“To Get the Patient the Best Care”: A Qualitative Analysis of Community Health Worker Integration in North Carolina Federally Qualified Health Centers

Objective: Research suggests that community health worker (CHW) integration within clinical care teams can improve chronic disease outcomes and address health-related social needs. However, the processes by which CHWs are integrated in Federally Qualified Health Centers (FQHCs) and organizational factors enabling their success remain incompletely understood. Within the context of a national initiative sponsored by the Centers for Disease Control and Prevention, this study assessed CHW integration across three North Carolina FQHCs with distinct patient populations, management systems, and levels of prior CHW experience to identify facilitators, barriers, and CHW impact. Methods: We conducted a qualitative evaluation using inductive thematic analysis of semistructured key informant interviews with CHWs, their managers, and clinicians at each FQHC. Transcripts were analyzed using reflexive thematic analysis to identify themes and extract representative quotes. Results: Facilitators included collaboration, targeted training, management systems, prior CHW and clinician experience, and organizational support. Barriers included unclear CHW role definition, CHW capacity and community resource constraints, and inconsistent communication about integration strategies. CHWs supported care coordination, health-related social needs referrals, and chronic disease management, improving patient engagement and outcomes. Conclusions: Findings confirmed known enablers and barriers to CHW integration, including role definition, capacity constraints, resource availability, and supportive leadership. We additionally identified novel factors impacting CHW integration, including the influence of prior experience of CHWs and clinical staff, CHW leadership in workflow development, the role of peer-learning collaboratives, and the importance of inclusive communication and data practices. Integration was most successful when CHWs shaped workflows, clinicians and managers had foundational CHW understanding, and collaborative learning spaces enabled peer exchange. These findings highlight the importance of CHW-centered program design and implementation, and may enhance existing frameworks for clinical integration of CHWs in FQHCs and similar settings.