NEW THIS SUNDAY: COMMUNITY HEALTH WORKERS -- A LOCAL SOLUTION TO A GLOBAL PROBLEM

Tuesday, 3rd of September 2013

COMMUNITY HEALTH WORKERS — A LOCAL SOLUTION TO A GLOBAL PROBLEM

Prabhjot Singh, M.D., Ph.D., and Dave A. Chokshi, M.D.

N Engl J Med 2013; 369:894-896September 5, 2013DOI: 10.1056/NEJMp1305636

Best viewed at http://www.nejm.org/doi/full/10.1056/NEJMp1305636?query=TOC

In the face of persistently lackluster job creation, the U.S. health sector is paradoxically seen as both a contributor to torpid macroeconomic growth and a source of local employment opportunities. Labor costs account for more than half of U.S. health care spending, but as payment structures shift from volume-based reimbursement to the rewarding of value in improving health, the locus of health care delivery will expand from facilities to communities. Ideally, patient care will take place not just in episodic encounters but also through continuous, community-based partnerships that include new entities and workers. Elsewhere in the world, such care has involved the use of community health workers (CHWs) — lay community members with focused health care training. We believe that scaling up the community health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs.

In many countries, CHWs are becoming paid, full-time members of community health systems. In sub-Saharan Africa, the One Million Community Health Workers Campaign is training, deploying, and integrating CHWs into the health system.1 In India, 600,000 CHWs are paid through a fee-for-service system to perform a specific set of primary care functions, such as immunization. In Brazil, community health agents are part of family health teams that now care for 110 million people. And growing evidence reveals the effectiveness of interventions by CHWs in multiple health arenas, such as maternal and child health and chronic-disease management.2

CHWs have been part of the U.S. health care landscape for decades, serving as community advocates, social activists, health promoters, and patient navigators, among other roles. In California and other border states, promotoras and promotores de salud address reproductive health, diabetes, and cardiovascular health. In Arkansas, CHWs have been shown to reduce Medicaid spending by reaching out to people with long-term care needs; in Alaska, theyre part of an effective primary care extension system. Multiple states have created formal accreditation programs for CHWs, and in 2009, the Department of Labor recognized CHWs jobs as a distinct category of employment. Yet despite these gains — and in part because of the organic way in which CHWs have emerged — there is little standardization across health systems in terms of gaining access to CHWs, integrating them into health care processes, and compensating them.

There are three models for organizing U.S. CHWs: employment of CHWs as extensions of hospital systems, management of CHWs through community-based nonprofit organizations, and management of CHWs by entities that operate at the interface between health systems and the community (see table Models for Organizing Community Health Workers (CHWs) in the United States.). The first two approaches reflect CHWs historical roles — as a means for broadening the health care systems reach and as community activists and health educators. The third approach aims to synthesize these roles while borrowing principles from global experiences with scalability and opportunities for financial sustainability. For example, the Prevention and Access to Care and Treatment (PACT) project drew from the nonprofit organization Partners in Health in integrating CHWs into a care-management program for patients in Boston who have HIV–AIDS. The PACT model was subsequently expanded to cover patients with diabetes or other chronic conditions. More generally, organizations dedicated to CHWs could support health systems by recruiting, training, and supervising CHWs. Longitudinally developed expertise in CHW management allows such organizations to provide interventions that are costly when delivered by more extensively trained health care workers and that are difficult to coordinate in community settings.

The Affordable Care Act (ACA) includes levers to shift our health care systems focus toward comprehensive, high-quality care for populations. Through structures such as accountable care organizations and incentives such as readmissions penalties, hospitals are increasingly responsible for the care of patients both in and outside the hospital. For example, hospital systems have invested in care coordinators, aiming to reduce readmission rates by stratifying patients according to risk level and tailoring their discharge interventions. As these systems look further beyond their own walls, they may see opportunities for lower-cost, CHW-based programs to demonstrate superior value.3

Beyond reducing readmissions, CHW programs may help to address the root causes of preventable chronic disease. Social exclusion, poverty, marginalization, and the built environment contribute to the high burden of chronic disease, particularly in low-income communities. But social services addressing these social determinants of health are too often fragmented. CHWs who can integrate knowledge of the local social service milieu with knowledge of patients individual circumstances can create a vital link for vulnerable populations. In concert with social workers, CHWs can mobilize social support, create avenues for family members to engage in the care process, and strengthen long-term community relationships that help patients sustain healthful behaviors.

Theres also an economic rationale for considering CHW programs. Employment of CHWs creates meaningful job growth for people with lower educational attainment (passage of the General Educational Development [GED] or higher tests) — often in low-income communities that have been hardest hit by the economic downturn — and particularly for women. From the perspective of a health system, CHWs may be a bargain, with mean annual pay of about $37,000 in 2012. Further research is needed to assess the cost-effectiveness of interventions by CHWs, but pilot programs have shown both reductions in spending for Medicare and Medicaid populations and clinical improvements in areas such as medication adherence and glycemic control.

To further develop the promise of CHWs, policymakers and health system leaders could take five initial steps. First, the evidence base for CHW programs should be shored up, through both additional, pragmatic clinical studies and consensus assessment of completed research. The Community Preventive Services Task Force could perform the evidence assessment, building on the 2007 Community Health Worker National Workforce Study. Additional studies should move beyond examining disease-specific, single-site pilots to larger-scale analyses of CHW integration into primary care, drawing from global research paradigms.4

Second, policymakers could address continued stagnation in job growth by promoting CHWs as a linchpin for health system restructuring. Indeed, Section 5313 of the ACA was dedicated to grants for underserved communities to employ CHWs — but was left unfunded. Revisiting this possibility could be productive, since the federal government is investing $67 million in the hiring and training of ACA “navigators” to help consumers with the new health insurance exchanges. Existing CHWs might be a natural fit for this role — and newly trained ACA navigators might consider becoming CHWs.

Third, the Department of Labor could support a harmonized approach to CHW certification across states. Certification helps to professionalize the community health workforce, driving quality standards for training and performance. The experience that Massachusetts had with policy development toward its 2010 CHW-certification law may hold lessons for a national effort.5

Fourth, the $1 billion second round of Health Care Innovation Awards from the Innovation Center of the Centers for Medicare and Medicaid Services (CMS) could include a focus on CHW-based interventions. If such innovations had beneficial effects on population health and cost, CMS could consider payment schemes to more broadly support CHW programs — for example, as part of Medicaid case management.

Fifth, dedicated community health workforce organizations could collaborate with insurance companies and hospitals to measure return on investment and to refine clinical protocols that support CHWs, as well as information technology linking patients, CHWs, and providers.

The most crucial lesson from global CHW programs is that the community rootedness of CHWs should be retained through careful, representative selection and by ensuring that CHWs spend most of their time in the community. In the United States, certain structural advantages, such as the strong network of community health centers, could facilitate CHW integration into the health system. The timing for investment in CHWs is also propitious, given the post-ACA landscape and the potential for meaningful job creation. Although the operational challenges of CHW integration are manifold, the global experience offers hope for U.S. communities.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the School of International and Public Affairs and Earth Institute, Columbia University; and the Department of Medicine, Mount Sinai Hospital — both in New York (P.S.); and the Department of Veterans Affairs, Washington, DC (D.A.C.).

References

1 Singh P, Sachs JD. 1 Million community health workers in sub-Saharan Africa by 2015. Lancet 2013;382:363-365
2 Bhutta Z, Lassi Z, Pariyo G, Huicho L. Global experience of community health workers for delivery of health related Millennium Development Goals: a systematic review, country case studies, and recommendations for integration into national health systems. Geneva: World Health Organization, 2010.

3 Kangovi S, Long JA, Emanuel E. Community health workers combat readmission. Arch Intern Med 2012;172:1756-1757

4 Victora CG, Black RE, Boerma JT, Bryce J. Measuring impact in the Millennium Development Goal era and beyond: a new approach to large-scale effectiveness evaluations. Lancet 2011;377:85-95

5 Mason T, Wilkinson GW, Nannini A, Martin CM, Fox DJ, Hirsch G. Winning policy change to promote community health workers: lessons from Massachusetts in the health reform era. Am J Public Health 2011;101:2211-2216