Factors to Consider
In seeking to improve care and reduce unnecessary hospitalizations, many healthcare systems are looking at the opportunity of expanding their use of community health workers (CHWs). The successful integration of CHWs into any healthcare system requires thoughtful planning, leadership, organizational readiness and a conducive cultural context. This section summarizes the evidence of CHWs’ effectiveness, best practices, critical success factors and lessons learned.
An overview of evidence on CHW programs is concisely summarized in The Commonwealth Fund’s article Integrating Community Health Workers into Care Teams.
CHWs have been shown to:
Community health worker programs have also been shown to help improve disease outcomes for patients with asthma, hypertension, diabetes, cancer, tuberculosis, HIV/AIDS, and depression, among other conditions.
Documented savings in CHW programs have been attributed to:
Benefits of CHWs integration into Patient-Centered Medical Homes:
A summary of the evidence on CHW integration into Patient-Centered Medical Homes is provided in Community Health Worker Integration Into the Health Care Team Accomplishes the Triple Aim in a Patient-Centered Medical Home, A Bronx Tale.
- Community health workers (CHWs) appear ideally suited to the care coordination niche of the Patient-Centered Medical Home, particularly for underserved, minority populations facing cultural and linguistic barriers to care 1Martinez Garcel, 2012; Volkmann and Castanares, 2011.
- Community health workers develop a trusting relationship with patients, serving as a 2-way liaison between the community and health care system, and there is ample evidence of their contributions to improved health outcomes, especially among those with chronic illnesses 2Babamoto et al., 2009; Balcazar et al., 2009; Brownstein et al., 2007; Bryant-Stephens et al., 2009; Cherrington et al.,2008; Findley et al., 2011; Krieger et al., 2009).
- Importantly, CHWs help reduce health care costs by decreasing emergency department (ED) visits and hospitalizations 3Balcazar et al., 2011; Gilmer et al., 2007; Ingram et al.,2008; Krieger, 2009; Rush, 2012; Waxmonsky et al., 2011.
- Thus, CHWs are well-positioned to encourage those marginalized from the health care system to seek care at the PCMH 4Epstein et al., 2010; Herman, 2011; Volkmann and Castanares, 2011.
The article also identifies the research “around the specific roles of CHWs in team-based settings (Cherrington et al., 2010; Farquhar et al., 2008; Keller et al., 2011) and on how CHW roles fit within the overall division of care within the PCMH (Crabtree et al., 2011).”
Key principles for successful integration of community health workers into a health care system are documented in Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Healthcare Settings from the Sinai Urban Health Institute.
These practice guidelines were developed to address gaps in the CHW professional literature and assist healthcare administrators, public health professionals, healthcare providers, CHWs, and communities in designing and implementing CHW interventions grounded in evidence-based science.
Avoid role confusion by defining the CHW’s scope of practice and clearly communicating the information to other healthcare staff working with the CHW.
Ensuring there is no confusion among staff about CHW roles and responsibilities will help promote successful integration of CHWs. When CHWs perform duties outside their job description or focus too much on patients outside of the intended population, it may create problems which limit the success of the intervention. To decrease role confusion and promote well-coordinated service delivery, studies recommend that programs develop strictly enforced intervention protocols.
CHW programs must work to achieve staff buy-in of the CHW intervention.
While many healthcare providers and staff express value in CHW integration, others are more hesitant to accept a new position on the health care delivery team. Program leaders should facilitate clear understanding of the CHW model and the intervention, and consider including key staff in program development to promote staff buy-in of CHW integration. For example, including medical professionals in the development of CHW trainings and in decisions involving professional boundaries may foster staff trust in the CHW model.
Create a welcoming and structured environment for CHWs.
CHWs should be greeted with staff support, proper space and supplies. This not only facilitates productivity but also communicate the CHW’s standing as an important member of the team. Promoting an atmosphere of teamwork and appreciation for each role on the delivery team can foster positive group dynamics.
Promote frequent communication and address any workflow issues.
Supervisors should meet with CHWs regularly. CHWs should also have frequent and direct communication and case discussions with others on the intervention team, including medical staff. Communication can be verbal, such as team meetings and informal conversations, and it can be written, such as documented case notes included in the patient’s electronic medical record.
It is crucial for leadership to ensure that existing staff and providers are aware that hiring a community health worker may mean a significant cultural shift to the organization – both in how the organization functions internally, and in how it meets the needs of its clients and patients. Sustained, frequent communication about how best to incorporate input from the new CHW(s) is recommended.
Critical Success Factors
- A powerful CHW champion. A CHW champion among the medical leadership is essential. The CHW champion ensures that the administration understands the CHW model and gets physicians and all clinical team members on board with the CHW model.
- Organizational commitment to the CHW program. With this commitment, the hospital could institute changes to procedures to accommodate the CHWs, support the program, for example, detailed job description, division of labor in the clinical setting, recruitment criteria and process, and tracking and evaluation of CHW contributions.
- Train clinical teams on the CHW model. Staff need to understand the mission and vision of the program. Because some clinical staff have little familiarity with the CHW model, they will need to learn how to work as a team with CHWs. This training leads to better integration of the CHWs, along with elimination of tension between the CHWs and other members of the team. Ideal integration includes clear definition of their care coordination role within the care team, meticulous recruitment, training and supervision by a senior CHW, and shared leadership of the care management team. By helping the team understand the patients’ backgrounds, constraints, and preferences, the CHW can help everyone better understand each patient.
- Employ a CHW supervisor/administrator as intermediary. This strengthens communication while simultaneously allowing CHWs to receive more focused, timely, and appropriate supervision. The supervisor can use their own experience to develop operational details of the CHW program. Community health worker leadership also conveys to the CHWs the value of their work, and it illustrates the career ladder being established for CHWs.
- Demonstrate improved outcomes and lower costs. Providing evidence of the benefits of the CHWs to staff is critical for obtaining organizational, administrative, and team-wide support.
The program development processes below are replicable, are scalable, and may be relevant to other patient-centered medical homes (PCMH) seeking to integrate CHWs.
- Co-locate community health workers in PCMH practices as full-time employees. This arrangement may minimize attrition and facilitate relationship development between CHWs and other staff. CHWs should be integrated into existing communication structures to minimize additional meetings. Co-location may encourage patient uptake of Self-Management Support (SMS) services and convey that CHWs are key team members.
- A significant portion of CHW time should be invested in community-based activities. This is essential for maintaining trust and addressing determinants of health at all levels of the ecological model. PCMH-based CHWs must not be relegated working exclusively within the health care setting.
- Ensure clinical staff understand the range of CHWs roles. Misunderstanding the role of CHWs can hinder their ability to contribute to team-based care. Train all team members, including clinical supervisors, on the CHW model as well as each person’s role in supporting the patient.
- Ensure that CHWs receive extensive, competency-based training, from established capacity development programs. While some difficulties can be overcome with ongoing mentorship and support of PCMH clinical staff, the program benefits when CHWs receive 80-hour capacity building training.
- Develop an Efficient Referral System. Providers may feel that identifying participants through the EHR does not target patients most in need of support so consider developing a process that refers patients with poorly controlled disease to CHWs.
- Train and coach CHWc to enter appropriate data in Electronic Health Records. Allowing CHWs limited electronic health record (EHR) access may improve communication and efficiency. Any documentation tools created should remain simple to use so that providing personalized support, rather than completing documentation, is CHWs’ primary focus. For example, CHWs could collect data on medication use, disease selfmonitoring, and physical activity levels.
- Develop a simple tool to lend structure to CHW–patient encounters. A brief guide can ensure that all visits include discussions about (a) social assets, barriers, and support needs; (b) medication use; (c) dietary and physical activity patterns; (d) self-monitoring and goal setting; and (e) education topics covered during health coaching. The guide should remain sufficiently simple so that CHWs still have time and flexibility to address individual needs.
- Prepare CHWs to address comorbid mental health conditions in a culturally appropriate fashion. Through training and/or mentorship, you may need to support CHWs in finding a way to address mental health conditions in a way that is still culturally appropriate. CHWs can also help shape the program to adapt to patient preferences. For example, providing group medical appointments or community-based learning may be appropriate for PCMHs serving populations that prefer community, rather than individual-oriented information.