Framing the Issue
- Often, the barriers to good health care are not medical, but have more to do with social, cultural or economic issues.
- Community health workers have an intimate understanding of the culture, languages and challenges of their neighborhoods and, therefore, are trusted by the people living there.
- CHWs can take on some of the nonclinical tasks that are now carried out by more highly trained and higher-paid nurses and physicians.
- CHWs can make sure individuals get to medical appointments, fill their prescriptions and have the basic necessities like housing and food.
Several years ago, an influx of Hispanics eager to find jobs in Philadelphia's booming restaurant industry posed big challenges for the city's medical clinics — limited or no health care coverage, limited English-speaking skills and an unfamiliarity with the intricacies of the U.S. health care system.
Determined to keep those patients from falling through the cracks, two local teaching hospitals deployed the veritable foot soldiers of health care — community health workers. The workers penetrated the nooks and crannies of the populace, finding the elderly widow without the means to fill her prescription, the diabetic who can't afford healthy foods and the pregnant teen with nowhere to turn.
Matt O'Brien, M.D., medical director and co-founder of Puentes de Salud, a nonprofit organization that promotes health and wellness in South Philadelphia, thinks the lessons learned in his city can be applied across the nation. Insurance exchanges are expected to bring millions of new patients into the system, many of whom face cultural or economic barriers to maintaining their health. The team-based, patient-centered approach can steer individuals to the care and medications they need, get some people treatment before their illnesses become critical, reduce unnecessary readmissions and trips to the emergency department, and ease the worsening shortage of primary care physicians. Because all those things have become such high priorities, more and more hospitals are hiring CHWs as staff, moving away from the volunteer model that has been most common.
Moreover, O'Brien maintains, it can do so in an efficient, cost-effective way. "I think there's a real need in health care for a lower-trained workforce who can do a lot of the things that are not done in the current system," he says. "So much of what impacts people's health has to do with social factors that we don't even address."
The community health worker — variably called community health adviser, lay health navigator or promotore — is by no means a new idea. In an analysis last September, Lisa Sprague, policy analyst for the National Health Policy Forum, an affiliate of George Washington University, noted that the first formal program in the United States dates to 1967 when the Office of Economic Opportunity funded CHWs to help American and Alaskan Indians better understand health care principles and maintenance. There were about 120,000 practicing CHWs as of 2005, according to the Health Resources and Services Administration, and the Bureau of Labor Statistics didn't classify the position until 2010.
Funding community health workers is handled differently from place to place. The Minnesota Community Health Worker Project created a standardized curriculum to teach the lay workers and, after demonstrating the benefits of using them, successfully advocated to have Medicaid reimburse them starting in 2008. Alaska's Medicaid program also funds CHWs, and other states are considering doing so. Federal Medicaid rules, however, do not recognize CHWs as reimbursable providers, Sprague notes in her study.
But there are other ways to find payment, whether they're "incorporated in a capitation rate, reimbursed on a unit basis under a Section 1115 waiver, or included under administrative costs for outreach and coordination activities," according to the study.
In Philadelphia, as elsewhere, providers use the CHW model to target low-income individuals who may be battling chronic disease or have language barriers to maintaining their health. The worker will show up at the hospital the day of discharge, says Shreya Kangovi, M.D., an internist and pediatrician with Penn Medicine, and serve as a "quarterback" during the transition to make sure the patient understands the instructions and can afford the co-pay,
While clinicians were effective at addressing illness, there was a disconnect when it came to the more social aspects of good health, Kangovi says. Telling a patient to cut salt out of his diet isn't practical if he depends on the local food pantry, which distributes food loaded with preservatives. "Patients come in and out of the hospital and in and out of doctors' offices and, while we do a good job treating their medical issues, it often just seemed like a Band-Aid for a lot of deeper socioeconomic issues that were occurring outside of the walls of the health care system," Kangovi says. "Those were really the things that were driving the underlying health problems."
The model has been community-rooted, says O'Brien, who is also an assistant professor of medicine at Temple University. CHWs usually have ties to the community they're serving, speak the language and understand the cultural nuances that often have an impact on care.
In one case, a 15-year-old girl was pregnant, alone and feeling overwhelmed. So, Puentes de Salud linked her up with a community health worker who stood by the teen's side from prenatal screening to delivery. In another case, a man in his 30s gained 75 pounds after moving to the United States from Mexico and became a diabetic. He "broke down crying," after hearing the diagnosis, O'Brien says. But with one-on-one, intensive lifestyle counseling from a community health worker, the patient lost all of the weight he'd gained and brought his diabetes under control in just a year.
"When someone comes into a clinic office for a 10-minute visit — someone who's got five chronic diseases and they're on 10 medicines — I can't give the amount of support that they need to really change their health behavior," O'Brien says. "That's something that requires much more intensive follow-up, and that's the kind of follow-up that the community health workers are able to provide."
While personal stories of patients helped by community health workers provide anecdotal evidence of success, hard data to quantify the concept's effectiveness is scarce so far. Penn Medicine this fall will release the results of a study on the impact it has made on readmissions and other quality measures.
The money issue
Funding has been a big roadblock for years, says Sergio Matos, executive director of the Community Health Worker Network of New York City and a former CHW. Too often, these programs rely on grants, which are sometimes specific to one disease, or other unsustainable funding sources. And in the past, providers have been focused on treating the sick when they reach their doors, rather than catching them upstream before their health problems exacerbate, says Matos.
"Those medical problems are showing up in the doctor's office, but they don't have a medical answer," he says. "You can't write a prescription for food insecurity or violence in your streets or lack of education or power inequalities — the things that are making people sick."
Matos maintains that the Affordable Care Act "really provides an opportunity for us to look at health differently, and community health workers are the missing piece. They look at the root causes of conditions, and the social and psychosocial issues that are leading to these very complex and expensive medical issues."
Penn Medicine funded its program through a variety of sources, from Penn Home Care & Hospice Services, to the departments of medicine and its advocacy budget, Kangovi says. This fall's report will show how well the model is working before the organization starts looking at a more sustainable funding method.
Matos, meanwhile, has advocated in New York for bundled payment to fuel CHWs. Ideally, the lay health person is part of an integrated team along with registered nurses, physicians and social workers. A global payment could be provided to the entire care team, he says, and then divvied up among the providers.
But to receive payments from third-party payers, there needs to be some sort of standardized training and credentialing for CHWs. The position historically has been a "poorly defined entity," says Paula Stillman, M.D., vice president of health care services for Temple University Health System in Philadelphia, with no clear entrance requirements for training or standard competencies when they're finished.
So the school, along with a consortium of other health-related entities, has worked to develop a clear course of study to target and train new community health workers. It includes a four-week curriculum, diagnostic assessments along the way and a final assessment. Eventually, it will equal a three-credit program that comes with state accreditation, Stillman hopes.
Aside from payment issues, community health workers have their own concerns, notes O'Brien. For example, some want to be careful that they don't become too integrated into hospitals for fear they'll lose the connections to the community and outsider status that make them a unique member of the care team.
On the flip side, some physicians worry that CHWs might interfere with their work. Stillman asserts that those fears are unfounded
"If we look to the future of health care delivery, it's a team sport," she says. "And the important thing is, because we might have a shortage, you only use the primary care physician for what he or she alone can do, and you take away some of the other tasks that can be done by a less-educated person. It's only beneficial. These people are not minidoctors. They're not diagnosing; they are the right arm of the health care provider."
In her study, policy analyst Sprague noted that the ACA provides opportunities for the expansion of the CHW workforce. One section calls for the secretary of Health & Human Services to establish a program to provide grants or contracts to establish "community-based, interdisciplinary, interprofessional teams" to support primary care practices — duties easily performed by CHWs, Sprague notes. Another section of the ACA calls for the Centers for Disease Control and Prevention and the HHS secretary to award grants to promote healthy behaviors in medically underserved communities by using CHWs.
Kangovi thinks that payers' interest gradually will be piqued with the emphasis placed on patient satisfaction and Hospital Care Quality Information from the Consumer Perspective scores. And providers will need to prove that such CHW models, used in the past to tackle specific conditions, can be scaled across diseases.
With calls to manage the health of a population, it's going to be essential for providers to have foot soldiers such as community health workers to pound the pavement and swarm the health issues in neighborhoods, before patients show up in the hospitals, says Fred Hobby, president and CEO of the American Hospital Association's Institute for Diversity in Health Management.
"They can serve as extra eyes and ears to hear about any kind of mass problem, like the spread of AIDs or cholera, because they're right there in the community," Hobby says. "They could revolutionize health care, but are we willing to invest the dollars to hire these people? We either pay on the front end to get out there and uncover these problems so that providers can treat them early, or we wait until the patient is acutely sick, admitted, runs up a tremendous hospital bill that they can't pay; or, to make it worse, they're discharged and there's no follow-up to the patient, and then they're readmitted again. That is a financial nightmare for a hospital, but that is the current paradigm."
Sergio Matos and the New York State Community Health Worker Initiative recommend that CHWs have multiple roles in their scope of practice. Here are Matos' five suggestions, outlined in the October 2011 report "Paving a Path to Advance the Community Health Worker Workforce in New York State."
Outreach and community mobilization
Tasks would include preparing and disseminating materials from the hospital to the community, finding and recruiting patients, assessing the strengths and needs of the community, visiting homes and promoting health literacy.
This could include organizing members of the community, as well as advocating on behalf of their concerns.
Case management and care
In this role, CHWs might engage families, assess the needs of individuals, help patients address basic needs like food and shelter, coach clients on problem solving and goal setting, coordinate referrals and follow-ups, give feedback to providers, and encourage patients to adhere to their treatment plans.
Here, the community health worker could help those unfamiliar with the health system to translate and interpret signs, navigate along their care path, coordinate referrals and follow-ups, and assist with any transportation issues that might impact care.
Community health workers also can help providers to conduct research on patients they serve, assisting with interviews, disseminating materials, computerizing data entry and Web searches, and engaging with any research partners.
A Real Degree and a Real Job
Temple University Health System graduated its first batch of community health workers in December, after screening 350 applicants and paring the list down to 40 to enter the program. Thirty-four graduated, and about 22 have been placed in jobs in health care systems throughout Philadelphia, most paid for by Medicaid managed care organizations, in settings from primary care to specialty practices, to the emergency department. In the latter, CHWs tried to target and intervene with patients who overused the ED, meeting them instead in their home and connecting them with primary care physicians.
Tiara Parker, one of the 34 new graduates, has assisted more than two dozen men and women with heart failure since starting her new job at Temple. The 30-year-old community health worker stops by to introduce herself when the patients are first hospitalized. But her role really kicks in after discharge, when she visits their homes to check if everything is falling into place. Does the patient have a ride to the follow-up appointment? Has the nurse stopped by? Where is the shower chair that was ordered?
Some patients might be too embarrassed to tell hospital staff they don't have a working stove or refrigerator, so vital to eating healthy food and keeping medicine safe. "Sometimes they will tell me that they don't have enough money for heating oil," Parker says. "They're not focused on going to the doctor in five days if they're living in a cold home."
Temple has designed the initiative to see if lay people — working with a team of nurses, social workers and other clinicians — can help run interference when obstacles emerge at home. The goal is to train natural leaders, those who are already their neighborhood's informal block captain, says Paula Stillman, M.D., vice president of health care services for Temple University Health System. "They are conduits, they are liaisons. And people trust them because they are from the community, of the community."
Of the 40 selected for the four-week training program, many were unemployed; the median annual income was $9,000, Stillman says. A clean criminal background check was required, as well as a GED, and meeting at least a 10th-grade reading level and a ninth-grade level for math. About one-third hold college degrees.
Parker, who has an associate degree and previously had been unemployed for about 18 months, passed the course, which included homework, oral presentations and training sessions with actors posing as patients. The best and most motivated of the crop have been employed by Temple and other local health systems, Stillman says. The payoff: a full-time $13-an-hour job totaling about $35,000 annually, plus health coverage and other benefits.
Stillman estimates the training cost to be about $6,000 per worker, paid by Temple and a mix of other local entities, including hospital systems and insurers. The rate of rehospitalizations, missed follow-up appointments and other health measures are being tracked closely, she says. Temple launched its second class this spring.
Repeatedly, health workers are reminded where their responsibilities stop and when they need to consult a clinician, Stillman stresses. But someone who has sat at the patient's kitchen table also might learn of medical issues that otherwise could be missed. When one of Parker's patients mentioned blood in her stool, the nurse Parker contacted recommended an emergency department visit to check for intestinal bleeding.
"The patients really trust her, and she will be the first call that they make if they don't feel well," Stillman says. — Charlotte Huff