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Evidence shows the effectiveness of integrating community health workers (CHWs) into care models serving high-risk patients to reduce emergency department (ED) use, increase primary care use, and address adverse social determinants of health (SDH). The Southwood Resource Center, part of a network of clinics established by Richmond City Health Department, utilizes CHWs to address disparities affecting underserved populations through primary care referrals and additional resource linkages. Local student-volunteers in partnership with CHWs conducted a community needs assessment to identify patient resource gaps, aid in design and implementation of SDH interventions, and examine the relationship between chronic disease management and ED use reductions.


English and Spanish-language surveys were conducted during patient visits to the SRC, in addition to other settings to facilitate representative sampling. A total of 134 responses were received, with Blacks (34%) and Hispanic/Latinos (65%) well represented.


Significant social determinants identified by the needs assessment included housing stability, and transportation and food access. Respondents indicated need for support managing chronic conditions including heart disease, diabetes, mental health and asthma. 1 in 3 respondents (31%) reported using the ED for primary care, and nearly 2 in 3 (66%) reported not having a family doctor. Barriers to health care included cost (35.6%), insurance status (50.4%) and transportation access (29.6%).


CHWs play an important role in identifying community strengths and resource gaps and linking patients to additional resources. Opportunities for service improvements include bilingual care coordination, chronic care management, health insurance navigation, food subsistence resources, and transportation support.

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Medicine and Health Sciences

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VCU Graduate Research Posters

Addressing Minority Health Disparities in Richmond: Results from a Health Needs Assessment of a Southside Community