Abstract
Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.
INTRODUCTION
Increased health care costs and demand have accelerated the need for resource-saving approaches that improve access to and delivery of primary care services. We define community health workers in primary care (CHW-PCs) as trained individuals with limited to no formal medical education who provide patient-facing support and services in primary care. CHW-PCs carry out functions that are person-centered, support team-based care, address social determinants of health, and promote health care access, patient engagement, and outcomes.1–4 Historically, these frontline health workers have been particularly effective when they share ethnicity, language, socioeconomic status, and life experiences with communities they serve,5 reflecting peer support.6 A growing body of research illustrates diverse ways that community health workers, best known for their role in community and global settings,5,7,8 can be utilized in primary care. Despite their potential to contribute as care team members,9–12 CHW-PCs remain largely underutilized.7,11 Guidance is needed on ways to best promote and expand CHW-PCs. CHW-PC roles vary across clinics, with numerous job titles and duties, making it difficult to identify best practices.2,3 Perspectives vary on what CHW-PCs do and their training and clinical support needs.
METHODS
Following PRISMA guidelines,13 we characterized patient care roles and functions of CHW-PCs in US primary care through a systematic mixed studies review.14,15 Supplemental Appendix 1, http://www.annfammed.org/content/16/3/240/suppl/DC1/, details the inclusion criteria, search strategy, quality assessment, data extraction, and PRISMA flow diagram of our systematic review. Briefly, we searched and screened articles for eligibility, assessed article quality using the Mixed Methods Appraisal Tool (MMAT),16 and extracted data on characteristics of CHW-PCs from articles meeting inclusion criteria. We used extracted data to: (1) qualitatively classify functions CHW-PCs perform using a modified Delphi card sort,17 and (2) quantitatively identify roles through k-means cluster analysis of functions.18 The card sort involved writing descriptions of what CHW-PCs do, which coauthors grouped by similarity into functional categories. To identify roles that involved multiple functions, we described each study as a binary vector of functions (ie, each function was marked as present/absent) and clustered vectors, varying the number of clusters (K) until reaching the best fit using silhouette width.19
RESULTS
Thirty studies met inclusion criteria (Supplemental Appendix 2, available at http://www.annfammed.org/content/16/3/240/suppl/DC1/).20–50 We combined articles about the same study33,34 and added detail from reference lists.51–56 Study designs included qualitative, quantitative (ie, randomized controlled trials, nonrandomized, or descriptive designs), and mixed methods. Most studies (24/30) scored moderate to high quality (MMAT ≥50%).
Community health workers in primary care characteristics were diverse (Supplemental Appendix 3, available at http://www.annfammed.org/content/16/3/240/suppl/DC1/), with over one-half targeting racial, ethnic, or underserved groups.* Most had administrative structures supporting their work, such as designated staff32,43 and regular team meetings.22,36 In addition to patient visits and phone calls, in one-third of studies CHW-PCs extended the reach of care teams through home visits† and documentation in electronic health records20,25,33,36,43,44 or registries.21,23,24,33–35,37,38
Functions
We qualitatively identified 12 distinct CHW-PC functions representing patient-facing services (Table 1).
CHW-PC Functions
Roles
Based on the distribution of CHW-PC functions across studies, k-means clustering indicated 3 clusters (average silhouette width = 0.23, SD = 0.7). Removing 6 studies with MMAT quality scores <50%21,22,28,40,46,50 had little impact on clusters (average silhouette width = 0.22, SD = 0.05). We labeled clusters as CHW-PC roles having similar constellations of functions: clinical services, community resource connections, and health education and coaching (Table 2). Nearly all studies depict multiple functions with some functions more prevalent than others (eg, health coaching, case management).
CHW-PC Roles
Clinical Services
Clinical services focus on health assessment and remote care more than other clusters.21–31 This role also performed other functions, but none provided literacy or social support. Examples include assessment of vital signs, lifestyle, health knowledge,23 psychosocial factors,22,26 and care through routine exams aided by remote communication with physicians.28 These services provide for patient dialog, helping care teams understand patients’ health, background, and preferences.22 An example is the “community health aid” who provided clinical services in remote Alaskan villages using scripted questions and directed exams for common health problems.24
Community Resource Connections
Community resource connections link patients with community-based services,32–40 such as referrals for transportation or food assistance.35 Ongoing social support and follow-up phone calls were common, yet remote care, education, and literacy support were uncommon. An example is “promotoras” who screen patients for depression by interviewing them about contextual factors (eg, unemployment) and help resolve those barriers with community referrals (eg, vocational training).37
Health Education and Coaching
Health education and coaching are key functions of the third role.20,41–50 Health coaching generally involved motivational interviewing46 and action planning to help patients achieve health goals.45 Health education typically targeted specific issues, such as cancer screening42,44 or self-management of a chronic illness.43 Nearly one-half of studies in this cluster provided follow-up and administrative support, yet none included health assessment or remote care. Examples include “peer health coaches” who counsel, teach, and support self-management in low-income diabetics47 or “care guides” who facilitate goal setting and care coordination.20
DISCUSSION
Community health workers in primary care focus on core functions that cluster into 3 roles. This categorization expands prior work in community and global settings5,7,8 and informs future design of primary care. Practices that embed CHW-PCs could enhance care while enriching the understanding of patients’ situations and needs.29,38 Our search strategy and heterogeneity in study designs, quality, or reporting practices, however, may have limited findings. We may have overlooked variations apparent only through unpublished sources. Nonetheless, a cost-effective workforce that includes CHW-PCs might help overburdened care teams meet the Quadruple Aim57 through community-based clinical services, resource connections, and health education and coaching.
Findings carry practical insights that extend current guidance10,58–61 for system and clinic administrators in planning diverse ways to incorporate CHW-PCs, such as devoted workspace.62,63 Home visits may extend the clinic’s reach, but require new strategies for remote supervision and technology access.64,65 Decisions about how to best utilize CHW-PCs depend on needs of patients and care teams, clinical workflows, financial viability, and addressing practice burdens while facilitating performance66,67 and cost-savings.68 Increasing the presence of CHW-PCs also requires training and clinical integration necessary to build this new workforce, 59,69 including certification,58 health information technology, and clinical oversight for the breadth of contributions CHW-PCs offer.
Acknowledgments
Group Health Foundation Partnership for Innovation Fund supported this work. We thank Dr Paula Lozano, Katie Bell, and Dr Sean McNee for their thoughtful feedback on this manuscript.
Footnotes
- Received for publication September 4, 2017.
- Revision received December 13, 2017.
- Accepted for publication January 11, 2017.
- © 2018 Annals of Family Medicine, Inc.
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