Community Health Workers: a National Perspective

Community Health Workers: a National PerspectiveCarl H. Rush, MRPCommunity Resources LLCSan Antonio, TexasIndiana Community Health Worker CoalitionCHW Symposium October 15, 2012Todays topicsWho/what is a CHW?Whats happening nationallyCHWs in a changing health care systemPolicy initiatives in other statesWhat needs to happen in Indiana?2Whats your definition of CHW?

3Community Health Worker Definition American Public Health Association (1)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.4Community Health Worker Definition - APHA (2)The CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such asoutreach, community education, informal counseling, social support and advocacy.

APHA Policy Statement 2009-1, November 20095What is distinctive about CHWs?Do not provide clinical careGenerally do not hold another professional licenseExpertise is based on shared culture and life experience with people served6We have noted earlier that the occupation of CHW is different from conventional occupations, even within health care and public health. The first distinction is that they generally do not provide clinical care, beyond some simple screening tasks such as blood pressure and demonstrating medical devices like a glucometer. There are a few exceptions, mainly in remote rural areas, such as the tribal Community Health Representatives and the Community Health Aide/Practitioners in Alaska.

The next three points, however, begin to get at the essence of the occupation. CHWs are effective because of their ability to create trusting relationships with community members. This is more important than their clinical knowledge; their clinical education is generally limited to essential knowledge in topics related to their specific job. They are typically not allowed to give any form of medical advice, and often refer patients to a clinical supervisor in dealing with detailed clinical questions.

They do, however, have what might be termed experience-based expertise, and are helpful to the system as well as to the community by using their understanding of the culture and social structure of the community they serve. This understanding is generally based on actually sharing cultural background and similar life experience with that community rather than on sociological theory or advanced social work methods.

Another distinction, and a strength of the CHW, is their ability to relate to community members as peers rather than purely as patients or clients. The conventional professional-to-client relationship can set up barriers to communication based on differences of power, status and culture; the CHW can avoid those distinctions, leading in many cases to greater trust, candor and cooperation on the part of the patient.

And finally, most CHWs do not hold a license in another profession. There are some cases of licensed nurses, social workers and other professionals who choose to practice as CHWs for reasons of personal preference or commitment. Some foreign-trained medical professionals also work as CHWs, but the vast majority of CHWs are otherwise unlicensed, hence the common use of the term lay workers to describe them.What is distinctive about CHWs? (contd.)Rely on relationships and trust more than on clinical expertiseRelate to community members as peers rather than purely as clientCan achieve certain results that other professionals can't (or won't)7CHWs and Patient NavigatorsPNs assigned to specific patients; CHWs often notPN duties are a subset of potential CHW dutiesPNs may have another occupational background (RN, MSW); this is a valid program design choice Patient navigation is a role or function, not a separate occupationWhats happening at the national level?National milestones for CHWsOpportunities in State planning for health care reformOther new federal CHW initiatives9National milestonesNational Community Health Advisor Study (1998)State CHW credentialing in TX and OH(2002-3)Massachusetts health care reform bill (2006)HRSA CHW National Workforce Study (2007)NUCC Provider Taxonomy code for CHWs (2007)Minnesota Medicaid State Plan Amendment (2008)OMB creates SOC code for CHWs (2009)

10Other opportunities in state health reform to promote employment of CHWsStandards for patient-centered medical homes and community health teamsStandards for preventive care benefitsRules for Medical Loss Ratios11Patient-Centered Medical HomesNational Committee for Quality Assurance accreditationStandards scored under 27 elements in 6 category areasLevel 1 = 35-59 points; Level 2 = 60-84 points; Level 3 = 85-100 pointsPatient-Centered Medical HomesArea 1: Enhance Access and ContinuityElement F: culturally and linguistically appropriate services (CLAS) Element G: the practice team - CHWs can add depth of understanding of the patient/family situationArea 2: Managing the Patient PopulationElement A: patient information; assuring the team has a complete picture, and patient/family are being candidElement C: patient assessmentElement D: population management; emphasizes prevention

Patient-Centered Medical HomesArea 3: Managing careElement A: patient remindersElement C: care management (care plan and follow-up)Element D: medication management (reconciling and recording)Area 4: Self-care support and community resourcesElement A: self-care supportElement B: referrals to community resourcesArea 5: Tracking and coordinating careElement A: lab test follow-upElement B: referral follow-upElement C: coordination and care transition CDC CHW policy e-learning seriesOWH CHW leadership trainingDOL apprenticeable trade approvalOMH Promotora/CHW initiativeNew federal CHW initiatives1515New Federal CHW initiatives (2)HHS working group on CHWsHUD CHW InitiativesCMS Medicare diabetes disparities pilotsCMS Center for Innovation

16Link to CDC E-learninghttp://www.cdc.gov/dhdsp/pubs/chw_elearning.htm

[include complete URL in browser]17Evidence of CHW effectivenessHard to present simple answers,but impact is evidentDiversity of CHW activities and health issuesIncreasing evidence of cost-effectiveness or return on investment from cost savings

Recent CHW ROI studiesAll show about 3:1 net return or betterMolina Health Care: Medicaid HMO reducing cost of high utilizersArkansas Community Connectors keeping elderly and disabled out of long-term care facilitiesCommunity Health Access Program (Ohio) Pathways reducing low birth weight and premature deliveriesTexas hospitals redirecting uninsured from Emergency Dept. to primary careLangdale Industries: self-insured industrial company working with employees who cost benefits program the mostSurge in state-level interestIn addition to established initiatives in MA, MN, FL, NY, RI -New movements in AZ, IL, MS, NM, SCRecent investigations by State in DE, MO, ND, UTDelaware Health AmbassadorsCHW Network of Buffalo (NY)Seattle-King County WACommon elements in all statesConcentrated education/awareness effortAgreement of scope of practice and qualifications/ skills standardsMost moving toward some form of credentialingStrategy for sustainable financing of CHW positionsResources for workforce developmentMobilizing CHWs to participate in the processWhat needs to happen in Indiana?What would you like to do?Who else should be involved?Who can provide leadership?How can the Coalition help?22Useful reports/linkshttp://links.chwsurvey.com23For more info:Carl H. Rush, MRPCommunity Resources LLCPO Box 5533San Antonio, TX 78201-0533(210) 775-2709(210) 241-3983 mobilecarl.h.rush@uth.tmc.edu24