Helping hands come from the community
Community health workers can help physicians and patients as part of a broader recognition that many factors that don't involve direct treatment can still drive medical outcomes.
Doctors treating patients at Henry Ford Hospital's general internal medicine clinic knew that they were sometimes in the dark about the financial, transportation, and other challenges that sabotaged their patients' ability to manage chronic conditions.
“What we often find here is that our patients will tell our medical assistants who are checking them in more than they might tell the physician,” said David Willens, MD, FACP, division head for general internal medicine at the Detroit hospital.
So several years ago, the clinic decided to hire a community health worker to assist with a phone-based insulin titration program. The program allowed patients to call in their blood glucose readings but also potentially share other frustrations, Dr. Willens said.
“We felt that the right person to ask those questions would be someone who hopefully would be most comfortable for those patients,” he said.
Community health workers, also sometimes described as lay health workers or, in Spanish, promotores, have enjoyed a bit of a renaissance in recent years. Their implementation has been rooted in part in the emergence of value-based reimbursement models along with a broader recognition that many factors that don't involve direct treatment can still drive medical outcomes.
In the U.S., there are slightly more than 56,000 community health workers, earning a median of $39,540 annually, according to 2018 data from the Bureau of Labor Statistics. The picture for return on investment is still mixed and evolving, although a recent JAMA Internal Medicine analysis of a Philadelphia-based model published in December 2018 tracked a reduction in hospital days and 30-day readmissions.
“It's exciting to see that this workforce that has been around for hundreds of years finally is gaining some awareness and acceptance in mainstream health care, period,” said Shreya Kangovi, MD, FACP, founding executive director of the Penn Center for Community Health Workers, which developed the model studied in JAMA Internal Medicine. But, she added, “I think the concern and the goal is to make sure that as the numbers grow, so does the effectiveness of these programs.”
Dr. Kangovi and others who are knowledgeable about community health workers, sometimes dubbed CHWs, said that adding their skill set to clinical teams is easier to propose than to accomplish. Along with making savvy hiring decisions and providing optimal training, program directors must ensure that CHWs' practice role is well defined and then—perhaps most difficult of all—provide them the opportunity to wield their intuitive skills.
At the heart of these decisions, as Dr. Kangovi wrote in a piece she coauthored in a recent Health Affairs blog post, is a fundamental question: How best to “integrate a grassroots workforce into health care without totally coopting it?”
A broadening role
The Affordable Care Act has led to a number of federally driven changes and initiatives relevant to community health workers. Since 2014, a rule change made by CMS officials has opened the door to reimbursing state Medicaid programs for services provided by nonlicensed practitioners, including CHWs. Some demonstration projects funded by the Center for Medicare and Medicaid Innovation have incorporated community health workers. Earlier this year, the National Association of Community Health Workers formally launched as a nonprofit organization.
Even so, the profession is still evolving, and how CHWs are defined and what roles they play can vary from state to state, sometimes overlapping with other positions, such as patient navigator, said Sydne Enlund, a policy specialist at the National Conference of State Legislatures who focuses on health workforce issues.
“I think one of the biggest challenges generally is really that there's no uniformity around the profession,” she said. “It's kind of like a patchwork among the states in terms of how they are using community health workers or whether they have mandatory certification or voluntary certification.”
While training is vital, Dr. Kangovi said, a required certification process can create barriers, discouraging talented individuals who might otherwise be great candidates.
As the Penn Center developed its CHW model, called IMPaCT (Individualized Management for Patient-Centered Targets), Dr. Kangovi said they learned a lot about the sort of traits needed to connect with vulnerable patients while interviewing numerous individuals from lower-income communities. Clinical credentials are not on that list, she said, and in some cases might be counterproductive “because it increases the social distance that they have with their patients.”
Moreover, some traits are largely innate and can't be taught, Dr. Kangovi said, such as “empathy or listening skills or a nonjudgmental nature.” To locate those natural helpers, Dr. Kangovi recommended moving beyond job boards and traditional human resources recruiting channels. Consider posting in soup kitchens, churches, YMCAs, and other community service programs, said Dr. Kangovi, who also outlined in a recent NEJM Catalyst piece other elements of training and implementation to develop a successful CHW program, including assessing effectiveness.
“It's really easy to believe in the narrative around community health workers and just take on faith that these programs are inherently going to work, but that has not been the case,” Dr. Kangovi said. “These are complex programs to get right.”
To date, the research jury is still out. One systematic review of 53 studies, published in 2009 by the Agency for Healthcare Research and Quality, found mixed evidence regarding the potential for CHW interventions to improve participants' behavior or health outcomes. The six studies that looked at economic and cost impact “yielded insufficient data” to evaluate cost-effectiveness relative to other community health interventions.
Another more recent 2017 systematic review, which focused on social determinant interventions more broadly, including CHWs, was similarly critical. Studies involving health outcomes showed mixed results, and higher-quality research is needed, the authors wrote in the American Journal of Preventive Medicine.
Yet other analyses have planted seeds for optimism. A 2018 report, which analyzed the impact of the federally funded Health Care Innovation Awards, found that out of six types of intervention components evaluated, ranging from health IT to telemedicine to workforce redesign, only community health workers lowered total health costs (by $138 per beneficiary).
In the JAMA Internal Medicine study, which randomized nearly 600 patients with multiple chronic conditions to usual primary care or CHW support, the impact on hospitalizations was notable. After six months, the usual care group had spent a total of 345 days in the hospital compared with a total of 155 days for the group supported by an IMPaCT community health worker. The 30-day readmission rate was 25.7% for the usual care group versus 7.9% in the intervention group.
Bridging the physician-patient gap
Community health workers can play a mix of roles, working with patients diagnosed with chronic conditions and those who are frequently hospitalized or, more broadly, working to reduce not just language but also cultural and other obstacles that can inhibit patients from speaking up, said Sergio Matos, a long-time community health worker who founded the National Association of Community Health Workers.
“There's an inequity between providers and recipients of health care,” said Mr. Matos, who also heads up a Brooklyn, N.Y., firm that works to advance the CHW workforce, as well as consults with hospitals or practices nationally. “Recipients don't always feel entitled to their voice in those encounters.”
There's also some entrenched cultural mistrust that CHWs can help ease, he said. “There are a lot of experiential and cultural beliefs that the medical system is really in it for themselves and that they're in cahoots with the pharmaceutical industry.”
If patients don't feel free to speak up, physicians may not realize that a patient is struggling to see the syringe because she can't afford glasses, Mr. Matos said. Another patient might not be taking his blood pressure pills but is loath to admit to his doctor that it's because they're impacting his sexual performance.
“The medical system tends to label those folks as noncompliant,” Mr. Matos said. “It's not that men don't want to control their blood pressure. It's just that the consequences of what they are being prescribed are not acceptable.”
At Henry Ford Hospital, Linda Hopkins-Johnson works with patients prescribed basal insulin, checking with them by phone on their latest readings as well as any other difficulties they might have encountered. As a community health worker who got her core competency training through the Michigan Community Health Worker Alliance, along with taking diabetes educator classes, she works under the oversight of a nurse. That way the nurse can focus on adjusting insulin dosages as needed and Ms. Hopkins-Johnson can delve into lack of adequate refrigeration and other daily challenges that undercut health, Dr. Willens said.
But that only works if the community health worker is accepted as part of the multidisciplinary team, Dr. Willens stressed.
“Accept their eyes and ears as important information just like you would history from a patient or from testing,” he said. “It's incredibly valuable, especially if they're bringing a different perspective than what you can elicit from a patient.”
Ms. Hopkins-Johnson is typically introduced to patients at one of their appointments, so they know who is on the other end of the line when she calls for their latest glucose readings.
“I try to build up that friendship or relationship with the patient as we talk,” she said. “Once they find out that I'm not a nurse or a doctor, then they'll tell me different things,” such as not being able to afford much food at all, never mind a special diet.
She brainstorms with them about how to achieve bite-sized goals. She encouraged one patient who couldn't walk all of the way around a track to walk halfway or even a quarter of the way and slowly increase from there. For some patients, kicking the sugar habit is the hardest, said Ms. Hopkins-Johnson, describing how some might consume four or five candy bars daily. She advises them to cut back over time and “to eat them earlier in the day while you're still moving around.”
An analysis of a year's worth of data involving 144 Henry Ford patients with diabetes who worked with Ms. Hopkins-Johnson found that 56.9% had lowered their HbA1c by at least 1% compared with 36.2% in a control group.
Pitfalls to consider
Dr. Kangovi cautioned that tying a CHW's responsibilities to a single condition or medical challenge, such as improving diabetes control or mammography screening, can make it harder to scale up the program. IMPaCT has developed a patient-centered approach in which the community health worker conducts a semistructured interview, soliciting where patients most want to improve their health.
For instance, one patient might need a reason to get out of bed in the morning, and the community health worker might help him sign up for an art class at the local rec center, Dr. Kangovi said. Another might be fretting most about affording glucose test strips, so they work on that first, she said.
“I think clinicians have a lot of reluctance or skepticism with letting patients drive the agenda,” she said. “But what we've found through three clinical trials is that the very patient-centered empowerment approach, rather than the targeted approach, actually I think is what lets us move these hard clinical outcomes in the end, that patients are the experts at what they need.”
In IMPaCT, the community health workers are embedded in clinical teams, so they build relationships with both a roster of patients and their clinicians, Dr. Kangovi said. She discourages clinics and practices who are considering adding CHWs to try to shoulder the logistics of hiring, training, and supervising them. A more efficient approach, she said, is to contract with an outside resource or center that can provide training and other services and then deploy the CHWs back to the practice.
Regardless of their precise roles and program designs, the work prospects for CHWs look bullish. Other 2018 data from the Bureau of Labor Statistics, which combines CHWs and health educators into a single category, predicts job growth of 11% through 2028.
All of these additional workers will need training in core competencies, such as communication, behavior change, and goal setting, Mr. Matos said, plus additional specialized training for those who will focus on pregnancy, diabetes, or another medical condition. The National Association of Community Health Workers is planning to compile a list of training resources, he said.
Like others, Mr. Matos emphasized that doctors and other clinicians should be ready to provide some latitude to maximize their investment in this growing CHW workforce. “They can't make life miserable for them and try to alter their character to be mini-doctors or mini-nurses,” he said. “You have to give them the freedom to do what they know how to do.”