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CentraCare Health

Community Health Worker Project Team
Community Health Worker Project Team

Improving Health in Diverse Communities:
The Community Health Worker Project

ICSI member CentraCare Health is making progress helping patients manage their diabetes in the St. Cloud, Minnesota area with its Community Health Worker project. This two-year project, started in March 2015, has allowed CentraCare to hire community health workers (CHWs), address cultural and language barriers, and partner with local employers and nonprofits to identify areas to improve diabetes health care. The project, funded by the Minnesota Department of Health, is primarily focused on working with the Hispanic and East African communities.

Led by program manager Eunice Adjei-Gyimah and three CHWs, the team utilizes chronic diabetes registry data to identify patients that would benefit from more consistent, coordinated care. The CHWs use their electronic medical record (EMR) to stratify and document patients and coordinate their care between primary care providers, diabetes educators, pharmacists and health care home coordinators.

Typically, when the primary care provider refers a patient for a home visit, a CHW visits with the patient and then recommends next steps for care coordination. Even though diabetes is the project’s main focus, there are sometimes opportunities to help with other issues impacting their health, such as a need for affordable housing. The program has reached nearly 400 patients so far, with some notable results, such as reducing blood sugar levels for a number of patients that were above 400 before the care coordination to 120 afterward.

Good communication and community partnerships are key to their success. For example, CentraCare partnered with the local Islamic center because people will come to a place of worship, and will feel comfortable attending an event there. “If their community leader (an Imam) is in attendance and says something, people in that community may also be more open to that information,” Adjei-Gyimah commented. “Working with the community to help identify and own whatever the problem(s) are in that community is a win-win for everyone,” she added.

Other partners that CentraCare is working with throughout its system to help this program succeed include:

  • Diabetes education teams
  • East-African and Latino community leaders and organizations, including the African Women’s Alliance and the Isaiah group
  • Stearns County Public Health
  • Various charitable organizations

“Bringing community health workers on board was an innovative concept for us, and is one way that CentraCare is going beyond our clinic walls,” Adjei-Gyimah said, noting that events and monthly leadership meetings are rotated among partner organizations to connect with the community and to break barriers and perceptions people have about health care. “This project is worthwhile in that it is allowing our workers to have an impact on the patient’s life and empowers the patient to navigate a complex health system so they can take better care of their health and that of their family,” she added. For more information, contact Eunice Adjei-Gyimah.

Pictured above, left to right are, front row: Eunice Adjei, Barretta Dante, Mahado Ali, Tess Foster, and Jennifer Wald. Back row: Fawzia Mohamed, Caryn Locke, Daniel Backes, Julia Draxten, Farhan Abdi, Michael Matanich, Paula Redemske, Caryn Locke, Paul Knutson, and Brittany Richter.

Updated 09/01/16