PHILADELPHIA -- Community health workers (CHW) are expected to be a growing and vital part of healthcare delivery in the United States as the Affordable Care Act is fully implemented. A slate of steps detailing how CHW programs can maximize their effectiveness and impact on patients and healthcare spending is provided in a new perspective piece in the New England Journal of Medicine by experts at the University of Pennsylvania's Perelman School of Medicine and New York University.
The piece offers guidance for the growing number of organizations who are looking to community health workers (CHWs) as a strategy for improving health outcomes and reducing costs.
CHWs are community members who are trained to help patients navigate health systems and address upstream issues -e.g. homelessness, food insecurity--that can affect health. The authors anticipate a dramatic increase in the number CHWs in the United States in the years ahead because of a number of recent policies, including regulations that allow states to approve reimbursement of CHW-delivered preventive services.
Yet, lead author Shreya Kangovi, MD, MS, assistant professor of medicine and founding executive director of the Penn Center for Community Health Workers warns, "We have been here before. CHWs seemed like the magic bullet in the global health arena in 1960-70s, but by the late 1980s, many programs failed to meet expectations and were terminated. This article is an attempt to learn from this history so we do not repeat the same mistakes."
The authors argue that while policies can facilitate expanded use of CHWs, programs must address five key implementation issues in order to maximize effectiveness.
First, the article suggests that CHWs should be integrated with formal health care providers, rather than operating through stand-alone, community-based programs.
The article also cautions against using CHWs to provide disease education or basic clinical care. Authors suggest that instead, CHWs focus on addressing upstream, non-clinical issues. This strategy minimizes liability concerns, reduces "turf" struggles with other clinicians, and allows health systems to invest in a single scalable model, rather than choosing among disease-specific programs.
Authors point out that many CHW programs tend to lack program-level infrastructure.
"Programs can't just focus on the CHW and ignore program-level guidelines like caseload, supervision and documentation," the authors note. The article offers open-source examples of program-level guidelines.
The article also cites high turnover as a major problem that has plagued CHW programs in the past. Authors suggest that this turnover would be reduced if programs used candidate-selection guidelines to identify CHWs with strong interpersonal skills, instead of simply relying on training.
Finally, the article explains that while many past CHW programs have not been scientifically proven, this is changing. Since 2010 there have been nearly 400 randomized controlled trials -the same research studies used to test new drugs or medical devices--of CHW programs. Authors suggest that organizations use CHW models that have been proven to work.
"This is an exciting time with new opportunities to leverage CHWs in the care of the highest-risk patients," says author David Grande, MD, MPA. "Addressing historic implementation barriers will allow programs to maximize this opportunity."
As CHW programs continue to grow, many states are exploring certification and credentialing for individual CHWs. The authors recommend program accreditation as a more effective strategy than credentialing of individual CHWs: "Unless we address program-level implementation barriers, employee-level standardization is unlikely to be effective."
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Journal
New England Journal of Medicine