Integrating Community Health Workers Into Medical Homes

Elizabeth A. Rogers; Sarah Turcotte Manser; Joan Cleary; Anne M. Joseph; Eileen M. Harwood; Kathleen T. Call

doi:10.1370/afm.2171

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Author response: Practical Implementation Tools
Elizabeth A. Rogers

Published on: 26 February 2018
Design for dysfunction
Shreya Kangovi

Published on: 08 February 2018

Published on: (26 February 2018)
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Author response: Practical Implementation Tools
Elizabeth A. Rogers, Assistant Professor of Medicine
Other Contributors:
We thank Dr. Kangovi for her compliments on our manuscript and for adding to this discussion. She argues that well-designed CHW programs have the potential to thrive even in under-resourced clinical settings.
We agree that there is great potential for broader implementation of CHW models in a wide variety of settings, including safety-net clinics and hospitals whose focus is underserved populations. To do this, ev...
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We thank Dr. Kangovi for her compliments on our manuscript and for adding to this discussion. She argues that well-designed CHW programs have the potential to thrive even in under-resourced clinical settings.
We agree that there is great potential for broader implementation of CHW models in a wide variety of settings, including safety-net clinics and hospitals whose focus is underserved populations. To do this, evidence-based CHW program design is critical. A well-designed CHW program's effectiveness will depend on a capable CHW workforce, necessitating rigorous and standardized CHW curriculums along with ongoing CHW training and professional development. Program implementation will also require CHW role clarity, including definition of scope of practice and educating team members to best align contributions to patient care. In this way, the term "CHW" can slowly come into our collective understanding, and that of our patients and communities.
Dr. Kangovi stated that CHW integration will require both advocacy and evidence-based program design. We believe that clinic leaders and others who introduce CHW programs into their clinics also need practical tools to overcome barriers and promote facilitators of CHW program adoption, such as those identified in our research. One concrete example of this is the State of Minnesota CHW Tool Kit. In partnership with WellShare International, the Minnesota CHW Alliance created this online resource commissioned by the Minnesota Department of Health. The tool kit provides prospective employers with both an understanding of the education and competencies of CHWs as well as practical guidance for practice integration of CHWs ( http://mnchwalliance.org/explore-the-field/mn-chw-toolkit/).
We see trends that favor greater integration of CHWs in our health and social services systems: growing evidence of CHW impact and program design; payment reform policies and metrics that call for value-based approaches with health equity measures; widening recognition of the importance of social determinants of health that CHWs are uniquely equipped to address; and availability of helpful tools and practice examples. We welcome additional comments about our research.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (8 February 2018)
Page navigation anchor for Design for dysfunction
Design for dysfunction
Shreya Kangovi, Assistant Professor of Medicine, Executive Director Penn Center for Community Health Workers
Dr. Rogers and her co-authors should be congratulated for a careful exploration of factors that influence integration of community health workers (CHWs) into patient-centered medical homes.
The most important contributions of this study were the honest concerns voiced by practices that had decided against CHW integration. These practice staff were aware of CHW programs and in some cases acknowledged their int...
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Dr. Rogers and her co-authors should be congratulated for a careful exploration of factors that influence integration of community health workers (CHWs) into patient-centered medical homes.
The most important contributions of this study were the honest concerns voiced by practices that had decided against CHW integration. These practice staff were aware of CHW programs and in some cases acknowledged their intuitive appeal. Yet they were skeptical about effectiveness and deterred by the experience of under-performing programs. Some participants spoke about the need for underlying infrastructure for CHW programs including supervision, so that the clinic staff wasn't "[throwing] people into situations they're not able to handle." Other practice staff worried about CHWs performing clinical work such as diabetes education. "I worry if somebody is explaining something wrong," explained a supervisor. Finally, clinical leaders were 'committed to sustaining hired staff' and were not convinced of the long-term financial sustainability of CHW hires.
It is tempting to dismiss these skeptical perspectives as uninformed or narrow-minded, but that would be a mistake. In fact, Dr. Roger's findings are well supported by decades of implementation science research on the successes and failures of global CHW programs.(1-3) These studies reveal that unsuccessful CHW programs often lacked infrastructure (hiring guidelines, supervision, caseloads, etc.). Programs that relied on CHWs for disease education or basic clinical care were in fact at greater risk for adverse patient outcomes. Perhaps most importantly, programs that were not evidence-based typically failed to deliver results necessary for long-term sustainability.
It is possible for CHW programs to survive these limitations if embedded in ideal environments that include clinical champions, innovative workplace culture and unrestricted CHW reimbursement. But these types of environments are rare. Most low-income patients--those who might benefit from CHWs--are more likely to receive their care in the real world, complete with overwhelmed providers, strapped budgets and low margins for error. CHW programs that are well-designed can thrive even in these somewhat dysfunctional settings.
Greater integration of CHWs into healthcare will likely require not only advocacy, but better program design. This study highlights important pitfalls that every CHW program ought to consider and carefully avoid.
References 1. Perry H. How Effective Are Community Health Workers: An overview of current evidence with recommendations for strengthening community health worker programs to accelerate progress in achieving the health-related millenium development goals. Baltimore, Maryland: Johns Hopkins Bloomberg School of Public Health 2012.
2. Berman PA, Gwatkin DR, Burger SE. Community-based health workers: head start or false start towards health for all? Soc Sci Med. 1987;25(5):443-459.
3. Kangovi S, Grande D, Trinh-Shevrin C. From rhetoric to reality--community health workers in post-reform U.S. health care. N Engl J Med. Jun 11 2015;372(24):2277-2279.
Competing interests: None declared
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Competing Interests: None declared.