Community Health Workers: An Answer to Growing US Health Care Needs, New Public Health Institute Report Finds

Barriers to Their Use and Practice Must Be Addressed

Oakland, CA — Community health workers and promoters can reduce avoidable emergency department visits by 42%, deliver an impressive 4:1 return on investment, ensure that more patients keep their medical appointments, and improve health outcomes, a new Public Health Institute report finds.

The time has come to bring community health workers (CHWs) and promotores “into the mainstream of the US health care system,” states the report, “Taking Innovation to Scale: Community Health Workers, Promotores and the Triple Aim.”

These trusted, lay community workers, for decades relegated to narrow roles, are well suited to make a broader contribution as members of primary care teams, the report finds. In this way, they would help meet the increased demand for health services as health reform expands insurance to more people and help meet “Triple Aim” objectives (see below). They would also serve as a key resource in implementing population health improvement strategies.

The report is published by the California Health Workforce Alliance, a program of the Public Health Institute.

“We need to scale up the use of community health workers in California to expand care to those newly insured under the Affordable Care Act, to control costs and to improve health outcomes – but also to address the social and environmental factors like poor housing, unemployment and having no insurance coverage that contribute to poor health,” said Kevin Barnett, DrPH,  co-director the Alliance “CHWs can bring deep and invaluable knowledge of the social and cultural context of their patients’ lives in their communities to team-based health care.”

The report calls for bringing the use of CHWs to scale and recommends the following actions:

• Promote statewide policies that address financial and professional requirements for expanding the use of CHWs.
• Expand statewide education, training and certification to support integration of CHWs into team-based care.
• Develop financing mechanisms that enable CHWs’ work to be appropriately compensated.

The Affordable Care Act recognizes CHWs as integral members of the health care workforce and for the key role they can play in achieving the goals of healthcare reform through participation in community-based health teams.

“Taking Innovation to Scale” surveyed 121 urban and rural community health centers and clinics in California to assess the roles of 1,644 CHWs and how these workers contribute to improving the care experience, improving the health of populations and reducing health care costs (these are known as the “Triple Aim” objectives). The overall number of CHWs employed by a wide range of California safety net providers has previously been estimated to be as many as 13,000.

The Alliance report highlights case studies that demonstrate the unique contributions and impacts of CHWs (with various titles) who work in a team-based approach to health care and wellness. These innovative models include:

• Inland Empire Health Plan Health Navigator Program. CHWs provide personalized education, guidance and advice to health plan members they visit at home who have a history of avoidable emergency department visits or aren’t current with well-child medical visits. They emphasize preventive care and which types of provider care are appropriate for non-emergencies. The program contributed to a 42% decrease in avoidable ED visits.
• Molina Healthcare Connector Program. CHWs targeted members who had high cost-utilization patterns, complex medical or behavioral health needs, or chronic conditions. The program’s pilot site in New Mexico delivered a 4:1 return on investment. Molina will expand the program into nine states, including California.
• La Clinica de la Raza Patient Navigator Program. In a pilot, CHWs referred patients at the Sutter Solano ED in Vallejo to an enrollment specialist who assists with coverage, connects them to a primary care provider at the local La Clinica and identifies other needs like food, transportation and employment. The pilot increased “show rates” for appointment by more than 70% and reduced return ED visits during one month to the lowest ever reported (4%).

CHWs serve as a bridge between individuals in the community and local social and health services. They facilitate access to services and improve the quality and cultural competency of services. They also build health knowledge and self-sufficiency through outreach, community education, informal counseling, social support and advocacy.

Two-thirds of the safety net providers surveyed employ CHWs in a range of roles in diverse settings – most often by assisting patients to gain access to medical care or community services. More than half reported providing health screenings, health promotion and education as well as advocacy for the patients’ health needs. The providers anticipated growing roles for CHWs in care coordination, particularly for chronic conditions, in the next five years.

However, expansion of CHWs into primary care faces barriers, the report found. The safety net providers had limited recognition of how to effectively integrate CHWs into team-based care and meet Triple Aim objectives; they also reported difficulties in expanding the scope of work for CHWs they currently employ and increasing the number of CHWs.

The survey findings indicated that expanding the level of CHW engagement and contributions is impeded by a lack of occupational identity (often because of a range of occupational titles), a lack of awareness among health care providers of their unique value, a lack of standardized training and credentialing requirements, and a lack of sustainable funding. Also, providers had limited access to external data and analytical capacity to document CHWs’ contributions to the Triple Aim objectives.

The Alliance report was funded by the Blue Shield Foundation.

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The California Health Workforce Alliance is a statewide public-private partnership of education institutions, health professions, employers and federal, state and local agencies. The Alliance advances comprehensive and coordinated strategies to build the health workforce needed to meet the demands of our increasingly diverse communities in California.