Community Health Workers Emerge as a Powerful Antidote to Racism in Hospital Care

When a 42-year-old Black woman arrived at a San Francisco hospital with severe hip pain, she carried her opioid prescription with her to the emergency department. She believed that without physical proof, clinicians would not believe she was taking her medication as prescribed. Her history seemed to justify the fear: she had previously been misdiagnosed with lupus and cancer, erroneously given chemotherapy, and overprescribed pain medications that led to an overdose. During her admission, an interventional radiologist answered her questions curtly and questioned whether she even wanted treatment. A surgeon later told her she was not a candidate for hip replacement because of her pain severity and opioid use, reversing what multiple physicians had said earlier. By the time she met the hospital’s new Health Advocate, she was tearful and exhausted. “This place and system have brought so much trauma,” she said. “Why am I not good enough to have the truth told to me?”

That patient, anonymized as “Michelle” in a new perspective article published in the Journal of General Internal Medicine, became a test case for a bold institutional experiment. A team led by hospitalist physicians at the University of California, San Francisco, launched a program embedding a community health worker, a trained health professional drawn from the community she serves, directly into the medicine wards. The worker, anonymized as “Alicia,” was a Black community health worker with experience in health care navigation, hired specifically to help Black patients navigate their hospitalizations, self-advocate, and communicate with clinicians. Over a single year, from November 2022 to October 2023, she supported 162 Black patients on the medicine wards, with the goal of improving patient experience, communication, and quality of care.

The rationale for the program rests on a substantial body of evidence documenting how anti-Black racism operates at both interpersonal and structural levels within US health care. Interpersonal racism, discriminatory interactions between individuals based on race-related assumptions, damages trust and impedes communication. Studies have shown that physicians engage in less patient-centered communication and display more negative affect with Black patients than with others. Two particularly well-documented manifestations involve pain: false beliefs that Black patients have higher pain tolerance and are more likely to be opioid-seeking. The consequences are measurable. Black patients are less likely to receive primary care pain screenings or opioid analgesics in emergency departments, even when presenting with the same conditions as non-Black patients. They are also less likely to receive physical therapy or surgery for pain management.

Structural racism extends far beyond individual encounters. Black people in the United States are systematically disadvantaged by inequities in health care, housing, education, and the criminal justice system, rooted in historic injustices that persist today. Even Black patients with high socioeconomic status and education face persistent barriers to care and health disparities. These structural forces produce earlier multimorbidity and mortality and a greater chronic disease burden. The authors note that Michelle’s difficulty refilling her pain medications reflects wider trends: Black patients on opioid analgesics are more likely to face restricted early refills, urine testing requirements, and lowered dosages, despite pain medication misuse being least common among Black patients.

These structural harms produce predictable downstream effects on trust and communication. Patients who have previously experienced racism in health care settings remain on higher alert for future racist encounters and may reasonably ascribe new challenges to racism regardless of their immediate cause. Michelle’s history of mistreatment, including wrongful diagnoses and an overdose from overprescribed medication, led her to view health care institutions as untrustworthy, which in turn complicated every interaction with her care team. The authors argue that while clinician compassion matters, the positive intentions of individuals are insufficient to overcome structural injustices. Institutions need interventions that operate at the level of the system itself.

For Michelle, the Health Advocate’s role was concrete and practical. Alicia attended care team meetings, listened, took notes, asked questions, and added context about Michelle’s preferences and goals. She validated Michelle’s frustrations, helped synthesize complex medical information, and brainstormed questions to ask physicians. She also helped manage expectations, reminding Michelle that surgery might not be possible and counseling her to stay focused on her core goals of increased mobility and pain control. Crucially, Alicia met with Michelle’s physicians separately, helping them understand Michelle’s perspective and relaying her concern about being perceived as non-compliant if she declined a proposed analgesic regimen she feared she could not refill. Michelle found the support so valuable that she requested no physician speak to her without Alicia present.

The program’s design drew on established models of cultural mediation and community-based advocacy, which have succeeded in reducing barriers to quality care for minoritized ethnic populations. Physician leadership recruited a Community Advisory Board of Black community members with patient or caregiving experience, which met monthly with Alicia and program leadership to advise on patient needs. The program used a patient-centered, participatory approach in which community members were active collaborators co-creating goals and outcomes, and early cases were discussed with leadership through a preceptorship model. Demand quickly exceeded capacity: patients expressed widespread appreciation, readmitted patients sought Alicia out immediately, and clinicians requested her support for additional patients, forcing her to prioritize the most urgent cases.

The evidence base for community health workers more broadly is encouraging. Because they share identities with the populations they serve, they are uniquely positioned to advocate for patients historically marginalized in health care. Randomized trials have shown that community health worker support improves patient-reported quality of care, satisfaction, and mental health, while benefiting health systems through reduced hospitalizations and shorter lengths of stay. By increasing trust, strengthening communication, promoting care access, and improving outcomes, the authors argue, these workers can address the downstream effects of structural racism that no individual clinician can dismantle alone.

Yet the program’s challenges were as instructive as its successes. There were no clear guidelines for integrating the role into the hospital, and although the Centers for Medicare and Medicaid Services and California’s CalAIM initiative have since published guidance, discrepancies remain and uncertainty persists about how best to incorporate community health workers. The team faced coordination difficulties with care teams, concerns that the role was redundant, and the absence of a clear department to house it. Sustainable financing proved equally difficult: a year-long internal grant protected faculty time and the health system funded the salary, but securing longer-term support was hard, even though the services were billable under Medicare, Medi-Cal, and commercial insurance.

The deepest challenges reflect the complexity of racism itself. The authors observed that attempts to minimize structural racism can inadvertently worsen interpersonal racism, for example if clinicians wrongly infer that community health workers are needed because Black patients are difficult to communicate with, or redirect racist comments toward the workers themselves. Community health workers, who share marginalized identities with their patients, are vulnerable to the same harms, along with moral distress and burnout. The team protected Alicia by rapidly involving leadership in difficult cases and escalating as needed, and they recommend hiring cohorts of workers within their own departments to build peer support, alongside clinician education and anti-racism training. They also flag a final concern: patients could become dependent on workers to speak for them, which the program countered by focusing on self-efficacy and empowering patients to advocate for themselves. If fully embraced and supported, the authors conclude, community health workers can help health systems deliver high-quality, anti-racist care to patients like Michelle, who have for too long been harmed by the very institutions meant to heal them.

Subject of Research: Community health worker integration to address structural racism and care inequities among hospitalized Black patients

Article Title: The Promise of Community Health Workers for Addressing Structural Drivers of Inequities Among Hospitalized Patients

Article References: Axelrod, J. K., Weiss Goitiandia, S., Brooks-Smith-Lowe, S., Sankaran, S., Shahram, Y., Oreper, S., Arrington, R., Burt, H., Garrison, X., Jr., Jones-Taplin, J., Loggins-Miller, I., John, M., & Dzeng, E. (2026). The Promise of Community Health Workers for Addressing Structural Drivers of Inequities Among Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10872-y

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10872-y

Keywords: community health workers, structural racism, health disparities, hospital medicine, patient advocacy, health communication, pain management, health equity, patient trust, hospitalization, anti-racism, health care financing