Table 3.

Implementation Recommendations: Illustrative Quotes from Key Informants

a. Intervention design
Leveraging the ability of CHWs to perform home visits: “[Inside their homes,] I think most people give you more feedback, and being right there in a person’s presence is better than over the telephone. That way, they can see you. You can see them and their body language.”—Community health worker (participant 12) “If they kept missing appointments, then the doctor would have me go to the house and find out what are the barriers that’s keeping them from coming to the clinic … let me give you an example. I had a patient who kept coming in and was saying that her medicines were missing … we went to the house, and found out that her son, her daughter’s boyfriend, and the daughter were taking her medicine. So, we went to the house and got him connected with the program, you know, so he could stop taking her medicine. So sometimes you go to the house, you find out it's more than just the patient who needs help.”—Community health worker (participant 4) “There’s a huge need for home palliative care that looks different than it would in the hospital or in the clinic, even … there’s still a huge need for community health workers. Again, it gets back to, their experience is different, their skillset is different, and I think it would just supplement, very nicely, the work that palliative care does of just supporting the patient and family.”—Palliative care clinician (participant 5)
Preintervention training for CHWs: “I think knowledge of the resources and maybe the red flags for when someone needs more urgent triaging, for especially depression, might be important. Kind of what are some of the things that might say I need—we need assistance ASAP for this patient? Otherwise, I think really just training and responding to emotion. Because so much of angst is related to just dealing with the emotion of all the ups and downs of illness, and treatment, and changes in functional status. That’s something that anyone in the health system can do, is recognize, and validate, and respond to emotion. That may actually help patients get to a more logical place where they can ask the questions that they need to ask. So, I think that could be something that would certainly be—I think that's helpful for any provider to be trained in, is recognizing and responding to emotion. Kind of knowing when questions are emotional, knowing when questions are more logical, and cognitive, and things like that.”—Palliative care clinician (participant 22)
Limiting caseload size: “You can spend hours with a patient when they’re at end of life and their family member who also need that support to be there for their loved one. It’s not a few minutes. It’s not a few minutes—therefore having an extensive caseload I would say will limit to an efficient [rather than thorough] job. I think there should be a limit placed on the patients that the community health advisors are advising or advocating for.”—Community health worker (participant 21)
Ensuring additional support for CHWs beyond initial training: “Provide them with equipment that they will need to be efficient … ‘We’re going to provide you with,’ we will say, ‘an incentive of $10 an hour, $20 an hour’ or whatever … but offering them a wage. And offering them the equipment, the technology that they would need. Possibly instead of using their own phone, which I have advocated for that—a community health advisor should not be using their own cell phones to communicate.”—Community health worker (participant 21) “I would say … every two to three months like refresher courses for [CHWs] just to continue to guide the CHWs, or to factor in something new, because you might have a new education piece that needs to be incorporated. So whatever you include [that is] new into the program, hold the training for the CHWs.”—Community health worker (participant 1)
Consideration of a disease-specific design: “We are trying to create what we call ‘disease-based pods,’ and within these pods are the nurse navigators, the disease-based social worker, intake specialist—all the people that can help a patient get through that cancer journey—and I think this person could fit very naturally into that … I think it would be really nice to see them as disease-based because I think each of the different diseases carries with it a different set of needs and pitfalls that could occur in those patients, and having someone kind of be more familiar with what would happen to that patient because it is going to be so different for each different disease. I think that would be really helpful.”—Cancer center leader (participant 23)

b. Intervention delivery
Importance of clearly defining roles and integrating into clinical workflow: “I think we all work very well together and there is that level of respect. I do know that on the flip side of it, there have been times that [navigators] have expressed and I have felt myself that they tend to be the so-called dumping ground … it got to be so much at one time that we were almost like minions who were running around delivering what needed to go where and that’s the truth. It just kind of got out of control. It snowballed. So, this one needs a meal bag. This one needs a blood pressure cuff and they felt used, devalued, and insignificant and we had to really work to get that off of us, if you will because we want to make sure that we have the respect that everybody else has in health care or anywhere else. So, you don’t want anybody to feel devalued or they’re less than or let them do the running, that kind of thing, because we are the eyes and the ears out there.”—Care navigator (participant 14) “There’s just a [need for] delineation of what the resource is that’s available, and making it clear of how to contact that [CHW], but also who or what are the appropriate things to escalate to that person. It’s all-around education of I think just awareness that that role exists, and then how best to utilize that role … I think it just gets back to making sure that the communication is there, that it exists, and how to use it appropriately.”—Palliative care clinician (participant 5)
Setting for CHW introduction and assessments: “Bring whoever that CHW is going to be on their care team, let them meet them in the hospital, and you introduce them to the CHW as well as to the role of the CHW. And the CHW can make a follow up visit right then and there. So you won’t be getting a random call: [makes surprised face] ‘Nah, you can’t come to my house!’”—Community health worker (participant 1) “Normally I would say part of the time they could probably work from home, but it’s always helpful to also introduce yourself face to face at some point with the client who you’re working with, and usually earlier than later.”—Care navigator (participant 20)
Balancing adaptability with standardization: “I think it’s fine for it to be adaptable, but I don’t think it should feel adaptable when you put it into place. I think that for the person in the job and the person that they’re taking care of … it should feel very concrete and discrete. And then you can, every three months, or every period of time, reassess and consider what roles and responsibilities you might want to add on or take away. But I think it should not feel vague, and it should not feel open-ended, in practice.”—Oncology clinician (participant 8)
Incorporating both expressed and observed patient needs: “After you meet the patient at their house, you’re doing observation of their house, not just what they’re telling that they need help with. Okay? ‘Miss Betty,’ she’s 75 years old. She’s having problems getting up and down the steps. What resource can I connect her with to get a lift in her house? And I’m telling you the Internet is part of a CHW’s resource. But if you’ve been in the CHW [world] … for some time, like you already know, well, ‘let me reach out to so-and-so and get her connected with this,’ and then you’ve got to follow up. Have they come out and [done] the assessment yet? Did they say that you have to pay anything towards it? Let me see who I can get you funding from. Like, good follow-up. That’s what the CHW role would be.”—Community health worker (participant 1)

CHW, community health worker.