursing for some services in some states and not others.
“A lot of community health worker roles rely on short-term grants,” said Neena Schultz, a director of the National Association of Community Health Workers. “Sustainability is something we talk about every day.”
The organization and other supporters are pressing for more state and federal funding. The new federal Rural Health Transformation Program, which is distributing $10 billion a year, will include funding for community health worker programs, but cuts to state Medicaid budgets could more than offset those gains.
The grants funding Connected Care for Older Adults continue, though. Guzman, employed by the nonprofit clinic One Community Health, keeps making her rounds.
One recent victory: A newly widowed patient in his 60s, struggling financially without his wife’s income, lost his housing and was sleeping in his truck. Through another patient, Guzman learned of an unused recreational vehicle whose owner was willing to donate it.
The widower now lives comfortably in a mobile home park.
When you’re in a patient’s home, “there’s a sense of ease,” Guzman said. “They feel safer talking about things. They don’t feel rushed. You develop a relationship, and they feel they have someone to advocate for them.”
The New Old Age is produced through a partnership with The New York Times.
