Abstract
This policy brief, commissioned by the California State Innovation Model (CalSIM) team of the California Health and Human Services Agency, explores the feasibility of using community healthcare workers (CHWs), and the range of potential models for CHW placement within the healthcare system, public health system, and/or community.
Insights Results
Overview of article/program
This policy brief explores the feasibility of using community health workers (CHW) and the range of potential models for CHW placement within the healthcare system, public health system, and the community
California’s State Innovation Model (CalSIM) Design Grant builds upon the framework, goals and indicators of the state’s Let’s Get Healthy California final report. 6 goals guide the framework: 1) Healthy Beginnings; 2) Living Well; 3) End of Life; 4) Redesigning the Health System; 5) Creating Healthy Communities; and 6) Lowering Costs
In general, there are 5 models of care using CHWs: 1) Member of the care team – CHW works to complement the activities of a lead provider, the CHW is used to enhance the care team’s productivity by assisting with coordination and communication tasks; 2) Navigator – Focuses less on clinical management and more on assistance navigating the healthcare system through referral support, appointment assistance, follow up and education about the appropriate use of services; 3) Screening and health education provider – CHW provides information and education about specific health conditions, self-care strategies, recommended treatment patterns and goal setting in a clinic or community-based setting; 4) Outreach/enrollment worker – CHW provides community and individual assistance for application and enrollment into available services; and 5) Organizer – CHW is a community leader and advocate who promote change by engaging the population in community development and leading civic engagement activities
One of the proposed CHW models is Living Well – Patient-Centered Medical Home for Medically Complex Patients. This proposal would place CHWs in medical practices as a part of a team-based care model serving medically complex patients with a significant chronic disease burden and high medical costs. CHWs would work in concert with the medical team to address social determinants of health, assist patients in navigating the healthcare system, provide health education, and promote self-management and increase self-efficacy. If implemented, CalSIM should consider: 1) Establishing a detailed understanding of the characteristics of the target population, and the drivers of their outcomes/behavior/expenditures, so that hiring and training of CHWs can be targeted to match the identified population needs; 2) Using a multi-payer framework to fund this model, to reach the broadest possible population of eligible patients and to simplify implementation for participating clinics/providers; and 3) Focusing CHW services in clinics/practices that already use a team-based care model, or have a demonstrated readiness to use team-based care practices. Providers with experience in a team based setting may be better able to effectively leverage CHW services and to maximize the value
of CHW time as a means to help all medical staff practice at the top of their license
The second proposed CHW intervention is Creating Healthy Communities – Patient Integrator at the Individual Level. The intervention would have CHWs in community settings to deliver a range of preventive programs, promoting long-term community improvement through advocacy, education, capacity building and networking. If implemented, CalSIM should consider: 1) Engaging CHWs and advocacy groups when designing the funding model, so that it achieves the goals of building sustainability and consistency while avoiding potential unintended consequences such as distancing CHWs from the community, decreasing CHW legitimacy, or limiting the flexibility and responsiveness that is essential to the success of this model; and 2) Selecting funding priority areas that not only align with the SIM initiative goals, but also align with community needs. California may consider undertaking a needs assessment as an early stage of the SIM initiative to help establish an understanding of community experience and outcomes at the baseline, community-identified needs, and CHW workforce capacity
Results
The 2 areas in which beneficial outcomes have been documented are healthcare costs and health outcomes
Evidence of the impact on CHW interventions on health outcomes is more robust and includes improved diet for those with diabetes, increased rates of compliance with cervical, breast and colonoscopy screening recommendations, and increased childhood vaccination rates
Research on cost outcomes of CHW programs show a positive return on investment, however, such research is limited. For example, CareOregon has shown a decrease in inpatient and emergency utilization for patients who completed the intervention
Key takeaways/implications
Overall, experts concur that the cost effectiveness of CHW interventions require further analysis
It’s unclear whether providers or community agencies should rely on volunteer-based CHW programs. Many argue that CHWs should be paid and that there are difficulties in building accountability and reliability using a volunteer-based model. However, if CHWs are paid, they may lose authenticity and trust in the community and organizations must also consider legal employment status
Training of CHWs must also be considered. There is a growing interest in mandated training or certification for CHWs by states, however, with this approach, it must be considered that these mandated trainings might exclude currently practicing or new CHWs who have little formal education, lack the resources to obtain training/certification or are undocumented
2 alternative financing mechanisms (besides grants) should be considered if CHW services are included in the CalSIM testing grant proposal: 1) Budgetary approach – a central organization establishes a budget for the CHW program and acts as the direct employer of the CHW workforce; and 2) Reimbursement to service providers for CHW services – Hiring, training, and supervision of CHWs is delegated to the direct service providers
Challenges associated with measuring the impact of CHW programs include difficulty in measuring certain outcomes (e.g., improved self-efficacy), impacts may not be immediately measurable, lack of data on the whole client, and likelihood of regression for high-cost or high-utilizing populations
Overall, the following should be considered in integrating a CHW intervention: 1) Involving CHWs and advocacy groups in the planning and design process; 2) Engaging CHWs to explore whether standardized training requirements should be established for CHWs practicing within the model; 3) Exploring feasibility of a centralized employment model for CHWs, to decrease administrative/ supervisory burden, promote consistency in CHW training and standards, and provide CHW peer support; 4) Designing a multi-payer and multi-stakeholder financing model that does not limit CHW services to specific groups of insured individuals; and 5) Incorporating a robust evaluation plan for the CHW initiative, ideally during the design phase to maximize planning and availability of necessary data
