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The Case for
Community Health Workers

Community Health Workers (CHWs) are
public health workers who are members of the communities they serve. (London,
Carey, Russell, 2015) “CHWs typically share ethnicity, culture, language, and socioeconomic
status with community members. Because they understand the context of patients’
lives—where they come from, how they do things, what their families and friends
expect, what foods they cook— CHWs can coach a patient to implement care
recommendations, such as diet, exercise, medications, and asthma-sensitive
cleaning strategies, that are manageable and also fit their lifestyles”.
(London, Carey, Russell, 2015).

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Since more states have begun to
participate in employing Community Health Workers, data has shown a reduction
of long term health care costs. This is due to the improvement of health care
accessibility and navigation in these communities. In response to this success,
Connecticut is currently working on legislation for certification and payment
models for CHWs. Many insurance companies and healthcare delivery systems are
unwilling to support payment models for Community Health workers, despite the
fact that there is significant data showing the benefits of CHWs working within
communities. The issues of certification and education are also a cause for
concern among payers.  Despite the fact
that there are still questions in need of answers, and issues that must be
worked out, this is a conversation that must continue. Through the examination
of the purpose and the benefits of community health workers, this paper will
attempt to begin to answer these questions and bring to light the importance of
supporting community health workers.

            What are
Community Health Workers and why are they an important part of the health care
delivery process?  “Many now recognize
that providing good health care has to go beyond the doctor’s office —
especially for minorities and low-income communities.” “Limited access to
healthy food, environmental perils, crime, insecure housing, insufficient
recreational opportunities and the absence of affordable transportation all can
have a huge effect on a person’s health. These factors, often called the social
determinants of health, are hard for clinicians to address during medical
appointments. To contend with them, hospitals, community health clinics, public
health agencies and some health plans are increasingly turning to community
health workers.” “A lot of us have struggled with food and housing and
transportation just like our patients have,” said Amy Smith, a community health
worker at HCMC. “We understand their struggles and know what it takes to come
out the other side.” “These shared experiences are one of the most valuable
assets a community health worker can have”, said Carl Rush of the Project on
Community Health Policy and Practice at the University of Texas-Houston’s
Institute for Health Policy. “For a low-income population, there is a power differential
between patient and provider that the provider is not in a good position to try
to resolve,” Rush said. Often, patients will confide important health
information to community health workers that they’d feel intimidated or ashamed
to reveal to their doctor or nurse. “Because we can spend more time with them
and don’t wear white coats and can talk to them about more than medical things,
they confide in us,” said Shawn McKinney, a community health worker at HCMC’s
Whittier Clinic. (Ollove, 2016). There is a sense of understanding and a
potential for a special type of connection between CHWs and community members
that brings to the table a variety of benefits the health care industry did not
previously have.

“Some key issues of debate are the
questions of what functions individual CHW’s can effectively perform,
considering level of education, type and duration of training, health needs of
the community, size and geographical spread of the population to be covered”.
(Rep.,2007)

Why should we invest
in community health worker services? Research shows that community health
workers enhance patient experience, strengthen care coordination, improve
clinical outcomes, and can help to control rising health care costs. “They
bring an understanding of patients’ culture, language, and community to the
health care team. They can be the team’s eyes and ears on the ground by
identifying obstacles patients face and tailoring health management strategies
to meet each patient’s needs”. “The health care system’s movement toward
value-based payment methods – which reward quality health care with incentive
payments – encourages providers and payers to meet ambitious quality standards
for all patients, including those who face significant barriers to achieving better
health”. (London, Love, Tikkanen,,2017).

“Return on Investment Research
confirms that intervention models involving CHWs create cost savings and
revenue enhancements across a wide range of health issues. For example:

?       CHWs
provided home visit services, appointment support, health literacy and
education, advocacy, and facilitated access to equipment and supplies to 691
high-risk patients enrolled in the New Mexico Medicaid managed care plan. An
evaluation of claims data for a sample of patients and a non-CHW comparison
group showed significant reductions in Emergency Department use,
hospitalization, and prescription medication producing an annual cost offset of
$3,003 per patient relative to the non-CHW comparison group. Total program
costs were estimated at $559 per patient per year (or $46.58 per month).

?       CHWs
in Seattle-King County provided a home environmental assessment, individual
consultations related to patient-specific action plans, educational and social
support, and facilitation to home environmental mitigation resources to 214
low-income, high-intensity children suffering from persistent asthma. Children
in the CHW group produced a cost off-set of $342 to $480 annual from reduced
use of emergent or urgent care.

?       CHWs
working with behavioral health care patients in Denver increased patient
utilization for primary care and specialty care and decreased utilization of
urgent, inpatient, and outpatient care. The model produced a cost savings of
$2.28 for every dollar.

?       CHWs
in Baltimore helped Medicaid diabetic patients reduce their emergency room
visits by 38% and hospitalizations by 30% translating to a cost savings of
$80,000 annually per CHW.

?       In
Connecticut CHW’s working as part of cross-cultural teams with pharmacists
provided Medication Therapy Management to 100 Limited English speaking persons
who had experienced extreme trauma. The average person had 6.1 medication
problems and the teams were able to solve 93% of the problems at a cost savings
of $3,032 per person per year”.

 (Rep.,2014)

“Certification without over-professionalizing
increases the likelihood that CHWs will get hired and that their services will
get paid”. In many states private nonprofit organizations focusing on the
promotion of CHWs play a key role in training and certifying CHWs.
Certification generally includes classroom training on core competencies, a
practicum or internship experience as well as an evaluation of skills and/or
knowledge. “It is important to note that in most states that have established
CHW certification processes, certification is voluntary”. A starting point for
Connecticut is to study the approaches of other states that have established
CHW certification systems. (London, Carey, Russell, 2015).

“While the CHW model has been used
successfully for many years, reliance on time-limited grant funding has created
sustainability challenges. Health reform and changes to federal rules have
opened new opportunities to integrate CHWs into Connecticut’s health care
delivery and payment systems. In order to maximize these opportunities, the CHW
policy agenda for Connecticut should include:

•                    
Enacting legislation to establish a process for
certifying CHWs, along with training and experience requirements, to document
CHWs’ skills for potential employers and insurers.

•                    
Implementing Connecticut’s State Innovation Model
(“SIM”) plan to establish training programs for CHWs and CHW supervisors to
improve and standardize knowledge and skills.

•                    
Adding CHW services to the set of Medicaid-covered
services and establishing a Medicaid payment rate to provide sustainable
funding for these cost-effective services.

•                    
Providing training for health care providers on how to
use CHWs to help achieve practice transformation goals.

•                    
Establishing a CHW task force to promote and coordinate
this agenda”.

 

Credentialing
and certification requirements for CHWs vary from state to state. “Qualified
CHWs hold competencies such as: communication skills; interpersonal skills;
service coordination skills; capacity building skills; advocacy skills;
teaching skills; organization skills; and knowledge base on specific health
issues. National and statewide initiatives exist to expand the CHW workforce.
For example, the Community Health Worker National Education Collaborative offers
a national community of practice website to support the development of college
responsive programs and to facilitate development of CHW educational resources,
services, curricula, and promising practice delivery strategies. Connecticut
can take advantage of CHW workforce efforts championed by other states
including Massachusetts, New York, and Texas. These states have developed
legislation, competency-based frameworks, curricula, certifications and
credentials, career pathways from CHWs to health care occupations, training
delivery systems, and professional organizations for CHWs”. (Rep.,2014)

Health care providers are under
pressure to meet higher quality of care standards, such as providing
recommended preventive screenings while reducing the need for expensive
emergency department visits. (London, Love, Tikkanen, 2017). “Studies show that
community health workers help underserved and high-need patients access the
right care at the right time by removing barriers to care. These services
enhance patient experience, improve population health outcomes, and reduce
costs”. (California Health Workforce Alliance, 2013).

Connecticut
can utilize current statistical data available from states that have
successfully created certification and education standards and proven
sustainable payment models to develop a sustainable model for CHWs in
Connecticut. CHWs have a proven track record of reducing barriers faced by
minority and impoverished communities face when attempting to navigate the
healthcare system. There is data to show the cost reduction in long term health
outcomes in these communities that CHWs work in.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

London, K., Carey, M., &
Russell, K. (2015). Tomorrow’s Health Care System Needs Community Health
Workers: A Policy Agenda for Connecticut (Rep.). Connecticut Health Foundation.

Ollove, M. (2016). Under Affordable
Care Act, Growing Use of ‘Community Health Workers’. Retrieved December 03,
2017, from http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/07/08/under-affordable-care-act-growing-use-of-community-health-workers

Community health workers: What do
we know about them? (Rep.). (2007). Evidence and Information for Policy,
Department of Human Resources for Health Geneva.

Community Health Worker
Certification in 15 States. (n.d.). Retrieved November 18, 2017, from https://www.cthealth.org/publication/state-chw-certification/

London, K., Love, K., &
Tikkanen, R. (2017). Community Health Workers: A Positive Return on Investment
for Connecticut (Rep.). Connecticut Health Foundation.

The Business Case for Community
Health Workers in Connecticut (Rep.). (2014). The Connecticut Department of
Public Health. http://www.healthreform.ct.gov/ohri/lib/ohri/CHW_Business_Case_2014_with_Task_Force_Final.pdf

 

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