Care management models built to address clinical risk fall short of fully addressing the nonclinical needs of many patients, particularly those covered by Medicaid or who are uninsured. Typical care management models center around a team of nurse care managers who coordinate care for patients with chronic illnesses. But as providers recognize that social needs often compound clinical acuity, it becomes clearer that traditional members of the care team aren’t equipped to address them.
Evidence suggests that community health workers (CHWs), which are non-clinical, non-licensed workers sourced from the community, can successfully partner with patients to fill many social gaps in care.