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Research ArticleOriginal Research

Roles and Functions of Community Health Workers in Primary Care

Andrea L. Hartzler, Leah Tuzzio, Clarissa Hsu and Edward H. Wagner
The Annals of Family Medicine May 2018, 16 (3) 240-245; DOI: https://doi.org/10.1370/afm.2208
Andrea L. Hartzler
1Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
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Leah Tuzzio
2Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Clarissa Hsu
2Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Edward H. Wagner
2Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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  • Community health worker clinical duties
    Carl H. Rush
    Published on: 16 August 2018
  • Community Health Workers
    Charles Q North
    Published on: 23 July 2018
  • Published on: (16 August 2018)
    Page navigation anchor for Community health worker clinical duties
    Community health worker clinical duties
    • Carl H. Rush, Research Affiliate

    I write to offer several comments, starting with an objection over one specific finding in an otherwise well-written and useful work.

    1. "CHW-PCs" (a term coined for the purposes of this paper) are described as having "little or no formal medical education," yet the authors include a specific category of roles in provision of clinical services which otherwise would require licensure. The example offered is...

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    I write to offer several comments, starting with an objection over one specific finding in an otherwise well-written and useful work.

    1. "CHW-PCs" (a term coined for the purposes of this paper) are described as having "little or no formal medical education," yet the authors include a specific category of roles in provision of clinical services which otherwise would require licensure. The example offered is that of the Alaska Community Health "Aid" [sic], which is commonly mistaken for a CHW. In fact, the State of Alaska does NOT recognize Community Health Aides (CHAs) as CHWs, and is engaged in concerted efforts to develop a separate CHW workforce, including an apprenticeship program operated by the Alaska Primary Care Association. I have confirmed this in direct contact with State and PCA officials. CHAs do receive substantial clinical training; one source of confusion is that they are (wisely) chosen for this role by the members of the villages they serve, which is similar to the foundational element of the definition of the CHW, namely that they should be "of" or "from" that community. They do offer preventive education, but they are viewed by the health care system more as midlevel providers than as CHWs.

    2. The authors acknowledge that CHWs have been "particularly effective" when they share key characteristics with the population served, but in fact there is scant evidence of the CHW "model" being applied at all outside low-income communities and communities of color. Historically, CHWs in the U.S. were first recognized at the federal level in anti-poverty policies of the 1960s, and the Indian Health Service's Community Health Representative (CHR) Program survives as the largest single federally-funded CHW program today. "Patient navigators" and "health coaches" can be effective in certain assistance to other populations, but they generally do not operate on a "peer support" basis as CHWs do, nor do they operate in as broad a range of roles as CHWs do.

    3. CHWs still face challenges in gaining acceptance, as the authors correctly emphasize. These challenges partly arise because officials in health care tend to think in clinical terms. CHWs have been at pains to clarify their primarily non-clinical practice, emphasizing that they cannot perform any duties that require a clinical license. They also generally resist efforts to add clinical duties to their roles. The growing recognition of the importance of social determinants has been helpful in justifying inclusion of CHWs in clinical teams for non-clinical reasons. But perhaps more importantly, it has also been challenging to explain a practice which is RELATIONAL rather than TRANSACTIONAL in nature. As new care structures demand of providers the capability to establish relationships and trust with their low-income patients, as well as maintain more candid and continuous communication with them, the value of relationship-based professionals (CHWs) can only increase.

    Competing interests: None declared

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    Competing Interests: None declared.
  • Published on: (23 July 2018)
    Page navigation anchor for Community Health Workers
    Community Health Workers
    • Charles Q North, Professor

    Hartzler et al make an important contribution to the literature by categorizing the roles of community health workers (CHW). During my 30 year career in the Indian Health Service I saw the role of the Community Health Representative (CHR) trasform to meet the needs of the Tribe and community. Initialy the role was losely defined and usually was to provide transportation for those without vehicles and public transport....

    Show More

    Hartzler et al make an important contribution to the literature by categorizing the roles of community health workers (CHW). During my 30 year career in the Indian Health Service I saw the role of the Community Health Representative (CHR) trasform to meet the needs of the Tribe and community. Initialy the role was losely defined and usually was to provide transportation for those without vehicles and public transport. The role changed to be more of an extender like a nursing assistant or medical assistant for the Public Health Nurse team. Eventually the role changed to that of a clinical prevention service educator and coach. At the University of New Mexico Hospital primary care clinics the CHW was integrated into our practices to address social determinants after screening by visit planners. We found that 4-11% of our patients had significant social problems. Our clinics in low socioeconomic status communities, not surprisingly, had more problems. We beleive that the CHW role has greatly aided our ability to address social problems over time and that they play an essential role on our teams. They funciton mostly to provide home visits and link patients with coummunity based resources. They work with RN case managers and social workers as extebders into the community. Their active case management over time is hard to quantify but anecdotally has improved outcomes and eased practice for clinicians in low resource environments.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 16 (3)
The Annals of Family Medicine: 16 (3)
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Roles and Functions of Community Health Workers in Primary Care
Andrea L. Hartzler, Leah Tuzzio, Clarissa Hsu, Edward H. Wagner
The Annals of Family Medicine May 2018, 16 (3) 240-245; DOI: 10.1370/afm.2208

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Roles and Functions of Community Health Workers in Primary Care
Andrea L. Hartzler, Leah Tuzzio, Clarissa Hsu, Edward H. Wagner
The Annals of Family Medicine May 2018, 16 (3) 240-245; DOI: 10.1370/afm.2208
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Subjects

  • Domains of illness & health:
    • Chronic illness
  • Person groups:
    • Vulnerable populations
  • Methods:
    • Mixed methods
  • Other research types:
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    • Professional practice
  • Core values of primary care:
    • Access
    • Coordination / integration of care
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    • Quality improvement
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Keywords

  • community health workers
  • primary health care
  • patient care team

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