Promising outreach practices: enrolling low-income children in health insurance programs in California

Community Health Workers in Schools: A Systematic Review

BACKGROUND

Community health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting.

OBJECTIVE

To determine outcomes and best practices of school-based community health worker interventions.

DATA SOURCES

PubMed, CINAHL, and SCOPUS databases.

STUDY ELIGIBILITY CRITERIA

This systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12th grade school setting. Articles were excluded if they described an intervention outside the United States.

PARTICIPANTS

Community health workers, children, and/or their parents INTERVENTIONS: School-based community health worker programs RESULTS: Of 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention.

LIMITATIONS

This review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9-21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.

Community health events for enrolling uninsured into public health insurance programs: implications for health reform

OBJECTIVES

To determine whether enrollment events may serve as a venue to identify eligible individuals, enroll them into health insurance programs, and educate them about the changes the Patient Protection and Affordable Care Act will bring about.

METHODS

More than 2900 surveys were administered to attendees of 7 public health insurance enrollment events in California. Surveys were used to identify whether participants had any change in understanding of health reform after participating in the event.

RESULTS

More than half of attendees at nearly all events had no knowledge about health reform before attending the event. On average, more than 80% of attendees knew more about health reform following the event and more than 80% believed that the law would benefit their families.

CONCLUSIONS

Enrollment events can serve as an effective method to educate the public on health reform. Further research is recommended to explore in greater detail the impact community enrollment events can have on expanding public understanding of health reform.

Measuring the impact of outreach and enrollment strategies for public health insurance in California

OBJECTIVE AND STUDY SETTING: To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Children's Health Initiative.

DATA SOURCE

Administrative enrollment databases.

STUDY DESIGN

The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children.

DATA COLLECTION

Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter.

PRINCIPAL FINDINGS

Between 2001 and 2007, enrollment grew in all three children's health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies.

CONCLUSIONS AND IMPLICATIONS

National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.

Enrolling in Medicaid through the National School Lunch Program: outcome of a pilot project in California schools

California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs. An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.

Changes Needed in the Healthcare System

Lay health workers can play a crucial role in connecting the community-in-need to the healthcare system. This article provides insights into how lay health workers, selected from underserved communities, view the issues faced in accessing the healthcare system. A sample of lay health workers responded to a questionnaire used to identify barriers they, themselves, experienced as well as get their perspectives on obstacles faced by their clients. The results demonstrated that lay health workers perceived themselves less affected by barriers as compared with their clients in regard to their provider relationship, getting health information, and their own personal attitudes and beliefs about healthcare. In addition, focus group discussions yielded recommendations and potential solutions to reduce barriers and improve the healthcare system, which included improved access to the facilities, management, scope of services offered, and provider behaviors. These results may benefit the efforts of healthcare professionals and researchers by enhancing their knowledge of, and facility to utilize and deploy, community resources, and, in turn, will assist underserved populations to better negotiate the system and obtain the services they need the most.

A systematic review of mammography educational interventions for low-income women

OBJECTIVE

We conducted a systematic review to examine the effectiveness of educational interventions in increasing mammography screening among low-income women.

DATA SOURCES

Bibliographic databases, including MEDLINE, The Cochrane Central Register of Controlled Trials, The Cochrane Database of Systematic Reviews, and the ISI Web of Science, were searched for relevant articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized, community-based trials targeting low-income women and published between January 1980 and March 2003 were included.

DATA EXTRACTION

The search yielded 242 studies; 24 met all inclusion criteria.

DATA SYNTHESIS

Three studies used mammography vans, three used low-cost vouchers or provided free mammograms, three used home visits, one used community education alone, one provided referrals, five incorporated multiple intervention strategies, two used phone calls, one used videos and print material, and five used primarily print material.

RESULTS

Of nine studies that reduced barriers to care via mammography vans, cost vouchers, or home visits, eight showed statistically significant increases in mammography screening. Seven of the eight studies that used peer educators had significant increases in screening, as did four of the five studies that used multiple (intervention) components.

CONCLUSIONS

Interventions that used peer educators, incorporated multiple intervention strategies, or provided easy access via vans, cost vouchers, or home visits were effective in increasing screenings. Mailed letter or telephone reminders were not effective in trials involving low-income women, which is contrary to findings from middle/upper-income studies.