Abstract
In the editorial of last month’s issue, Dr. Galiatsatos challenged young physicians to “Motivate the Community, Implement Health and Wellness Initiatives, and Thus Empower Our Patients to Better Manage their Diseases”. This is a daunting task for physicians to do themselves, even with community partnerships. Nonetheless, physicians can be effective team leaders in this effort if they build the patient centered medical home and use their healthcare team members wisely.
Citation
Miller WC. Community Health Workers Can Have an Integral Role in Community Medicine. SM J Community Med. 2015; 1(2): 1009.
Introduction
In the editorial of last month’s issue, Dr. Galiatsatos challenged young physicians to “Motivate the Community, Implement Health and Wellness Initiatives, and Thus Empower Our Patients to Better Manage their Diseases”. This is a daunting task for physicians to do themselves, even with community partnerships. Nonetheless, physicians can be effective team leaders in this effort if they build the patient centered medical home and use their healthcare team members wisely.
Community Health Workers (CHW’s) are an emerging vital member of this physician-lead preventive medicine team. CHW’s have been around for decades, but only since U.S. healthcare reform, have CHW’s become a more visible work force capable of bridging the gap between medical practice and community members. The Centers for Disease Control and Prevention, Department of Health and Human Services, Affordable Care Act, and American Public Health Association, amongst others, all have their own definition of a CHW. Even so, these definitions share some common characteristics. First and foremost, CHW’s are members of the community they serve. The fact that CHW’s share ethnicity, language, socioeconomic status, culture, and experiences of the people they serve gives CHW’s clear insight into what treatment plans and/or healthcare initiatives may work or not work for individual patients and communities
The definitions for CHW’s also initiate skills, competencies, and scope of practice for CHW’s. Building community capacity and helping patients gain access to healthcare services is a critical role of CHW’s that is difficult for healthcare providers or allied health professionals to fulfill. With “One foot in the healthcare system and one foot in the community”, CHW’s are in a unique position to advocate for patients and work on behalf of communities where there are healthcare disparities. CHW’s do this by helping patients overcome personal barriers to lifestyle change and by helping communities overcome policy, environmental, and service barriers to support healthy lifestyles. The people skills that are critical and advantageous for CHW’s allow them to work with patients through informal counseling and education to improve chronic disease self-management. The potential for CHW’s to help improve care for vulnerable populations; help achieve the triple aim of better care, better health, and lower costs; and advance population health is too promising to be deterred [1]. Why then, haven’t CHW’s been more quickly integrated into the patient centered medical home model?
The global answer to this question is that the training and certification of CHW’s is not uniform across the country [2] and that the effectiveness of CHW’s has not been recognized [1]. Only a handful of states across the country have adopted a statewide credentialing system for CHW’s, while a handful of other states have partial or highly focused CHW certification programs [2,3]. Educational backgrounds for CHW’s range from some on-the-job training to formal college based programs that grant certifications or associate degrees [3]. Most CHW’s are trained by either their employers or by peer mentors and their training is not based upon a uniform set of core competencies. This lack of accepted CHW training standards, core competencies, and accepted scope of practice impedes the CHW’s ability to link individuals, families, and communities to a full range of healthcare support [3].
In spite of the lack of consistency in CHW training and certification, CHW’s have demonstrated their importance as extenders of care beyond clinic walls and between doctor visits. The vast majority of research on CHW effectiveness shows that they are most successful working with patients who are high utilizers of the healthcare system-meaning those patients who frequently visit hospitals and emergency rooms and who have poor chronic disease self-management. These effective CHW’s generally work with the healthcare team on patient care coordination and case management. The CHW’s provide extended care by performing time-intense patient-centered tasks such as educating patients on chronic disease self-management, scheduling patient follow-up visits, making home visits, helping patients with medication management, and helping patients gain access to social services and community resources. What has not been shown in the literature is how CHW’s can be effective in community health. This lack of community health effectiveness information is probably due to the more prominent need to show the financial value of CHW’s in clinical practice. Indeed, a recent live poll revealed that 57.5% of those surveyed said the biggest challenge to integrating CHW’s into health care systems is financing their work [4]. Due to the barriers of limited recognition (diversity of training) and lack of a business case (cost effectiveness), most CHW implementation programs have been grant funded; and as with many grant-funded initiatives, sustainability is an issue.
The last major barrier to integrating CHW’s into the preventive medicine team is fear of the loss of patient control. This fear is not specific just to CHW’s, but is a valid fear of the patient centered medical home. As more professionals work with a patient on all aspects of health, how does one professional know what the other professional is doing with the patient? How does the primary care physician know where in the patient-care continuum the patient lies, if a primary care physician does not have control of patient care? This barrier is not insurmountable, and as mentioned in the previous editorial, medical education (including graduate medical education and continuing medical education) can play a major role in building individual and community trust in the healthcare system.
As healthcare reform and other pressures push the healthcare system to move beyond the traditional provider-centric model to one that also addresses the broader social and environmental determinants of health, engaging CHW’s as critically important members of the primary care team is one of the most important strategies available to us [1].
References
4. University of Texas Health Sciences Center at Houston. National Academy for State Health Policy Webinar Live Poll. 2015