Table 1

CHW-PC Functions

FunctionDefinitionExamples From Included Studies
Care coordinationProvides information and assistance to patients about receiving care from institutions and providers outside of primary careNavigates individuals at risk for coronary heart disease by making medical referrals to local clinics and health care providers23
Meets with patients following each clinic appointment to help direct them to the laboratory or to other appointments20
Health coachingProvides self-management support to patients through counseling involving collaborative goal setting, problem solving, and action planningHelps patients design action plans to achieve goals chosen by the patient47
Contacts patients, educating them about smoking cessation resources, motivating them using motivational interviewing techniques, and helping them decide which treatment to pursue46
Providing social supportProvides a supportive, but non-therapeutic relationship, such as peer-based informational, emotional, or instrumental supportAdvocates on behalf of patients by serving as “culture brokers”50
Provides emotional support, validates patients’ feelings, asks open-ended questions, and listens reflectively39
Leads walking club and assists with group peer support meetings focused on coping with life with chronic disease, stress management, group empowerment, and other group-selected activities38
Health assessmentPerforms clinical assessments within or outside of clinic appointmentsPerforms quarterly clinical assessments of A1C, blood pressure, weight, and foot condition (eg, visual and monofilament assessment)33
Interviews individuals about their health concerns, including survival and social concerns such as parental stress, nutrition, access to medical care, crime, domestic violence, mental health, and substance abuse29
Resource linkingHelps patients access local services using standardized resourcesRequests community-based services for transition from hospital discharge, such as transportation, Meals on Wheels, and in-home supports (eg, home health aid)21
Provides links to supportive community resources and tracks referrals made to local programs to address patient-identified community and policy issues affecting disease management32
Case managementAssesses patients’ needs and provides personalized assistanceExplores each patient’s specific barriers to receiving care and develops and implements an individualized plan to address these barriers, such as scheduling appointments, resolving insurance, accompanying patients to follow-up appointments, and making home visits42
Identifies, trouble shoots, and responds to patients’ post-discharge concerns, such as reminders and transportation assistance for upcoming appointments, barriers to obtaining medications, concerns that might require nurse intervention, and poor understanding of self-management instructions21
Medication managementProvides limited medication reconciliation without making recommendationsCounsels patients on medication adherence, uses physician-approved protocols to assist patients in home titration of antihypertensive medication, and notifies physician to fax prescription to the pharmacy25
Assists with pharmacy activities, including helping patients obtain medication refills for chronic health problems24
Remote primary careProvides limited primary care services in remote areas (eg, first aid, simple chronic disease care, follow-up care)Provides emergency care, routine clinical services, laboratory screenings, physical examinations, preventive health assessments and follow-up on call 24 hours a day28
Provides all primary care in their community in consultation with a remote physician who calls regularly to elicit descriptions of patient signs and symptoms and to provide specific instructions for care31
Follow-upMonitors patients outside of office visitsMakes weekly telephone calls to patients to discuss overall well-being, adherence to action plans, and blood pressure values25
Tracks patients overdue for colorectal cancer screening by calling or meeting patients in the health center44
AdministrationProvides front desk reception (eg, data entry)Updates patients’ medical records with colorectal cancer screening results44
Assists in appointment scheduling, responding to patients concerns and updates contact info21
Targeted health educationProvides information and didactic skills training to patients with specific health needsMakes home visits to deliver curriculum with hands-on activities focused on type 2 diabetes, its complications, nutrition, physical activity, blood glucose self-monitoring, adherence to medications and medical appointments, and mental health41
Educates patients about diabetes and the importance of blood glucose control, medication adherence, diet, and exercise33
Health literacy supportHelps patients understand medical advice and recommendations, including translation servicesClarifies questions stemming from patients’ encounters with health care providers, acts as an interpreter to enhance communication between patients and providers, reinforces teaching provided by health care providers49
Assists patients in reading medical forms to address limited functional literacy50
  • A1c = glycosylated hemoglobin; CHW-PC = community health workers in primary care.