Research: A Model for Improving Community Health on Navajo Nation

For more than 50 years, Community Health Representatives (CHRs) have formed the backbone of the Navajo Nation’s health system. 

Trained as nursing assistants, the corps of roughly 80 CHRs consult patients in their homes throughout the vast, largely rural Navajo Nation – some 27,000 square miles spanning portions of New Mexico, Utah, and Arizona. CHRs conduct health screenings and home safety assessments, help people access medical resources, conduct well baby checks with Public Health Nurses (PHNs), and work directly with patients to manage chronic conditions. 

In addition to the often long distances between patients and clinicians, CHRs are able to bridge linguistic and cultural divides—between the English and Diné (Navajo) languages, between science and spiritual beliefs, and between western and traditional medicine. 

In 2009, the Navajo Nation invited individuals affiliated with Brigham & Women’s Hospital and Partners In Health (PIH) to help better integrate CHRs into the health system through the Community Outreach and Patient Empowerment program, or COPE. Incorporating as a Native non-profit organization in 2014, COPE has worked with CHRs and the clinical facilities serving the Nation to better coordinate care, conduct training sessions, and develop a standardized suite of health promotion materials for use by CHRs during home visits with high-risk individuals. 

In 2014 and 2015, COPE staff surveyed CHRs about their perceptions of and experience with the intervention, and their findings, published in the journal BMC Public Health, point to a positive impact on clinic-community linkages. 

“We knew that CHRs themselves are in the best position to guide the program,” says Hannah Sehn, who has worked with CHRs as part of the COPE work over the past nine years and a co-author on the paper. “So rather than say, here are all the things that are wrong, we listened to them—we tried to see things from their perspective. And it’s really by implementing the suggestions they gave us that we’ve been able to strengthen their role.”

Information as power

One suggestion was to improve communication between CHRs and clinic staff, including by expanding access to patient data. Before COPE began working with the CHR program, CHRs weren’t able to access a patient’s electronic health record (EHR), which had limited their ability to document patient encounters. After COPE facilitated access to EHRs for several groups of CHRs, those groups reported better communication with clinicians and felt recognized by clinicians as part of their patients’ care team. 

COPE also sought to strengthen CHR-clinician relationships by organizing monthly training sessions led by clinicians. “For example, if the training was foot care, we’d have the podiatrist from the health facility lead the training,” says Olivia Muskett, a co-author on the paper who was a CHR before joining COPE staff as the Training & Outreach Specialist. “The CHRs can learn from the podiatrist’s expertise, while the podiatrist gets a better idea of the challenges in the community, the things CHRs are seeing day-to-day.”

Other efforts to strengthen community-clinic linkages include establishing consistent referral processes, enabling clinicians to refer patients to CHRs, and the coordination of case management meetings, where CHRs and other members of the care team, such as PHNs, come together to discuss mutual patients. COPE also supports joint home visits, giving CHRs an opportunity to build collaboration with clinicians, something they say enhanced their ability to address key health challenges, including type 2 diabetes.   

Rising concern about diabetes

Over the past several decades, diabetes has significantly increased among American Indians, and its rising prevalence owes in large part to low consumption of fresh fruits and vegetables and increased consumption of highly processed foods. It’s estimated that 1 in 3 individuals on Navajo Nation are now diabetic or pre-diabetic, and with more and more cases in their communities, CHRs have made the management of diabetes a focus of their work.    

Prior to partnering with COPE, CHRs say, they made their own training materials. But given their limited contact with clinicians, they couldn’t be sure that the messages they were sharing in their communities were consistent with the guidance patients were getting in health facilities.  

“CHRs told us they wanted health promotion materials that were Navajo specific,” adds Muskett, “particularly for individuals with uncontrolled diabetes.”

With that feedback, she says, COPE developed a flexible curriculum of modules for addressing diabetes that can be provided to CHRs in either printed format as flipcharts or on pre-configured tablets. Each module used a “motivational interviewing” approach, encouraging CHRs to explore how a patient feels about a given topic rather than offering unsolicited advice. 

As one CHR told a focus group, the motivational interviewing “taught us how to communicate with our patients, how to talk to them, to not just give [them] yes and no questions.” That led, in turn, to increased trust between patients and CHRs, some of whom reported spending home visits “just listening to patients express their emotions.” 

And that’s characteristic of the approach COPE takes to strengthening the role of CHRs, says Sehn. “We see that the answers lie within the community itself,” she says. “From its inception, this has been a community-driven process, and I think that’s why it worked so well.” 

“We are the ones who have to believe change is possible and work with patients to make healthy change a reality,” wrote members of the Gallup and Shiprock Navajo Nation CHR program in a 2011 article for the Journal of Ambulatory Care Management. With the new tools provided by the COPE program “and our many years of experience guiding us,” they added, “we know if we are persistent and believe it, we make a difference.”