No one should have to choose between paying for housing, feeding their family or receiving medical care. Yet this is the reality for many in our community. Recognizing these barriers, Nebraska Health Network began addressing the root causes of health inequity in 2019, with a formal health equity strategy established in 2022.
Mallory Callahan, MPAS, PA-C, vice president of value-based care, said "NHN’s health equity strategy is built on the belief that every person deserves the opportunity to achieve their highest level of health and wellness - regardless of financial or societal barriers."
NHN focuses on identifying and addressing social determinants of health through standardized screening, risk stratification and the use of Z codes to document non-clinical barriers to care. "Our central focus is to ensure that underserved populations receive equitable access to care,” Callahan said
A New Role on the Care Team
Social determinants of health create significant challenges for individuals, often making it difficult for them to focus on their health and take charge of their future. To address this growing challenge, a new role on the care team has emerged...the Community Health Worker.
Community Health Workers are trusted members of the community. They have a deep understanding of the unique challenges that local individuals may face and play a vital role in connecting them to services and resources that help support their health, well-being and personal goals. CHWs work in partnership with clinical teams to help address patient needs.
Methodist Health System and Nebraska Medicine have integrated this approach into their care teams through the roles of Community Health Workers and Community Service Navigators. Currently, six individuals serve in these vital community-facing roles, working to improve access and support beyond the clinical setting.
"Community Health Workers are central to NHN’s equity strategy. As trusted, non-clinical team members, they provide on-the-ground support and help bridge the gap between clinical care and community resources," Callahan said. “Their presence reduces the burden on clinical staff, improves care coordination, and fosters trust with patients as CHWs understand and advocate for the communities they serve. By addressing foundational needs such as housing, food and transportation, CHWs enable patients to better engage in their health, driving improved health outcomes, which is imperative in a value-based world.”
NHN helps train CHWs across the state as part of a three-year grant issued by the Health Resources and Services Administration in partnership with the UNMC College of Public Health. As part of this effort, NHN hosts monthly “CHW Cafes” facilitated by Population Health Coordinator Kelly Mand. These gatherings provide space for CHWs to connect, share resources, navigate difficult scenarios and engage in continued learning.
Hector Sanchez Mancia, a CHW at the Methodist Hospital, follows a structured schedule that includes rotations in the emergency department and the inpatient unit. In Fremont, Nicole Buresh and Lesly Hernandez, the local CHWs, follow a similar schedule between the ED and inpatient units while also including designated office hours to support individuals outside of the hospital setting. Hector, Nicole and Lesly play a vital role in meeting patients where they are and taking the time to truly listen. They create a safe space for the individual to share details about their living situations and environmental factors that may be impacting their overall health.
“In the hospital setting, nurses and providers are focused on assessments, medication management and collaborating with multiple teams to diagnose and treat medical conditions. While essential, these responsibilities often leave limited time to explore the full context of a patient’s life outside the hospital,” said Melissa Heavican, MSN, RN, CPHQ, LSSGB, service executive, Methodist Fremont Health. “That’s where Community Health Workers make a difference. By listening deeply and building trust, Nicole and Lesly help uncover important social and environmental factors that might not otherwise come to light."
Services Provided by CHWs Include:
- Assistance in locating food pantries and meal programs to ensure nutritional needs are met.
- Helping individuals navigate housing instability by providing rent support or identifying temporary shelter options.
- Assessing challenges with basic utilities to maintain consistent heating, electricity, and water services.
- Transportation assistance, particularly for individuals who struggle to attend medical appointments due to a lack of reliable travel options.
- Guiding individuals to apply for medical insurance programs such as Medicaid and Medicare to help reduce the financial barriers to care.
For more information about the CHW program or Community Relay, our online patient resource, please contact Kelly Mand, population health coordinator.
