Written by Laura Williamson, American Heart Association News
WILLIAMSON, West Virginia — Lyle Marcum can’t drive to the doctor when he’s feeling ill. He couldn’t go to a downtown grocery store if there was one, which there isn’t.
But when he has a hankering for fresh watermelon, he takes his wheelchair across the railroad tracks to where the Williamson Health and Wellness Center operates a farmers market.
As he shops for fresh fruits and vegetables, the 71-year-old stops to chat with the community health workers he credits with keeping him alive.
“If it wasn’t for them, I wouldn’t be here today,” he said.
Marcum lost his left leg to Type 2 diabetes and has been diagnosed with high blood pressure and heart disease. He’s one of thousands of residents who benefit from the center’s work tackling the devastatingly high burden of chronic illness in this small, rural Appalachian community in southwestern West Virginia.
At the center of it all are the community health workers, or CHWs, whose job includes helping clients learn to eat healthier and so much more.
The CHWs literally keep hearts beating in this coal-mining town along the Tug Fork River, overlooking the Kentucky border. Williamson is the seat of Mingo County, where the population has been steadily falling for years.
In a state ranked among the least healthy in the nation, where nearly 1 in 3 people describe their health as fair or poor, statistics suggest Mingo County’s roughly 22,000 residents face the biggest health challenges of all.
Their life expectancy is an estimated 67.2 years based on figures from 2019-2021, according to the latest County Health Rankings and Roadmaps data. That’s compared to 72.9 years for West Virginia and 77.6 for the nation during that same time period.
About 17% of adults in West Virginia have diabetes and 15% have cardiovascular disease – the highest rates in the nation, according to an America’s Health Rankings’ analysis of federal data that also showed 43% have high blood pressure. The county rankings show roughly 42% of Mingo County adults struggle with obesity, 37% are physically inactive and 28% smoke – all rates that exceed state and national averages. Poverty, lack of health insurance and scarcity of hospitals and health care professionals exacerbate these challenges.
Williamson residents also have high levels of food insecurity. So, community health workers distribute boxes of heart-healthy foods and show residents how to cook them.
Because the area lacks recreational facilities, CHWs organize walking groups and free community yoga classes. They also go to the homes of people like Marcum to take blood pressure and blood glucose readings and to help them manage their medications.
One of the most important roles the health workers play is to listen to their clients’ problems and encourage them when they feel frustrated and discouraged.
“They’re like family,” said Marcum, who told his care team, “I don’t need a wife. I got you all.”
“Some of these people have no family,” said Stephanie Bowman, a certified nurse practitioner and project manager for the CHW program in the department of family and community health at Marshall University’s Joan C. Edwards School of Medicine in Huntington, which provides ongoing training and technical assistance to their sites. “Just to have that visit even once a week, it makes all the difference in that person’s life.”
Williamson was the first of 24 sites serving 800 people across West Virginia, Kentucky and Ohio to use the CHW model developed under a 2012 federal grant.
The CHW model quickly proved successful. Within six to 12 months after enrollment, 60% of participants had lowered their A1C – a test that measures average blood glucose control for the past two to three months – by 2.4%. Emergency room visits fell 22% and hospitalizations declined 30% within a year.
When the grant ended in 2015, the model’s developers obtained funding to replicate it on a larger scale, while working with health insurers and Medicaid managed care organizations to create a shared payment plan that would sustain it on a longer-term basis.
Initially focused on helping people with high-risk diabetes, the model expanded in 2017 to cover other chronic illnesses, including heart disease and chronic obstructive pulmonary disease, and continues to expand.
CHWs are at the center of care teams managed by a nurse, nurse practitioner or doctor, who stays in contact with the primary care provider to make sure a care plan is being followed. CHWs are full-time employees and work directly with the patients, reporting back to the nurse. They are intentionally not medical professionals.
“The community health worker is a peer, a neighbor,” Bowman said. “They know the community and they understand the culture. They have the ability to see the person in their home, with the patient at ease, to be in a space where they can learn their self-management skills.”
When a patient enters the program, “we ask that they do a home visit right away,” Bowman said. Sometimes, a patient is reluctant to have someone in their home, so they meet at a neutral location, such as a library or a park. “But eventually that home visit happens, and that’s when the transformation begins.”
Once a CHW enters a home, they can identify the challenges the patient faces, Bowman said. They may not have enough resources to feed themselves, or they may be eating foods contributing to their illness. They may not be getting enough physical activity or know how to properly manage their medications.
“Sometimes it’s just a matter of needing better organization or understanding what resources are available when they have food insecurity,” she said.
Sometimes, the problem is keeping medical appointments.
“A lot of times, people don’t go to the doctor unless there’s something wrong with them,” said Samantha Runyon, one of Williamson’s community health workers. “And then they have transportation issues, insurance issues.”
Checking blood glucose and blood pressure levels regularly allows the team to better track people’s health so they don’t get sick, Runyon said. “If they have high blood sugar, we can speak to their doctor and get changes made to their medications sooner, rather than them waiting until their follow-up appointment to see the doctor.”
More often than not, a personal bond forms. And that’s when real progress begins, Bowman said. Community health workers “have the ability to connect and build rapport with the patients. When they do, magic just happens.”
Tony Delong can attest to that. His blood pressure and blood glucose levels were so high that when he first went to the wellness center for a checkup, he was immediately enrolled in the CHW program.
“They got me started that day,” he said, remembering how his A1C had climbed to more than 14% – double the goal for most people living with diabetes. After prescribing medication, CHWs “came to my home and called me every couple of days to do my readings – my weight, my blood pressure and check my blood sugar.”
The 64-year-old said the CHWs didn’t just manage his health. They also provided moral support and encouragement, getting him involved in support groups for people with diabetes and heart disease. They encouraged him to walk several miles a day and provided him with a blood pressure monitor so he could take readings on his own. Within a few months, his A1C was within goal and his blood pressure had returned to normal.
“They kept me motivated, and that includes helping me with things to eat,” Delong said. “I used to be a meat-and-potatoes guy. Now I’m practically a vegetarian.”
A big part of the job is helping people manage their risk factors to prevent progression of heart and kidney disease, said Melissa Justice, a nurse on one of the care teams.
Craig Warren has both. The 57-year-old entered the program a decade ago after he had a stroke, then had a toe amputated from nerve damage caused by Type 2 diabetes. The medication he took for his toe contributed to kidney damage, Justice said, and three years ago Warren received a kidney transplant.
Justice works with him to keep his blood glucose and blood pressure levels under control so that he doesn’t need to see his kidney doctor, 30 miles away in Logan, or his transplant team, 81 miles away in Charleston. His cardiologist is also 80 miles away, in Huntington.
“We have to keep up the preventive work so they don’t have to see a specialist,” said Justice, who coordinates the wellness center’s community health worker program. “We have no specialists here.”
Justice said the people they see have made steady progress, particularly in blood pressure control. In 2019, 65% of patients had blood pressure under control. In 2020 – the first year of the COVID-19 pandemic – that percentage rose to 72%, increasing to 75% in 2021. Currently, about 77% of patients maintain blood pressure within the normal range.
While enrollment in Williamson’s program was initially slow, it quickly picked up and at times, they’ve had more people seeking services than they could help.
“I’m one of the lucky ones,” Warren said. “I’m lucky to be alive.”
American Heart Association News sent reporters to five states to cover rural health challenges, and how people in rural America are working to overcome them.