A Community Health Worker Program Development & Toolkit for Affordable Housing and Community Development Organizations 
 

Executive Summary

Prior to the COVID-19 pandemic, NeighborWorks began exploring the Community health worker (CHW) model as an opportunity to deepen its network’s housing and health equity strategy work in communities. As the COVID-19 pandemic swept across the country in 2020, NeighborWorks network organizations met the moment and quickly pivoted their core community development and housing work to respond to their communities’ and residents’ urgent health needs. NeighborWorks network organizations coordinated vaccine clinics and food drives, connected residents to personal protective equipment and healthcare, and supported rent stabilization and other activities to respond to community needs exacerbated by the pandemic. 

In a bid to adapt and shift programs and services, fulfill resident’s needs, establish new partnerships, secure funding, sustain long-term operations, and support keeping communities healthy, safe, well and connected, NeighborWorks started to hear from network organizations that there was interest in formalizing COVID-19 response work into the long-term operations of their organizations. NeighborWorks researched the model, engaged in conversations with the network, and connected with external partners and recognized that CHW models could serve as a vehicle to advance health equity in communities continuously challenged by economic stability, education, social and community context, health and health care, and the neighborhood and built environment. The CHW model appeared to be a sustainable service model that could bridge connections between residents, health equity, and health and social services. Community development and housing organizations are in a unique position to implement CHW models as they are often connected to community needs and have the partnerships and organizational infrastructure in place to impact community health and wellbeing. 

In 2021 NeighborWorks America, in collaboration with healthcare consulting firm Health Management Associates (HMA), launched the Community Health Worker Learning Lab (CHWLL) to support Network organizations piloting or expanding CHW programs. NeighborWorks America provided grant funding, training, coaching, and technical assistance for 12 Network organizations to explore, implement, launch, or expand CHW models. Using lessons learned from the CHWLL, the Healthy Homes & Communities team and HMA simultaneously developed a CHW toolkit in collaboration with the grantee cohort to support the Network, and the community development and housing field at large, implement a sustainable CHW program model. 

This CHW toolkit covers eight major components of a CHW program that housing and community development organizations should consider when implementing a CHW model. Real examples, stories, and challenges were sourced directly from the CHWLL grantees and embedded throughout this toolkit to provide a window into the nuances of implementing a CHW program as a housing and community developer. We hope that this toolkit helps your organization think through the factors and conditions that could prime your CHW program for success. 

Overview of NeighborWorks Community Health Worker Models

Community health workers (CHWs) – A new, growing healthcare workforce provides opportunities for NeighborWorks network organizations

What is a community health worker?

Community health workers (CHWs) are public health workers who apply their deep understanding of the experience, language and/or culture of the communities they serve to carry out one or more of the following roles:

• Provide culturally appropriate health education, information, and outreach in community-based settings, such as homes, schools, clinics, shelters, local businesses, and community centers
• Serve as a bridge between individuals, communities and health and human services, including actively building individual and community capacity
• Assist people to access the services they need
• Provide direct services, such as informal counseling, social support, care coordination and health screenings
• Advocate for individual and community needs

Other terms that may be used for CHW can also include:

• Care coordinator
• Family advocate
• Health coach
• Health educator
• Health and wellness program coordinator
• Health navigators
• Outreach worker
• Patient navigator
• Peer coaches
• Peer counselor
• Peer health leader
• Peer navigators
• Promoter or promotores
• Service coordinator

CHWs are distinguished from other health professionals because they:

• Are hired primarily for their cultural competence and understanding of the populations and communities they serve 
• Spend a significant amount of time conducting outreach, community education and help navigating health and social needs

CHW program benefits can include:

• Increased access to healthcare and behavioral health (mental health and substance use).
• Improved confidence to talk to a doctor about health issues.
• Increased access to food, transportation, or other social and community resource needs.
• Better chronic disease (heart disease, high blood pressure, diabetes, etc.) management.
• Increased experience of social support.
• Reductions in home environmental hazards and risks that contribute to asthma symptoms, lead poisoning, injuries, etc.
• Creating improve and accurate community resource guides.

There are three primary CHW program models that NeighborWorks network organizations implement and that leverage network organization capacity, relationships, and experience. These are CHW programs that:

1. Enhance Resident Service Coordination in multiunit affordable housing.
2. Provide a One-Stop Shop to address multiple social needs, many offered by the network organization itself.
3. Provide Health Condition-focused outreach, education, and supports (e.g., asthma, diabetes, behavioral health).

Enhanced Resident Service Coordination Model in Multiunit Affordable Housing 

The enhanced service coordination model may focus on two populations with distinct needs:

• Senior-focused programs may (1) assess health and social needs of residents, (2) increase access to food, medications, healthcare, transportation to faith services and social events, senior services, and shopping, (3) assist with healthcare coordination and follow up, (4) provide wellness activities, and (5) offer linkages to healthcare providers through telehealth.
• Family-focused programs may (1) provide childcare, child development, kindergarten readiness and education needs, (2) increase access to behavioral health services (mental health and substance use treatment), (3) provide healing and trauma services, (3) provide chronic disease education and management, and (4) support access to food, medications, healthcare, transportation needs.

One-Stop Shop Model to Address Multiple Social Needs (Community Action Program, Community Building and Engagement, Comprehensive Community Development)

The one-stop shop model can be located at a network organization’s office or deploy the network organization’s trained CHWs to work directly in a healthcare organization where they will engage community members. This CHW program model primarily focuses on social risk screening, sharing information about community resources and supporting referrals that meet important health related social needs. For information about social risk screening tools see section Component Five: Data Collection, Management, and Security. 

Common domains for social risk screening and navigation in a one-stop shop model that address the social determinants of health (SDoH) include: 

• Behavioral healthcare access
• Childcare access
• Domestic Violence
• Education needs
• Employment needs
• Energy and utilities assistance
• Food access/insecurity
• Financial counseling and assistance
• Healthcare access
• Housing and rental assistance
• Legal services
• Social support
• Transportation

Health Condition-Focused Models 

A health condition-focused model will provide enhanced training for the CHWs in a particular health priority such as asthma, diabetes, hypertension, or behavioral health needs. Common health condition focused CHW programs within the NeighborWorks network include: 

• Comprehensive healthy homes programs that focus on asthma, lead, indoor air quality, mold remediation, injury risks, integrated pest management and other home-based health concerns.
• Behavioral health stabilization programs, commonly called supportive housing programs usually focus on supporting residents with mental health conditions and/or substance use disorders to remain stable in recovery.
• Comprehensive chronic disease programs may focus on reducing uncontrolled diabetes, cardiovascular disease, or hypertension risk factors.
• COVID-19 programs that focus on increasing vaccination rates in heavily impacted communities, distribution of personal protection equipment and supplies, education about vaccines and other supports. 

       

Acknowledgements

This toolkit was developed by NeighborWorks® America (NeighborWorks) in partnership with Health Management Consultants (HMA) with funding support from NeighborWorks America. The toolkit was informed by the meaningful work and progress of NeighborWorks network organizations who participated in the Community Health Worker Learning Lab. This Learning Lab occurred over 24 months and was jointly implemented by NeighborWorks and HMA. 

We would like to express our deepest gratitude for the support and guidance of:

• Our program team, made up of Romi Hall and Surbhi Sardana from NeighborWorks America and Akiba Daniels, Iliana Gilman, Kelsey Moore, Maddy Shea, and Robert Muschler from Health Management Associates. 
• Our colleagues at NeighborWorks America, particularly Paul Singh, Lee Anne Adams, and the Health Liaison team
• The network organization participants in the Learning Lab including Asian Americans for Equality, Beyond Housing, Chicanos Por La Causa, Coachella Valley Housing Coalition, Community Partners of South Florida, Fifth Avenue Committee, Madison Park Development Corporation, Montgomery Housing Partnership, NeighborWorks Blackstone River Valley, New Kensington Community Development Corporation, ONE Neighborhood Builders, and St. Mary Development Corporation.

About

The Healthy Homes & Communities Division at NeighborWorks America 
NeighborWorks America is a congressionally chartered and funded nonpartisan nonprofit. NeighborWorks provides communities — through its network of more than 240 member organizations in every state, the District of Columbia and Puerto Rico — with affordable housing, financial counseling and coaching, training, and resident engagement and collaboration in the areas of health, employment and education. NeighborWorks builds the skills, supplements the resources and amplifies the reach of network organizations so they can empower more individuals and transform more communities than they could on their own. NeighborWorks supports its network and the broader community development field with grant funding, peer exchange, technical assistance, evaluation tools and training. Recognizing the deep tie between community development and health, for the past decade NeighborWorks has supported its network members in working to improve living conditions and address inequities. Today, nearly 70% of the NeighborWorks network is advancing health strategies in their communities

The Community Health Worker Learning Lab 
In 2021, NeighborWorks America launched the Community Health Worker Learning Lab as part of a longstanding set of capacity building opportunities to help network organizations and NeighborWorks better understand how the community health worker model could be integrated into affordable housing and community development settings. Working with Health Management Associates as the consultant partner, twelve network organizations received funding, training, one-on-one coaching, and other capacity building support to explore, launch, or implement the community health worker model within their organizations to improve the health and well being of residents in their communities. The findings from this Learning Lab will inform future support to the NeighborWorks network and the wider community development field as they pursue health strategies and programs to create healthier communities.