Community Health Workers Fill Valuable Roles in Accountable Care

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A health worker checks a man’s breathing. Many community health workers work within the ethnic or cultural communities that they’re a part of. Photo: Flickr.

Community health workers are emerging as a cost-effective way to engage patients and caregivers to lower costs for healthcare’s “frequent flyers” who habitually visit emergency rooms and fill hospital beds.

CHWs have been part of healthcare worldwide for decades, and are becoming more prominent in the U.S. because of healthcare delivery reform. The Centers for Medicare and Medicaid Services will allow state Medicaid agencies to reimburse for preventive services provided by non-clinical professionals, such as CHWs, if a physician—as of Jan. 1, 2014—recommends them.

Accountable care has provided an impetus toward population-based care. Accountable care organizations and patient-centered medical homes are responsible for providing better care to attributed patients while holding down costs. The average CHW salary in 2012 was less than $38,000.

CHWs are increasingly becoming full-time employees of health systems seeking to minimize hospital readmissions and control chronic conditions. CHWs generally are not trained as doctors or nurses, and are often recruited directly from the communities they serve. The goal is to help individuals navigate the healthcare system, manage chronic illnesses more effectively, and access preventive care.

CHWs typically share deep cultural roots with their clients. They often share similar values, ethnic background and socio-economic status, and they usually speak the same language as those they serve.

They often work with people in impoverished communities who lack access to quality healthcare, lack the means to pay for healthcare, do not speak English fluently, or have cultural beliefs, values, and behaviors that differ from those of the U.S. healthcare system. The result is that CHWs help health systems become more culturally appropriate and relevant to those they are seeking to reach.

Texas’ Department of State Health Services developed a CHW 160-hour certification program 12 years ago to develop communication and navigation skills, as well as knowledge of community resources.  The state requires 20 hours of continuing education every two years.

Amy Raines-Milenkov, assistant professor of obstetrics and gynecology at the University of North Texas Health Science Center, leads a community-based research project, called the Building Bridges Initiative, that aims to fill gaps in social services for the estimated 1,500 refugees who resettle in Tarrant County annually. Many have lived for years in refugee camps in nations such as Iraq, Somalia, and Bhutan.

Many refugee women have trouble getting help with health issues including reproductive health, diabetes, and depression, and learning how to navigate the U.S. healthcare system. Meanwhile, many of the women are struggling with economic instability, and lack knowledge of U.S. culture or the English language.

Building Bridges developed educational programs focused on refugees who no longer receive case management from resettlement agencies, which typically ends after eight months. The program holds meetings with large groups of refugees from various countries, and it explains how to apply for and maintain health services.

The Building Bridges program recently was awarded a $1.3 million grant from the Cancer Prevention and Research Institute of Texas to use CHWs for cancer prevention, education, and screening for refugee women.

Baylor Scott & White has used CWHs since 2005. The program has become a chronic disease management program embedded into eight Baylor patient-centered medical homes, according to Christine Sneed, nurse manager of care coordination for Baylor Physician Services. The system has added two programs to assist low income, uninsured hospitalized patients with finding primary care after discharge.

Beyond CHW state certification, BS&W provides other CHW training, depending upon their roles. For example, CHWs completed 50 hours of diabetes-specific training for the Diabetes Equity Project, a forerunner of the Chronic Disease Management program.

Jim Walton, president and chief executive officer of Genesis Physician Group and a former Baylor executive, helped inaugurate the BS&W program and plans to use CHWs to bolster the independent practice association’s accountable care efforts. He said BS&W’s research confirmed that use of CHWs in the Diabetes Equity Project reduced blood glucose levels. Their efforts also cut hospital readmissions by half and lowered emergency-department costs by 19 percent. He calls CHWs “a viable part of the new healthcare workforce to help with patient engagement.”

JPS Health Network also uses CHWs to improve self-management of diabetes among Tarrant County residents. CHWs are being hired to treat homeless people to reduce inappropriate emergency room utilization at JPS Hospital, and for a new initiative to encourage women at JPS school-based clinics in low-income communities to take advantage of preventive healthcare services. That effort is aimed ultimately at reducing Tarrant County’s infant mortality rate, which historically is above state and national averages.

Sharon Phillips, interim chief operating officer for ambulatory care and behavioral health services for Parkland Health & Hospital System, said her system uses seven community development specialists to serve in CHW-type roles. The specialists, which have been used since the late 1990s, support Parkland’s community-oriented primary care clinics to help understand the health needs of the clinics’ neighborhoods and advise the clinics on what services to offer. They also are trained as certified application counselors to help patients who are eligible for insurance on the exchanges.

Texas Health Resources also does not use CHWs. However, the system has operated a Faith Community Nursing program since 2001. Six coordinators work with more than 150 Faith Community nurses at 75 church congregations’ communities to promote wellness and prevention. Texas Health Presbyterian Hospital Dallas began a Faith Community Health program in 2012, using lay health promoters to foster wellness and prevention in 14 churches representing 25,000 residents.

“Research shows that people are more comfortable getting care in their faith community,” Caryn Paulos, director of the Faith Community Nursing program. “They trust their faith community and feel cared for there.”

Steve Jacob is editor-at-large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at steve.jacob@dmagazine.com.

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