What Community Health Workers Do
Older Americans increasingly rely on a quiet but powerful force in healthcare — community health workers. These trusted local professionals serve as a bridge between patients and the medical system. They handle challenges that doctors and nurses simply cannot address during a brief clinic visit. From arranging church rides for isolated seniors to helping cancer patients document end-of-life wishes, their work fills a critical gap in care.
The American Public Health Association defines a community health worker as a “trusted member” of a local community — or someone with unusually close understanding of it. Notably, this closeness allows them to advocate for patients in ways formal medicine cannot.
Real Visits, Real Impact
Home Visits That Change Lives
In rural Oregon, community health worker Sandy Guzman makes her rounds across The Dalles, Hood River, and beyond. On a recent Monday, she visited a woman in her 60s who lives alone and faces deep social isolation. After a serious fall and surgery, the woman uses a wheelchair. She wanted to attend a nearby church but felt too shy to ask for help.
Guzman called the pastor directly. A volunteer driver now picks the woman up every Sunday.
The following day, she visited a patient with heart failure who lives without a proper kitchen or heating. Together, they explored HUD housing options and assisted living possibilities — arriving at a concrete plan. Furthermore, on Wednesday, she drove 20 miles to comfort an 81-year-old woman whose partner of 40 years is battling cancer. Guzman arranged therapy sessions for the distraught woman. However, on that visit, she simply sat, listened, and offered tissues.
“Honestly, sometimes just sitting and listening is the best response,” Guzman said.
Eyes and Ears for the Medical Team
Community health workers also conduct cognitive and mental health screenings. They monitor medication use, coordinate follow-up appointments, and log findings directly into electronic health records. In addition, they install wheelchair ramps, help patients apply for food benefits, and report suspected financial abuse.
“It’s like being the eyes and ears for the doctors,” Guzman said, “to see what’s happening outside the 20 minutes they get to spend with patients.”
The Growing Workforce Behind Senior Care
Who These Workers Are
Community health workers have operated since the 1960s, particularly in rural and low-income areas. Today, the Bureau of Labor Statistics counts roughly 65,000 of them — though the National Association of Community Health Workers believes this is an undercount. They work under many titles: community health educators, outreach specialists, and promotores de salud, among others.
Why Demand Is Rising
Healthcare professional shortages and a rapidly aging population are driving strong momentum for this workforce. Sam Cotton, who directs curriculum for several programs at the University of Louisville, notes that what unites these workers is simple: “They talk like the people they work with.” Consequently, patients feel understood — and more willing to engage with the care they need.
Connected Care for Older Adults Program
Oregon’s Connected Care for Older Adults program employs community health workers across five rural clinics and one clinic in neighboring Washington. Workers become state-certified after 90 hours of online training. Each worker is allotted 90 days per patient, primarily through home visits.
Their patients face serious barriers. Many cannot drive to grocery stores or pharmacies. Moreover, few have completed advance directives — legal documents specifying the care they want during a health crisis.
“They can’t get to a grocery store. They’re not taking their medications,” said Elizabeth Eckstrom, chief of geriatrics at Oregon Health & Science University, who helped launch the program in 2022. Connected Care workers tackle every one of these non-medical barriers, from food access to housing benefits.
The cost per patient for the 90-day program is $1,500. Workers earn $25 per hour with full benefits — a worthwhile investment given the outcomes.
Research Proves the Value
Fewer Hospitalizations, Lower Costs
A study of Connected Care patients — average age 77 — found substantial drops in emergency department visits and hospitalizations. Since ED visits can cost thousands and hospitalizations tens of thousands, the $1,500 program cost proves highly cost-effective.
At Stanford University, oncologist Manali Patel found similar results in a clinical trial at the VA Palo Alto Health Care System. Many veteran patients were dying in the ICU when they would have preferred to be at home. However, when a lay health worker made regular calls to help patients understand options and file advance directives, outcomes shifted dramatically.
More than 90% of participating veterans had their care goals documented, compared with fewer than 20% in the control group. These patients also had fewer emergency visits, fewer hospitalizations, and higher hospice enrollment.
Evidence from Cancer Care
Additionally, in oncology clinics across Arizona and California, bilingual lay workers made regular calls to cancer patients over 75, assessing pain, nausea, and depression. Alerting care teams to these issues substantially reduced hospitalizations and saved an average of $12,000 per patient. A JAMA editorial called it a “low-tech, human-administered intervention” that “reaped huge dividends.”
“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.”
Funding Gaps and the Road Ahead
Despite clear evidence of their value, funding remains unstable. Since 2024, Medicare covers some community health worker services — but not all. For instance, driving 30 miles to a remote patient’s home is not reimbursed. Medicaid coverage varies by state, leaving many programs dependent on short-term grants.
“Sustainability is something we talk about every day,” said Neena Schultz of the National Association of Community Health Workers.
The federal Rural Health Transformation Program distributes $10 billion annually and includes funding for these programs. Nevertheless, Medicaid budget cuts at the state level could offset those gains significantly.
Connected Care’s grants continue for now. Guzman keeps making her rounds. One recent success: a newly widowed man in his 60s had lost his housing and was sleeping in his truck. Through another patient, Guzman found someone willing to donate an unused RV. The man 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. You develop a relationship, and they feel they have someone to advocate for them.”
