3. Hiring CHWs
“My work is influenced by my experience of being homeless and housing unstable as a kid. Because of the life experiences that come as part of that chaos, I know that under issues of untreated mental illness and substance abuse there is a person who just wants to be happy, like everyone else.” ~ Community Health Worker
Finding the right person
Listen as CHW supervisors and CHWs explain what to look for in a CHW.
The ability to grasp complexity is key to the success of a CHW. Particularly when working with individuals experiencing homelessness, it is important for the CHW to understand that adequate health care does not just mean going to the clinic. CHWs need to have an understanding of how food, housing, education, employment, and other social determinants affect the health of their clients.[i]
Effectiveness of a CHW hinges upon their ability to establish rapport with the population. Personal qualities and individual traits such as good listening skills, communication skills, compassion, respect, empathy, determination, and logic must be brought to the job, not added afterwards.[ii]
If someone has the right personality and the passion to be a CHW, other job skills can be developed and strengthened over time. On the other hand, someone who has lots of work experience and advanced job skills but is uncomfortable doing street outreach or working in shelter settings is not likely going to be a good fit for the role of a CHW.
To effectively fulfill these roles and responsibilities, a CHW needs to possess certain personal qualities. Qualities that contributed to the success of CHWs involved in the National HCH Council’s project included:
- Openness to working closely with clients who struggle with issues related to mental illness and addiction at all levels.
- Respectful sensitivity and non-judgmental attitude towards clients who may suffer from multiple traumas and/or disabilities.
- Strong interpersonal and social skills with an ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds.
- Ability to convey a strong presence one-on-one, in meetings, and in the community.
Additional advice from the Field – When hiring a CHW, the following qualities are most important:
- A great sense of humor
- The ability to handle rejection and confrontation
- The ability to connect and empathize
- A lot of energy
- A passion for the population
- Compassion, empathy, and patience
- The ability to walk into an agency, talk to people, and build relationships
“You just have to have a desire to work with the population that we work with otherwise you won’t last. You can’t do a training for that; that has to come with the person. Computer skills can be learned, compassion cannot.” ~ Supervisor
HCH programs should prioritize hiring someone from within the community that is being served assuming adequate training and supervision resources are available. It is vital to carefully consider the context of the overall patient population when recruiting a CHW.[iii] The acceptance of an individual by the patient population will affect their ability to inspire meaningful change in their clients. A kinship develops between clients and CHWs when that CHW has shared experiences and comes from the same community.
Health Centers participating in the National HCH Council’s project were encouraged to look for leaders among their Consumer Advisory Boards (CABs). A CAB is comprised of individuals with the experience of homelessness who are currently or formerly engaged in services delivered by the organization. Several CHWs who participated in the National HCH Council’s project were identified as potential candidates through their local CABs while others were hired from the local community.
Interviewing Potential CHWs
Is this person passionate?
A major benefit of hiring an individual who is formerly homeless is the HCH is providing an opportunity for an individual to harness their own personal knowledge and experience and use it to help their peers. Many CHWs serve as role models for fellow community members.[iv] It is the lived experience that often inspires people to want to work with others experiencing homelessness. This type of passion and non-judgmental empathy is vital for CHWs. Passion is something a CHW will have to bring with them to their work; it is not a teachable skill. An absence of passion and dedication to this population may affect a CHW’s longevity within the HCH clinic.
Sample Interview Questions:
- Why is it important to you to work with this population?
- What unique perspective do you bring to this work?
- On really tough days, what will keep you from giving up?
Is this person able to maintain boundaries?
What makes peer support so powerful is the ability to share stories of overcoming tremendous challenges. Sharing this lived experience provides hope for peers who are currently struggling with similar issues. However, CHWs should have enough chronological distance from their period of homelessness or substance dependence in order to maintain healthy boundaries and support their clients. It can be a challenge to identify former consumers who are ready to take on the responsibility of being a CHW. Situations can quickly become problematic if CHWs are unable to separate their experience from that of their clients. This can be a risk to clients of the HCH clinic but we also do a great disservice to CHWs when we put them in a situation that may be triggering.
- Risk to clients – If a CHW is unable to maintain healthy boundaries with clients, this will negatively affect the clients’ experience in accessing care. In this situation, a CHW may create a co-dependent relationship with the client, begin to blur the lines between a professional and personal relationship, and/or take on more responsibility than appropriate.
- Risk to CHW – Alternatively, a strong passion and commitment to the work can sometimes lead to a CHW overcommitting and overworking. Individuals drawn to this work are typically tremendously kind and sensitive to the plight of their clients. A concern for all CHWs is the possibility of falling into a rescuer mentality. If the CHW begins to take on a client’s problems as if they were their own, they may see any setback experienced by their client as a personal setback. They may also attribute set-backs in their clients’ lives as a direct result of their own personal failings. When CHWs are unable to maintain healthy boundaries, they risk burnout, unprofessional relationships with clients, possible liability, and possible job loss.
Sample Interview Questions:
- You have a 48yr old client named John who currently sleeping under a highway downtown. He’s just started taking his medications regularly and is feeling better but is really afraid that someone is going to steal his medication. He asks you if you will hold onto them for him. How do you respond to John?
- You have a 19yr old client named Brandy who has been staying with a friend but has to move out in a few days. She and a friend have found an apartment but it won’t be available until the following week. She doesn’t feel safe going to the shelter and asks if she can stay with you for just one or two nights until her apartment is available. How do you respond to Brandy?
- What does success look like for you? What does success look like for your clients?
Is this person open, flexible, and willing to learn?
The shared experience present between a CHW and a client is an asset as long as the CHW understands change happens differently for everyone. What worked for the CHW in the past may not work for clients and that’s ok. CHWs need to respond with flexibility and openness.
CHWs should understand and accept that the ways in which they achieved sobriety, secured housing, and/or re-connected with family are not the only ways in which clients can achieve similar goals. Rigidity is a quality that can become problematic for CHWs. A mentality of “I know better” or “you wouldn’t understand” is unproductive and does not benefit anyone.
Example: While doing street outreach, CHW Dan meets an individual who binge drinks several days a week and is complaining of stomach pains. This individual is interested in finding housing and is not sure if he wants to go to clinic but wants to talk more with CHW Dan about what’s going on in his life. CHW Dan agrees to meet with this individual but only if he goes to an AA meeting with him first.
Sample Interview Questions:
- What are some areas where you would like more training?
- You’ve overcome many obstacles in your life, what are some different ways that your clients may overcome those same obstacles?
Job Description Templates
[i] Berthold, T., J. Miller, and A. Avila-Esparza, eds. (2009). Foundations for Community Health Workers. San Francisco, CA: Jossey-Bass
[ii] Zuvekas, A, L. Nolan, C. Tumaylle, and L. Griffin. (1999). Impact of Community Health Worker on Access, Use of Services, and Patient Knowledge and Behavior. Journal of Ambulatory Care Management, 22 (4)
[iii] Partners in Health. (January 2013). Unit 7: Improving outcomes with community health workers. Retrieved from: http://www.pih.org/library/pih-program-management-guide/unit-7-improving-outcomes-with-community-health-workers
[iv] Partners in Health. (January 2013). Unit 7: Improving outcomes with community health workers. Retrieved from: http://www.pih.org/library/pih-program-management-guide/unit-7-improving-outcomes-with-community-health-workers