Peninsula Home Care Becomes First Home Care Agency in the Region to Deploy Community Health Workers

Published on - December 9, 2014

How can we help you take better care of yourself?

SALISBURY, MD – Health providers across the nation are turning to community health workers (CHWs) to serve as connectors between health care consumers and providers. Peninsula Home Care is leading the way as the first home care agency in the region to offer community health worker services through a partnership with Peninsula Regional Medical Center’s Population Health Program.

“While community health workers do not replace our team of skilled nurses and therapists who treat patients in the home, they add another level of care by serving as a liaison between healthcare, social services/resources and the community,” said Nancy Bagwell, Peninsula Home Care branch director. “We want the community to know that they do not have to be a home care patient or homebound to receive care and support from a community health worker. CHWs are available to anyone in the community with a health-related need.”

Community health workers are serving people in the region through a partnership between Peninsula Regional Medical Center (PRMC), Peninsula Home Care, the local health department, MAC Incorporated (the Area’s Agency on Aging) and other regional healthcare providers. PRMC recognized mandates and changes occurring through healthcare reform and knew it was time to find ways to coordinate and provide healthcare services outside the hospital walls. Patients eligible for a community health worker are identified in the hospital as needing additional intensive case management upon discharge. PRMC then coordinates any referrals to a partnering agency with a CHW close to the patient’s home.

“When someone is in the hospital with a chronic disease, they require more complex case management and then a case manager who can oversee the continuum of care and work with their primary care physician and other specialty doctors once they get home,” Bagwell said. “Community health workers are those case managers who can provide a higher quality of service at no additional cost.”

“Community health workers are frontline public health workers who have a close understanding of the communities they serve,” said Karen Poisker, PRMC’s vice president of population health. “They provide outreach, education, referral and follow ups, case management, advocacy and home visiting services to those who need an advocate to help them navigate the healthcare system. They assist individuals and families in developing the necessary skills and resources to improve their health status and self-sufficiency.”

The individuals receiving services are referred to as clients instead of patients because each person’s needs are unique. Some may require clinical care while others are in need of social assistance such as food security or help navigating a particular insurance or Medicare system.

Currently, Peninsula Home Care CHWs are serving more than 20 clients on the Eastern Shore of Maryland every week. Clients do not have to meet home care requirements to receive services. The CHW makes regular home visits and follow-up phone calls serving as an advocate for health and daily living needs. The program is offered over a six-week time period but can be extended depending on the client’s needs. Community health workers are available to clients from 8:30am to 4:30pm (Monday through Friday).

Examples of Community Health Worker Services Include the following:

  • Health Education – Illness Risk Factors, Signs and Symptoms
  • Community Resources – Meals on Wheels, Medicare, Social Security
  • Chronic Disease Self-Management
  • Tele-Health Services
  • Scheduling Doctor Appointments
  • Medication Management
  • Meal Planning
  • Pain Management
  • Home Safety
  • Stress Management
  • Fall Prevention
  • Coping Skills

“I like to think of myself as a community health counselor,” said Kelly English, PHC Nurse Navigator. “The very first question I ask every person I work with is, ‘How can I help you?’ Their immediate needs may not be something on a medical chart but maybe it’s finding a way to sign up for Meals on Wheels. Establishing a level of trust is by far one of the most important things I can do to help a person in need. Once the trust is there, I am able to discover other health and daily living needs they have that I can help with.”

As a PHC nurse navigator, English is responsible for training certified nursing assistants to become certified community health workers. The program requires applicants to study criteria set by a national standard and pass an exam on the materials. English is one of 10 Peninsula Home Care community health workers currently working in the field. She is also certified in chronic disease self-management and Stepping On, a fall prevention program.

To learn more about Peninsula Home Care and the community health worker program and services, call Nancy or Kelly at 410-543-7550.

About Peninsula Home Care

Providing skilled nursing, physical, occupational and speech therapy for more than 30 years, Peninsula Home Care ensures that all patients are involved in their plan of care and strives to give them every opportunity to maintain their independence in the home. The agency has served more than 50,000 patients in Wicomico, Worcester and Somerset counties in Maryland and Sussex and Kent counties in Delaware. In 2017, PHC and PHCN were designated as Preferred Home Care Provider by Peninsula Regional Medical Center and Nanticoke Health Services.


Serving Sussex County & Lower Kent Counties in Delaware and Wicomico, Worcester & Somerset Counties in Maryland

View Full Site