The following stories illustrate the value of the non-clinical, social determinants of health services provided by a CHW in the Ways2Wellness CONNECT program. Patients with chronic diseases are referred to the program because they are struggling to get or stay healthy. The following short vignettes illustrate some of the simple things that CHWs have assisted clients with that have resulted in clients who are healthier, happier, and able to enjoy their life and family.

Thomas takes control of his diabetes:
Thomas was a patient with diabetes. His A1C had risen significantly and his provider was worried about his health and medication adherence. His community health worker started off doing weekly check-ins with him to look at his blood sugars and talk to him about what may be going on. Thomas said that he took his medications appropriately, but when his CHW asked him to go through his medications with her, they realized that he was completely out of a diabetic medication and he couldn’t say how long it had been! Together, they got the medication reordered and set up a pillbox. His CHW continued to check in every week to see how the pillboxes were working for him and to discuss his blood sugar levels. When there was a high or low that was outside of his usual range, they would talk about what had been different that day and tips for next time. Through these visits, Thomas was able to learn about what snacks were appropriate to treat his sugar lows, and what was considered a ‘low.’ Thomas also had been self-dosing his insulin, not understanding how it could be affecting him later in the day. When Thomas began taking all of his medications as prescribed, his CHW began sending his blood sugar readings to his provider on a weekly basis and then the provider was able to adjust his medications to avoid the lows he was getting in the morning that were prompting him to eat several high sugar snacks. By changing this cycle, Thomas was able to get himself back on track and his A1C dropped from 9.2 to 7.8! Thomas continues to move forward with new skills to appropriately manage his diabetes.

Julie walks in new shoes:
Julie was referred to the Ways2Wellness Connect program for diabetes management. Upon meeting with her CHW, it became clear that Julie had an injury to her foot months before and was advised by a doctor to have her toe removed because of the injury and complications associated with diabetes. Julie’s CHW helped her navigate the scheduling of appointments with her doctors as well as for her operation and helped her arrange for transportation to and from those appointments. When Julie had her toe removed and was recovering from her surgery, her CHW helped facilitate communication between with her provider to ensure that she understood after care and that her provider knew her questions. Julie and her CHW worked on diabetes management and she worked toward testing her blood sugar three times a day, and writing down her blood sugar, insulin, and when she ate her meals around testing. Testing her blood sugar became an exciting goal for her and each week, Julile became more excited about showing her results to her CHW and talking about her diabetes management. Each of her blood sugar testings were in a good range and because Julie’s doctor had her using a “sliding scale” for insulin, Julie seldom had to use it. Her A1C was at a good level as well. When Julie decided to change providers, her CHW gave her information on CHWs that worked with her new provider. After a few months of not working with Julie anymore, her CHW had the pleasure of seeing Julie again for a brief visit. Julie was excited to see her CHW and catch her up on how things were going for her. she was happy to share that she has continued to manage her diabetes and that she received the diabetic shoes that they had worked on getting her. She was thrilled with her new purple shoes – her favorite color!

Tracie finds new confidence:
A client, Tracie, was referred to W2W CONNECT because she was not making it to her appointments with her provider. Tracie told her provider it was because she could not afford to pay her portion of the visits.  Her CHW was asked to go and help her complete the application for the hospital’s patient financial assistance, which they did. Her CHW was also able to help her with some other paperwork, including applying for Medicaid, Food Stamps, and prescription assistance.  In speaking with Tracie, her CHW found out there were other reasons why she was not going to her appointments.  Tracie’s daughter had recently passed away unexpectedly at the hospital and she was having trouble going there because of the memories it would bring back.  Tracie admitted that she was feeling very depressed and had a history of depression.  She knew she needed to talk to someone, but was reluctant to go to a bereavement group or to see a counselor. It wasn’t that Tracie didn’t want to, but she was having trouble getting herself to go.  After talking about this for a while and working with her provider’s office, Tracie finally agreed to try and meet with a counselor and behavioral health specialist at least once.  Her CHW was happy to find out that Tracie made it to her counseling appointment and made such a positive connection with her counselor that she decided to continue to meet with her.  After a few visits, and with the assistance of the behavioral health specialist, Tracie scheduled visits for her other medical appointments and went to the appointments.  Over time, Tracie’s CHW saw a positive change in Tracie and is confident in Tracie’s own confidence to work towards her goals with her new providers.

Steven and the power of community and connections:
When Steven was referred to the Ways2Wellness Connect program, he was suffering from severe Parkinson’s disease and a major seizure disorder. He had Home Health nurses visiting him multiple times per week and was going to his local PCP for care. During his intake appointment, it was brought to the attention of his Community Health Worker, that Steven was a Vietnam Veteran and that he was sleeping on an old donated hospital bed; the springs were poking into his back, causing sleepless nights, bed sores, and additional pain. He lived with his wife and older son, both disabled and unable to work or drive.

After the first visit with his Community Health Worker, Steven’s CHW made a call to the Veterans Association to see if they could provide him with a hospital bed, and after a few questions, the Care Coordinator Nurse felt he needed to be seen right away. During his initial visit to the VA, it was determined that his Parkinson’s was most likely caused by exposure to Agent Orange during his time at war in Vietnam.

Because of his connection to the VA, Steven has received more inclusive Veterans Benefits. He connected with a PCP through the VA and transportation to his appointments. He received at home supports at no cost, including a new hospital bed, electric wheel chair, trapeze for his bed, and a handicap ramp. His medications started being delivered by the VA to his door, so his wife and son no longer needed to make the long walk to the pharmacy.  The VA equipped Steven with an oxygen concentrator, allowing them to send back his current machine that he was paying out of pocket for. When Steven passed away, his family did not have the money to fulfill Steven’s wish to be cremated. Steven’s CHW reached out, to many different charities in their community, and their donations were able to cover the cost of Steven’s cremation, whose remains were then buried at the VA Cemetery, at no charge, with a beautiful Military service performed for the family. This also secured a burial for his wife, when the time comes, with minimal cost to Steven’s son. The power of connections that CHW’s make, is evident in this case. Sometimes it’s as simple as a phone call and other times it’s as powerful as the community in which they live.