Community Health Workers in the Primary Care Setting: Successful Practices and Training Development
Tuesday, January 17, 2017
Fabiola Herrera, BS, and Lizdaly Cancel, BA
Clinical Health Navigators for Benton County Health Services
Editor's note: Fabiola and Lizdaly will be presenting a session on this topic at the Western Forum for Migrant and Community Health in San Francisco on February 23
After years of talking about Community Health Workers (CHWs), people still don’t know who they are or what roles they carry out. The American Public Health Association’s classification defines a 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 worker 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”.[i]
At the same time, CHWs in a primary care setting are not a new concept anymore. CHWs continue to be a growing workforce in primary care as part of care teams where they can provide a continuum of culturally and linguistically appropriate services to patients in clinical and community settings. The presence of CHWs in primary care is a result of the increased understanding of the role CHWs play in addressing the impact that social determinants of health (SoDH) have on a person’s health and the subsequent reduction of the related health care cost to the patients.
Each program model that CHWs use is unique at serving the needs of the population and area where they work. In this article we will review the model that the CHW program at Benton County Health Services in Corvallis, Oregon offers specifically for those serving as part of their primary care teams. We will explore the evolution, challenges, lessons learned and successes, as well as the steps we have used to allow for replication of this model as part of the work that has been developing during the last eight years at this clinic setting.
Retrospection of Clinical Health Navigators in Benton County Health Services
Community Health Workers – also known as Promotores, lay health workers, or health navigators – have traditionally worked in an outreach capacity in a variety of community settings. For the last eight years, the Benton County model has called for the specific use of CHWs in the role of Health Navigators (HNs) as part of the multidisciplinary care team to help improve patient outcomes.
In 2008, Benton County Health Services hired the first CHW in the role of Clinical Health Navigator (CHN) for a part time, grant funded position. Outreach and community engagement was an important piece of the CHN work, but working with providers and patients in the clinic setting was the main emphasis. This CHN focused on engaging and advocating for Spanish speaking families in the services of the clinic. Closed loop referrals, by utilizing community education and delivery of programs such as Living Well with Chronic Conditions, was an important part of the HN role.
By 2009 the Health Navigation team was created and more services started to become part of the work that the CHN offered, such as Medicaid enrollment, Oregon MothersCare, direct referral to medical/social services and Public Health programs, outreach and in-reach to patients, scheduling labs and office visits with primary care providers, and outside referrals such as dental and vision appointments. Unfortunately, because the CHN did not have a station in the clinic care team area and was therefore not easily visible or accessible, engagement of CHN services by the care team was slow. However, once the CHN began working closely with the Nurse Care Coordinator, the care team began to see the value of the Navigator’s work and other clinic sites started asking for their own navigator.
Stable funding was allocated to cover the Clinical Health Navigator position which lead to the development of additional responsibilities in the clinic, such as providing one-on-one self-management diabetes education, and using standing orders to schedule labs and provider office visits.
In 2012, a second CHN was added to the clinic, allowing one CHN to focus on diabetes self-management and the other on women’s health issues. Their role in the clinic was firmly established by this time, and they began to be recognized as integral members of the primary care teams.
Around this time, a generic description for Health Navigators (HNs) was created to allow for standardization and permit mobility of HNs within the team. Protocols, standard orders, and limited self-management visits continued to be part of the daily work, but new responsibilities appeared, such as home visiting and joint visits with care team members. A diabetes self-management curriculum was developed and utilized by the CHNs.
By February of 2014, CHNs gained a seat in the “care team pod” and became essential members of the care teams, which consisted of the Provider, Medical Assistant, Registered Nurse Care Coordinator, Pharmacist, Panel Manager/Referral Coordinator, Behaviorist, Health Navigator, and Client Service Representative). This opportunity in part attributed to the ongoing efforts at ensuring the recently adapted Patient Centered Primary Care Home (PCPCH) model was implemented at the CHC. It provided a patient-centered, comprehensive approach of care by utilizing every care team member at the top of their skill set. The Diabetes Self-Management curriculum was revamped and adapted to the clinic population to allow for utilization with other chronic conditions. English and Spanish versions were created and it continues to be the base of self-management teaching across Benton County clinic sites.
Pilot Projects and APM
In 2015, BCHS, in collaboration with our local CCO, began a pilot project to develop the infrastructure of a Community Health Worker training and supervision “Hub” for the Willamette Valley. Over the next 18 months, BCHS hired, trained, and supervised five CHNs and then placed them in local primary care clinics in Benton and Linn counties. In addition, three more CHN were hired as a result of additional funding sources coming from an Alternative Payment Methodology (APM) pilot at the Benton County clinics.
The scope of self-management and other services that the CHNs provide continue to expand with the increased demand from providers for chronic disease self-management (Diabetes Mellitus, Pre-Diabetes Mellitus, Weight Management, hypertension, and elevated lipids), home visits, care coordination, and joint visits with medical providers.
Challenges to integration and funding for CHWs, and steps to a successful model
The establishment of a successful program involves many steps. Although CHWs have been present for decades in communities across regions and countries, integrating CHWs into a primary care setting involves time, leadership, vison, insight, adequate funding, and constant effort. A successful process of integration also requires knocking on doors, creating networks, and as our leadership says, “enter through a small crack, slowly open it and be persistent until you open it wide enough that it now holds a space for you”. Initially, establishing a strong foundation with each CHW will ensure the continuation of the work that they do; later on, ensuring the uninterrupted presence of the CHW is crucial to keep the community engaged and allow for a trusting relationship in the CHWs’ work.
When the process of replicating this model was initiated at Benton County to allow for expansion of the program, many aspects for adequate integration were challenged by the lack of understanding and knowledge of the work that CHWs do, as well as the lack of stable funding to support public health and community programs. Many CHW programs are supported and financed by grants which creates stress and the need to look for funding opportunities to avoid interruption of ongoing programs.
Challenges and strategies:
Ongoing funding to support a program presents a challenge. When funding ends, a need has been uncovered, and its termination leaves a “hole” in services. Depending on the founding source, limitation of services and populations stipulated in contracts limits creativity in programming. In contraposition, the majority of CHW programs are not able to bill for services which increases the need to be creative when it comes to funding opportunities.
Understanding the unique value the CHW brings and maintaining good communication between the CHW and the immediate supervisor is a crucial piece that can present a challenge. Ensuring effective communication allows for the adequate performance of the work the CHW does in the clinic and community settings. The support of managers to CHWs should be based on the understanding of the nature of their work.
Education and bridging the clinic-community culture gap helps the care team to understand how to use CHW (so that they aren’t left to do interpreting and transportation). It is necessary to work directly with the care team, giving presentations to display what CHWs can do; bringing in data, patient stories, touch numbers, and to share CHWs trainings and ongoing education.
Developing standard tools for CHWs to use with patients and care teams provides confidence and standardization of the work that CHWs do, and promotes good communication with clinics and community. It is important to mention that in order for the CHW be able to facilitate access and utilization of services it is crucial that the CHWs can have flexibility with scheduling, working hours, and places where they will serve the patient and that the organization understands and accounts for those circumstances.
The steps for a successful model:
Hiring the right people as CHWs increase acceptance from the community that will be served, as well as the organization, and the community partners or other organizations.
Providing standard and customized intensive training in the initial months of employment is crucial as this provides the CHW with the tools to offer support, advocacy and assistance in a variety of areas. Some examples include motivational interviewing, Medicaid enrollment, health literacy, popular education, SoDH, and CPR. Distinct training prepares the CHW to offers specific-topic services like smoking cessation, diabetes management, weight management, and women's health. At the same time, it is important to offer continuous education to ensure the CHW is up-to-date on the latest tools and knowledge required to offer excellent service to the community.
Create, identify and maintain proper documentation (data, processes, and protocols) will ensure consistency and transparency of service delivery across all sites. This also helps provide necessary information to keep the program sustained.
Encourage and promote CHW participation and/or input in the development of programs will allow growth, address community needs accurately, and increase CHW professional development opportunities.
Opportunities for new funding and projects allow the program to grow to accommodate community needs and preferences. It is important to have a champion willing to write grants and seek funding, including give program presentations to the clinic governing board and to community partners.
The administration support and understanding of the role of CHWs is imperative to guarantee the work CHW do in clinics is protected and validated. The supervisor onsite needs to understand the unique value that a CHW brings, and has confidence in their work, this creates a trusting relationships between HNs and supervisor.
The road ahead
The CHW workforce continues to grow in our clinic and in the last 2 years this model has expanded to serve a bigger population. In this article we have only discussed our Clinical Health Navigators, who currently number 10…but we are not alone on this journey. CHNs are only part of the Health Navigation Team, which also includes nine Insurance HNs, one Dental HN, one Interpretation/Translation HN, three School HNs, and one Community and Policy HN, for a total of twenty five HNs. We have come a long way since starting in 2008 with one part time HN – we are now one of the biggest teams within Benton County Health Services.
[i] American Public Health Association “Community Health Workers”. Retrieved from https://www.apha.org/apha-communities/member-sections/community-health-workers/
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