York County, Pennsylvania is home to more than 400,000 people, and York City, the county seat, is among the fastest growing metro regions in the nation. The region's large Mennonite population is being joined by newcomers, with a 155 percent increase in Latino residents since 2000.

It is also home to an initiative exploring the impact of community health workers on rates of low-birthweight infants, the driver of an estimated annual societal cost of $26.2 billion nationwide. The project is a road test of a new model of care – and a new but very traditional kind of healthcare provider – in the shift to value-based population health.

The health of much of York County is looked after by Family First Health (FFH), a federally qualified health center with its main clinic smack in the middle of York City. FFH knows that a newborn's birthweight is a key predictor of infant health and family wellbeing – and the overall health status of a community. It also knows that as of 2012 the rate of low-birthweight infants born across rural York County is 8 percent, but in metro York the rate jumps to 11.5 percent.

In the spring of 2017, FFH set out to reduce that rate. Supported by a Memorial Health Fund Grant and the York County Community Foundation, FFH designed a program, Connections for a Healthy Pregnancy, to pair community health workers with at-risk pregnant women in the three ZIP codes that make up York City.

That geographic concentration makes sense to researchers like Prabhjot Singh, M.D., who studies the health of communities. “It's crucial to organize healthcare delivery around some unit of geography where people live, around communities, and to build an operating discipline around that," says Singh, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai in New York. That way, Singh says, "all healthcare providers understand that one core metric: Whether a group of people in a place are getting healthier over time. And then you can focus your efforts."

Inspired by the evidence-based success of the national Nurse-Family Partnership, which is open to first-time mothers only, FFH's Connections program was designed to answer the question: How can community health workers engage with still-at-risk moms having a second child and guide them from intervention to self-sufficiency?

Designed in collaboration with the Penn Medicine School of Community Health Workers and structured on the Pathways Community Hub model, Connections started with four community health workers: Roseann Stewart, Claudia Salazar, Arlene Feliciano and Abigail Williams. All had roots and networks in York, and all were hired for an essential characteristic: “They naturally gravitate toward helping others," says Casey Darling-Horan, manager of the Connections program for Family First Health.

The Connections health workers serve to link mothers to community services that address social determinants of health and remove nonclinical barriers to care. As trusted, familiar members of the community, with a deep understanding of their patients' lives, the health workers also serve as a seamless conduit of communication between patient and provider.

“We already have care coordinators who reach out to disengaged patients who have been to the hospital and the emergency department three or more times," says Darling-Horan. “But community health workers are totally different. Care coordinators aren't going out to homes, and they're not texting patients saying, 'Hey, can I meet you at McDonald's for a cup of coffee and we can talk about what's happening in your life?' as the community health workers do."

Community health workers are a key member of healthcare systems in many resource-poor nations, but still underutilized in the U.S. “One thing that we often overlook in the United States is people," says Singh, a recent guest on athenaInsight's "Decoding Healthcare" podcast. “You've got to take that will and skill from communities, then identify through rigorous selection processes who is able to step up and take part in care. It's an open secret in the rest of the world that people can do a lot more than we think they can."

FFH's newly hired health workers receive 100 hours of classroom instruction on pregnancy, breastfeeding, infant and maternal health, depression, and tobacco cessation. They also do resource mapping of the community to learn all available services, from parenting classes to food pantries, and how clients can navigate them. They are taught how to use assessment and screening tools and motivational interviewing. And they go on home visits, shadowing nurses from the local Nurse-Family Partnership and the City of York Bureau of Health.

Then the health workers are ready to meet referred patients in the offices of two local ob-gyn practice partners. “The cornerstone of this work," says Darling-Horan, “is that our first interaction with the mom must be in the ob-gyn office after they've seen their provider. That connection shows that partnership between the physician, the community health worker, and Family First Health – and helps the patient understand that we're in this together."

After her first meeting with a client in a clinical setting, health worker Arlene Feliciano sets off to visit the mother at her home. In the first year of the program, the four health workers will meet in person with 206 mothers.

Feliciano soon discovers that every mother has different needs. “We have moms who are experiencing homelessness and moms who just want to know if they qualify for food stamps," says Feliciano. “But most love the support. You can tell they feel more positive after we meet. We encourage them, let them know 'You can do this, we're here to help.' And when we do, they're very excited about the program."

At the home visit, Feliciano and her client complete paperwork and do a needs assessment. But most important, they build rapport so that Feliciano can help her client become capable in navigating support systems. Whether mothers need food stamps, a crib, or bus passes, says Feliciano, “Our goal is to help them learn to look for resources on their own. After all, we're only going to be with them until their babies are three months old."

That enhanced capability has the potential to spread across the community as mothers teach mothers about resources for healthy pregnancies and newborns. It even increases the ability of physicians and nurses, says Singh, who calls community health workers “the missing layer" in American healthcare systems.

“Once you start to have this sort of seamless connectivity — people who are really following your patients, who understand the community — it loops back to effect clinical decision-making," says Singh. "The relationship with community service is a category of capability that's missing" in current-day healthcare, he says.

As Family First Health continues to collect data on the impact of the Connections program, early indicators are promising. Of the 97 mothers who engaged with the program through May 2018, 25 have given birth. And 21 of those babies were born with a healthy weight between 2,500 and 3,999 grams. (The weights of four other babies born to date has not yet been confirmed.) FFH is encouraged by that trend, but it is the qualitative results the team finds most exciting.

“I see genuine joy when community workers have been able to have a breakthrough with a mom, or help one connect to a resource, or empower someone to ask questions about her care to her providers," says Darling-Horan.

Singh agrees that empowered patients are at the core of healthy communities — and one of the most powerful tools to achieve that is “the use of rapidly trained community health workers who know their community."

Gale Pryor is senior editor of athenaInsight. Photographs by Darlene DeVita.