Community Health Workers and Your Health Center: the Time is Now
Wednesday, December 14, 2011
Posted by: Joy Ingram
Carl Rush, MRP, University of Texas Institute for Health Policy Project on Community Health Worker Policy and Practice
CHWs, also known as Promotores de Salud, outreach workers, lay health advisors and other titles, have been contributing to public health for decades, but have come to greater prominence in recent years through a growing body of research attesting to their contributions, recognition as an occupation by the U.S. Department of Labor and prominent mention in the Patient Protection and Affordable Care Act.
There are important opportunities for CHCs and their advocates in this environment. State and federal policy, however, have not kept pace with the growing interest in the CHW workforce. As many as 20 states are seeing significant movement toward more supportive policies around CHWs, but they are not formally coordinated in any way.
Who are CHWs?
The American Public Health Association (APHA) has defined the CHW as “…a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.
“This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
“The CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”
What is distinctive about CHWs? Community Health Workers:
• Do not provide clinical care
• Generally do not hold another professional license
• Have expertise based on shared culture and life experience with population served
• Rely on relationships and trust more than on clinical expertise
• Relate to community members as peers rather than purely as client
• Can achieve certain results that other professionals can't (or won't)
CHWs have shown promise in addressing many high-priority concerns in public health and health care for the underserved. They have proven impact in important areas such as:
• Access to care
• Prenatal/perinatal care
• Chronic disease management
• Long term care (in support of home- and community-based care)
• Utilization of services, especially reducing inappropriate use of the ER
In recent years there has also been a growing body of evidence suggesting that CHWs have significant potential to help control costs, and in some cases to improve provider revenue by qualifying patients for benefits and increasing regular use of primary care. Unpublished data from CHW employers suggest that that these savings can justify employment of CHWs on the basis of internal “return on investment” (ROI) without third party payment or dedicated grant/contract funding. These data have been neglected until recently as a potential sustainability strategy, partly because employers have less incentive than researchers to publish. These results can be dramatic: one Texas-based health system found internal returns of from 3:1 to 15:1 from employing CHWs in different local sites (Paret 2010). Health insurers have also found significant returns (Johnson 2011).
Why CHCs should care about CHWs at this time
The healthcare system generally is under pressure to improve quality and reduce costs, while also improving access and reducing disparities. Yet most community, rural and migrant health centers have not embraced the full potential of CHWs to be part of these efforts.
New models of care such as the patient-centered medical home (PCMH) and Accountable Care Organization (ACO) highlight two distinct advantages of CHWs, which CHCs can embrace:
(1) Effective PCMHs and ACOs will have to maintain a higher level of patient-provider communication in terms ofopenness/candor and also continuity. Who better than CHWs to perform this role, with their ability to create trust and interact with the patient and family in home and community settings?
(2) Proposed new entities such as the ACO generally will be held accountable for the broad health status of an enrolled population as well as delivering care. The CHW is uniquely positioned to move fluidly between clinical and community settings, between individual care and population health activities.
CHW roles in the PCMH and ACO
In partnership with medical professionals, a CHW can serve as the team member with expertise in cultural factors and social determinants. Recent studies suggest that clinicians are coming to recognize the need for help in this area (RWJF, 2011). Experience also suggests that CHWs can be valuable members of care teams because CHWs can:
- Facilitate patient-provider communication
- Spend more time with patient and family, including home visits
- Facilitate more complete patient-provider communication (candor), potentially making diagnosis and treatment more efficient and effective
- Communicate more frequently and continuously with patients
- Reduce numbers of patients “lost to follow-up”
- Improve care transitions and help reduce hospital readmissions
Integration of CHWs into the primary care setting is also timely as these new structures and payment methods emphasizepatient-centered rather then disease-centered care. CHWs historically have often been isolated in grant funded “projects” and “programs” rather than integrated into the mainstream operations of a provider institution. This has limited even theconsideration of sustainable financing for CHW positions.
What’s happening at state and federal levels?
More complete integration of CHWs into clinical care will require both public policy action and organizational change (Volkmann 2011, Rosenthal et al 2010). Policy change is required in multiple interlocking domains: occupational standards/regulation; workforce development; sustainable financing models; and standards for data, research and evaluation around CHW practice. Payers and potential employers of CHWs are looking for standard skills or qualifications in CHWs, but standardized training may not be available unless there is a viable job market for CHWs.
At this writing as many as 20 states have some form of CHW policy initiative underway, in many cases sponsored and/or led by the state health department. In this region you are probably aware of Oregon House Bill 3650 (2011), which creates an “Integrated and Coordinated Health Care Delivery System” for public programs. The new “Coordinated Care Organizations” must provide assistance from CHWs in “navigating the health care delivery system and in accessing community and social support services.” A 2011 Rhode Island bill on health equity (S0481A) also creates mandated roles for CHWs, and a chronic disease management bill in Pennsylvania (HB 342, introduced January 2011) specifically includes CHWs as well.
Opportunities for CHW services under federal healthcare reform (Affordable Care Act) often require involvement in state planning for ACA implementation. CHWs are mentioned in or related to ACA provisions in a number of places:
• National Health Care Workforce Commission (§5101)—includes CHWs as primary care professionals
• Grants to Promote the Community Health Workforce (§5313)—CDC to award grants to employ CHWs
To promote positive health behaviors and outcomes
In medically underserved communities
• Area Health Education Centers (§5403)—CHWs added to mandate for training
• Hospital Readmission Reduction (§3025)—high potential for CHW role in meeting standards
• Patient-Centered Medical Homes (§3502)—natural role for CHWs as part of “Community Health Teams”
• Patient Navigator Program (§3509)—HRSA favors employing CHWs (grants awarded August 2010).
• Maternal, Infant, and Early Childhood Home Visiting Programs (§2951)—grants to States. CHWs not mentioned; case will have to be made
• Center for Medicare and Medicaid Innovation (§3021) –not mentioned in law but interested!
Opportunities In State Planning To Promote Employment of CHWs
CHCs and CHW advocates should be looking to several key discussions in state health reform planning, seeking opportunities to influence inclusion of CHWs in reform efforts. For example:
• Standards are being established for “patient-centered medical homes” and “community health teams.”
• Outreach will be required for the implementation of Health Insurance Exchanges starting in 2014.
• Standards are being created for preventive care benefits in all health plans.
• Rules are being proposed for Medical Loss Ratios (limits on the percent of health plan revenue that can be spent on administration and profit): It’s important that the work of CHWs not be classified as “administrative” even though it is also not specifically clinical.
New Federal CHW initiatives
There are other recent signs of more active and organized interest in CHWs, mainly within USDHHS, with specific actions from the CDC and other HHS agencies, and recent indications that the Office of the Secretary will initiate greater agency-wide coordination of efforts involving CHWs. Other Cabinet Departments such as Labor and HUD have embarked on their own CHW initiatives. Key federal initiatives include:
- entitled “Promoting Policy and Systems Change to Expand Employment of Community Health Workers (CHWs)” is available at http://www.cdc.gov/dhdsp/pubs/chw_elearning.htm
- Office of Women’s Health CHW leadership development training initiative
- Approval by DOL of CHWs as an “apprenticeable trade”
- Office of Minority Health Promotora/CHW promotional initiative
- NIH (National Health Lung and Blood Institute) three year strategic planning initiative on the CHW workforce and translating research into practice
- HUD CHW Initiatives: HOPE VI sites and National Library of Medicine partnership
- CMS Medicare diabetes disparities pilots and Mississippi Health First initiative
- CMS Center for Innovation workforce grant announcement (Nov. 2011)
What now? Potential regional/national national initiatives for FQHCs
If CHCs are to gain the full potential benefits of these trends, some initial educational effort will be required. Potential employers of CHWs are often uninformed or have limited perspectives on CHW roles and functions. There is a need for a major effort in stakeholder education. This has come about in part because many in healthcare view their personnel as either clinical or administrative; the CHW is neither, so the concept requires explanation.
Policy change also will require negotiation of clear boundaries in scope of practice between CHWs and other professions. Those who perceive CHWs as encroaching on nursing practice (for example) may resist change, often in covert ways.
The CDC e-learning series cited above is intended to help bring stakeholders to a common understanding of the CHW field and requirements for policy change. You are invited to require this series, refer others to it, and engage in discussion with other stakeholders about what you learn.
Johnson D, Saavedra P, Sun E et al. (2011) Community Health Workers and Medicaid Managed Care in New Mexico. J Community Health, Sept. 2011.
Robert Wood Johnson Foundation (2011). Health Care’s Blind Side: The Overlooked Connection between Social Needs and Good Health. Princeton, NJ: RWJF, December 2011. Accessed 12/10/11 athttp://www.rwjf.org/files/research/RWJFPhysiciansSurveyExecutiveSummary.pdf
Rosenthal EL, Brownstein JN, Rush CH et al. “CHWs: Part of the Solution.” Health Affairs, July 2010. Download fromhttp://content.healthaffairs.org/cgi/content/abstract/29/7/1338
Volkmann, K.; Castañares, T. (2011) Clinical Community Health Workers: Linchpin of the Medical Home. J Ambulatory Care Manage 34(3) 221–233
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