Providing great care isn’t meant for just a hospital or clinic setting.
Carrie Hawley is a manager for Sanford Health’s enterprise care management team, supporting the community health worker programs across the health system. She said by having positions like community health workers on staff, Sanford Health is uniquely positioned to help all patients, no matter their situation.
“Community health workers are in place to assist patients with bridging the gap between healthcare and community services. When we address the whole patient and the social drivers of health, we remove roadblocks that many patients face, therefore setting them up for better healthcare outcomes,” she said.
Navigating healthcare can be tricky
As a nurse herself, she knows that navigating healthcare can be complicated for patients who don’t have previous healthcare experience or knowledge.
You add in all the logistical challenges patients are facing before they even get to their appointments, like transportation, temporary housing, and food access and insecurity, and it can feel overwhelming for patients.
Because of this, some don’t even make it to their appointments.
“It’s really hard for a patient to worry about their high blood pressure or uncontrolled diabetes when they aren’t sure when or where their next meal comes from,” Hawley said. “Maybe they’re without stable housing or can’t physically get to appointments – without a working vehicle or access to public transit – to see their provider to follow up on their chronic diseases.
“Despite our best efforts and all our screenings in place, patients can still fall through the cracks. Another example: a patient not taking their medication because they have difficulty reading or understanding written instructions and therefore don’t know how to take their medicine. A patient may also not be taking their medication because they cannot afford to buy it.”
Related story: Sanford Health addresses top community health needs
Opening doors to community resources
Amanda Stark and her family live in Mitchell, South Dakota. Her husband works overnights, and she’s a homeschooling mother.
She said she and her family are on a tight budget and worked with Kristi Bitterman, a community health worker in Mitchell, to find help and resources for their situation.
“We didn’t know that there was a program for our gas bill where we got a discount. She’s helped me figure out how to do the food pantry if it was necessary. She got us set up with the library, so now my kids can walk over to the library and do that as part of their schooling,” Stark said.
Bitterman connected Stark’s family with the Mitchell Recreation Center to use for her kids’ physical education requirements. She also connected Stark with the South Dakota State University Extension program, which offers 24/7 access to educational materials and helpful information.
The Starks used the SDSU Extension program for education on nutrition.
“It’s a six-week program all about nutrition. They actually do the cooking there at the SDSU Extension Mitchell Regional Center. They have a kid kitchen there too. They got to learn nutrition education and how to prepare meals and get recipes. It’s a really neat program to take advantage of,” said Bitterman.
Open the report: Community Health Needs Assessment
Stark said she’s never felt judged, and instead felt like Bitterman was only there to help.
And it’s OK to ask for help.
“There’re more resources out there that people might not realize,” Stark said. “Sometimes you need to reach out and ask for help, and you’re not going to face that judgement that you think you’re going to face, especially with people like Kristi. She’s there to work with the public and help the individual.”
Building trust to improve a patient’s health
Community health workers help patients overcome barriers that aren’t always visible.
By building trust, providing education and connecting patients with the right resources, they support individuals in navigating complex health needs and better understanding their care plans.
In some cases, community health workers help patients better manage medications by encouraging conversations with pharmacists, clarifying care instructions and identifying tools that make medication routines easier to follow.
Through ongoing relationships and collaboration with care teams, community health workers help patients become more engaged in their health, improve adherence to recommended care and gain confidence in managing their well-being.
By listening without judgment and addressing each person’s unique challenges, community health workers play an important role in improving health outcomes and creating a more supportive care experience.
‘As little or as much as a person wants’
Bitterman said it’s gratifying to be able to help people in whatever season of life they’re in.
“Sometimes people are in a rough place when I get the chance to meet them, and they just feel like there’s not much hope, nowhere to turn. Even if I’m able to help them get one resource, even if it’s just a discount on their phone bill, it’s something. It’s a place to start,” she said.
“My job can be as little or as much as a person wants. We’re here to go through and connect people to the resources available as they need them,” she added.
There are nine community health workers at Sanford Health in South Dakota:
- Aberdeen
- Mitchell
- Sioux Falls (five at this location)
- Watertown
- Chamberlain
There are also community health workers across other Sanford Health communities.
In North Dakota, there are five community health workers for four communities: Fargo, Bismarck, Hillsboro and Mayville. In Minnesota there are four: two in Bemidji and two in Worthington.
To be connected to a community health worker, a patient must get referred through their primary care provider or RN care manager.
Learn more
- Sanford Health connects patients to community resources
- Wellness pantry program feeds patients at doctor visits
- Sanford report details pledge to patients, communities
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Posted In Aberdeen, Back to School, Brookings, Chamberlain, Children's, Community Impact, Family Medicine, Mitchell, Rural Health, Sioux Falls, Thought Leadership, Watertown, Women's
