Season 1
November 8, 2018

Episode 3: Boots on the Ground

The Problem Community Health Workers

Sometimes we need someone who’s walked the same roads as us to help us with our health. Learn how Community Health Workers are moving the needle on addiction in Indiana.


It’s been awhile since you were in the doctor’s office. When you were there last time, she gave you your diagnosis and she wrote you a prescription. It seemed serious. She asked you if you had any questions and of course you did, but in the moment it all seemed a little much, a little overwhelming. She told you to call the office if you thought of anything else that she was happy to help. You started the long drive from the city back to your home in the sticks and then you got back to life.

Months go by. You take the medication as best you can. Sometimes you go to groups online that talk about your diagnosis and they seem pretty helpful for answering questions. You try and change your habits and in a few months you had back in for a follow-up. It’s gotten worse. Your doctor tells you some other changes you should have been making. Changes the groups never even discussed. She tells you the foods you should have been avoiding, exercises you should have been doing. It’s all brand new information to you. A lot of brand new information. You go home and you keep trying. Who knows what she’ll say next time from the Regenstrief Institute. This is The Problem with Phil Lofton.

Millions of Americans live with limited access to medical care. It’s estimated right now that nearly one in six Americans live more than 30Millions of Americans live with limited access to medical care. It’s estimated right now that nearly one in six Americans live more than 30 miles away from a hospital with emergency services.

That number is not expected to go down. That’s just the tip of the iceberg, too. About a third of women who live in rural areas have to drive over half an hour for OB-GYN care. Scarcity of mental health, dental and other specialized care can even lead people in rural areas to load those responsibilities onto their family doctor, many of whom don’t have adequate training to deal with those needs, and that’s not even mentioning the gaps in communication that can lead to serious medical misunderstandings. After all, what if a doctor and patient can communicate well about the seriousness of the condition? What if there’s a serious roadblock and how those two parties talk about health goals or nutrition or exercise. It helps to have someone in the community from the community that has a similar background. Someone who can visit folks in their homes and see how they’re living day to day.

That’s where community health workers come in. Community health workers, who were called the new professionals when their profession was first recognized, are part of the medical tradition that goes back to the early 20th century in China. The barefoot doctors of China were individuals who received about six months of training. For 50 years, a total of nearly 2 million barefoot doctors serve the poor and rural areas of China, providing public health services like family planning and medications as well as eastern medicine treatments. These weren’t just city people who were dropped into the country, though most of them spent around half of their lives as farmers, so they were very aware of the context of the lives of the people that they treated. Other countries and other organizations saw the benefit of this model and they gave it a shot in Bangladesh. BRAC, formerly known as building resources across communities, trained and mobilized locals to become paramedics. In Iran, Brazil, Tanzania, and more community health workers have been mobilized to help reduce infant mortality to astounding effect. But what’s that got to do with opioids and what’s that got to do with Indiana? Meet Deb Litzelman.

They are not social workers, they’re not nurses, they’re not public health workers in any way. They’re trained as health coaches. … And they really are coaches. – Debra Litzelman, MD

I am a professor of medicine at IU School of Medicine. I’m the associate director for Health Services Research here at Regenstrief Institute and I am the director of Education for the IU Center for Global Health.

Over the past few years, she’s made an impact getting community health workers out and involved in central Indiana through a series of projects.

The community health workers that have been involved in the projects that I’ve worked with here in Kenya and in Indiana, are lay workers. So they are purposely intended to be people who come from the communities in which they’re working in serving. They’ve grown up in the community, they know the nuances of what it’s like to live in the community. They look and talk like members of the community, so they’re embraced by those that they come and knock on their door, are engaged in the community. Our community health workers here in the United States, in Indiana on our projects are maybe high school or GED equivalent. Some of them do have a little bit more, a formal education, but that’s not required and in fact it actually sometimes it makes them less approachable. So we have carefully selected them for their skills, their empathy skills, their ability to want to serve and be out there and about, but those are the most important aspects of our community health workers.

They are not social workers, they’re not nurses, they’re not public health workers in any way. So they’re trained as health coaches. So that’s another name we have for them. And they really are coaches. They’re there to be supportive. They are trained, so they have information on our five pillars on smoking cessation, on food insecurity, obesity, on substance abuse, mental health disorders, anxiety, depression on safe sleep practices for infants and on breastfeeding. So those are our five pillars that they focus on and they have resources and information on all of those. They also are connected with a lot of the community resources so they can get more mothers and grandmothers and fathers pack and plays for safe sleep and sleep sacks and they can help them get signed up for WIC and tell them what they need to take to the office to get that done, et Cetera, et cetera.

So they’re quite competent lay workers who are really connected. They are known by the community, they’re accepted by the community members. There is no barrier between them and the healthcare system or them and somebody with a white coat or somebody who they perceive as being an authority who might judge them, who might, you know, just not be available for them when they most need them. And they’re out in the community, so they are out and about doing home visits. So they meet the folks anywhere they want to meet – the laundromat, etc. Our first responders are connecting them. So these are folks who never make it to the door of our clinics and our hospitals. So they’re very key to accessing those who are most in need, who don’t ever show up on our doorstep or show up too late.

A while back, Dr Litzelman started with WeCare. WeCare recruited new mothers, then partnered them with coaches who would help them form good habits. What’s more, participants regularly receive text message updates about local resources like free diapers, free food, and more. It was very effective, but they started to notice a pattern.

When we looked at the 1500 people we were following for WeCare and WeCare Plus, 15 percent were self-reporting concerns about, or reporting use of, illicit substance medications that were not prescribed to them. Opioids were among the list, but there was also methamphetamines, a lot of marijuana, and this is separate from smoking. Smoking is another huge addiction, a concern that we have for our, our moms and women. So that’s in brief why we decided that this was a perfect opportunity to overlay the concerns around opioid addiction and substance use disorder. On top of WeCare and WeCare plus.

CarePlus is a new program recovery coaches approach women at local hospitals who have recently given birth to a baby suffering from neonatal abstinence syndrome.

NAS is neonatal abstinence syndrome. So that is the syndrome, that, a baby shows at the time of delivery if the mother has a substance use disorder and has been actively using during pregnancy. It can be that that woman was actively using illicit substances or might have even been on suboxone or methadone and the baby because it’s in their system, will have withdrawal symptoms that could be minimum or severe, severe enough to put that baby in the intensive care unit for sometimes several weeks if not more. And so those, those women who deliver often need a lot of support, a lot of care, a lot of training on how to attach with their child who can be quite irritable and very hard to calm just because of the withdrawal. The mothers often feel like they’re guilty and are shamed and then also feeling like they don’t have the skill sets to take care of that baby. So everything we can do to help them gain those skillsets and keep the mother baby together as long as it’s a safe environment for the child.

CarePlus works with these mothers, they recruit them into the study and then they start to help them.

Well, we measure at intake the risky behaviors. And then the follow-up is documented by our community health workers. So if somebody screens positive for smoking, for example, the community health worker will follow up. They will use motivational interviewing methods that they’re trained in to assess the person’s interest in readiness for change at the right time. They were already interested. They can refer them to a baby and me tobacco free programs where they can get free diapers for staying off cigarettes. Their partners can also be part of the programs and encouraged to be part of that. So, we have measured a, a percent decline in smokers have pregnant and postpartum women. We measure using validated tools, depression and anxiety, for example, and again, over the period of time of followup, we’ve shown a decrease in scores from higher to lower being a better outcome. So that’s occurred. We’ve had more women getting emergency food packs for food insecurity, connected to food pantries and things. More importantly though of those that were, who screened positive for food insecurity, 60 or more percent of those women had gone on to get officially got enrolled in WIC and SNAP or food see sustainability, security for their families and themselves. So these are the kinds of things that we’ve measured for. Those are three examples.

A big part of why the WeCare related projects like CarePlus have worked is because of the people who have given their time to help others. People like Carolina. She’s a recovery coach and care plus she recruits mothers into the program, gets to know them and their family and helps them do life.

My job is just to be a support, right? But, I guess when I’m able to actually see that in someone’s life, it makes a big difference, because you can see, you know, that this person knows that there’s someone that’s going to help them, that’s someone that I’m going to understand them and that they don’t have to feel too alone. Also, you know, me providing resources, gives them hope and gives them kind of like, not a way out, but they can start looking for those resources themselves now that maybe I’ve given them a few and they can start, you know, just building their life, you know, from where they were.

Carolina was hired early because we, even before the grant got started, we saw that she was such a gem, in terms of her empathy and caring and her experience. So she’s had a year of work in a methadone clinic in New York, Harlem, and a year of work at the methadone clinic here in Indianapolis doing individual and group counseling. Again, those jobs are slightly different than the expectations for an addiction recovery coaches, but it certainly demonstrated her interest, knowledge and experience with, with people with addiction and the ability to, be a year, two years into this to really be committed. And so she was hired, she went through a special training to become an addiction recovery coach and is now already being a resource for our current. WeCare coaches to refer to her, anyone who’s interested in having extra care or concern around their addiction.

Plus she’s doing her own independent recruitment from treatment centers and now currently through the care plus program funded by Fairbanks. We’ll be recruiting mother babies, have babies who are born with neonatal abstinence syndrome out of one of our, our local and icu neonatal intensive care units. Through the work of people like Carolina, community health workers can have a huge impact on lives. Lots of times though, success can be bigger than just one person success. To me, I’m on a project this large with a problem, this big is any step toward improving positive behaviors in diminishing negative unhealthy behaviors. And we’ve done that. We’ve done that in all five of our pillars. The next layer of success is healthy birth weight, because a low birth weight baby as at risk for infant mortality, but even if there’s not a mortality outcome with that, a low birth weight baby might be in the NICU for a long periods of time, may have developmental delays, may have learning disabilities, etc.

So anything we can do to get a baby born over 5.8 ounces is a major outcome for us. So that’s the second layer. And then ultimately with the WeCare , WeCare Plus, our major outcome is decreasing infant mortality, which is a major problem in this state. So those are all successes add to CarePlus then the overlay with women with substance use disorder often comorbid with mental health concerns, depression, anxiety, and even more serious mental health issues is getting them connected to behavioral health folks and in recovery counseling, whether it be formal with in or outpatient addiction treatment centers or the major informal networks with narcotics anonymous alcoholics anonymous around the city, which is free or if they’re still afraid of that, not ready for those big steps to just meet with our coaches who we have a special force of community health workers who get extra training in addiction recovery as addiction and recovery coaches so they can serve in terms of a supportive role, encouraging, helping them stay clean, helping them get clean, helping them connect, get over their fear of approaching a treatment center, if they relapse to not shame or blame them to be there for them and get them back on track. So we, we are quantifying, measuring all of that and that will be our measures of success.

I think definitely if a mom is still struggling with using heroin or any other drug, the fact, you know, that they started thinking about not using anymore about understanding what they need to do to stop using, you know, like not hanging out with certain people or eating healthier, or seeing me more often or looking forward to seeing me, that, you know, because if mom starts making those changes, then that baby, you know, it will be taken care of. Another big success is if Dad is part of the family and the Dad is supportive of mom, you know, because a lot of times, again, you know, if they don’t have any support, they don’t feel that they can do this. Right. , so if there is people in the family that supports moms or dad, you know, then we also know as a health worker or a recovery coach that you know, there’s someone else in that child’s life that you know, it’s going to take care of. It’s going to be part of that baby’s life in a positive way.

One of the biggest ways that community health workers succeed is through the trust they build with their clients. That trust is built on empathy. Something Carolina says we could all use a little more of when we talk about folks with substance use disorder.

I think a lot of people focus a lot on, you know, they made that show ways that’s their fault. But I think, you know, we fail to understand that once they are kind of like too deep in their addiction, you know, that it’s not just one decision of say, okay, I’m going to stop using because at that time, at that point, your brain has adapted to that specific drugs. So it’s not just, you know, that person is going to stop using right away. So, you know, more like this stigma, I think, you know, kind of hopefully… I don’t want to say can go away because it’s not just going to go away. But, you know, I guess more education, and ,you know, a lot more support too.

Well, community health workers can make personal impacts on opioid addiction and family health. They can’t fix it all.

Sometimes, as a recovery coach, we can feel useless or powerless. I think that’s a better word, a powerless, because there isn’t a lot of help out there.

For starters, the field is often understaffed, under equipped and underused, but when they’re used well, community health workers can be a powerful addition to healthy, robust larger scale solutions like health systems and hospitals. Come back next time when we zoom out a little bit, we’ll talk with Eskenazi Midtown CEO Ashley Overly about how health systems can make an impact in fighting the opioid crisis. Join us then on the problem, our theme and additional music cues. In this episode, we’re written and performed as always by Tessa White and the Natchez Trace. The problem is produced at studio 132 in the Regenstrief Institute in Indianapolis, Indiana. We connect an innovate to provide better care and better health. Learn more about our work and how you can get involved at, and see bonus content from this episode, including sources, pictures and more at

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