COMMUNITY HEALTH WORKER PANEL¹

The session moderator, Karen Murphy from Geisinger, opened the session by explaining that it would have three components. The first portion would be a panel of community health workers (CHWs), who are “on the ground” directly touching people’s lives. The second portion would be four presentations related to CHW workforce issues, and the third portion would be a discussion with workshop participants. The CHW panel included the following individuals:

• Shanteny Jackson, Richmond City Health District and Virginia Community Health Worker Association (VACHWA)
• Kevin Jordan, Damien Ministries and Maryland Community Health Worker Advisory Committee
• Orson Brown, Penn Center for Community Health Workers
• Adriana Rodriguez Palacios, Oregon Community Health Worker Association (ORCHWA)

Karen Murphy opened by asking the panel members what they see as the role of a CHW and how it intersects with the health care delivery system.

Shanteny Jackson explained that while the specific role varies by community, standard activities include navigation, outreach, advocacy, and education. She clarified that “navigation” refers to navigation within the health care system. “Outreach” means connecting to the services available in the community. “Advocacy” involves empowering clients to be self-sufficient and address barriers. “Education” refers to strategies that transform barriers into advantages and allow progress toward achieving the goals of thriving individuals and thriving communities.

Kevin Jordan answered by stating that he sees CHWs as the liaison between the community and the clinical or health care setting. CHWs are members of the community they are trying to reach. Their goals are to engage other community members, bring them into a clinical setting, and link them to health services. Jordan noted that CHWs address a continuum of care and provided an example based on his experience addressing HIV/AIDS. First, CHWs conduct outreach and education regarding HIV and sexually transmitted infections (STIs). Next, they work to bring people in for an initial walk-in screening using rapid HIV testing. Depending on that test result, CHWs try to link the person to a clinical setting that offers a “gold standard” HIV test. CHWs support members of the community, communicate with both medical and nonmedical case managers, and help to ensure that people show up to appointments. Jordan explained that medical and nonmedical case managers at the entity where he works have said that CHWs are helpful in providing support, increasing retention, and improving medication adherence.

Orson Brown added that an important role of CHWs is to bridge gaps in the health sector. He noted that many patients in the communities they serve may mistrust or misunderstand medical professionals or feel that they are not being heard. The role of the CHW is to get to know patients and partner with them to develop an achievable plan for meeting health goals. Brown noted that his organization, the Penn Center for Community Health Workers, has seen success from CHWs helping people first to understand the barriers preventing them from attending doctors’ appointments, and then to develop a plan for addressing them.

Murphy next asked the panelists what they see as key elements of success for a CHW. Adriana Rodriguez Palacios responded by stating that, most importantly, a CHW has to be a trusted member of the community who can identify the real needs of that community. Brown agreed with Palacios and added that appropriate training and oversight are also important for CHWs’ success. He pointed out that CHWs can easily get overwhelmed or burned out by the work, and support from management is important in overcoming this.

Jackson also added that it is important for CHWs to be part of a multidisciplinary team that includes clinical staff. Each team member has a unique role, and the team-based approach facilitates addressing multiple challenges that a person may have. For example, at the Richmond City Health District where Jackson works, team members include a resource center specialist, CHW, nurse practitioner, and public health nurse. The resource center specialist welcomes and registers the clients and refers them to the CHW if any issues cannot be addressed initially. The CHW connects with the clients before they see a health care provider to address any initial questions, which allows the health care provider to focus on their medical needs. Next, a client may reconnect with the CHW for help with navigating to a particular service or addressing other social needs.

Murphy next asked how the CHW profession is growing or changing over time. Jordan responded that he has been a CHW for 5 years, and in that time, he has noticed researchers and public health officials dedicating more attention to CHWs and their role. For example, in Prince George’s County, Maryland, where he lives, a workgroup was established in 2014 to advise on the types of training and workforce development that CHWs need. In 2018, Maryland passed a bill to create a CHW advisory committee on trainings and certifications. As another example, in the District of Columbia the Department of Health recently began considering what a CHW structure might look like and invited community members and other stakeholders to participate in discussions. Jordan added that there is a trend toward developing a certification for CHWs because other health professions, such as nursing and social work, require certifications, which provide increased recognition and credibility. Some states, such as Virginia, have made progress toward requiring certifications for CHWs. Jordan noted that Maryland and the District of Columbia are also moving in that direction, but there are no requirements yet.

STANDARDIZED, SCALABLE, AND EFFECTIVE COMMUNITY HEALTH WORKER PROGRAMS TO IMPROVE POPULATION HEALTH

Shreya Kangovi from the Division of General Internal Medicine, the Perelman School of Medicine, and the Penn Center for Community Health Workers at the University of Pennsylvania began her presentation by sharing a story of a patient² who had suffered childhood trauma and spent time incarcerated as an adult. When he was released, he struggled with estrangement from his family and difficulty finding housing. He lived in an abandoned store without heat and tried to take his life nine times in a 6-month period. He was hospitalized each time and met with a psychiatrist and social worker but ended up in the same situation. During the final hospitalization, this patient met a CHW named Cheryl, who took the time to get to know him as a person. She asked him when he had last laughed. He responded that he had not wholeheartedly laughed in 27 years, and the last time was when he was out bowling. When he was discharged from the hospital, Cheryl and another CHW took him bowling, which reminded him that there could be joy in life. After that outing, CHWs worked to get him the behavioral health, primary care, and housing support he needed. However, it was their creative and “outside-the-box” thinking that was successful in getting him the help he needed. Kangovi explained that CHWs live the “health for all” motto, which often involves more than just the health care system.

Kangovi defined CHWs as individuals who come from within and are demographic mirrors of the communities they serve. They are uniquely altruistic, or “natural helpers.” CHWs differ from navigators, health coaches, and care coordinators, although they perform all of these roles at times. The concept of a CHW has existed for at least two centuries, gaining and losing prominence over time. Kangovi pointed out that, historically, CHW programs have failed more than they have succeeded. She noted five reasons, according to a global review of the implementation science literature. The first reason is that often the wrong people are hired for the job, leading to turnover rates of 50–77 percent cited in the published literature (Nkonki et al., 2011). Improved recruitment strategies, behavioral screening, and case-based interviews could help address this issue. The second reason is lack of standardized infrastructure, such as supervision, management of caseload, and processes to ensure safety of CHWs in the field. Kangovi noted that there is often no intervention model for CHWs to follow. She suggested that manuals for CHWs, managers, and program directors could help to address this issue. The third and fourth reasons relate to lack of balance between clinical integration and retaining grassroots identity. The final reason is the lack of scientific evidence regarding the field of social determinants broadly and CHW programs specifically. Kangovi noted that most studies on the impact of CHWs have been pre–post studies with limitations that overestimate the effect of CHW programs and create a hype that she sees as damaging in the long term.

Kangovi provided suggestions for elevating the CHW role by systematically addressing historical limitations. To improve hiring, organizational and psychological principles have been used to develop hiring algorithms unique to the CHW workforce, which has reduced turnover. To create standardized work practices, easy-to-read manuals have been written and refined with input from CHWs. Manuals have been developed for CHWs, supervisors, and program directors. Trainings and certifications have also been produced for all levels, including CHWs, supervisors, and program directors. Kangovi developed a software application for CHW workflow, documentation, and reporting, noting that CHWs often document their engagement in a patient’s electronic medical record, pulling them further into the medical model. She added that the software was designed because there is a need for technology to support a CHW workflow that goes beyond screening and referral.

Kangovi further emphasized the need for more research on whether the CHW model is working and how it can best operate with the goal of improving population health. She mentioned that there have been three randomized controlled trials (RCTs) assessing the effectiveness of the Individualized Management for Patient-Centered Targets (IMPaCT) worker model. Kangovi’s presentation highlighted that these studies, published in the American Journal of Public Health (Kangovi et al., 2017) and the Journal of the American Medical Association (Kangovi et al., 2014), have shown consistent improvements in outcomes in some areas, including a 65 percent decrease in cost and 12 and 16 percent increases in access and quality, respectively.

Kangovi stated that programs often overestimate return on investment (ROI) because these estimates come from pre–post studies that are often limited by regression to the mean. Based on the three RCTs, Kangovi’s team has estimated the ROI for the IMPaCT model to be $2:1. This validated and favorable ROI has fueled rapid expansion of the program within Philadelphia and across the country. The Penn Center has served 10,000 patients in the Philadelphia region and disseminated tools, training, and technical assistance to 1,000 organizations nationwide.

Kangovi explained that the Penn Center is also working with accreditation bodies, such as the National Committee for Quality Assurance, to consider CHW program-level accreditation, which shifts the burden of accreditation and training from the individual CHW to the program employing the CHWs. Kangovi closed her presentation by highlighting important issues to consider, including the tension between individual versus program accreditation, the role of science in evaluation of CHW programs, and a career ladder for the CHW workforce.

COMMUNITY HEALTH WORKER WORKFORCE DEVELOPMENT AND THE OREGON COMMUNITY HEALTH WORKERS ASSOCIATION

The next presentation by Noelle Wiggins from ORCHWA provided participants with background on the association and how it operates.^3,4 This included an overview of its origins, its funding, how it interacts with Oregon’s coordinated care organizations (CCOs), and its work in evaluation and research with and about CHWs and in CHW training and workforce development.

Wiggins began by sharing ORCHWA’s definition of CHWs: “trusted community members who participate in capacitation, or empowering training, so that they can promote health in their own communities…. Communities can be defined by race/ethnicity, geography, age, sexual orientation, disability status, other factors, or a combination of factors.” ORCHWA also supports a longer definition⁵ of a CHW developed by the American Public Health Association, with which they have been involved since the 1990s. ORCHWA’s CHW definition is complemented by its understanding of CHW and promotor/promotora history. She noted that this model grew out of natural helping and healing mechanisms that have existed in all communities since the beginning of human history. CHW models became formalized in areas where people were systematically denied health care and the conditions necessary for good health. Therefore, the CHW model is dedicated to increasing health equity.

As background on ORCHWA’s history, Wiggins explained that Oregon has had a history of successful CHW and promotor/promotora programs since the 1960s. Foundational CHW programs in the state have included the community health representative program founded at the Confederated Tribes of the Umatilla Indian Reservation in 1967, outreach worker programs that began in county health departments during the HIV/AIDS crisis in the 1980s, and the El Niño Sano (“The Healthy Child”) program that was started in 1988 at La Clinica del Cariño in Hood River, Oregon. Wiggins’s first job with CHWs in the United States was as the program director at El Niño Sano.

In 1994, promotores from El Niño Sano, which functioned for 10 years, helped organize the first statewide CHW, promotor, and promotora organization under the auspices of the Oregon Public Health Association. In 2011, CHWs and allies in the state of Oregon became aware that policy was being created about them as part of health care reform, and while individual CHWs were involved, the profession did not have a unified and organized voice. With funding from the Northwest Regional Primary Care Association, two leadership development workshops were organized in two regions of Oregon. These served as the jumping off point for ORCHWA, with the mission to “serve as a unified voice to empower and advocate for CHWs and our communities.”⁶ ORCHWA held its first meeting in November 2011.

Initially, ORCHWA did not have any funding and was supported by in-kind donations from the Oregon Latino Health Coalition and Community Capacitation Center at the Multnomah County health department. After a few small to moderate grants, in 2017, ORCHWA received a 2-year, $3 million investment from Health Share of Oregon, the state’s largest CCO. As Wiggins explained, in Oregon, a CCO is a group of health systems and provider groups that apply to the state to be funded to serve Medicaid beneficiaries in a given region. As of the date of the workshop, ORCHWA had more than 13 funding sources, including grants, contracts, and fee-for-service arrangements, providing an annual budget of more than $3 million, which Wiggins noted is a large budget for a CHW association.

Wiggins highlighted the importance of Health Share’s investment, the purpose of which was to support ORCHWA in building infrastructure that would allow it to serve as a broker between health systems that want to access the services of CHWs and promotores and community-based organizations that employ these individuals. Wiggins sees several benefits to this arrangement. First, she believes that CHW programs need to be supported by health care reform and the funding that comes with it. Second, CHWs in culturally specific organizations are often supported to maintain cultural world views and cultural approaches to health. Third, CHWs in community-based organizations may be better able to play a full range of roles, including organizer and advocate. Wiggins also hopes that this arrangement will increase salaries for CHWs in community-based organizations.

When the infrastructure is fully developed, ORCHWA will offer certification training for CHWs and their supervisors, have an online case management platform, and provide research and evaluation services. Wiggins explained that ORCHWA was also developing a contract with Kaiser Permanente and pursuing contracts with other health systems.

Wiggins next described ORCHWA’s training and workforce development programs. Assessment of training needs happens both formally and informally. A regional and statewide assessment serves as the formal mechanism. ORCHWA employs CHWs and convenes three collaboratives, including CHWs, their supervisors, and funders, which also allows it to receive regular feedback informally. The methodology and philosophy ORCHWA uses for CHW training is Popular/People’s Education, which is associated with Brazilian educator and political theorist Paolo Freire and based on the idea that the people most affected by inequities are the experts about their own experience. ORCHWA and its community-based organization partners also provide cross-cultural, culturally specific initial and ongoing training.

Wiggins concluded by explaining that ORCHWA is committed to conducting research and evaluation with and about CHWs to contribute to the body of credible evidence in partnership with CHWs using a community-based participatory research and evaluation framework. ORCHWA is also committed to building the skills of CHWs as researchers, including supporting them to obtain more formal education when they so desire.

COMMUNITY HEALTH WORKER TRAINING AND THE FUTURE OF THE PROFESSION⁷

Michael Rhein and Dwyan Monroe from the Institute for Public Health Innovation (IPHI) spoke about where and how CHWs fit into the health sector, CHW training needs, the ROI of employing CHWs, the state of CHWs and CHW associations, and changes to the role with changes in the health care system and an increased focus on population health.

Rhein explained that as the public health institute serving the District of Columbia, Maryland, and Virginia for the past decade, IPHI has the mission of leading innovative solutions to public health issues in the region and working at a systems level to address workforce development, advocacy, capacity building, convening, and leading the development of effective interventions.⁸ As Rhein described, the community health workforce is not a panacea, but it is an integral component of a strategy to address health equity. IPHI has trained more than 600 CHWs in its region in the past 10 years and is leading conversations around scope of practice and certification, providing resources for demonstration projects and pilots, and conducting evaluations. The organization is also working to advocate for the CHW profession and ensure that CHWs and their partners have a “seat at the table” where decisions about them are being made.

Rhein highlighted that as a result of work by IPHI and partners, the District of Columbia, Maryland, and Virginia have all worked collaboratively with CHWs to define scope of practice, core competencies, and training requirements, and progress has been made toward CHW certification. In addition, employment opportunities for CHWs have been created and integrated into the business models for hospitals, Medicaid-managed care organizations, and health departments. CHWs have been involved as leaders and advocates in this work.

Despite significant progress, Rhein noted several areas where there is still work to be done. First, he sees a need to address the lack of awareness, understanding, and appreciation of the CHW role and more fully integrate them into multi-disciplinary teams. Second, he highlighted an ongoing tension between CHWs’ community roots and the move toward increased professionalism and certification (and the health system’s call for this). To manage this, IPHI advocates for voluntary certification, and Rhein noted that certification and training needs may vary depending on the community and the CHW’s scope of work. He believes it is important for the CHW role to be owned by the community and for there to be respect for its “lay” history. Rhein also sees the need for more sustainable financing mechanisms, such as including CHWs in value-based contracts and Medicaid managed care approaches. Rhein also suggested that health care providers, health departments, and other entities that employ CHWs see them as part of their business model, including the ROI, rather than simply funding them through grants.

Monroe began by explaining that she is a former CHW with 25 years of experience. Monroe noted the importance of understanding that lived experience is half the experience that CHWs bring, and the training that is provided is intended to address particular diseases and issues and give CHWs an opportunity to become part of the health professional workforce. The training also provides access to employer-financed education for people who might not otherwise have that opportunity, through mechanisms such as apprenticeships. This removes an educational barrier to recruiting the right people for the CHW role. Monroe explained that IPHI, for example, offers a $100 course that addresses CHW core skills and competencies and provides basic health information, including an overview of all major chronic diseases, mental health issues, and trauma-informed care. IPHI also promotes health equity through a 2-day perspective transformation training for CHWs that addresses prejudice, race, and the CHW role.

Monroe noted that IPHI also supports team integration, and she added that there is interest among organizations employing CHWs in providing initial training for CHWs but less interest in team-based trainings that include the CHW, supervisor, and other team members and provide an opportunity to discuss issues related to triage and workflow. She suggested that when problems are reported with a CHW, they may stem from team-based issues.

Related to CHW advocacy, Monroe explained that there are about 45 CHW associations or networks and an entity called Unity that hosts a national CHW conference. These organizations unite CHWs and give them a “voice.” She suggested that, as with nurses and other health professionals who may seek ongoing professional development to meet accreditation requirements, CHWs would benefit from outside workshops, trainings, and conferences that address and support their critical role.

POPULATION HEALTH WORKFORCE SUPPORT FOR DISADVANTAGED AREAS PROGRAM⁹

Katie Wunderlich from the Maryland Health Services Cost Review Commission presented on the challenges of integrating payment for CHWs into the business model of delivering health care across the care spectrum. She also described how Maryland has promoted the use of CHWs through regulatory processes and health care system initiatives, including financing mechanisms for hospitals and other community-based organizations. Although CHW services are often not reimbursed in a fee-for-service payment model, Maryland has a unique value-based approach that allows hospitals to use revenue to pay for CHWs’ services and other services that promote community and population health.

As background, the Maryland Health Services Cost Review Commission is a state agency responsible for setting hospital rates throughout the state. The agency also leads a statewide health care delivery transformation focused on breaking down siloed sites of care and coordinating care across the health care setting. As Wunderlich explained, the state’s “total cost of care model” that has resulted from this is intended to coordinate patient care across both hospital and nonhospital settings, improve health outcomes, and constrain cost growth. Hospitals are compensated using a value-based payment system, which allows for health and social services that promote population health to be incorporated into and paid for by the hospital system. The model is provider led and focused on sustaining rural hospitals. There has also been a focus on population health improvement, using incentives to address the health of the population the hospital serves, break down silos, and coordinate care across the spectrum. To that end, one specific goal is incorporating CHWs into the health care delivery system.

In 2015, the Maryland Health Services Cost Review Commission approved a 3-year, $10 million initiative for hospitals to hire and train workers from areas of high economic disparities and unemployment. Participating hospitals had to match half the funds and hire, train, and support workers to fill new positions focused on improving population health and meeting other goals identified in the total cost of care model. As Wunderlich described, there were two main goals of the program. The first was to provide employment opportunities in disadvantaged communities, as stable employment is an important social determinant of health. The second was to improve population health in Maryland through workforce investments.

Funding was provided through this initiative for Garrett County and for the Baltimore Population Health Workforce Collaborative. The Baltimore Collaborative was the larger of the two and involved 9 hospitals with a goal of hiring 208 total CHWs, peer recovery specialists, certified nursing assistants, and geriatric nursing assistants by fiscal year (FY) 2019. The program was renewed, and funding will continue to support training and hiring through June 2022. Other key program partners included the Baltimore Alliance for Careers in Healthcare, which served as a training coordinator and intermediary with the hospital systems; Turnaround Tuesday, which provided support with recruiting, essential skills training, and wraparound services for workers; and CHW, nursing assistant, and peer recovery specialist organizations, which provided technical training for workers in these professions.

Wunderlich presented data on program outcomes. As of June 2018, 114 workers were trained and hired, including 73 CHWs. The training and hiring will continue through FY 2022. Patient care activities that were possible as a result included care coordination, health education and health system navigation, companion care and patient escort, transitional care, peer recovery, and linking to community services. Services were focused on a diverse patient population, concentrating on high-use and high-risk Medicare patients.

Wunderlich concluded by sharing some insights and lessons learned. First, there was a slow start, as it took time for hospitals to implement the idea of using their rate-setting system dollars for CHWs and for a collaborative to be established among Baltimore hospitals. There is still work to be done to reach the initial goal of training and hiring 208 workers. Second, community partnerships have been vital to recruiting, retaining, and providing wraparound services for workers to address retention. Another insight was the challenge in quantifying the impact or ROI of one CHW embedded in a hospital’s larger population health initiatives. Anecdotal evidence provided support for renewing the program. Another goal for the program and similar ones is to provide upward mobility for workers in the hospital delivery system and larger health care system.

DISCUSSION

Following the presentations, there was an opportunity for members of the audience to ask questions of the CHW panelists and session presenters. Terry Allan from the Cuyahoga County Health Department in Greater Cleveland opened the session by asking the speakers what resources might be available for CHWs and nonprofit organizations that have relationships in the community and want to develop an agency to run their own business, as either a CHW or an organization employing CHWs, respectively. He noted that he has worked with CHWs and community-based organizations that could use support with business and back office operations.

Rhein responded that he sees a need for large institutions and government agencies to employ community members while also supporting smaller community-based organizations through authentic business partnerships. Large institutions provide an opportunity for CHWs to be members of integrated health care teams. CHWs in these positions can also help large organizations establish relationships with and reach deep into communities. Large institutions can also address economic opportunity as a determinant of health through CHW job creation and investment in communities. Rhein sees an indispensable role for grassroots community-based organizations that are themselves a way to reach into communities. He suggested that large institutions both hire community members as staff and form meaningful business relationships with community-based organizations that have traditionally had peers on their staff and have trust-based relationships with the community.

Wiggins added that ORCHWA contracted with CCOs so that individual community-based organizations would not have to do so. With this arrangement, ORCHWA is the broker between community-based organizations and the large health care institutions, providing the contracting capacity, relationships, training for CHWs and supervisors, support for creating job descriptions and recruitment, and evaluations of program impact.

Kangovi pointed out that there could be tension between the goals of workforce development and of improving population health. Using a firefighting analogy, she asked whether the goal is training firefighters or putting out fires. She suggested that the goal is putting out fires (i.e., improving population health), because if the goal is workforce development, the investment may or may not be effective in achieving the ultimate goal of improving population health. Kangovi also noted that partnerships with communities are often operationalized as partnerships with community-based organizations, the leadership of which may not represent those community members intended to benefit from the initiative.

Palacios also reiterated the importance of training for other team members who work with CHWs on how best to integrate CHWs into the workflow and the roles they can play outside the health care setting. She noted that one activity she did as a CHW was to collect signatures in support of sidewalks and lighting to improve the community’s safety. She stated that while there may not be a billing code for this type of work in a health care setting, it is an important component of a CHW’s job.

Kevin Barnett from the Public Health Institute and the California Health Workforce Alliance added three points for discussion. First, he suggested that CHW training programs be certified rather than CHWs themselves, explaining that many of the best CHWs with whom he has worked in California are undocumented and lack a high school diploma. Program certification allowed the medical community to be confident in the scope of the CHW training to supplement workers’ lived experience and prepare them to work in health care teams. Second, Barnett pointed to the need to educate mainstream organizations regarding the benefits of hiring CHWs. Third, he highlighted the potential for the Pathways Community HUB Model of CHW engagement (PCHI, 2019), which is similar to ORCHWA’s model of engaging CHWs through a nonprofit organization that partners with all of the payers and providers in an area. Barnett noted that this model allows CHWs to retain their agency and move beyond individual patient care management to broader population health improvement.

Wiggins responded to Barnett’s third point about the Pathways model by suggesting that it be considered a method of evaluating the work rather than a payment model. Kangovi added that she supports Pathways as a way to bring health and social services organizations together, often using the same technology platform, to monitor the many health and social needs of a single individual. She noted that the CHW is the “human element” that can help the person address a spectrum of needs.

Kangovi also suggested that a successful CHW program involves both infrastructure and training. She recommended that a larger goal could be to develop a successful CHW program ecosystem that could be replicated and implemented anywhere in the United States. Wiggins phrased this as “spreading the CHW paradigm, which is community focused, [is] nonhierarchical, and values life experience, throughout the health system and dominant culture systems.”

Sagar Shah from the American Planning Association asked how planners can help to train and support CHWs. Jackson responded that partners outside the health sector can support CHWs by establishing relationships and including CHWs’ perspectives on committees and subcommittees where decisions are being made. Points made by the speakers in this section are highlighted below (see Box 4-1).

BOX 4-1

Points Made by Individual Speakers and Par ticipants.