Presentation in Atlanta, 11/10/14, on evidence concerning community health workers

1. Community Health
Workers:
the State of the Evidence
Ashley Wennerstrom, PhD, MPH, Tulane Schoos of Medicine - New Orleans
Carl H. Rush, MRP, University of Texas School of Public Health - Atlanta
Samantha Sabo, DrPH, MPH, University of Arizona, Mel and Enid Zuckerman College
of Public Health - Scottsdale
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2. Topics
 Definitions
 Why CHWs now?
 What CHWs do – and the skills required
 State of the Evidence
 Activity at the federal and state levels
 Key challenges in CHW policy and workforce
sustainability
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3. What’s your definition of CHW?
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4. Community Health Worker Definition
American Public Health Association
 The CHW is a frontline public health worker who is a
trusted member of and/or has an unusually close
understanding of the community served.
 This trusting relationship enables the CHW to serve as a
liaison/link/intermediary between health/social services and
the community to facilitate access to services and improve
the quality and cultural competence of service delivery.
(cont’d)
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5. Community Health Worker Definition
American Public Health Association
 The CHW also builds individual and community capacity by
increasing health knowledge and self-sufficiency through a
range of activities such as:
 outreach
 community education
 informal counseling, social support and
 advocacy.
APHA CHW Section, 2006
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6. CHWs are unlike other
health-related professions
 Do not provide clinical care
 Generally do not hold another professional
license
 Expertise is based on shared life experience
and (usually) culture with the population
served
(cont’d)
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7. CHWs are unlike other
health-related professions
 Rely on relationships and trust more than on
clinical expertise
 Relate to community members as peers rather
than purely as client
 Can achieve certain results more effectively
than other professionals
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8. Why CHWs Now?
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9. Why are we discussing CHWs?
 Growing diversity of U.S. population
 Growing prevalence of chronic diseases
 Growing complexity of health care
 Cost pressures on health care system
 Shortages of clinical personnel
 Commitment to reducing health inequities
 Recognition of social/behavioral determinants of health
 Growing experience/evidence base with CHWs
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10. Why are we discussing CHWs?
 The “Triple Aim”
 Improving the patient experience of care (including quality
and satisfaction);
 Improving the health of populations; and
 Reducing the per capita cost of health care
 Health care reform: changing accountability for
outcomes: CHW as members of health care teams
 Accountable care organizations (ACOs)
 Patient-centered medical homes (PCMHs)
 Incentives to reduce costs, improve care
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11. CHWs can be the integrators!
Health Care
Individual Level
Disease Research
& Intervention
Public
Health
SDOH
research &
intervention
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
Social determinants
have not been
integrated in clinic
practice or health
care systems
Leads
to lower value,
substandard care
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12. What’s happening in the States -
and at the federal level?
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Worker Direct Care*
Care Coordination/
Health Promotion
Population­Based
Prevention/
Outreach/
Health Promotion
Payment Options Reporting
CHW
PWS
NAV
X
X
X
PCPCH Payment
or
CCO‐ICM Capitation
Documentation in
Medical Record
CHW
PWS
NAV
X
X
X
CCO‐ICM Capitation
Or
CCO Sub‐Contracted Entity
CCO Reports
Expenditures on
Financial Report **
Doula X Payment to Provider, Hospital
or Birthing Center is enhanced
when Doula is utilized
FFS Claim for Delivery is billed
with modifier
CCO reimbursement is depend‐
ent on the business practice of
the plan
CHW‐Community Health Worker; PWS‐Peer Wellness Specialist; NAV‐Personal Health Navigator
*Direct Care services are provided under the supervision of a Licensed Healthcare Professional
**(Identify the specific report and line item)
***FFS reimbursable for individuals approved for MH 1915(i) Home and Community Based State Plan Option, Dis‐
cussion currently underway to amend the State Medicaid Plan, Rehabilitative Services Option which will authorize
FFS OHP for this HCPCS code.
Oregon Health Authority
Medical Assistance Programs
Non­Traditional Health Workers Financing Options

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17. © 2014 Community Resources LLCUpdated 10/1/14
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18. States are pursuing various models in
CHW policy innovation
 Legislative: Texas, Ohio, Massachusetts, New Mexico,
Illinois, Maryland
 Medicaid rules: Minnesota, Wisconsin, DC
 Policy driven by specific health reform initiatives:
New York, Oregon, South Carolina + SIM states
 Broad-based coalition process: Arizona, Florida.
Michigan
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19. Federal agencies are increasing support
for CHW strategies
 CDC priority on support for policy and systems change
 CDC and HRSA support for TA at state request
 HHS CHW Interagency Work Group
 Office of Women’s Health:
Women’s Health Leadership Institute
 CMMI Grantee CHW Learning Collaborative
 National Health Care Workforce Commission
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20. What CHWs do –
and the skills required
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21. CHWs perform a
wide range of Core Roles
 Cultural mediation between communities and health
and human services system
 Providing culturally appropriate health education
and information
 Assuring people get the services they need
Source: National Community Health Advisor Study, Univ. of Arizona, 1998
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22. CHWs perform a
wide range of Core Roles cont’d
 Informal counseling and social support
 Advocating for individual and community needs
 Providing [some] direct services and meeting
basic needs
 Building individual and community capacity
Source: National Community Health Advisor Study, Univ. of Arizona, 1998
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23. CHWs are employed in many different models
of care
 Member of primary care team
 Patient navigator
 Provider: services, screening, education
 Outreach/enroll/inform concerning specific programs or
services
 Organizer/advocate
Source: HRSA CHW National Workforce Study, 2007
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24. CHWs maintain a unique balance of accountability between
community and health care system
 Roots of CHWs in social justice and economic opportunity
 Many are still grassroots volunteers, especially Promotores
 Increasing interest from health care employers
 CHWs must preserve integrity of community relationships
 As part of personal values
 As an essential factor in their effectiveness!
 Constant balancing act: relationship vs. task
 Compromise: providers/payers can contract with community-based
organizations
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25. CHWs are increasingly employed in innovative
settings combining clinical care and population
health
 Hybrid (Community HUB, Accountable Care
Community, Health Neighborhood)
 Outsourcing to CBOs
 Social entrepreneurial (Canadian co-op)
 South Carolina CHW initiative
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26. The State of the Evidence
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27. Evidence base on CHWs is
growing but complicated
 Hard to present simple answers,
but impact is evident on health outcomes, health
knowledge/behaviors, and costs
 Diversity of CHW activities and health issues means
no unitary measure
 Increasing evidence of cost-effectiveness or “return
on investment” from cost savings
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28. Evidence of CHW impact on
health outcomes is clear in many areas
 Birth outcomes: clearest evidence of preventive impact
 Diabetes: A1c, BMI, HTN, health behaviors
 Asthma: symptom control, missed days
 Cancer screening rates > early detection
 Immunization rates
 Hospital readmissions (care transitions)
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29. Financial ROI can be dramatic
Recent studies all showing about 3:1 net return or better:
 Molina Health Care: Medicaid HMO reducing cost of
high utilizers
 Arkansas “Community Connectors” keeping elderly and
disabled out of long-term care facilities
 Community Health Access Program (Ohio) “Pathways”
reducing low birth weight and premature deliveries
 Texas hospitals: redirecting uninsured from Emergency
Depts. to primary care
 Langdale Industries: self-insured industrial company working
with employees who cost benefits program the most
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30. Citations for ROI
 Johnson D, Saavedra, P, Sun E, et al. Community health workers and
Medicaid managed care in New Mexico. J Community Health; 2011; DOI
10.1007/s10900-011-0484-1
 Felix HC, Mays GP, Stewart MK, et al. The care span: Medicaid savings
resulted when community health workers matched those with needs to
home and community care. Health Affairs. 2011;30(7):1366-74.
 Redding S, Conrey E, Porter K, Paulson J, Hughes K, Redding M.
Pathways Community Care Coordination in Low Birth Weight Prevention.
Matern Child Health J; Aug 2014; DOI 10.1007/s10995-014-1554-4
 Dols J. Return on investment from CHRISTUS Health CHW program.
PowerPoint presentation, Houston TX, 2010.
 Miller A. Georgia firm’s blueprint for taming health costs. Georgia Health
News; July 27, 2011.
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31. Key policy areas for consideration in
states that want to advance the CHW
workforce
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32. 4 key policy areas require attention
1. Occupational definition (agreement on scope of
practice and skill requirements)
2. Sustainable financing models
3. Documentation, research and data standards
(records, evidence of effectiveness and “ROI”)
4. Workforce development (training
capacity/resources)
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33. 4 key policy areas require attention
1. Occupational definition
 Need agreement on CHW Scope of Practice (SOP)
and skill requirements
 Linked to awareness/education effort
 Broad consensus needed
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34. CHW Scope of Practice
gradually gaining traction
 SoP formally adopted only in MA, MN
 States with certification (TX, OH) currently have
broader definitions
 States relying on the 1998 National Community
Health Advisor Study “Core Roles” as starting point
 Derived from national surveys and focus groups of CHWs
and employers
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35. 4 key policy areas require attention
Cont’d
2. Sustainable financing models
 Support CHWs as permanent, integrated workforce,
rather than on short-term
 Encourage internal financing by employers as well as
3rd-party payment
 High potential in new models of care (PCMH, ACO)
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37. 4 key policy areas require attention
Cont’d
3. Documentation, research and data standards
Records, evidence of effectiveness, and ROI
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38. 4 key policy areas require attention
Cont’d
4. Workforce development
 Training:
 Must be competency-based, learner-centered, participatory
 Emphasize field work, mentoring, and include on-going practice-based
assessment
 Should be offered in various settings: familiar, accessible
 Who pays?
 How much classroom pre / post-hire?
 Employers must consider career development
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39. Key Strategy Points in Policy Change
 Education and awareness effort needed first
 Need “Champions” in various stakeholder groups
 Interdisciplinary collaboration & self-determination
 Recognize history of CHW leadership & advocacy for
profession
 Take action with CHWs, not for them
 New APHA policy statement under consideration
 CHW networks and associations may need support
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40. Key Strategy Points in Policy Change
cont’d
 Is legislation needed? At what point?
 Learn from other states’ experience with
legislation:
MN, MA, NM, IL, MD & others in progress
 Using local and national workforce data
 Remember: Not all CHWs work in health care!
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41. Thank you!
 Ashley Wennerstrom, PhD, MPH
awenners@tulane.edu
 Carl H. Rush, MRP
carl.h.rush@uth.tmc.edu
 Samantha Sabo, DrPH, MPH
sabo@email.arizona.edu
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