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Community Health Workers

Table of Contents

About

Community Health Workers (CHW) play an important role in the identification, prevention, and risk management associated with Chronic Kidney Disease (CKD). 

Background

For decades, primary care has nationally served as the front line of the American health care system, but access to a regular, high-quality source of affordable primary care is not equal for all Americans. For large portions of society, geographic, social, financial, and other issues create high barriers to health care. Social factors that inhibit access to quality care, including preventive care, are called social determinants of health (SDOH). Studies suggest these factors account for 80 to 90 percent of an individual’s health 1, and often involve limited access 2 to:

  • Social and economic opportunities.
  • Social supports and resources such as quality schools and quality housing.
  • Neighborhood and workplace safety.
  • Healthy food, clean air, and safe water.

These social factors create barriers to care and weaken trust in the health care system. In surveys and studies, physicians say they do not have the time or “sufficient staff support to address patients’ social needs — such as access to nutritious food, transportation assistance and adequate housing — even though these needs are as important to address as medical conditions." 3

Community Health Workers, on the other hand, are experts at managing SDOH. They specialize in bridging people and communities to health care services. Community health workers have or build in-depth awareness of local community assets and trusted resources. Their cultural competency and frequently their language skills help build trust, and they employ a network of both traditional and nontraditional resources to connect people to the right care at the right time and in the right place. 

Community Health Workers and Chronic Kidney Disease

Chronic kidney disease (CKD) is a serious public health burden that Community Health Workers can effectively address. 90% of people with CKD don’t know this silent condition is ushering them to heart disease, kidney failure and death. And most do not know they are even at risk of CKD. 

But community health workers can raise awareness of risk factors – such as hypertension and diabetes – and connect people to proper testing, diagnosis, and care including:

  • CKD screening- risk assessment/risk score and scheduling clinician follow-up
  • Post COVID kidney assessment
  • Blood pressure or diabetes screening and management
  • Address social determinants of health – Food access/food insecurity, transportation, and access to care/insurance.
  • Patient education- awareness, early CKD management, lifestyle change/healthy behaviors, treatment options for ESKD
  • Care coordination – primary care and specialists, transplant evaluation process

As part of the National Kidney Foundation’s initiative CKDintercept, engaging Community Health Workers to help increase rates of diagnosis and proper disease management is a critical path to ensure high risk communities are not left behind.

Voices of Community Health Workers

"The power of CHWs is not in our specialty but is in our versatility!"  
-Ryan Smith, STL CHW Coalition

“Keeping up with resources is one of the biggest CHW challenges. Who has it, what is available, and being connected to the community... “
-Daron Caswell, Missouri Families and Communities Together CHW

National Kidney Foundation Community Health Worker Training Modules

The NKF has developed training modules to help prepare Community Health Workers to support kidney disease detection, risk reduction and self-management especially among disadvantaged populations.

To enroll in trainings for Community Health Workers specific to Chronic Kidney Disease

and receive your certificate of participation upon completion of the module

Enroll Now

Kidney Disease and Risk Factors

Enroll Here

To enroll in a brief course on the Community Health Worker training content below 

and receive a certificate of participation upon completion of the module

Enroll Now

About Kidney Disease - Module 1

Learning Objectives:

  • State what the kidneys are & how they work
  • State some functions of the kidneys
  • Describe how kidney disease progresses
  • State ways chronic Kidney disease (CKD) is treated
  • Recognize that fear and grief are usual responses to kidney disease
  • Outline tools for screening and diagnosis Kidney Disease

About Kidney Disease - Patient Resources

After viewing this module, the following tools can be incorporated into your practice:

 

CKD Risk Factors and Management - Module 2

Learning Objectives:

  • Describe the conditions that cause chronic kidney Disease
  • Explain the risk factors for chronic kidney disease
  • Discuss management strategies for CKD

CKD Risk Factors and Management - Patient Resources

After viewing this module, the following tools can be incorporated into your practice:

 

Living with Kidney Disease: Social Determinants of Health

Enroll Here

To enroll in a brief course on the Community Health Worker training content below and receive a certificate of participation upon completion of the module

Enroll Now

Living with Kidney Disease: Social Determinants of Health - Module 3
Learning Objectives:
  • Understand the components that make up SDOH​
  • Understand how SDOH may affect patients with CKD​
  • Understand how CHWs may work with patients to address SDOH

Living with Kidney Disease: Social Determinants of Health - Patient Resources

After viewing this module, the following tools can be incorporated into your practice:

CKD and Notes on Nutrition

Enroll Here

To enroll in a brief course on the Community Health Worker training content below 

and receive a certificate of participation upon completion of the module

Enroll Now

CKD and Notes on Nutrition - Module 4

 

Learning Objectives: 

  • Chronic Kidney Disease key nutrition concepts
  • Community Health Workers' vital role in CKD nutrition care
  • Nutrition tools and resources to support Community Health Workers

CKD and Notes on Nutrition - Patient Resources

After viewing this module, the following tools can be incorporated into your practice:

Kidney Failure Treatment and Care

Enroll Here

To enroll in a brief course on the Community Health Worker training content below 

and receive a certificate of participation upon completion of the module

Enroll Now

Kidney Failure Treatment and Care - Module 5
  • Explain, in simple terms, how the kidneys works, what causes kidney failure, and why early detection is crucial for better patient outcomes.
  • Have the skills to education patients with kidney failure about various medical interventions, such as adherence to medications, monitoring progress.
  • Promote kidney health in the community, engage in outreach activities to encourages regular kidney screenings and healthy lifestyle choices.
  • Provide emotion support to patients with kidney failure and their families, connecting them with appropriate mental health resources when necessary.
  • Possess the knowledge and tools to help patients with kidney failure navigate the complex healthcare systems.

Kidney Failure Treatment and Care - Patient Resources

After viewing this module, the following tools can be incorporated into your practice:

NKF Spring Clinical Pre-Conference: Community Health Workers Unite to Improve Outcomes in Chronic Kidney Disease

Enroll Here

This course was recorded at the NKF's Spring Clinical meeting held in Austin, Texas in 2023.

To enroll in a brief course on the Community Health Worker training content below 

and receive a certificate of participation upon completion of the module

Enroll Now

CHW Impact on Addressing Kidney Disease - Module 6

Community Health Workers Impact on Addressing Kidney Disease

 

Learning Objectives:

  1. Understanding fundamental health system challenges that CHWs are poised to address.
  2. Discuss the evidence for CHWs in chronic disease care from a global perspective.

 

Kidney Disease: A Primer - Module 7

Kidney Disease Education for Community Health Workers: A Primer

Learning Objectives:

  1. Detail normal kidney functions and tests used to measure kidney function
  2. Explain kidney disease stages
  3. Outline how kidney disease develops and disease manifestations
  4. Outline treatment options

CHW Roles as Kidney Disease Educators and Patient Navigators - Module 8

Community Health Workers: Their Vital Roles as Kidney Disease Educators and Patient Navigators

Learning Objectives:

  1. CHW history and definition
  2. CKD Education
  3. Individualized education
  4. Benefits of CHWs
  5. Challenges

Community Health Workers Pre-Conference Q&A

Community Health Workers Pre-Conference Q&A

 

Community Health Worker Training Modules

Check back regularly for more training modules!  

Patient Education Tools and Resources

Patients also need information and tools to understand their condition and build the motivation to set and achieve goals to protect their kidney health. The NKF can help here, too. Clinicians can refer patients to Kidney Pathways, an online resource to help patients understand their condition and steps they can take to stop it from progressing. This site uses a very brief questionnaire to help patients interact with their own lab results so they can access a custom course that walks them through important topics in plain language. 

Below is a comprehensive inventory of tools and resources Community Health Workers for use when interacting with patients: 

Many of these valuable resources are also available in Spanish with some of the 2-sided flyers additionally available in Arabic, Bosnian, Dari, Farsi, Kinyarwanda, Nepali, Pashto, Somali, Swahili, and Vietnamese. 

Other Patient Resources

  • NKF Cares is our Patient Help Line, offering support for people affected by kidney disease, organ donation or transplantation. Patients, family members and caregivers are able to speak with a trained professional ready to answer questions and address concerns. Support, assistance, and resources are provided in English and Spanish. The toll-free phone number is 1-855-NKF-Cares (855-653-2273) or email nkfcares@kidney.org.
  • NKF Peers is a national, telephone-based peer support program that connects people who want support with someone who has been there before. This program is designed to help people adjust to living with stage 4 or 5 chronic kidney disease, kidney failure, a kidney transplant or those interested in living donation. People interested in receiving support or becoming a mentor can  complete an online application or email nkfpeers@kidney.org, or call 1.855.NKF.PEERS (1.855.653.7337). 
  • CKD Kidney Dietitian  and eatright.org  to find a registered dietitian who specializes in kidney disease.
  • Kidney Risk Quiz: is a tool to aid in early detection of kidney disease. 
  • Kidney Learning Center: The NKF Kidney Learning Center is designed for patients to better understand and care for kidney disease. Here you will find educational activities on an array of carefully selected topics by well known health experts on the subject.
  • Online Communities: National Kidney Foundation communities offer a safe and supportive place where patients and caregivers can share experiences, ask questions, and get answers related to kidney health, kidney disease, transplantation and living organ donation. Participation is free and anonymous.

     

 

Community Health Worker Resources

The following point-of-care tools empower CHWs to provide comprehensive care, educate patients, promote preventive health measures, and enhance the overall health and well-being of the communities they serve and are free to download.

 

CKDintercept

CKDintercept is a groundbreaking initiative from the National Kidney Foundation to improve chronic kidney disease testing, recognition and management in primary care.

For more information on the initiatives and programs within CKDintercept:

Sources

1 Recent estimates attribute 10 to 20 percent of health outcomes to medical care, 30 percent to genetics, 40 to 50 percent to behavior, and 20 percent to the social and physical environment. Individual behavior and the environment are often studied together as the non-medical determinants of health. 8 In studies that only consider modifiable determinants and ignore genetics, the non-medical factors account for 80 to 90 percent of a person’s health, and the contribution of medical care remains 10 to 20 percent. 
Read more: https://www.americanactionforum.org/research/understanding-the-social-determinants-of-health/#ixzz7vxlhyOxX 

2 https://www.healthcarevaluehub.org/cost-and-quality-problems/browse-cost...

3 https://vcha.uic.edu/wp-content/uploads/sites/169/2021/03/Health-cares-b...

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