Kentucky Homeplace Meets Clients for Health Services, Education and Research in Appalachia

Shirley Prater distinctly remembers one of the many clients she's served in her six years as a Community Health Worker (CHW) for Kentucky Homeplace. The client was diabetic, but had run out of medication due to financial challenges. 

"Her husband had become disabled, she had no insurance, no income," said Prater.  "But we got her medicine for her. She'll say to me to this day, 'You kept me alive. You're the reason I'm here.' She actually gave herself an injection while she was sitting in my office. It's a humbling experience whenever you know that you've helped someone who thought there was no hope."

Prater is one of more than 20 CHWs employed by Homeplace, which was established in 1994 at the UK Center for Excellence in Rural Health (CERH) to help medically underserved residents access the medical, social and environmental services and resources they need. As lay health workers selected from the communities in which they live and work, CHWs occupy a unique role in the health system, building personal relationships with clients in order to navigate them to health providers and resources in the community. They emphasize preventive care, health education and disease self-management.

And perhaps most uniquely, a CHW will go directly to the client.

"We go up these hollers where other people don’t go. We meet them at their house, we meet them at the doctor's office. A lot of people don't have transportation and have to pay someone to take them," Prater said.

As the case of transportation illustrates, and as any CHW can attest, sometimes a client has a pressing need—financial, personal, or otherwise—that must be addressed before they can think about their own health care.

"You can't get mommy to have a pap [test] if baby doesn't have shoes," said Fran Feltner, DNP, director of the CERH.

The ability to help clients identify and address their most pressing needs—and advocate on their behalf — epitomizes the critical role of CHWs in communities that experience greater burdens of illness and difficulty accessing health care.  Kentucky Homeplace CHWs work with clients to overcome any barriers to health, which means the scope of their work regularly extends beyond health-related services. CHWs often find themselves assisting a client who needs home heating assistance, getting lumber donated for a wheelchair ramp, helping someone understanding their social security mail, or making connections with food benefits. This level of care coordination requires extensive administrative duties as well.

"There's nobody else that fills in the gaps," said Prater. "But there's a lot of leg work involved, a lot of T's that need crossed and I's that need dotted and we fill it out for them."

CHWs can also help fill gaps in patients' understanding of their own health and provide critical health coaching those clients otherwise wouldn't receive. Prater recalled that the diabetic patient she assisted with Medicaid and medication didn't know that skipping meals could affect her blood sugar.

"We educate clients on their illness and prevention, and whatever their doctor recommends. I've had people that have come to me who have never ever had an eye exam, even though they're diabetic. So you have to assess the needs, and whichever direction you need to go in, that's where you head," she said.

Since 1994, the CHWs of Homeplace have connected tens of thousands of rural Kentuckians with medical, social and environmental services that they otherwise might have gone without; health coaching, medication assistance, and care coordination constitute the majority of services. In fiscal year 2014 alone, 7,870 clients received 344,282 services, providing more than $24 million of services and medication. With around $1.3 million in funding, Homeplace services render more than $17 return on investment for every dollar spent on the program.

Several CHWs, including Prater, have also been trained as Kynectors, helping their clients learn about health coverage options available through kynect and the Affordable Care Act. If a client is newly insured, a CHW can help them understand the complicated world of health insurance.

"I had one client who was approved for Medicaid and didn't even know it.  We called to make sure [she was approved], and then we called the drug store," she said. "They filled three of her prescriptions before she even got over there. She had no clue she had been approved. And she said she'd been skipping medicine."

Over the last five years, CHWs have also become much more involved in making connections between their clients and researchers from the University of Kentucky who are working to find ways to improve health. The CHWs have supported community-based research ranging from lung cancer, cardiovascular disease, depression, and studies for improving diabetes outcomes.

"They've expanded their roles so much," said William Mace Baker, director of Homeplace.

The CHWs have become skilled in locating and enrolling often hard to reach research participants, collecting background and measurement data using computer database programs, and providing overall research support. As trusted members of their communities who understand the values and special needs of their clients, CHWs offer research support that helps assure more representative client samples for health studies, increased adherence to study protocols, and less likelihood of withdrawal from studies.

Dr. Susanne Arnold, associate professor in Medical Oncology and Radiation Medicine at the Markey Cancer Center, worked with the CHWs to conduct research investigating lung cancer and exposure to trace element.

"What the Homeplace people do is actually go into the homes of volunteers who have cancer and also normal volunteers and do a long questionnaire where they discuss health related issues, health practices, environmental exposures, job history and the like, as well as collecting water and soil samples from the home and, interestingly hair, blood, urine and toenails," she said.

While conducting research can be very complicated, Arnold said that "the easiest part has been working with Kentucky Homeplace, because they are a community partner that knows the area, they know their community, they live here and they know what works and what doesn’t work."

Feltner agrees that the CHWs are essential for effectively engaging potential research participants in the region, noting that they can reach out to them while providing a service at the same time.

"I think if you had the University of Kentucky come up and hang a sign in Appalachia, Kentucky to say, 'Hey, I'm here to research lung cancer,' you would not get the response that you would get from having people from the community reach those people," she said.

The Homeplace CHW training curriculum developed at the CERH has since been used in several other states and community access programs awarded by the Health Resources Services Administration. Cancer navigators and a stroke navigator here in Kentucky were also trained with the Homeplace curriculum.

"Our main goal is getting people what they need to live with health," said Feltner.

Media Contact: Mallory Powell, Mallory.powell@Uky.edu