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Environmental Scan: Including Community Health Workers in Clinical Teams | Streamline Winter 2016

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Over the past five years there has been a strong push to include Community Health Workers (CHW) in clinical teams. This movement is backed by the large body of evidence demonstrating the capacity of CHWs to prevent diseases and manage care for a variety of health conditions, such as asthma, hypertension, diabetes, cancer, immunizations, maternal and child health, nutrition, tuberculosis, and HIV/AIDS.1  In addition, the Affordable Care Act’s (ACA) recognition of CHWs as contributing and valuable health professionals and how they can relate patient-centered care has brought more attention to the field of Community Health Work.2-3

A guiding framework for CHW integration into mainstream health systems is known as the “Triple Aim.” The framework was developed by the Institute for Healthcare Improvement and describes an approach to optimizing health system performance that centers around three dimensions:

  • Improving the patient experience of care;
  • Improving the health of populations;
  • Reducing the per capita cost of health care.4

This framework has been translated into the development of Patient Centered Medical Homes (PCMH), a health care model that naturally aligns with the core concepts of the field of Community Health Work in regards to providing patient-centered care. Guided by the triple aim goals and the recent push towards patient-centered care, the use of CHWs in clinical roles has slowly emerged as an effective and recognized practice in mainstream health care.

Key Findings

Although key thought leaders and institutions in the health care field, including the Institute of Medicine, have recognized the potential for CHWs to provide cost-effective and higher-quality health care interventions, the adoption of this practice has been slow.5  However, there have been several studies that have contributed information on how we can understand this role.

Methods for Integration

According to the Centers for Disease Control and Prevention (CDC), as part of a clinical team, CHWs can: 

  • Provide outreach in a community setting; 
  • Measure and monitor blood pressure;
  • Provide health education; 
  • Assist a patient with adherence to medication regimens; 
  • Help find ways to comply with treatments; 
  • Navigate the health care systems; 
  • Provide social support to patients and family members;
  • Assess how a self-management plan is helping patients meet their goals;
  • Assist patients in obtaining home health devices to support self-management; and,
  • Support individualized goal setting.6

Another common finding has been that a CHW has the ability to act as a cultural bridge between communities and health care providers.7  By acting as an intermediary, a CHW is able to provide context to a medical team about patients’ attitudes, behavior, and environment that can inform the development of an effective care plan.8  One doctor even commented that the insight the CHWs were able to provide made her a better doctor.9

Although CHWs working in a clinical setting are based out of a hospital or health center, they are generally still active in the community. In many cases, the CHWs accompany doctors or nurses when working with patients in the hospital or health center, but the CHWs are also responsible for conducting a certain number of home visits in a certain time period.10

A critical step in integrating CHWs into a care team to fill these roles is to clearly communicate what the CHW’s role on the team will be and what services they can provide. As a member of the care team, a CHW should be treated as a peer, should provide input on a care or intervention plan, and should be kept informed of any development or changes regarding a case.11  To reinforce that CHWs are peers on a clinical team, a program in Massachusetts recommends only hiring full-time CHWs.12   Although CHWs will contribute to a care plan and provide supportive services as peers, it is also important to delineate the role of the CHWs as complementary and supportive. As they do not have a clinical background, CHWs should not be treated as nurses or social workers, but rather as experts in the community.13

Frequent team meetings are also cited as a critical activity to building a cohesive care team with the inclusion of a CHW. Team meetings are a time for the clinical care team to collectively provide input and feedback regarding an assigned care plan for a patient. This is the optimal time for the CHWs to provide context and input to the care plan as it is developed.14

To ensure that CHWs are seamlessly integrated into the clinical setting, regular supervision is essential.15  In recent clinical interventions, CHWs were most commonly supervised by Nurse Practitioners (NP)16 , however CHWs can also be supervised by a social worker, case manager, or physician.17  In NP/CHW teams, the NP will typically collaborate with the CHW to develop an intervention plan, but will manage other clinical aspects of care, such as consulting with a physician and making lifestyle recommendations. The CHW will reinforce the treatment plan and recommendations outlined by the NP.18 

Recruitment and Training Needs

Naturally, successful integration of a CHW into a clinical setting is highly dependent on recruiting the right candidate and providing the appropriate training. Many of the same interpersonal and behavioral qualities that have been recommended for CHWs in the past apply to the primary care setting, including: 

  • Communication skills, 
  • Compassion,
  • Self-motivation, 
  • Capacity to learn, 
  • Ability to work in a team,  
  • Integrity,
  • English and Spanish proficiency,
  • Ability to establish trust,
  • Multicultural competency.19

No degree requirements were cited, other than a high school diploma. However, in many circumstances specialized training or a certification was required.20  If the ideal candidate did not have the required certifications or trainings, the organizations typically provided it for them.21  Experience in the field in a different role and a deep understanding of the community were also main considerations for recruitment in some programs.22

Training in the clinical field is critical, especially if the CHW is brought on without the required certifications and trainings. Trainings that are offered within the organization can be based on national guidelines and should include topics such as confidentiality, technology, and data collection.23  One Federally Qualified Health Center that integrated CHWs into its clinical team cited the Minnesota curriculum and textbook, “Foundations for Community Health Workers” as resources used during training.24  It is also important to note that training should not be limited to just CHWs. Training CHW supervisors on strategies and techniques for supporting CHWs is equally as important.25

Finally, like most other programs, ongoing training will help CHWs fill gaps in their knowledge or skillset. Realistic costs for the training should be estimated and budgeted for, prior to hiring the CHW.26

Challenges and Successes in State Approaches

One of the most common challenges in integrating CHWs into the mainstream health care system is the lack of sustainable funding.27  CHWs are often funded by organizations through grants to provide education and outreach services only.28  Funding acquisition for CHWs in clinical settings was a challenge prior to the ACA because health care providers were charged per service rendered. New legislative initiatives initiated by the ACA have encouraged the inclusion of CHWs on medical teams by incentivizing quality of care over quantity of care in payment structures and by expanding opportunities for states to reimburse CHWs through Medicaid.29 

Even before the ACA, the state of Minnesota was able to develop an exemplary system of funding that allowed CHWs to easily be included in the mainstream health system. Under this system, a CHW’s hourly wage can be directly reimbursed by Medicaid.30  This system is largely viewed as the prototype for developing sustainable funding systems.31

Although there have been some successes in states like Minnesota, health care providers have been slow to integrate CHWs into their workforce.32  In instances in which CHWs have been successfully integrated, illustrating the return on investment to high level leadership or policy makers has been key.33  By helping patients navigate the health care system, assisting with medication and treatment adherence, and connecting patients to the appropriate resources, CHWs can significantly divert unnecessary medical spending. A CHW program implemented in Arkansas saved the Arkansas Medicaid Program over two million dollars over the course of three years.34  Illustrating this kind of return on investment has caught the attention of policy makers and health care leaders more effectively than other evidence of success. 

Another issue is the lack of understanding of the CHW position.35  This is largely a result of an overall lack of workforce development and a lack of occupational regulation. Some states, such as Massachusetts and Minnesota, counteracted misconceptions by developing training curricula and certification programs to standardize and define the field of community health work. This standardization has helped to clarify what is the role of CHWs and where they fit in primary care.36 

Clinical Performance Measures

Most clinical performance measures have fallen into one of the three dimensions outlined in the triple aim strategy: clinical outcomes, improvement of a population’s overall health, and cost-effectiveness of the medical intervention. Some examples include changes in blood pressure or the number of inappropriate visits to an emergency department a patient makes.37  However, thus far, clinical performance measures have generally been in controlled research situations. The majority of these performance measures were designed to have a control group and an intervention group, which for most health care providers will not be a realistic situation. Defining generalizable and accurate clinical performance measures has remained a challenge in the field for some.

Future Implications 

Overall, with the reforms to the health care system affecting health care delivery and payment structures put in place by the ACA, the number of CHWs working in the primary care setting is expected to increase. Strategies to prepare for this change should include statewide campaigns to disseminate key findings on CHW programs; implementing a statewide infrastructure for CHW education, training, and certification;38  establishing a sustainable funding system;39  and developing standardized measures for success.40

By MHP Salud

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