Community health workers are being dispatched to the front lines of care delivery to better understand patients' socioeconomic circumstances and steer them away from costly ER visits in favor of cost-efficient and proactive care.
This article first appeared in the July/August 2016 issue of HealthLeaders magazine.
Healthcare systems are trying to improve patient outcomes and reduce costs by ensuring high-risk patients receive preventive care and comply with medical orders. But oftentimes patients have obstacles in their lives clinicians are unaware of that keep them from engaging with the health system.
Enter the community health worker, or CHW—an emerging resource that is becoming a critical part of the integrated care team.
CHWs are being dispatched to the front lines of care delivery by primary care practices, health systems, and insurers to better understand patients' socioeconomic circumstances and steer them away from costly ER visits in favor of cost-efficient and proactive care.
The American Public Health Association, publisher of the American Journal of Public Health, defines a CHW as "a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served." APHA adds: "This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery."
While some healthcare organizations require CHWs to have college degrees or certification in a health-related field, others place more emphasis on a CHW's knowledge of community services, language skills, and shared life experiences with the target patient population.
Priority Health's Medicaid insurance plan, which has more than 100,000 members in Western Michigan, uses CHWs "to meet the patient where they live," says Sheila Wilson, director of care management for the Medicaid product at the nonprofit health plan in Michigan. CHWs work one-on-one to advocate for members, mentor them, and help them navigate the complex medical and social systems. They resolve barriers to care such as transportation, safe living conditions, jobs, nutrition, culture, and language. She puts the CHW need bluntly: "If people don't know where they're sleeping or getting their next meal, they can't get to the next step of care."
Something as seemingly simple as coordinating office visits for a mom and baby can be the difference between life and death, according to Wilson, who illustrates the CHW impact for stakeholders with this recent example: A mother in poor health was overwhelmed by the number of doctors' visits she and her baby faced following the newborn's 133-day stay in the NICU. She missed the baby's appointments, leading to the baby's readmission to the hospital 58 days later.
Priority Health dispatched a social worker and a CHW to help the mother in-hospital and through the transition home. The CHW, among other things, created a more manageable schedule of coordinated doctors' visits so the mom didn't have to leave the house as many times a week with the medically fragile baby. The CHW then followed up with the mom daily. "You have to wonder what would have happened to that child and mother had we not been there," Wilson says.
Although Priority has had CHWs, previously called field service representatives, for more than 20 years, it formally hired four CHWs in 2014 to assist its high-risk Medicaid population, and it hopes to soon grow that number to eight.
"We know CHWs are valuable members of the patient care team, and we continue to determine how we best can demonstrate the impact and value of CHWs."
Priority's CHWs gain their case-loads in two ways: risk stratification and provider referral. Priority analyzes claims to see which members are using the ER as a primary care service or are in the ER because they didn't properly manage their chronic conditions. Also, Priority's partner providers are able to call in a CHW to assist patients.
Working closely with services already established in the patient's community, CHWs are able to assess and address member needs quickly, such as getting a domestic abuse victim into a shelter, connecting families with nutritional needs to food banks, and using translators to help families understand care instructions.
Wilson says the return on investment of CHWs is proven in the shift from ER visits to preventive care and monitoring granular improvements, such as better A1C rates of diabetic patients paired with CHWs. "We can engage people through other communications, but we have far more success when we engage them face-to-face," she says.
Integration is essential
Hennepin County Medical Center, an integrated hospital and clinic system serving downtown Minneapolis and surrounding neighborhoods, integrated CHWs into its primary care clinics as part of its patient-centered medical home certification, which, in Minnesota, is referred to as Health Care Homes certification. According to Hennepin's publication A Year in Review, its clinics had nearly 600,000 visits in 2015.
While social workers handle patients with mental health–related issues and nurses deal with patients' medical management, CHWs are charged with identifying other issues that patients encounter, such as transportation challenges, understanding how to access primary care, basic education about chronic conditions, and how to afford medications.
Kristen Godfrey Walters, MPH, community care coordination manager at Hennepin, says the health system's 30 CHWs, a majority of whom are based in primary care clinics, bridge gaps in care, freeing other clinicians such as nurses to work at the top of their licensure.
Hennepin uses a risk-stratification model within the EMR to identify clients for CHWs, including inpatients; patients with chronic conditions such as diabetes, asthma, and vascular care; patients who are no-shows for visits; and other red flags. "The CHW's main goal is to get people back into the primary care system," Walters says.
Caseloads for the CHWs are larger than Walters would like, with each CHW handling as many as 200 patients annually. Ideally, she would like to see that drop to 80–120 patients and is fine-tuning Hennepin's recently developed risk-stratification model, based on CMS-HCC Medicare Risk Adjustment Model, which identifies patient risk of future healthcare utilization based on clinical complexity. She says Hennepin already has modified the model to be more specific to pediatric conditions and is working to better incorporate social determinants of health. For example, an unstable housing indicator is being developed to incorporate the risk of individuals who are homeless. Determinants like that affect the amount of care coordination and support services that impact CHW caseloads but may not be reflected in the current risk stratification, she says.
Referrals play a hefty role in broadening the CHWs' workload as well. If a CHW is working with one child in a family, he or she might take over the needs of all the children. Providers also have recognized the CHWs' value through patient satisfaction surveys and program evaluation, and, as a result, have boosted referrals. Walters says the care coordination model evaluation focuses on decreasing unnecessary utilization (ED and inpatient visits), increasing primary care visits, reducing readmissions, and reducing length of stay, for example. "We know CHWs are valuable members of the patient care team, and we continue to determine how we best can demonstrate the impact and value of CHWs," she says.
Beyond the clinic walls
At the Penn Center for Community Health Workers, a community/academic partnership funded by the University of Pennsylvania Health System, 24 CHWs supervised by managers with extensive social service experience assist 1,500 high-risk patients annually. The CHWs support patients of two hospitals and five primary care facilities that are part of UPHS, as well as a Veterans Affairs Medical Center and a federally qualified health center. All facilities are located throughout West and Southwest Philadelphia.
A primary requirement for the CHWs, according to Penn Center for CHWs Director Jill Feldstein, is to share similar life experiences with the patients. "Do they have the skill set to get the patient to open up about what's going on in life?" she says. "Our patients have tremendous stress, such as poverty, community violence, and housing instability. The CHW has to be able to build a trusting relationship."
"Nurses and doctors can only handle who walks through the door. They need an army of people who are creative and skilled to manage other parts of the care system. We're moving from being a reactionary system to a proactive system."
CHWs were integrated into UPHS because patients voiced a disconnect from healthcare providers. They felt the doctors didn't understand what it was like in the real world for patients. Feldstein says in 2011 Penn Center for CHWs hired a community-based interviewer to ask high-risk patients about their experience with healthcare. "We recorded, transcribed, and analyzed the interviews. Over and over again, we heard patients talk about the disconnect they felt from traditional medical personnel. An illustrative quote was: 'They can give you advice, like here's the kind of medicine you need. But they don't really know how it works in the real world,' " she says.
CHWs are assigned to hospital and outpatient care teams and meet with patients, asking them what they need to be able to focus on their health. Together, they develop an action plan and the CHW helps the patient to carry it out. CHWs embedded in hospital teams work with patients for two weeks to three months, providing social support, advocacy, and navigation in the transition from hospital to home. In the outpatient setting, CHWs work with patients for six months, providing support, health coaching, and navigation to help patients manage their chronic conditions.
The Penn Center for CHWs determines patient eligibility for the CHW intervention by using information extracted from the medical record: geography (residence in an eight ZIP-code area with the highest rates of household poverty and readmission to system hospitals), insurance status, chronic disease status, and current hospitalization.
"CHWs help solve everyday challenges facing high-risk patients such as childcare, transportation, and emotional support," Feldstein says. A CHW might accompany a patient to the YMCA to work out or host a three-way call to understand prescription coverage.
CHWs join the communication flow of the clinical practice itself, participating in daily huddles, sending and receiving EMR messages, and attending case conferences. "Every time we integrate CHWs into a new care team, such as the Veterans Administration, we introduce the program, meet with all the patient teams, and illustrate the impact with a case study," Feldstein says.
CHWs also regularly meet with one another to share best practices, troubleshoot, provide constructive criticism, and participate in professional development.
Transforming care with CHWs
At Montefiore Medical Group, which provides primary and specialty care services in more than 20 locations in the Bronx and Westchester County, the quest to achieve PCMH certification, which the system received, illuminated the need for CHWs.
CHWs are embedded at sites with populations that are more challenged and less affluent, and have a high prevalence of chronic conditions. "They bring patients back into the system who have been lost," says Namita Azad, transformation manager at Montefiore.
The primary focus of the four CHWs—that number is expected to grow to eight or nine in the near term—is care coordination and care management. CHWs are used as patient liaisons, health educators, and patient navigators for group visitors. And although the PCMH model targets Medicaid, Montefiore provides CHW services to all patients.
Even with the anticipated growth in the CHW workforce, Azad says it won't be enough. "We're never going to be at ideal levels in terms of staffing, because we're always going to want to make more use of CHWs," she says.
For instance, she would like to see the CHWs go out into the community and do patient engagement, but that requires coordination and level setting not possible right now. "That's the next frontier," she says.
However, that doesn't mean the CHW voice isn't strong internally. The CHW is an equal member of a multidisciplinary transformation team that includes nursing staff, front desk operations, health educators, psychiatrists, and physicians. "CHWs have been designed into the workflow and help drive quality improvement," Azad says. "If we're putting together a workflow on outreach to diabetic patients, it will not be firmed up until we receive input from the CHW and the health educator."
"Nurses and doctors can only handle who walks through the door. They need an army of people who are creative and skilled to manage other parts of the care system," Azad says. "We're moving from being a reactionary system to a proactive system."
Sending out an SOS
In 2008, Dodie Grovet, LISW, program manager at Long Beach, California–based Molina Healthcare, which operates health plans for families and individuals who qualify for government-sponsored programs and medical clinics across the country, received a report about high ER usage among members of the New Mexico plan.
"Instead of receiving care from their primary care physicians, they were utilizing the emergency room. Members were hospitalized because they weren't managing their chronic conditions on an outpatient basis," Grovet says.
Grovet deployed CHWs, now called community connectors, to interface with members in their home settings. They addressed diabetes, asthma, heart disease, and other medical conditions as well as addressing social determinants of health that impact members' ability to access care. Within two to three years, Grovet was able to demonstrate cost savings—a 4:1 ROI—and improved health outcomes for members.
"The New Mexico health plan served as the pilot for the program, and once leaders saw the positive results, they implemented the program enterprisewide," she says.
Today, risk stratification also looks at escalation in medication usage for chronic conditions, visits to pain doctors, claims and scheduling, and even homecare oxygen orders. The CHW can offer to connect the patient to necessary services such as diabetes clinics and eye doctors.
Caseloads are fluid at Molina. "Even after members have received the full continuum of services from a community connector, should they require further intervention, the door is left open. Members always have access to a community connector," she says.
Cancer screenings
Gloria Coronado, PhD, senior investigator and Mitch Greenlick Endowed Scientist for Health Disparities at Kaiser Permanente Center for Health Research, used CHWs to study a serious challenge in the Latina community. Despite breast cancer being the most common cancer among women in the United States, Latina women are more likely than non-Latina whites to be diagnosed with breast cancer in advanced stages, according to Coronado.
"We know from data that Latinas don't get mammography screenings. They are unaware of the need for screening unless they have symptoms, or they may fear the possibility of having cancer," Coronado says.
With the help of Sea Mar Community Health Centers, which provide medical, dental, and behavioral services in clinics throughout Washington state, Kaiser Permanente Center for Health Research looked at whether having a promotora—a community health worker—visit Latinas in their home and use motivational interviewing skills increased their likelihood to get screened for breast cancer. Free mammography screenings were offered in conjunction with the study.
"In addition to the home visit, the promotoras called the women to check in two weeks after their visit to discuss their next step toward getting screened, including talking to a friend or scheduling a screening," she says.
"The result was a modest but significant increase in screenings, but even a modest increase, when it comes to cancer, could save lives," Coronado says.
She acknowledges that promotoras might be an expensive proposition for health systems, but said costs could be decreased with automated phone calls and other low-cost reminders that would winnow the CHW targets. "Only the people that didn't respond to the less-intensive reminder would need follow-up," she says.
She stresses: "I do think the community health worker has a unique perspective and connection with patients that other people in the health system do not."