MHP Salud

COMMUNITY HEALTH WORKERS AND THE

SOCIAL DETERMINANTS OF HEALTH

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Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

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Introduction

The importance of social factors in people’s health has been recognized since the modern development of public health as a discipline during the 1800s.1 In the twentieth century, in its constitution, the World Health Organization (WHO) effectively identified health as encompassing social well-being, and inequality as a danger in the protection of health.2 This key role of the WHO in defining the social determinants of health (SDOH) was formalized in 1998 with the publication of the first edition of “Social Determinants of Health: The Solid Facts” and later, in 2005, with the establishment of the Commission of Social Determinants of Health. Today, global and national organizations and individuals have developed a vast new literature on the social determinants of health, including research on their importance, how to understand them and define them, and the develop-ment of tools to identify them and address them. This brief will present some general information on social determinants of health, available tools for data collection on SDOH, and the role that Community Health Work-ers (CHW) may play in implementing SDOH programs.

What are the Social Determinants of Health? According to the World Health Organization (WHO), the social determinants of health are the “conditions in which people are born, grow, live, work and age.” These circumstances, which are shaped by the distribution of money, power and resources, are mostly responsible for health inequities.3

Ten Social Determinants of Health In 2003 the WHO published a second edition of their seminal document “Social Determinants of Health: The Solid Facts,” incorporating what at that time was new and stronger evidence developed since the publication of the first edition. Ten determinants were identified and supporting evidence of their impact in shaping health is presented for each one of them. These ten determinants, which are heavily interrelated, are:

1. The Social Gradient: shorter life expectancy, as well as the most common diseases, are more commonas one moves down the social and economic ladder. Disadvantages are related to material and socialassets, as well as to insecurity and poor education.

2. Stress: Continued anxiety, insecurity and isolation have a strong impact over health. This impact accu-mulates over time and can increase the odds of premature death and poor mental health.

3. Early Life: Pregnancy and early childhood conditions serve as the foundations for adult health, evenimpacting health at a biological level.

4. Social Exclusion: Social exclusion as a result of poverty, discrimination and other forms of hardship im-pacts people’s health and their access to beneficial resources such as education or services.

5. Work: In addition to having or not having a job, work conditions affect the risk of developing certainhealth conditions. The level of control over one’s work, as well as the demands and rewards of certainoccupations, have been identified as impacting health.

1 Engels, F. (1993). The condition of the working class in England. Oxford University Press, USA. 2 WHO, Constitution of (1946). World Health Organization. 3 WHO. (n.d.) About social determinants of health. Retrieved March 20, 2018, from http://www.who.int/social_determinants/sdh_ definition/en/

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6. Unemployment: Job security has a positive impact on health, while higher unemployment rates result inpremature death and illness.

7. Social support: The existence of sources of support, and the good quality of those existing social rela-tions, act as protective factors for health.

8. Addiction: The use of substances is a response to adverse social circumstances, but at the same time is asignificant factor in worsening individuals’ health. It is also an important driver of health inequalities.

9. Food: The availability and cost of healthy and nutritious food is a main factor in determining what peopleeat. However, access to food is unequally distributed in society.

10. Transport: Access to healthy transportation methods, such as walking and cycling, can help address thechallenge of growing sedentary patterns. It can also impact environmental quality by reducing road traf-fic.

As members of the community they serve, Community Health Workers can be an extremely effective tool for ad-dressing these issues. Their deep knowledge of the communities, coupled with the trust and rapport they build with their clients, make Community Health Workers a natural fit for addressing the holistic issues of SDOH that are intrinsically intertwined with the health outcomes of their clients.

Methods and Tools for Collecting SDOH Data There are several tools available to health centers and organizations interested in better monitoring the social determinants of health of their patients. This section presents some resources currently available.

Data Collection Tool Offering Standardization: The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

The PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) is the result of an effort between multiple national organizations, funders and health centers and networks to assist health centers and other providers in collecting data regarding patients’ social determinants of health.4 The assessment was developed to align with national initiatives such as Healthy People 2020, clinical coding, and health centers’ Uniform Data System (UDS), with a focus on developing standardized and actionable measures. The assessment tool collects information through 17 core questions on the following issues:

4 National Association of Community Health Centers. PRAPARE - NACHC (2016) Retrieved March 20, 2018, from http://www.nachc.org/ research-and-data/prapare/ 3

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Basic personal characteristics: Ethnicity / race, seasonal or migrant farm work, veteran status, and language

Family and home: Number of family members living together, housing situation, housing instability, and neighborhood

Money and resources: Educational attainment, employment, health insurance, income, material security (food, clothing, utilities, etc.), transportation

Social and emotional health: social support, stress

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In addition to these sections, the PRAPARE tool also includes four optional questions on issues such as incar-ceration, refugee status, physical safety, and intimate partner violence. The PRAPARE tool is available in English and Spanish.

An important goal in developing the PRAPARE tool is the collection of standardized data on all core measures, as this is considered necessary to “accelerate population health planning, facilitate benchmarking across organizations, and document patient complexity that can inform payment models and risk adjustment.” 5 For this reason, in addition to the PRAPARE tool itself a range of resources have been developed and made avail-able for health centers and other providers, to aid successful and standardized implementation. Resources include the PRAPARE Implementation and Action Toolkit, as well as recorded trainings and webinars. Trainings and webinars cover issues such as an introduction on SDOH, the PRAPARE tool itself, case studies, best prac-tices, and functionalities of available EHR templates such as eClinicalWorks and NextGen.

Data Collection Tool Offering Flexibility: Social Needs Screening Toolkit Another effort in developing a comprehensive tool for health systems to collect data on SDOH is the Social Needs Screening Toolkit from Health Leads. This toolkit was developed based on a patient centered approach, as well as on researched and clinically-validated guidelines from organizations such as the Institute of Medi-cine, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC). The guiding principles for this tool and its suggested implementation are brevity and simplicity (maximum of 12 questions, fifth grade reading level), use of validated questions, integration into clinical workflows, patient pri-oritization, and piloting before scaling. The tool was updated in 2018 to include a fully translated Spanish ques-tionnaire template, as well as additional questions to address new topics and better align with other resources such as PRAPARE.

The 2018 Social Needs Screening Toolkit suggested questionnaire includes eight questions on the following need domains:

• Food insecurity• Utility needs• Housing instability• Financial resource strain (child care and health care)• Transportation• Education (health literacy)• Social isolation and supports

Two additional suggested questions ask patients to indicate whether they consider the needs reported to be urgent, and whether they would like to receive assistance on any of the identified needs. Additional questions on the core domains, as well as questions on other optional domains, are also available in the toolkit. Each question includes information on whether it has been validated, its level of specificity (general to focal), and the literacy level required. Additional domains included in the 2018 Social Needs Screening Toolkit are:

• Exposure to violence• Socio-demographic information• Employment• Health behaviors, behavioral / mental health

Emphasizing a different perspective than PRAPARE, rather than focusing on the collection of standardized data across all users, the Social Needs Screening Toolkit focuses on flexibility. The core questionnaire is suggested as a recommendation, with the toolkit offering health centers guidance on how to build a strong and reliable questionnaire on SDOH according to their needs.

5 National Association of Community Health Centers. PRAPARE - NACHC (2016) Retrieved March 20, 2018, from http://www.nachc.org/ research-and-data/prapare/

MHP Salud implements Community Health Worker programs to empower underserved Latino communities and promotes the CHW model nationally as a culturally appropriate strategy to improve health.

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Other SDOH screening tools

Other available tools for the collection of SDOH data are the Accountable Health Communities screening tool, developed by CMS.6 This tool includes 10 items on five core domains: housing instability, food insecuri-ty, transportation, utility needs, and interpersonal safety. In addition to those core domains, sixteen supple-mental questions address: financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities.

Developed exclusively for a pediatric setting, WE CARE (Well-child care visit; Evaluation; Community re-sources; Advocacy; Referral; Education)78 is a screening tool that assesses needs in six domains: parental education, employment, childcare, housing stability, food security, and utilities. In addition to asking about the need, the survey includes follow-up questions on desire to receive help on that need, and whether there is need of immediate assistance.

6 Centers for Medicare and Medicaid Services. (2016). Accountable health communities model. 7 Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-304. PMID: 25560448. DOI: 10.1542/peds.2014-2888. 8 Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project. Pediatrics. 2007;120(3):547-558. PMID: 17766528. DOI: 10.1542/peds.2007-0398.

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How can Community Health Workers address SDOH?

Community Health Workers (CHWs) are public health workers who are trusted members of the communities they serve or have an unusually close understanding of them. Due to this trusting relationship, CHWs serve as intermediaries between their communities and health and social services. In their role CHWs facilitate ac-cess to services, improve the quality and cultural competence of those services, and help build individual and community capacity by increasing health knowledge and self-sufficiency.9 In addressing access to services, cultural competence, health knowledge and literacy, as well as self-sufficiency, CHWs’ roles often intersect with the social needs of their clients that impact their health; that is, the social determinants of health. Strong evidence exists supporting the effectiveness of CHWs in impacting the health status of underserved populations, 10 11 which are by definition those most adversely impacted by the social determinants of health. As such, CHWs are ideal health providers for addressing the SDOH of communities and/or clinical populations.

Case studies of CHW programs addressing SDOH While most CHWs in some capacity address the social needs of their clients, some programs have specifically focused on CHWs’ role in this area.

• In Acción para la Salud, CHWs from agencies in three different Arizona counties were trained in com-munity advocacy. In their encounters CHWs identified problems, formulated solutions, and describedchange efforts; in their work they were able to initiate discussions about SDOH, and identified possiblesolutions to address issues such as neighborhood conditions, the availability of opportunities, and ac-cess to services.12

• In the Pathways to a Healthy Bernalillo County, CHWs focus of work included both medical care andnonmedical social determinants such as housing, food security, education, utilities, and transporta-tion. In their model, payment structure was based on health outcomes for clients rather than encoun-ters, supported by a sustainable funding stream achieved through community advocacy.13

9 American Public Health Association (n. d.) Community Health Workers. Retrieved March 20, 2018, from https://www.apha.org/apha-communities/member-sections/community-health-workers 10 Swider, S. M. (2002). Outcome effectiveness of community health workers: an integrative literature review. Public Health Nursing, 19(1), 11-20. 11 Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., ... & Fox, D. J. (2010). Community health workers: part of the solution. Health Affairs, 29(7), 1338-1342. 12 Ingram, M., Schachter, K. A., Sabo, S. J., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., & Carvajal, S. C. (2014). A community health worker intervention to address the social determinants of health through policy change. The journal of primary prevention, 35(2), 119-123. 13 Page-Reeves, J., Moffett, M. L., Steimel, L., & Smith, D. T. (2016). The Evolution of an Innovative Community-Engaged Health Navigator Program to Address Social Determinants of Health. Progress in community health partnerships: research, education, and action, 10(4), 603-610.

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Supporting CHWs in Addressing SDOH: Best Practices

Supported in the existing evidence that confirms the effectiveness and value of CHWs in addressing SDOH, the Hispanic Health Council (HHC) developed the policy brief “Addressing Social Determinants of Health through Community Health Workers: A Call to Action.” In this brief the HHC argues in favor of promoting healthcare policy that supports CHW services to best serve the needs of the communities most affected by health inequi-ties. The specific recommendations include specific actions on:

1. Payment: Payment of CHW services that is based on outcomes and covers services that address SDOH.

2. Duties: CHW job duties that provide sufficient time and range to address SDOH (e.g. extended face-time with clients and home visits).

3. Recruitment: CHW recruitment based on candidates’ unique understanding of the communities served.

4. Training of CHWs: Training of CHW that involves experienced CHWs in their design and delivery, andthat include in their curriculum education on SDOH and health inequities; skills such as communica-tion, service coordination, data collection, and documentation in EHR; and principles and techniques ofpopular education.

5. CHW Supervision: Training of CHW supervisors, and a supervisor to CHW ratio that facilitates high qual-ity supervision.

6. Integration to Clinical Teams: CHWs integration to clinical teams through training of all members ofthe healthcare team, to help ensure that CHWs’ role is valued, understood, and supported by all teammembers, and that CHWs are actively included in care team meetings and in the documentation of ser-vices provided.

7. Documentation: Training of CHWs in documenting the effects of their work on SDOH, for example indata collection, and the ongoing implementation of process and impact evaluations for continuousquality improvement and program sustainability

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SDOH-specific training to support CHWs As suggested by the HHC Policy Brief, training CHWs in SDOH and health inequities is an important action step in supporting their effectiveness in addressing them. This includes training CHWs in the collection of SDOH data through instruments such as the ones presented in the previous section, as well as in the analysis and action based on SDOH data collected. Additionally, and depending on the specific needs of their communities, CHWs may require training on specific issues or programmatic topic areas. Examples of SDOH topics in which CHWs may need appropriate training, as identified by the National Health Care for the Homeless Council, include:14

• Substance abuse and addiction: commonly abused substances among the population, signs and symp-toms of impairment, options available.

• Mental health diagnoses and treatment: common mental health diagnoses, symptoms of these diag-noses, what to do in a crisis.

• Trauma response and trauma informed care: trauma and how does it affect someone’s behavior, trau-ma informed care.

• Common chronic diseases: common chronic conditions and their signs, symptoms and treatments.

• Harm reduction: philosophy and best practices in harm reduction, stages of change.

CHWs are at their most effective when they receive appropriate and comprehensive training. This is especially imperative in addressing holistic health concerns as a part of a SDOH strategy.

Interested in implementing a Community Health Worker program that addresses the Social Determinants of Health? MHP Salud can help!

MHP Salud 2111 Golfside Dr. Suite 2B Ypsilanti, MI 48197

info@mhpsalud.org 956.968.3600

mhpsalud.org

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under cooperative agreement number U30CS09744, Technical Assistance to Community and Migrant Health Centers and Homeless for $617,235 with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be

construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

National Health Care for the Homeless Council. (2016) Integrating Community Health Workers into Primary Care Practice: A Resource Guide for HCH Programs. Training CHWs. Retrieved March 20, 2018, from https://www.nhchc.org/chw-2-section4/ 14