Personalizing Care with Community Health Advocates

Personalizing Care with Community Health Advocates


Who are Community Health Advocates?

Community Health Advocates act as navigators and liaisons to provide members with empathetic support and real-time problem solving necessary to enable health and wellness. Research shows that 80% of what makes us healthy or unhealthy happens outside of the doctor’s office – most of what affects our health happens in our homes and neighborhoods. These advocates support members by serving as a bridge between communities and healthcare systems.


What does a Community Health Advocate do?

  • Builds rapport and engages with members to understand the member’s needs and provides informal support
  • Assesses members for unmet social needs, such as housing and food, using social determinants of health survey tool
  • Identifies areas for support and co-develops a plan with member
  • Makes referrals to community resources and advocates for additional resources based on survey data

Social Determinants of Health tools

Social Determinants of Health, such as access to nutritious food and proper housing, may affect a person’s health, functioning and quality of life. If issues like housing or food insecurity are identified on a call, our Community Health Advocates can connect members with resources and organizations that are designed to help meet their social, mental and financial needs.

Community Health Advocates use tools to help find resources and connect members to organizations that can help meet the needs of the whole person.

Success Stories

Kenneth Lee

Kenneth Lee had been living out of a 1979 Ford cargo van in Galt. His fortunes changed with help from Blue Shield of California's Community Health Advocate program, part of its Health Reimagined initiative.

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Jose Herrera

Jose Herrera was able to prepare for a lung transplant thanks to our community health advocate program, which provided him with personalized, in-home care.

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Maria's story represents how Blue Shield of California is reimagining how we approach health care by integrating healthcare technology and community to improve people's health.

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“I was referred to Lauren by my OB/GYN's office for resources that were available to me due to my pregnancy…With Lauren, I had the opportunity to get connections to things that I never thought would be possible. I am a single mother with 4 girls ages 8, 5, 4, and 5 months...

…Lauren helped me through it all and made me feel like I was superwoman…Lauren made sure that my kids were getting everything they needed. She assisted me with getting my newborn a bed…

Thank you again for allowing Lauren to assist me and my family during our hardest of times.”

~ Anne, Blue Shield of California member

Provider testimonials

“Having a CHA helped patients get resources right away…with a CHA in the office, we have someone to connect [patients to resources] in the moment. And it helps the practice understand what our patient needs are.”
“I can’t imagine practicing without [our CHA] now…we had no idea how many patients had [social] resource needs.”
”As a clinician, it’s helped us to make sure patients don’t fall through the cracks. Having [CHAs] there to follow-up with patients gives ease of mind and it’s a weight off my shoulders – the follow-up, the accountability, and providing resources for the patients.”

Frequently Asked Questions

Community health advocates (CHAs) are non-clinical workers who have first-hand understanding of those they serve based on shared lived experiences from their own and/or families’ health, and typically come from the communities where members reside. The relationships they build with our members and communities is based on trust, which enables the CHA to serve as a link between the health system, social services, and the community to facilitate access to services and help improve the quality and cultural competence of service delivery.
Each CHA is required to have experience working with people who need assistance with health and social issues. Additionally, CHAs undergo 64 hours of training that addresses core roles, responsibilities, and competencies, with an emphasis on social justice, cultural humility, motivational interviewing, mental health, and chronic health conditions.
There are other commonly used names for community health advocates, including community health workers, community health promoters, health navigators, health advisors, and promoters.

Community Health Advocates work directly with patients to navigate the health system and connect them with community resources that address their social needs.

CHAs build rapport and engage with members through telephone or in-person based on member preferences. They use a social determinants of health screening tool, called PRAPARE, to identify areas where they may need support and co-develop a plan with the member.

They help connect members to community resources, such as, but not limited to:
  • Employment and/or financial assistance
  • Navigation assistance
  • Counseling and social support
  • Transportation
  • Food or meals
  • Housing or rent assistance
  • Substance use programs

Additionally, CHAs can help overcome barriers to accessing health services by visiting patients at their homes, accompanying patients to medical and related appointments, and assisting patients with completing forms to access needed services.

Our Community Health Advocates provide their assistance at no cost to Blue Shield of California members.

Research has estimated that only 20 percent of a person’s health and well-being is related to the health care services he/she receives. A person’s socioeconomic factors, physical environment and behavioral factors drive the remaining 80 percent of health outcomes. These factors are broadly known as social determinants of health, which include education, job status, income, housing, employment, transportation, diet/food security, social connectedness, and violence.

We must identify immediate, unmet social needs and barriers to health to provide the needed services and referrals, which will result in reduced social care gaps, improved health outcomes, and decreased healthcare utilization.

In our pilots at provider practices, the Community Health Advocate program has shown success in implementation and practice. We are seeing an impact in:

  1. Connecting patients to healthcare and community resources
  2. Engagement with CHAs and their care team
  3. High provider and staff satisfaction with the program and an increased understanding of the social needs of patients

We expect the benefits to be consistent as we expand this program to more members.