Community Health Worker Training on Older Adults: A Qualitative Needs Assessment

Abstract

Background:

Community health workers (CHW) are frontline public health personnel who serve as liaisons between vulnerable patient populations and the healthcare system. They are instrumental in health promotion and education for urban-dwelling older adults. However, no research exists on training that community health workers receive on age-friendly healthcare. This paper explores CHW education on the 4M’s of an Age-Friendly Health System and identifies areas where additional training may be necessary.

Methods:

As part of a two-pronged qualitative needs assessment, four focus groups were held with a total of 17 community health workers and semi-structured interviews were conducted with ten clinicians, including both healthcare providers and social workers. Focus group and interview transcripts were then analyzed for major themes in Dedoose, a qualitative coding software.

Results:

Clinicians most often identified Mentation and Mobility as areas where CHW can have the greatest impact. Correspondingly, CHW felt under-equipped to assist patients in these areas and expressed strong interest in additional training. In general, CHW and clinicians agreed that Medications and What Matters do not fall under CHW scope of practice.

Conclusions:

Our findings confirm the critical role that community health workers can play in promoting the health and wellbeing of urban-dwelling older adults. However, we also demonstrate that many CHW lack adequate training in age-friendly care. To meet the social and medical needs of a rapidly-aging U.S. population, there is a pertinent need to develop a novel community health worker training curriculum on Mentation and Mobility.

Introduction

The U.S. population of adults 65 and older is projected to rise from 54.1 million in 2019 to 94.7 million in 2060.¹ Health disparities among older adults are particularly apparent in diverse urban centers, where neighborhoods are often stratified by race and socioeconomic status. In Chicago, for example, populations of older Black adults living on the city’s South and West Sides experience higher rates of chronic disease and shorter overall life expectancy compared to their non-Hispanic white counterparts.² There is an increasing need for community-based approaches to meet the complex medical and social needs of an aging population.³

One such approach involves the use of community health workers (CHW) as conduits between patient populations and the medical establishment. CHW do not provide clinical care but can facilitate outreach programs for health screening and education. They are often trusted members of the communities they serve and, as such, are uniquely positioned to address health disparities among older adults through advocacy and cultural understanding.^4,5 By partnering with the CHW workforce in diverse urban centers, hospital systems can further expand the Age-Friendly Health Systems (AFHS) movement into underserved aging populations. Launched in 2016, the AFHS movement seeks to improve the care of older adults by focusing on the “4M’s:” Mobility (helping older adults move safely), Mentation (identifying dementia, delirium, and depression), Medications (using Age-Friendly medications when possible), and What Matters (aligning care with older adults’ health goals).⁶

Previous studies have successfully implemented CHW-led interventions to monitor medication safety, assess fall risk, screen for depression and dementia, and help older adults manage chronic conditions such as diabetes and hypertension.^{7,8,9,10,11,12} More recently, attention has shifted toward the potential of CHW to facilitate conversations about advance care planning (ACP) and promote ACP documentation among older adults.¹³ However, much of this preexisting research focuses on CHW working with rural communities and populations outside of the United States. No published literature exists on the education and training that CHW, specifically those practicing in major cities, receive on age-friendly care.

The present study addresses a gap in the existing literature by addressing the age-friendly training needs of CHW who work with diverse urban populations of older adults. Through a qualitative needs assessment involving focus groups with CHW and interviews with clinicians, this study aims to identify areas of older adult health in which CHW require further education, specifically within the 4M’s framework. We explore the potential of urban CHW as public health paraprofessionals, their experiences collaborating with geriatric-focused clinicians to meet the needs of community-dwelling older adults, and the relevance of the AFHS 4M’s framework to the future development of CHW training programs.

Methods

Study Design

This qualitative study received approval from the Institutional Review Board (#IRB22–1410) to identify possible gaps in CHW knowledge regarding the 4M’s of the AFHS. We conducted four in-depth, semi-structured focus groups with CHW to understand their experience working with older adults, their prior training on older adult health, and their desire for additional training on the 4M’s. Participating CHW primarily work or volunteer at organizations that serve communities on Chicago’s South and West sides. We also conducted 10 semi-structured interviews with clinicians – social workers, nurse navigators, and physicians – who work with older adult patients and who currently utilize or might benefit from CHW support. All participating clinicians work in Chicago-based hospital systems that range from private academic to public county.

Recruitment & Eligibility Criteria

Study investigators formed an advisory board of four experienced CHW who work in underserved communities in Chicago. Advisory board members played a key role in assisting with creating study instruments and recruiting a diverse group of participants, in part by contacting CHW through their own professional communities. CHW were considered eligible if they had a caseload of at least 50% older adults, one-year minimum work experience, and spoke English or Spanish. Clinicians were considered eligible if their clinical practice was comprised of at least 40% older adults. Methods of CHW and clinician recruitment included flyer distribution and snowball sampling, in which potential participants disseminated recruitment materials to their networks. Interested participants completed an online screening and consent form. Eligible participants were invited by email to participate over Zoom.

Focus Group and Interview Methodology

CHW focus groups took place between March and May 2023. Each lasted approximately ninety minutes and was recorded for transcription purposes. Three of the focus groups were held in English and one in Spanish. To reduce bias in data collection, focus groups were conducted by trained facilitators. One facilitator was fluent in Spanish and able to lead the Spanish focus group. At least one study team member was present at every focus group to serve as a timekeeper and notetaker. The focus group facilitator’s guide included a series of open-ended questions developed collaboratively by the research team and CHW advisory board. The guide allowed for adjustments as the discussion proceeded. The questions were designed to probe into participants’ prior training on the 4M’s and their comfort level implementing the 4M’s in daily practice. The focus groups also provided opportunities for CHW to respond to one another’s perspectives and generate a rich commentary about their lived experiences.

Clinician interviews took place between April and July 2023. Each lasted between 30 minutes and an hour and was recorded for transcription purposes. Interviews were conducted by various IRB-approved study personnel. The interview guide asked clinicians to reflect on the structure of their practice, including current or potential areas for CHW contribution to team-based care, and opportunities to strengthen CHW training in the 4M’s.

Data Analysis

Focus groups and interviews were transcribed verbatim and compared to the original recordings for accuracy and clarity. The Spanish CHW focus group transcript was translated into English. Transcripts were then entered into Dedoose, a qualitative data analysis software. One member of the study team coded the transcripts for major themes and subthemes; the resulting codebook was amended, adapted, and consolidated as data analysis progressed. Additional study staff validated code applicability through inter-rater reliability tests within Dedoose.

Results

Seventeen CHW participated in four focus groups, each comprised of 3 to 7 participants, and 10 clinicians participated in semi-structured interviews. Table 1 shows the demographic characteristics of all participants. Sixteen CHW reported that over 50% of their clients are older adults, while 13 reported that their CHW training included topics pertinent to older adults. All of the clinicians stated that over 50% of their patients are older adults. At the time of their interview, five clinicians were employed as social workers, four were employed as physicians, and one was employed as a nurse navigator.

Table 1:

Demographic characteristics of study participants (N=27)

Community Health Workers (N=17)
Characteristic	Sub-category	N (%)
Gender	Female	17 (100)
Age (years)	20 – 29	4 (23)
	30 – 39	2 (18)
	40 – 49	2 (12)
	50 – 59	6 (35)
	60 – 69	1 (6)
	Prefer not to say	1 (6)
Race	Hispanic	10 (59)
	Asian	1 (6)
	Black	6 (35)
Highest education level	High school	1 (6)
	2-year college	5 (29)
	4-year college	7 (41)
	Graduate	4 (24)
Primary language spoken	English	6 (35)
	Spanish	6 (35)
	Other or bilingual	5 (30)
Length of CHW work experience	6 months - 1 year	4 (24)
	1 – 2 years	2 (12)
	2 – 4 years	6 (35)
	> 4 years	5 (29)
Percent of clients aged 65 and over	Less than 50%	1 (6)
	More than 50%	16 (94)
Did your CHW training include topics specific to older adults?	Yes	13 (76)
	No	4 (24)
Clinicians (N=10)
Characteristic	Sub-category	N (%)
Gender	Female	10 (100)
Age (years)	20 – 29	1 (10)
	30 – 39	6 (60)
	40 – 49	2 (20)
	50 – 59	1 (10)
Race	Hispanic	1 (10)
	Asian	3 (30)
	White	6 (60)
Percent of clients aged 65 and over	More than 50%	10 (100)
Type of clinical practice	Hospital-based practice	4 (40)
	Ambulatory clinic	6 (60)
Role	Social worker	5 (50)
	Nurse navigator	1 (10)
	Healthcare provider	4 (40)
Length of employment in current position	< 1 year	1 (10)
	1 – 3 years	1 (10)
	3 – 5 years	3 (30)
	> 5 years	5 (50)

CHW reflections on their current practice, specifically as it pertains to older adults, were categorized into three major themes:

1. Prior education and experience regarding older adults (Table 2)

2. Desired additional education on older adults (Table 2)

3. General reflections on older adult care needs and cultural norms

Table 2:

CHW perspectives on prior and desired education on geriatric care

	Prior education and experience regarding older adults
	Summary Points	Representative Quotes
Medications	Few had formal training Some described helping patients keep their medications organized	“I don’t think I’ve ever received any direct training as a community health worker. We always redirect patients to have that conversation with the provider.” “We remind clients there needs to be strict control regarding how much a certain medication to take and a method to organize.” (trans. from Spanish)
Mobility	Few had formal training Some had on-the-job experience assessing fall risk in patients’ homes	“My training was more so resources on getting assistance with mobility … getting the cane or walker, things along those lines.” “I have very little experience in this specific area, but … sometimes it comes up with, like, they’re having difficulties with their activities of daily living.”
Mentation	Few had formal training or experience Some had taken a mental health first aid course	“Some things I learned with experience, not necessarily training, is to just be patient and reassure the person that it’s OK. Take your time to remember.” “We screen some of our patients with a PHQ9 and then assess if there needs to be a referral to psychotherapy.”
What Matters	None had formal training in advance care planning Some described initiating informal conversations about care goals	“I might ask them if there are any goals that they’re working on, and that may give me some clues as to what matters most to them, who’s important to them.”
	Desired additional education on older adults
	Summary Points	Representative Quotes
Medications	Interest in training on common chronic conditions in older adults and their associated medications	“I would like to know more about … how to address like some of these medication concerns in the population, where sometimes they refused to take the medication, how to navigate that.”
Mobility	Interest in learning how to screen for fall risk and other mobility issues	“Maybe if there was a tool that could help us better assess mobility in and out of the home, I think that would be super helpful.”
Mentation	Interest in learning the differences between cognitive issues such as dementia and delirium	“It may have been nice to have learned how to recognize potential signs of mood conditions like depression … requiring referral to a psychologist.” (trans. from Spanish)
What Matters	Interest in learning how to navigate conversations about end-of-life care with older adults	“Just the overall education of what the person is currently going through and the possible end results, and what resources to help aid them through that process.” “For us being taught how to have that conversation, we can be very impactful.” (trans. from Spanish)

Clinician perspectives on the capabilities of CHW were categorized into two major themes:

1. Perceived roles and strengths of CHW (Table 3)

2. Desired changes in CHW training (Table 3)

Table 3:

Clinician perspectives on the current role of CHW and desired changes in CHW training

	Perceived roles and strengths of CHW
	Summary Points	Representative Quotes
4M’s	CHW play a minimal role in helping patients with medications or advance planning However, CHW can bring concerns about medication non-compliance, fall risk in a patient’s home, or sudden cognitive changes to a provider’s attention	“If there was an issue where someone realized like, someone’s out of medication or there was an adverse reaction, I don’t doubt that [the CHW] wouldn’t bring it to us.” “If mobility comes up, [the CHW] would probably talk about it, but … they’re not having deliberate conversations about mobility.” “[The CHW] is not necessarily focused on helping manage mood, but more kind of noticing if mood may be factoring into an issue, then she’ll highlight it to the social service team.”
Resource navigation	Most clinicians we spoke to felt that the most important role of CHW is working with patients to obtain social services	“We have community health workers who can help patients navigate Pace and homemaker services and things that are a bit time consuming for us [social workers].”
In-home interaction	CHW are uniquely positioned to make observations about a patient’s home environment and social needs	“We’re dealing with patients who are in and out of the hospital a lot because they’re complicated, and so just having yet another way to give them support and to understand what they’re dealing with at home and how that has an impact on their health, I think is pretty invaluable.”
Cultural bridging	CHW can bring cultural awareness and sensitivity to their relationships with patients	“I do feel like a lot of consumers relate to CHW’s more than they do to social workers or any other profession, just because they’re sort of like the bridge between the hospital and the community. They trust them in a different way.”
	Desired changes in CHW training
	Summary Points	Representative Quotes
Medications	Most clinicians said that CHW involvement in medications should be minimal and limited to helping patients with organization	“Right now the role of CHW is not so much focused on medication, but could there be more push on home visits and then checking with the patient in-person in the home to see if they are taking their medication.”
Mobility	Some clinicians said that CHW need formal training on specific mobility hazards to look out for in patient homes	“It would be relatively easy to teach the information that was needed for them to be able to then intervene. And I think that would be great, because they’re already asking lots of questions about the patient’s living situation.”
Mentation	Most clinicians said that CHW would require formal training on cognitive decline in older adults in order to screen for them	“We’ve trained the CHW’s in how to escalate things like suicidality and homicidality, but not general concerns about memory impairment.” “One gap that I’ve noticed is in the memory piece of things. I think that’s not something that [the CHW] is particularly well versed at assessing.”
What Matters	Most clinicians said that CHW involvement in advance care planning should be minimal and limited to informal conversations around care goals	“As long as they have the communication skills that can help to facilitate the goals of care discussion, it doesn’t have to necessarily be a goals of care discussion – just maybe a conversation about what’s important to a patient.”

CHW Themes & Quotes

Prior education and experience regarding older adults

CHW reflections on their previous training were sub-divided into each of the 4M’s (Table 2). The majority of CHW were unfamiliar with the 4M’s as a conceptual framework, although some described learning about older adult health issues related to Mobility and Mentation. One CHW said her training “taught us the difference between dementia, Alzheimer’s, and the different signs … it was more or less how to relate to the person.”

CHW mainly shared anecdotes about on-the-job learning experiences, rather than formal education, relevant to Mobility and Mentation. While in patients’ homes, CHW said they felt comfortable identifying fall risks and assisting patients with obtaining a walker or other mobility devices. Some CHW were trained to screen for depression with a Patient Health Questionnaire-9 (PHQ-9), but none were trained to screen for dementia. “I never received formal training,” said one CHW, “but from experience, I think I can identify signs of mental impairment.”

Compared to Mobility and Mentation, few CHW had received training on Medications or What Matters. Some stated that while visiting older adults at home they helped organize pill boxes or notified the patient’s care team about a needed refill. Additionally, since CHW are often able to spend significant time with their clients, some said they informally speak with older adults about care goals. One CHW with prior experience working in a nursing home said she focused on “asking what was important to them and where they were trying to get back to in terms of their health, like with mobility.”

Desired additional education on older adults

CHW perspectives on desired education were sub-divided into each of the 4M’s (Table 2). Regarding Medications, CHW expressed interest in basic training on common chronic conditions and the risks of polypharmacy in older adults. Regarding Mobility, while some CHW felt they could intuitively identify fall risks in an older adult’s home, others expressed interest in a concrete screening “tool that could help us better assess mobility.”

While some CHW had taken a broad Mental Health First Aid course, most were interested in learning more about cognitive decline in older adults. One CHW described her uncertainty about how to approach mood fluctuations in older adults, stating that she wanted to know “what is it that I could do to accommodate and be flexible to how [a client’s] behavior might be that day.” Finally, CHW expressed interest in basic training on the various long-term care options available for older adults to better navigate conversations about What Matters. “You know with hospice,” asked one CHW, “what comes along with those lines of hospice? Or, if they need to be in a nursing home for a specific reason, what comes along with those lines? So, I guess just the overall education of what the person is currently going through and the possible end results.”

General reflections on older adult care needs and cultural norms

Across all focus groups, CHW made similar observations on the care needs of older adults, particularly those who live in low-income urban communities. Many said that older adults lack adequate support at home and need help accessing resources to remain independent. Other common challenges included low health literacy, difficulties using technology, and pandemic-induced social isolation. One CHW who primarily works with Chinese Americans stated that “among my serving population … they usually deprioritize mental health.”

CHW observed that stigma around mental health and memory loss seemed to intersect with older adults’ varying cultural norms. “My opinion of older adults,” said one CHW in the Spanish focus group, “they have the mentality and culture, especially Latinos, they think, I’m OK, I don’t have depression or dementia … I just had a lapse in memory” (English translation). Similarly, a CHW who works with predominantly Black populations of older adults told us that advance care planning (ACP) is “one subject that they really don’t want to talk about. So, we have the conversation but it’s like pulling teeth. It’s taboo.”

Clinician Themes & Quotes

Perceived roles and strengths of CHW

According to most clinicians we interviewed, a key role of CHW is helping patients access resources such as housing, transportation, public benefits, and homemaker services. By assisting with lower-level social needs, CHW enable clinicians to focus on more complex, high-acuity issues. “It becomes this triage process of, okay, here are some things I certainly know a CHW could address and could probably address quicker than me,” said one social worker. Clinicians also highlighted the ability of CHW to visit homebound patients and keep them connected to their care team.

Most clinicians said they were unaware of any formal training CHW received on the 4M’s but felt that CHW were capable of noting concerns about Medications, Mobility, or Mentation – particularly during home visits – and elevating these concerns to the patient’s healthcare provider. At some institutions, clinicians said that CHW help patients obtain mobility devices; at others, nurses manage mobility equipment. Most clinicians said that CHW were not responsible for discussing What Matters with older adults.

Desired changes in CHW training

Most clinicians we interviewed saw the potential benefit of implementing additional training for CHW on the 4M’s. Clinician reflections were sub-divided into each M (Table 3). Clinicians felt that CHW involvement in Medications should be limited to being the “eyes and ears [in patient homes] to then report back to the clinical staff.” Regarding What Matters, one social worker said she felt “very territorial” about working with patients on ACP, while another clinician thought that CHW could be trained to facilitate informal “conversation[s] about what’s important to a patient.”

Clinicians identified the greatest opportunity for CHW to be involved in Mobility and Mentation. Regarding Mobility training, clinicians felt that CHW should know how to identify fall risks in the home and discuss mobility challenges with patients. “We can’t be in their house with them,” said one clinician, “so anything that [the CHW] would notice that could potentially prevent the patient’s falls.” Regarding Mentation, clinicians felt that CHW did not have adequate training in dementia, delirium, and other forms of cognitive decline that affect older adults. One said that CHW required “some basic education about like, what is mild cognitive impairment, what is normal aging, what is dementia. They don’t have to be necessarily a specialist, but even just equipping them with enough kind of baseline knowledge to kind of have a sense that okay, these patients are going to have problems with short term memory.”

Discussion

This study confirms the unique role that CHW can play in building trust with older adults, facilitating community-based health interventions, and helping patients access critical social services.¹⁴ Furthermore, we demonstrate that urban CHW already assist older adults with Medications, Mobility, Mentation and What Matters, even if they are unfamiliar with the broader conceptual framework of the 4M’s. Among the CHW and clinicians we interviewed, Mobility and Mentation had the greatest consensus as two areas where CHW, based on their scope of practice, are poised to make the greatest impact.

By combining multiple qualitative sources, this paper contributes a novel perspective on the strengths of CHW working with older adults in resource-poor urban communities. CHW expressed enthusiastic interest in learning how to better care for older adults, and many spoke passionately about working with aging patients who feel “invisible.” CHW told us that, during home visits, they informally check for fall risks and make observations about changes in a patient’s mental status. Despite this, most CHW feel that they do not have the tools to confidently identify mobility concerns or distinguish between normal and abnormal forms of memory impairment. This lack of knowledge could pose problems, as many clinicians pointed out, because CHW can have a strong influence on their patients’ well-being. As the number of older adults with Alzheimer’s is projected to double between 2020 and 2060, it is imperative that CHW are trained in recognizing the basic signs of dementia and its impact on patient decision-making.¹⁵ CHW training programs do not typically include dedicated education on the general concept of age-friendly health nor on the unique medical concerns of an aging population. As such, we recommend that CHW receive broad training on the principles of age-friendly health and concrete education on all 4M’s, with a particular focus on Mobility and Mentation.

Recent literature has also demonstrated that Black and Hispanic older adults receive less ACP compared to older white adults, perhaps due to racial and cultural discordance between patients and providers.¹⁶ These disparities suggest that community-based approaches to ACP may help destigmatize and promote the importance of discussing end-of-life care. The clinicians we spoke to largely felt that What Matters, particularly more technical aspects of ACP documentation, should remain under the purview of social workers and physicians. It is also possible, however, that bolstering CHW training and engagement in this space could empower marginalized patients and facilitate meaningful dialogue between older adults and their providers. Further research is needed to determine the extent to which CHW should be involved in conversations around ACP with older adult patients.

Despite the strengths of this study, some caveats deserve mention. Because we only collected data from CHW and clinicians based in Chicago, it may be difficult to translate this study’s findings to other urban centers. Nonetheless, the reflections of CHW were not specific to their experiences working in Chicago, but rather spoke to the spectrum of medical and social challenges that older adults face in cities across the U.S. Second, the study’s small sample size could limit generalizability. However, from our in-depth conversations with participants, we were able to achieve theme saturation while also recruiting and enrolling a diverse study population. Third, our assessment of CHW education and experience was based on participant recollection; as a qualitative study, we could not account for the significant variability in CHW training programs. More urgently, however, this study’s qualitative nature enabled us to gain insight into CHW lived experience, including “‘non-traditional’ sources of knowledge” that might not reveal themselves through quantitative analysis and are necessary to inform next steps in curriculum development.¹⁷ The heterogeneity of community health work also raises further questions about embedding CHW in larger networks of healthcare professionals. Though these concerns are beyond the scope of this study, further research is necessary to elucidate the barriers to integrating CHW into health systems.

In summary, this study supports previous findings that, as CHW scope of practice evolves, there are many ways that CHW can positively impact community-dwelling older adults. By focusing on the knowledge gaps of urban CHW, this study also establishes CHW as important targets for continuing education on the 4M model of older adult care, with a special focus on Mobility and Mentation. Next steps include designing a novel CHW training curriculum based on the input of geriatrics providers, pilot testing it with the intended audience, and determining how to best make such a curriculum freely and publicly available.

Key points

• Community health workers are frontline public health personnel and are often instrumental in health promotion and education for vulnerable patient populations.

• This study finds that, although urban community health workers regularly assist older adults with medical and social needs, many receive little to no training on age-friendly care.

• Based on their scope of practice, community health workers would benefit from additional education on age-friendly topics such as recognizing dementia and delirium, assessing for fall risk, and addressing mobility concerns.

Why does this paper matter?

• Community health workers can serve as trusted liaisons between populations of urban-dwelling older adults and the healthcare system. It is necessary to design a novel age-friendly training curriculum for community health workers to help meet the needs of a rapidly-aging U.S. population.