By: Amanda Keddington
This is the second feature in CHW Central’s 2026 series on CHWs Supporting Older Adults, which brings together perspectives from different regions of the world on the growing role of Community Health Workers in supporting older adults. In this feature, Amanda Keddington shares insights from a needs assessment conducted in geriatric clinics in the United States, highlighting how CHWs can help bridge gaps between healthcare and the social needs that shape healthy ageing. As the series continues through August 2026, we invite you to explore the diverse experiences and lessons being shared from both research and practice. If you missed our first feature, What Community Health Workers Make Possible in Supporting Older Adults by Prof. Arkers Wong, you can read it here.
Introduction. Older adults often face health challenges that extend beyond the clinic doors. Many older adults live with multiple chronic conditions and socioeconomic constraints such as food insecurity, housing instability, financial stress, social isolation, all of which can contribute to adverse health outcomes (Administration for Community Living, 2022). These social needs impact whether an individual can attend appointments, follow treatment plans, live in safety at home, or maintain quality of life. Older adults living in rural locations or underserved areas in the United States have poorer health outcomes, a higher prevalence of illness and are more likely to die from leading causes of death than their urban counterparts (Carter et al., 2021; Dye et al., 2018).
In geriatric care, these issues can be difficult to identify. Although providers and family members may notice a missed appointment, delayed follow-up, worsening chronic disease progression, or repeated hospital admissions, clinics often have limited time and resources and may lack systems for addressing patients’ associated health needs.
Needs Assessment. This challenge was the foundation for a needs assessment conducted in geriatric clinics within a large integrated health system in the United States (Keddington & Gee, 2025). At the time of the assessment, CHWs were not embedded within the geriatric clinic workflows. Instead, this project examined whether integrating CHWs into the health system could help address gaps in follow-up, referral coordination, and support for older adults with complex medical and social needs. Three geriatric clinics within this system served urban and rural communities. The chart review analyzed 2,065 patients across 5,867 visits over an 11-month period. What emerged was not only a possible staffing solution, but also a clearer picture of how current workflows were functioning and where they were falling short in meeting patients’ needs.
The assessment identified many strengths in the geriatric clinics. These included a strong commitment to patient-centered care, an interdisciplinary approach to supporting patients, and awareness among staff that social needs affect health outcomes. Screening for social needs was also already built into clinic practice through the PRAPARE screener tool (PRAPARE, 2024), giving teams a consistent method to identify patient concerns. Significantly, clinic staff understood the importance of holistic care and wanted better ways to support patients.
Findings. While the assessment showed that systems were in place to identify patient concerns, it also indicated that clinics were falling short in responding to them. To identify opportunities for addressing patients’ socioeconomic needs, the review analyzed clinic workflows. It showed that workflows broke down in several ways. Referrals were dependent on already-busy clinicians, care managers, or staff. Responsibility for referrals was not clearly defined. Communication between clinic teams and outside organizations was inconsistent, and providers did not always receive timely feedback after a referral was made. Sometimes, providers would not know whether a patient had connected to services until the next clinic visit, often several months later. For older adults with multiple chronic medical and social needs, that kind of delay can be significant.
These findings point to an important lesson in older adult care. Screening tools can help identify unmet social needs, but screening alone is not enough. Patients need someone who can help translate a screening result into follow-up, problem-solving, and connection to resources. They may also need support that is relational, persistent, and responsive.
CHWs are experts in bridging the space between clinic care and everyday life. They help patients navigate services, follow through with referrals, build trust, reduce the use of healthcare services, and improve communication (Moreno et al., 2021; Ohuabunwa et al., 2021). They can help clinics better understand the social and cultural realities for individual patients that shape health. In older adult care, CHWs can play a particularly important role in identifying patients’ multiple health and social needs and coordinating services.
The needs assessment suggested that embedding CHWs within the healthcare system could strengthen care coordination and improve workflow integration (Carter et al., 2021; Moreno et al., 2021). Rather than relying entirely on external referrals, clinics could benefit from a team member whose role was specifically designed to follow up on social needs, help patients navigate services, and maintain stronger communication between the clinic and the patient. The analysis found that integrating CHWs as direct employees within the healthcare system was a feasible strategy to address the complex needs of older adults and overcome barriers in communication, referral clarity, and workflow.
Takeaways. For organizations considering CHW integration in older adult care, one useful place to start may be with workflow questions rather than staffing questions alone (Afzal et al., 2021). What social needs are most common in your patient population? What happens after a need is identified? Who is responsible for follow-up? Where does communication break down? How long does it take to know whether a patient actually received help? These questions can reveal a great deal about whether a clinic is equipped to respond to social needs in a timely and coordinated way.
Even when a CHW program has not been implemented, the process of examining social needs and workflow gaps can be valuable. It can show where older adults are most vulnerable, where staff need support, and where systems may need to change.
This work was about more than just one proposed role. It showed that better older adult care depends not only on what happens in the exam room, but also on how well health systems respond to the realities of everyday life.
Amanda Keddington, DNP, RN, is an Assistant Professor at the University of Utah College of Nursing, where she is the director of the RN-to-BSN nursing program and serves in academic leadership roles supporting curriculum development and student success. Her expertise includes healthcare equity, community-based care models, leadership development, and nursing education. Dr. Keddington’s scholarly work and publications focus on examining strategies to advance healthcare equity through the integration of Community Health Workers within healthcare systems. She is also involved in initiatives related to workforce development, interdisciplinary collaboration, and improving access to care for underserved populations.
References:
- Administration for Community Living. (2022). 2021 profile of older Americans. Retrieved from https://acl.gov/sites/default/files/Profile%20of%20OA/2021%20Profile%20of%20OA/2021ProfileOlderAmericans_508.pdf
- Afzal, M. M., Pariyo, G. W., Lassi, Z. S., & Perry, H. B. (2021). Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships. Health Res Policy Syst, 19(Suppl 3), 103. https://doi.org/10.1186/s12961-021-00753-7
- Carter, J., Hassan, S., Walton, A., Yu, L., Donelan, K., Thorndike, A.N. (2021). Effect of community health workers on 30-day hospital readmissions in an accountable care organization population. JAMA Network Open, 4(5). https://doi.org/doi:10.1001/jamanetworkopen.2021.10936
- Dye, C., Willoughby, D., Aybar-Damali, B., Grady, C., Oran, R., & Knudson, A. (2018). Improving chronic disease self-management by older home health patients through community health coaching. International Journal of Environmental Research & Public Health, 15(4). https://doi.org/10.3390/ijerph15040660
- Keddington, A. S., & Gee, J. (2025). Improving healthcare equity through community health worker employment in an integrated health system. Geriatric nursing, 65, 103485. https://doi.org/10.1016/j.gerinurse.2025.103485
- Moreno, G., Mangione, C. M., Tseng, C. H., Weir, M., Loza, R., Desai, L., Grotts, J., & Gelb, E. (2021). Connecting Provider to home: A home-based social intervention program for older adults. Journal of the American Geriatrics Society, 69(6), 1627-1637. https://doi.org/10.1111/jgs.17071
- Ohuabunwa, U., Johnson, E., Turner, J., Jordan, Q., Popoola, V., & Flacker, J. (2021). An integrated model of care utilizing community health workers to promote safe transitions of care. Journal of the American Geriatrics Society, 69(9), 2638-2647. https://doi.org/10.1111/jgs.17325
- Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. What is PRAPARE? https://prapare.org/what-is-prapare/
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