As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.
This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large.
Who are Community Health Workers?
While CHWs hold many different titles and roles, the American Public Health Association’s classification best defines them as “a frontline public health worker who is a trusted member and/or has a close understanding of the community served.”
They also can be defined by what they are not: CHWs are not physician extenders, nor are they unskilled labor. Community Health Workers have a long and proud history of accomplished service in the U.S. and abroad in reaching traditionally underserved populations within communities that typically have both complex medical and social needs.
CHWs work daily to combat the ethnic and racial disparities in health care documented more than a decade ago by the Institute of Medicine. In addition, CHWs are on the front lines of alleviating the negative effects of social determinants of health implicated as primary factors in overall health by the Robert Wood Johnson Foundation.
Overcoming Obstacles to CHW Integration
The Network for Excellence in Health Innovation (NEHI) convened a day-long meeting, with support from the Jewish Healthcare Foundation, the Rose Community Foundation and the Association of American Medical Colleges, to explore CHWs’ capacity to transform health care delivery in the U.S.
Experts discussed opportunities and challenges as states and health systems pursue training and certification policies that optimize CHWs’ potential. This event highlighted the need for further dialogue on the issue as well as policies that support the inclusion of CHWs in the collaborative health environment.
Other takeaways from the meeting included:
A Thoughtful Approach to Workflow Redesign
As research mounts to support the return on investment of CHWs and their potential role in reducing costs and improving health outcomes, innovative health systems like Hennepin County Medical Center, Camden Coalition of Healthcare Providers, University of Pennsylvania Health System, and Molina Healthcare are integrating CHWs as full and, often, lead members of their care teams. This required redesigning care processes and infrastructure to fit new needs.
Community health workers have not traditionally been included as providers in most delivery systems, so physician response to CHW integration varies depending on their level of familiarity with the workforce and the value they see CHWs bringing to patient care. Additionally, social workers, nurses, case managers and other medical professionals could perceive some overlap with CHW duties and their own, which may lead to anxiety over job security.
Health systems have addressed these hurdles by focusing early efforts on relationship-building, organizing regularly scheduled meetings and “huddles” between participants, educating managers to know when and how to delegate work to CHWs, and working with nurse and social services management to define the role of CHWs within their particular system’s culture, including leadership positions.
From the CHW perspective, additional issues have emerged. Population health needs traditionally have not been within the purview of the delivery system, nor are electronic health records structured to document social determinants of health and interventions to overcome them. These leading health systems have spent significant investments in health information technology and analytic support to better capture data collected by CHWs, as well as identifying high-risk patients who need to be connected to a CHW, and tracking patients’ progress and care plans.
The more deeply integrated CHWs become within care teams, the more doctors and other providers are interested in recognizing the important role that CHWs play in supporting the health of individuals and communities.
CHW Voice in Certification and Training Processes
As states and health systems struggle to develop and adopt training and certification standards for the CHW workforce, CHWs must be fully involved so that their perspectives and experience inform the process. Qualities of a successful CHW are hard to teach, such as an empathetic nature and ability to understand human behavior and the communities served.
Seeking out CHWs with these characteristics is just as important as the curriculum they receive. Certification and training programs should be built to reinforce CHWs’ diverse strengths in providing informal counseling, sharing appropriate health information, and building community capacity to address underlying causes of health inequities rather than focusing on health professionalization norms.
Alan Weil, Editor-in-Chief of Health Affairs and a speaker at the event, eloquently describes in his blog post this tension between professionalizing the community health work force and protecting its values.
“We should honor the wisdom and experience of CHWs as they define their future rather than assuming that they will be absorbed into a health care system that is only beginning to learn how to support people in their communities,” Weil writes. No matter which path policymakers take, for it to be successful, CHWs will need to lead the process.
Community Health Workers Benefit All
Tapping the CHW workforce has the potential to bring improvements across multiple sectors invested in collaborative community health:
- traditionally underserved individuals will receive increased access to services, including those that can improve factors related to social determinants of health;
- whole communities will have better resources to improve health cohesively and comprehensively;
- health care delivery systems can benefit from the skills, community knowledge and cultural competency that CHWs possess in order to connect with those at risk for poor health outcomes;
- public and private payers may see reductions in total health care spending; and
- community health workers will receive increased compensation and more professional training
Achieving true collaborative community health will require bringing all stakeholders to the table. It’s time to set a place for CHWs.
