United Way works actively throughout the Greater Atlanta region to help pair community health workers with patients to help them avoid expensive and unnecessary emergency room visits.

Choose HEALTH partners with local hospitals and community health centers to employ and train community health workers who go out into communities to meet with patients that may have a history of treating conditions by visiting emergency rooms instead of a primary care physician or clinic. CHWs are frontline public health workers who are trusted members of the community and have a close understanding of the communities in which they serve.

As advocates, CHWs must be knowledgeable about services and be able to make contacts within the community. CHWs help families who may have language and cultural barriers and empower families to negotiate their needs with medical staff, social services or other community-based organizations.

Emergency rooms are the least effective way for people with routine or chronic health conditions to be treated. Frequent users of emergency rooms represent a small group of both insured and uninsured, vulnerable patients; however, this group accounts for a disproportionally high number of ER visits and medical care costs.

United Way saw that patients in Greater Atlanta were often waiting until the condition became too serious before they received any treatment. So, they used the emergency department as a primary treatment source. This resulted in exorbitant medical bills.

Ebony Johnson, United Way senior manager of Health, said high-risk patients are typically those managing treatment for diabetes, cardiovascular or respiratory conditions or a combination of conditions related to obesity. They didn’t have the money, or, in some instances, the transportation available to make those regular doctors’ appointments, Johnson says.

“The community health workers, through a set of interventions, do most of the work in the [patient’s] home setting to provide health education and try to improve the safety and well-being of the home,” Johnson said. “Some of the folks are not in the best living conditions and there’s an issue around transportation, so the community health worker gives them resources, so they can get access to those things. CHWs work with participants to eliminate barriers around access to medical equipment and medication, housing, food insecurity and transportation.”

Community health workers spend about 70 percent of their time in the community focusing on educating people on how to manage chronic conditions, and they also accompany patients to doctors’ visits, she said.

“A good portion of our patient population is 50 and older, and we have some patients that do have family support, but we help with the education about the chronic conditions and helping them navigate to make an appointment and tell them what to do,” Johnson said. “If they are someone who doesn’t have insurance it’s even more difficult for them.”

Johnson said Choose HEALTH partners with health systems and federally qualified health centers throughout Greater Atlanta. There are partners in Fulton, DeKalb and Gwinnett and Choose HEALTH does work in the rural counties to address health disparities around diabetes.

“Our biggest partnership is with Grady [Health System],” Johnson said. “It has been in existence since 2012. We target folks coming into Grady, and using community health workers, we have been able to reduce ER encounters and readmissions in the 90th-percentile.”

Bianca Barker works as a community health worker at Oakhurst Medical Center primarily educating patients in an area with a large refugee population. Barker said she gets referrals from different providers and works toward providing a “path to wellness” for the patients.

She supports patients who suffer from diabetes and need education on treating that issue. So, she helps lead diabetic self-management and health education classes. She also assists obese patients who have hypertension. She teaches classes on nutrition and how to manage diseases and potentially lose weight.

“We work with the American Heart Association very closely and identify those people who are in need of a blood pressure cuff or need consultation,” Barker said. “We give them one-on-one lessons about nutrition and help them enroll in the YMCA, which helps them lower their hypertension, as well as improve their overall health.”

Barker, who has a Bachelor of Science degree in biology and master’s degree in public health, said she specialized in community health. This helps her as she serves a large population that has a lack of resources and education.

Barker works with patients to develop health goals, which help to keep them out of the emergency department, as well.

“I feel like I’m not directly a social worker and not a physician, but I give health education about individual care and their overall health and how it deals with finances and their mental stability,” Barker said. “Where a physician can’t, I bridge the gap for that overall health.”

Johnson said Choose HEALTH has expanded its work to include interventions to treat pregnant women and newborns. Johnson said they have noticed a trend of emergency rooms treating a high rate of expectant moms, some of which have not received adequate care. CHWs would divert these women from the ER and work to connect them to regular prenatal care and provide health and parenting education, as well as address social barriers in their home.


For information about Choose HEALTH and how to donate, visit www.unitedwayatlanta.org/program/choose-health/