Study design and population

Prior to the start of this study, each of the 4 clinics had integrated teams of CHWs to assist patients who were identified as having a health-related social need. All four clinics were affiliated with Atrium Health Greater Charlotte Region and primarily served populations with lower socioeconomic status and from historically marginalized racial and ethnic groups with high rates of chronic medical conditions, such as hypertension. The clinics are located throughout Greater Charlotte in diverse neighborhoods (Supplemental Fig. 1) and served diverse populations (Supplemental Table 1). We included these clinics because they were the first four clinics at Atrium Health that had integrated CHWs and the high number of patients with unmet health-related social needs.

Table 1. Characteristics of the program evaluation participants

^aIncludes Middle Eastern/North African, multiracial, and unknown; ^bincludes liability, sponsored agencies, Tricare, Worker’’s Compensation, and other governmental programs.

The CHWs were employed within the clinic and only worked with individuals who were patients at the clinic. The CHWs all received formal training through the University of Pennsylvania’s IMPaCT program and were certified through the North Carolina CHW training, which include training in working with medical providers, motivational interviewing, and de-escalating conflict [Reference Kangovi, Mitra, Grande, Long and Asch11,13]. As part of routine clinical care, all patients who presented for a visit were assessed for health-related social needs using the CMS Accountable Health Communities Health-Related Social Needs Questionnaire [6]. Patients identified as having an unmet need based on the questionnaire were referred by the clinician or staff to one of the clinic’s CHWs. If available, the CHW would meet with the patient in-person at the time of the visit to discuss the patient’s needs and assist with accessing community resources. If the CHW was not available at the time of the visit, she would contact the patient by phone. The CHW worked with the patient for at least 4 weeks and as long as 6 months based on patient’s needs.

We conducted a prospective mixed methods cohort study between 12/2022-4/2024. All adults (≥18 years) who had been referred to a CHW and had uncontrolled hypertension (defined as blood pressure >140/90 at the time of the visit) were eligible. After a potentially eligible patient was identified by clinic staff or a provider, a study team member contacted the patient, either in person or by phone, to discuss the study purpose and procedures, review eligibility criteria, and obtain informed consent. We limited this study to patients with uncontrolled hypertension because populations that have been socially and economically disadvantaged are at higher risk of uncontrolled hypertension and to determine the potential impact of assisting patients with social needs on blood pressure management. We excluded participants if they were unable to speak English or Spanish or had a severe cognitive impairment that would limit their ability to provide informed consent, and we enrolled 35 participants in the study. The Wake Forest University School of Medicine Institutional Review Board approved this study.

Quantitative data collection

We collected blood pressure and survey data on participants at baseline, 3 months, and 6 months. All participants were provided an ambulatory blood pressure cuff and education on how to check their blood pressure using the cuff at the time of enrollment. The surveys (see Supplemental Tables 1 and 2) included questions on participants social needs [6], medication adherence (based on questions from the National Health Interview Survey), and hypertension self-efficacy (from the Hypertension Self-care Profile) [Reference Han, Lee, Commodore-Mensah and Kim14]. We also assessed acceptability of working with the CHW using the Acceptability of Intervention Measure (AIM) [Reference Weiner, Lewis and Stanick15]. Data collection occurred either in-person or by phone. We also collected demographic data on all participants through data extraction from the electronic health record and at the time of baseline survey collection. We only collected demographics at baseline to reduce the participants’ burden in completing the follow-up surveys and because the participant demographic characteristics collected for this study were unlikely to change over the 6-month period. Participants received a $20 gift card for each data collection timepoint (up to $60 total).

Table 2. Participant’s perspectives on working with a community health worker

Qualitative data collection

All participants were also offered the opportunity to participate in a semi-structured interview. To facilitate the interview, we developed an interview guide through a detailed review of the literature, consultation with outside experts, and input from our community advisory committee and clinical operations steering committee (see Supplemental Table 3). The community advisory committee consisted of 6 members who were either patients within the health system or members from local community organizations that assisted with social needs. Our clinical operations steering committee consisted of 10 health system or clinic leaders who had been involved in the integration of the CHW teams. The interview guide focused on 3 domains: 1) the effects of social needs on blood pressure control, 2) perceptions of working with the CHW, and 3) how to most effectively integrate CHWs. The guides were pilot tested for face validity with patients who were not included in the study.[Reference Moser and Korstjens16] Interviews occurred approximately 4-6 weeks after participants were referred to the CHW and lasted approximately 30 minutes. Participants received an additional $25 gift card for participating in an interview.

Quantitative data analysis

We summarized patient characteristics using means and standard deviations (for continuous measures) and frequencies and percentages (for categorical measures). We used repeated measures ANOVA to evaluate the change in continuous outcomes (e.g., blood pressure) over time, and we used generalized estimating equations to evaluate change in categorical outcomes (e.g., social needs) over time. We used a 2-sided hypothesis test and considered an α <0.05 significant. We conducted all analyses using SAS version 9.4.

Qualitative data analysis

All interviews were audio recorded, de-identified, and transcribed. The transcripts were then entered into ATLAS.ti software for data management and coding. We conducted a thematic analysis utilizing deductive and inductive coding, creating a codebook with definitions after initial review of all of the interviews, and then iteratively refined definitions and added codes as themes emerged throughout the coding process.[Reference Moser and Korstjens16] Two members of the research team independently applied codes and then came together to evaluate and compare coding. If there was not agreement, they discussed their perspectives and revisited the codebook until consensus was reached. Text segments were then reviewed by code and summarized. Code summaries were synthesized into themes and organized using the principles of reflexive thematic analysis.[Reference Boeije17] We used triangulation with our community advisory committee and clinical operations steering committees to evaluate and establish the validity of the results.[Reference Moser and Korstjens16,Reference Boeije17]