Community Health Worker Goes Where She’s Needed, Including Home Visits

Jasmine Swain assists pediatric patients and their families at a specialty pediatric clinic in Wilmington, North Carolina. But what she does for her clients goes way beyond addressing their physical health.

Swain, a community health worker at Novant Health Nunnelee Pediatric Multispecialty Care Clinic, said her job description is simple. “I’m here to connect patients to the resources they need to help them thrive,” she said.

What does that look like? A lot more than it sounds. She helps families drill down on complex challenges that can be connected to the child’s health issues, advocates with schools and other institutions and sometimes makes home visits so she can assess what’s really going on.

Multiple specialties are housed in Nunnelee’s two clinic locations for pediatric patients who need special treatment and interventions. Those include pulmonary, GI, endocrinology/diabetes, cardiology, neurology, urology, pre- and post-surgical care, hematology and the pediatric infusion program, among others. Swain could be involved in helping patients in any of those departments.

Doctors and team members refer a patient to Swain if they think the patient could benefit from the extra help she offers. Some triggers that may get Swain involved:

  • Uncontrolled diabetes.
  • Need for advocacy at school.
  • Body mass index (BMI) greater than the 95th percentile.
  • Diagnosis of a developmental delay.
  • Involvement with the Department of Social Services (DSS).
  • Family barriers related to social determinants of health – things like food insecurity, housing insecurity, transportation, financial struggles.
  • Language barrier.
  • Grandparents serving as caregiver.

Swain came to Nunnelee via a rural health grant, which pays her salary for a year. The clinic plans to keep her on once the pilot program ends; she’s making that much of a difference.

She previously worked in a mental health facility for five years and also worked with a family with a special needs child for four years. “It’s just always been in my world to be there for others,” Swain said. “It made sense with this job. I do love getting to go out into the community and help people.”

Nurse Vanessa Van Gilder manages the clinic where Swain works. “Jasmine and other community health workers take care of things that aren’t in the realm of healthcare but affect people’s health,” Van Gilder explained. “If those simple, basic things – housing, food, transportation – aren’t met, then your health won’t be a priority.”

‘A real aha moment’

Not long ago, doctors at Nunnelee had a young patient struggling with his weight and behavioral issues. He and his mom were missing appointments, and the staff worried about the care the boy was getting at home. They looped in Swain.

“When Jasmine got involved, she discovered that the mom couldn’t read well,” Van Gilder said. “There’s so much verbal information given to patients, so we provide written information they can refer to after their appointment. Written information provides a way for them to go back and refresh their memory. But if you struggle with reading, then that information isn’t useful.”

“It was a real aha moment,” she continued. “It wasn’t until Jasmine went into the home and started talking with mom that she realized mom had trouble reading. She’d been missing appointments and was confused about her son’s medicine. Jasmine put it all together and was able to help her take better care of her child.”

“Jasmine’s discovery helped the staff understand, ‘OK, with this parent, we have to do things a little differently,” Van Gilder added. “We have to simplify what is complex. Maybe we need to check on this mom more and give her a call and see how things are going and not just wait until the next appointment.’”

It’s all about achieving health equity. Swain’s involvement – and home visits – helped solve a mystery. And ultimately this mom is able to take better care of her child.

Another parent of a patient has three children. Her teenage son struggles with his weight, is prediabetic, has PTSD and is undergoing testing for autism. “His last school, his middle school, wasn’t supportive at all,” the mom said. (Healthy Headlines is not naming the parent to protect the child’s identity.)

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“They kind of treated him like a bad kid. So, when Jasmine offered her help, I said yes,” the mother said. “I needed the school board to take me seriously. Jasmine just stepped right in. I was having trouble finding testing for him for autism. And she immediately found someone for that. She attended the Zoom meeting. Anything I had questions about, she was on it immediately. On one of her home visits, she even brought over a portion plate to help him see what healthy portions look like. She went above and beyond.”

He was home-schooled this year, but he’s doing so well now that he’s planning to attend high school for 10th grade this fall. “Jasmine helped us get a special plan in place,” the mom said. “If he needs to leave the classroom because of an anxiety attack, he’ll be able to. ”

“She advocated for us,” she concluded. “I was very grateful to have her on our side. My boy has had a rough time. It’s hard for him to trust other people, but he trusts Jasmine. He really bonded with her, and that’s a big deal.”

Having Swain on staff is crucial to providing the best possible care, Van Gilder said. “We see patients at a point in time; we see them when they come into the clinic. What Jasmine is able to do is to see a different perspective. And that’s outside the clinic – generally in the home. So, if it looks to us like the parent isn’t caring for their child, it may be that their whole world is in chaos.”

“She can see a different side of the patient and the things that affect them, that could then affect how they provide care to their child,” she added.

“What I love about community health workers is that these are peers to our parents,” Van Gilder added. “The people hired for these positions – they’re not healthcare-trained. But they may have experienced a similar life situation to some of our parents. There’s a different level of trust there.