Building a Collaborative Community Health Worker Program

Part of SFCCC’s CHW 2023 CHW cohort at graduation, from left to right: Maria Sanchez, Blanca Trujillo, Mia Mitchell, Stephanie Dhalliwal, and Julianna Trujillo.

When the COVID-19 pandemic hit the United States in March 2020, Blanca Trujillo found herself in a surprising new role. She had been working for MEDA, the Mission Economic Development Agency, helping Mission residents apply for affordable housing through Dahlia, the San Francisco Housing Portal. As a trusted member of the community, word quickly spread that Trujillo was well connected with resources for housing, food, and other relief programs. Before she knew it, her phone was ringing off the hook. Callers from Alameda, Contra Costa, and San Mateo counties were asking for her help in getting connected with resources like rental assistance, food, and PPE. Although her professional expertise was limited to the city of San Francisco, she found herself searching the internet to find contacts, applications, and resource centers for whoever was on the other end of the line. “People were asking where my office was” Trujillo shares with surprise, “I was at home!”

Trujillo is what’s known as a Promotora de Salud, or Community Health Worker (CHW). Promotoras/CHWs are trusted members of the community who serve as a link between community members and medical or social services to facilitate access and improve the experience, quality, and cultural competence of service delivery. Because they are members of the communities they serve, Promotoras/CHWs have a close understanding of their patients’ needs. She now works at the Mission Neighborhood Health Center, where, alongside her colleagues Maria Sanchez and Evelyn Cornejo Rodriguez, she is a participant in the San Francisco Community Clinic Consortium’s Community Health Worker Program. In addition to their full-time roles in the clinic, roughly three hours a week, the Promotoras take classes at City College of San Francisco, where they’re students in the Community Health Worker program, one of the oldest and most respected in the country. With the state’s expansion of Medi-Cal benefits to cover CHW services last summer, it is expected that this certification will allow graduates to provide covered services, like health education and navigation.

SFCCC’s CHW program, which is in the middle of its second year, was made possible by a grant from the Crankstart Foundation, a San Francisco-based family foundation, and is currently operating in eight member clinics, including Mission Neighborhood Health Center, as well as SFCCC’s own Street Outreach Services and  Veterinary Street Outreach Services programs. Under the leadership of program director Felipe Flores, 23 CHWs have been placed in the community. Inspired by an apprenticeship model, the program provides participants with a combination of on the ground work experience, education and certification through the partnership with CCSF. In addition to regular classes, participants attend a learning community hosted by Flores and SFCCC staff, in which they receive additional training and reflect together on what they’ve been learning. The program graduated its first cohort, which included Sanchez and Trujillo, this May.

Flores joined SFCCC from Planned Parenthood, by way of the San Francisco AIDS Foundation, where they served as the Associate Director of PrEP and HIV Positive Services. A San Francisco native, who spent the early part of their career working as an HIV testing counselor, Flores had a deep-seated understanding of the importance of Community Health Workers. “We were very intentional about who we wanted to be in the role of the Director of the CHW Program…we wanted someone who is from San Francisco and is very well connected with the community, and I think a big success of the program is because of Felipe’s past work experience and connections with community based organizations” shared Beau Sanchez, Director of Workforce Development at SFCCC, and a close collaborator on the CHW program.

This collaborative spirit has been a hallmark of the CHW program. When Deena Lahn, VP of External Affairs and Health Policy at SFCCC, first heard about the Crankstart grant, she saw an opportunity to bring SFCCC’s member clinics together to “do something more collectively than we’ve often been able to”. One of Flores’s first moves was to form a steering committee of leaders from the participating clinics where needs, ideas and hurdles could be discussed. Some clinics, like St. Anthony’s Medical Center, already had active CHW programs, while others had never employed CHWs. The nature of the grant gave member clinics considerable latitude in deciding how the CHWs would function in each of their communities. Flores explains, “The majority of the funds have to go directly to salaries for CHWs, but because we know that CHWs do so much, there’s so much freedom within that space for a clinic to really decide what are the priorities and needs for their own communities to have the highest impact.” In steering committee meetings, clinics can bounce around ideas for utilizing CHWs, models for integrating them into the clinic’s workflow, and sometimes even planning a collaborative event. CHWs from Mission Neighborhood Health Center and Planned Parenthood NorCal recently came together to co-host a presentation on reproductive health and family planning resources. “This is one of our more successful collaborative projects” adds Lahn, “it’s made me be much more optimistic about the outcomes of a multi-year, multi-clinic project.”

While Flores initially had concerns that clinics would be hesitant to participate in a program that required their employees to be in school part of the week, the outcome has been positive, with all participating clinics signing on to the CCSF component, some even asking for more time to add additional students. For the Promotoras at Mission Neighborhood Health Center, the program’s educational component is a step towards expanding their reach and impact even further. “The certificate is exciting because it gives us more ability to support families” says Sanchez. Trujillo agrees that the classes help her to do better in her job, “it’s hard, but I like it. I do my job the best I can because I am learning- learning technology, English, the health topics. I think I’ll be more prepared to do the work I love.”

Sanchez, of SFCCC, explains that being in close contact with the cohort’s instructor at CCSF has been vital to the success of the program. “Understanding the different academic backgrounds folks were coming from, we’ve realized there are various pathways that CHWs can take to ensure that they have a successful path.” SFCCC has been able to work with CCSF to develop different course sequences to accommodate participants' differing needs. The Crankstart grant has also enabled SFCCC to cover school expenses for CHWs who don’t qualify for “Free City”, CCSF’s free tuition program for San Francisco residents. “Being able to take that off of their plate and go ahead and submit their payments, the peace of mind that that’s provided to some of our team members has been nice to see” shares Flores. The graduation ceremony, held at CCSF in May, was a significant moment for all. “It re-lit my enthusiasm” shares Flores. For Trujillo, graduating from the program is a milestone she is proud to model for her children, nephews, and nieces,  “I like to set this example for my kids…they’re proud of me, I am achieving my dreams”.

A new cohort of CHWs will begin the CCSF program in the fall, while graduates, like Sanchez and Trujillo will continue in their roles at Mission Neighborhood Health Center. For SFCCC, the success of the program is a testament to the power of the community when given the opportunity to come together and work in tandem. At a recent steering committee meeting, Sanchez (of SFCCC) recalls one clinic asking the group if anyone could share resources for onboarding a new CHW, “it’s been so cool to see the clinics organically make those connections and calling on each other, they’ve built this connection.” Similarly, the CHW learning community has forged bonds between program participants from clinics across the city. Sanchez sees CHWs sharing resources, “They don’t work together day to day, but they’ve formed a network that’s really strong…it’s such a benefit for the clients and patients.” For the Promotoras, the lesson too, is in the impact of community-based healthcare, “I think everybody should know about the work we do” shares Trujillo, “I would like every clinic to have Promotoras working on health issues. When people can tell you are one of them, they open their heart.”