United Way pilot program uses health workers to link community with resources

Christopher Stallworth was driving home from work last year when something unusual happened.

He got lost.

Driving the four miles from his job at Taco Bell to his house in the Queen City neighborhood, Stallworth realized he didn’t know where he was. He didn’t recognize the streets or any landmarks.

Over the past several months, Stallworth’s vision had been deteriorating. He had been hospitalized after passing out because of unmanaged diabetes. The diabetes gave way to cataracts that were clouding his vision. By 2020, he found himself lost in the city where he’d lived most of his life.

“I had just completely given up,” Stallworth said.

About 18 months earlier, Stallworth was diagnosed with diabetes during a trip to the emergency room. At the ER, doctors told him to manage his diabetes and to follow up with his family doctor in a week. But Stallworth didn’t have a family doctor. He said he had stopped trying to care for himself. His eyesight was getting worse and he didn’t have the energy or motivation to save himself, he said.

Now, Stallworth, 39, has prescription glasses and jogs in his neighborhood. He had surgery to remove his cataracts and has lowered his blood sugar down to a healthy level. He often walks to work, and just started a new job. Physically and mentally, he feels better.

The difference from a year ago, when Stallworth got lost on a familiar route home with cataracts clouding his vision, to today is in large part thanks to the intervention of community health workers in Victoria, Stallworth said.

Health workers like those who helped Stallworth are at the heart of a new pilot program from United Way of the Crossroads. The program, which began this year, is working to connect people who need support, like Stallworth, with the resources that can get them back to stability.

Brooke Garcia, the director of United Way of the Crossroads, said the pilot program is focused on preventing people in crisis from falling through the cracks and getting completely left behind.

“It’s basically getting them past their crisis point, assessing their actual needs, and making sure they have what they need in order to get to the point where they'll be ready for the agency’s services,” Garcia said.

‘A warm handoff’

Every Wednesday at 10 a.m., a group of community health workers sets up shop at Christ’s Kitchen, Victoria’s only daily soup kitchen. They have a simple set up: A folding table, sign-in sheet, a few bins of documents.

But over their weekly sessions at Christ’s Kitchen, the health workers have tackled pretty much any obstacle or road block that people come to them with. In the last three months, the four health workers have assisted about 70 people, with problems ranging from difficulty signing up for a COVID-19 vaccine to helping families without stable housing find shelter.

The health workers have helped people battling drug and alcohol addictions; people who sleep in Victoria's parks and parking lots; people who have been diagnosed with a mental illness but don't know how to navigate Texas' complex behavioral health systems.

Seemingly simple obstacles - like not having a government-issued identification - can prevent people from getting even the most basic services. IDs are sometimes required by homeless shelters, meaning that without one, people with no place to go have no choice but to sleep in parking lots or on park benches. Although many agencies require IDs, few have the ability to help people who need IDs get them

Tasks like these are where the health workers come in, working with people to find three sources they can use to verify their identities.

The health workers and the support they provide are the heart of the United Way’s pilot program to create a “warm handoff” between people and social service agencies, Garcia said.

Currently, there are four health workers involved in the United Way’s pilot. Kim Pickens, a longtime advocate for the homeless community in Victoria, is working for the United Way to assist people and to help the United Way expand the program. Jodi Sandoval and Kayla Gutierrez, who work for the Victoria County Public Health Department under the Be Well Victoria program, are also part of the team, as is Trish Hastings, executive director of Christ’s Kitchen.

Garcia said ideas for the program began to emerge as people involved in social services began to notice repeated patterns of people falling through the cracks. For example, a homeless mother might get referred to a food pantry for help signing up for SNAP. But without an ID, the food pantry can do little to help her.

“The bigger thing that we’re looking at is that the community navigators are designed to lessen the burden on both the individual client and the service provider,” Garcia said.

Who are community health workers?

In Victoria, the United Way program isn’t explicitly focusing on a certain health measure, like reducing diabetes prevalence, or one specific service, like helping people without housing find affordable places to live.

But programs centered around community health workers, also known as promotoras de salud, have a documented track record of helping improve overall health outcomes in the communities where they work, said Jill Feldstein, the chief operating officer of the Penn Center for Community Health Workers.

An analysis of three programs centered around community health workers found that patients in high-poverty regions of Philadelphia who did receive support from a health worker had fewer hospitalizations and fewer days in the hospital than patients who did not get any support from health workers.

And a group of researchers studying a range of health care programs to determine which ones could lower costs while also maintaining or improving the care provided to people found that of the six different types of innovations they examined, “only innovations using community health workers were found to lower total costs.”

Part of the reason programs like these are so effective, Feldstein said, is because the right people are recruited to do the work. Being a community health worker is less about the certification process or specific training, and more about the workers themselves.

“A lot of people want to talk about, like, what do CHWs do?” Feldstein said. “And I always refocus on the conversation on who are community health workers, because it’s really the identity that drives a big part of the effectiveness.”

The most basic definition of a community health worker is that they are people who are trusted within the communities where they work. That trust is usually built by both the health workers’ life experiences and their intrinsic qualities, Feldstein said. So, for example, a health worker working in a community with a large veteran population might also have served in the armed forces. And then on top of that life experience, health workers need the personal qualities that can allow them to do difficult and often pain-staking work, like being a good listener, Feldstein said.

Despite their name, community health workers are not trained or expected to do clinical care, like distributing vaccines or diagnosing someone with a disease. Their roles vary depending on the community and the program, but they are typically asked to be the link between people in their communities and the broader health and social services systems.

Pickens, Hastings, Gutierrez and Sandoval know many of the people they work with on a first name basis, and in some cases have years or even decades of shared history that helps them build trusting relationships. That includes Stallworth, whose health was in a free fall before he got assistance from Victoria's health workers.

In 2018, Christopher Stallworth was working at a local McDonald’s when he fainted. He was admitted to the emergency room, where physicians measured his blood glucose level at 633, according to his medical records. For someone without diabetes, a healthy blood sugar range is between 70 and 100 milligrams, meaning Stallworth’s blood sugar was more than four times the healthy range. During his stay at the hospital, Stallworth was diagnosed with diabetes for the first time along with a range of other health problems stemming from the untreated diabetes, according to his medical records. When he was admitted to the hospital, he was diagnosed with diabetic ketoacidosis, one of the most serious conditions that can develop from diabetes. Left untreated, diabetic ketoacidosis can lead to a diabetic coma or death, according to the American Diabetes Association. He was also found to have a damaged kidney, which was also the result of the untreated diabetes.

When Stallworth was discharged from the hospital, he had a diagnosis but no support or advice. His discharge summary said a diabetes educator “educated the patient on disease process and management,” and advised Stallworth to make a follow-up appointment within a week.

He continued to work, even as his eyesight got worse and as his diabetes went unmanaged.

Last year, Stallworth said, he ran into Sandoval and Hastings at Christ’s Kitchen one day. They saw that Stallworth had lost a lot of weight, and that he was listless and had little energy. They asked how they could help, and ended up getting him appointments with local doctors to manage his diabetes and get an insulin prescription, figuring out how to get Stallworth eye surgery to remove his cataracts, and helping him work toward a healthier lifestyle as he continued to manage his diabetes.

The challenges that social service agencies are facing in Victoria and surrounding counties is daunting. In Victoria, about 18% of adults under the age of 65 don’t have health insurance. An estimated 16% of adults in Victoria have been diagnosed with diabetes, roughly double the nationwide average, according to the CDC’s National Health Interview Survey. About 14% of county residents live below the poverty line, according to census estimates.

Ultimately, Garcia said, the United Way hopes to expand the pilot program so that there is a community health worker in each of the counties the United Way serves. In the next five years, the United Way also plans to more seriously investigate plans for a community resource center, where access to a range of social service agencies could all be housed under one roof, she said. Such a facility would allow for a “one-stop shop” for people in crisis to get all the assistance they need without heading down a long line of referrals and appointments.

Leaders in Victoria have discussed concepts for a community resource center in the past, Garcia said, but those projects have never gotten off the ground. Now, Garcia said she is more optimistic that the United Way or one of its partners will make the idea a reality. The difference this time around might just be the community health workers, who are ensuring the work is focused on the community.