Transforming the delivery of care in the post-health reform era: what role will community health workers play?

The Launch of Massachusetts Community Health Worker Certification: Findings From the Massachusetts Community Health Worker Workforce Surveys

OBJECTIVES

The launch of state certification for community health workers (CHWs) in Massachusetts in 2018 aimed to promote and champion this critical workforce. However, concerns exist about unintentional adverse effects of certification. Given this, we conducted 2 cross-sectional surveys to evaluate this certification policy.

METHODS

We conducted surveys of CHW employers and CHWs in 3 sample frames: community health centers and federally qualified health centers, acute-care hospitals, and community-based organizations. We administered the surveys in 2016 (before certification launch) and 2021 (after certification launch) to answer the following questions: Was certification associated with positive outcomes among CHWs after its launch? Did harmful shifts occur among the CHW workforce and employers after certification launch? Was certification associated with disparities among CHWs after its launch?

RESULTS

Certification was associated with higher pay among certified (vs noncertified) CHWs, better perceptions of CHWs among certified (vs noncertified) CHWs, and better integration of certified (vs noncertified) CHWs into care teams. We found no adverse shifts in CHW workforce by sociodemographic variables or in CHW employer characteristics (most notably CHW employer hiring requirements) after certification launch. After certification launch, certified and uncertified CHWs had similar demographic and educational characteristics. However, certified CHWs more often worked in large, clinical organizations while uncertified CHWs most often worked in medium-sized community-based organizations.

CONCLUSIONS

Our evaluation of Massachusetts CHW certification suggests that CHW certification was not associated with workforce disparities and was associated with positive outcomes. Our study fills a notable gap in the research literature and can guide CHW research agendas, certification efforts in Massachusetts and other states, and program efforts to champion this critical, grassroots workforce.

Understanding critical factors associated with integration of community health workers into health and hospital systems

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Evaluating the impact of community health worker certification in Massachusetts: Design, methods, and anticipated results of the Massachusetts community health worker workforce survey

Background

Professional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey.

Methods

Design of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response.

Anticipated results

Wave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework.

Conclusions

The Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.

Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention

OBJECTIVE

To examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes.

METHODS

The sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c.

RESULTS

The group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress.

CONCLUSIONS

Path analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os.

PRACTICE IMPLICATIONS

Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services

Background

Arterial hypertension (aHT) is the leading cardiovascular disease (CVD) risk factor in sub-Saharan Africa; it remains, however, underdiagnosed, and undertreated. Community-based care services could potentially expand access to aHT diagnosis and treatment in underserved communities. In this scoping review, we catalogued, described, and appraised community-based care models for aHT in sub-Saharan Africa, considering their acceptability, engagement in care and clinical outcomes. Additionally, we developed a framework to design and describe service delivery models for long-term aHT care.

Methods

We searched relevant references in Embase Elsevier, MEDLINE Ovid, CINAHL EBSCOhost and Scopus. Included studies described models where substantial care occurred outside a formal health facility and reported on acceptability, blood pressure (BP) control, engagement in care, or end-organ damage. We summarized the interventions’ characteristics, effectiveness, and evaluated the quality of included studies. Considering the common integrating elements of aHT care services, we conceptualized a general framework to guide the design of service models for aHT.

Results

We identified 18,695 records, screened 4,954 and included twelve studies. Four types of aHT care models were identified: services provided at community pharmacies, out-of-facility, household services, and aHT treatment groups. Two studies reported on acceptability, eleven on BP control, ten on engagement in care and one on end-organ damage. Most studies reported significant reductions in BP values and improved access to comprehensive CVDs services through task-sharing. Major reported shortcomings included high attrition rates and their nature as parallel, non-integrated models of care. The overall quality of the studies was low, with high risk of bias, and most of the studies did not include comparisons with routine facility-based care.

Conclusions

The overall quality of available evidence on community-based aHT care is low. Published models of care are very heterogeneous and available evidence is insufficient to recommend or refute further scale up in sub-Sahara Africa. We propose that future projects and studies implementing and assessing community-based models for aHT care are designed and described according to six building blocks: providers, target groups, components, location, time of service delivery, and their use of information systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13467-4.

Influence of contextual socioeconomic position on hypertension risk in low- and middle-income countries: disentangling context from composition

Background

Hypertension has emerged as the single most significant modifiable risk factor for cardiovascular disease and death worldwide. Resource-limited settings are currently experiencing the epidemiological transition from infectious diseases to chronic non-communicable diseases, primarily due to modifications in diet and lifestyle behaviour. The objective of this study was to examine the influence of individual-, community- and country-level factors associated with hypertension in low- and middle-income countries (LMICs).

Methods

Multivariable multi-level logistic regression analysis was applied using 12 Demographic and Health Survey (DHS) datasets collected between 2011 and 2018 in LMICs. We included 888,925 respondents (Level 1) nested within 33,883 neighbourhoods (Level 2) from 12 LMICs (Level 3).

Results

The prevalence of hypertension ranged from 10.3% in the Kyrgyz Republic to 52.2% in Haiti. After adjusting for the individual-, neighbourhood- and country-level factors, we found respondents living in the least deprived areas were 14% more likely to have hypertension than those from the most deprived areas (OR = 1.14, 95% CI 1.10 to 1.17). We observed a significant variation in the odds of hypertension across the countries and the neighbourhoods. Approximately 26.3 and 47.6% of the variance in the odds of hypertension could be attributed to country- and neighbourhood-level factors, respectively. We also observed that respondents moving to a different neighbourhood or country with a higher risk of hypertension had an increased chance of developing hypertension, the median increase in their odds of hypertension was 2.83-fold (95% CI 2.62 to 3.07) and 4.04- fold (95% CI 3.98 to 4.08), respectively.

Conclusions

This study revealed that individual compositional and contextual measures of socioeconomic status were independently associated with the risk of developing hypertension. Therefore, prevention strategies should be implemented at the individual level and the socioeconomic and contextual levels to reduce the burden of hypertension.

Scorecard metrics for assessing the extent of integration of community health worker programmes into national health systems

BACKGROUND

The effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed.

AIM

This article presents an integration scale - CHW Programme Integration Scorecard Metrics (CHWP-ISM) - for measuring the extent of CHW programme integration into national health systems.

SETTING

Literature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries.

METHODS

A deductive-inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics.

RESULTS

Analysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization's (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity.

CONCLUSION

The proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.

Community health worker roles and their evolving interprofessional relationships in the United States

In the United States, growing attention to the cost of care, the social determinants of health, prevention, and population health, signals a refocusing of efforts on value-based care. Just as Accountable Care Organizations and alternative payment models exemplify this shift in attention, so does the increasing integration of Community Health Workers (CHWs) into the US health care system. CHWs are often referred to as "bridge figures," helping clients to navigate what are oftentimes complicated pathways to access a variety of needed services. The integration of CHWs into interprofessional care teams is a process that takes time, and can lead to conflict as traditional care models are disrupted. Through focus groups with CHWs in rural and urban areas of four states, this work identifies and describes three early stages in the evolving interprofessional relationships between CHWs and other care providers. These stages are characterized by: (1) a lack of knowledge and understanding of CHW roles, (2) conflict and competition, and (3) engagement and integration of CHWs into patient care teams. A better understanding of the evolving process of CHW integration is critical to facilitate education and training that will more quickly encourage the development and efficacy of modern models of interprofessional care that include CHWs.

Framing the Integration of Community Health Workers Into Health Care Systems Along Health Care and Community Spectrums

Research calls for community health worker (CHW) integration within health systems, yet there is no agreement regarding what CHW integration is or guidance for how it can be achieved. This study examines factors associated with CHW integration in community and health care settings using a qualitative descriptive multiple-embedded case study of CHW teams at the University of Illinois at Chicago. Data were collected via semistructured interviews/document review and analyzed using thematic coding and quantitative content analysis. Factors associated with higher clinical integration included culture, communication, protocols, and training while higher community integration was associated with accessibility, relationships, and empathy.

Community Health Worker Training Curricula and Intervention Outcomes in African American and Latinx Communities: A Systematic Review

In recent years, community health workers (CHWs) have emerged as key stakeholders in implementing community-based public health interventions in racially diverse contexts. Yet little is known about the extent to which CHW training curriculums influence intervention effectiveness in marginalized racial and ethnic minority communities. This review summarizes evidence on the relationship between CHW training curricula and intervention outcomes conducted among African American and Latinx populations. We conducted a literature search of intervention studies that focused on CHW public health interventions in African American and Latinx populations using PubMed, PsycINFO, ERIC, CINAHL, EMBASE, and Web of Science databases. Included studies were quantitative, qualitative, and mixed methods studies employed to conduct outcome (e.g., blood pressure and HbA1c) and process evaluations (e.g., knowledge and self-efficacy) of CHW-led interventions. Out of 3,295 articles from the database search, 36 articles met our inclusion criteria. Overall, the strength of evidence linking specific CHW training curricula components to primary intervention health outcomes was weak, and no studies directly linked outcomes to specific characteristics of CHW training. Studies that described training related to didactic sessions or classified as high intensity reported higher percentages of positive outcomes compared to other CHW training features. These findings suggest that CHW training may positively influence intervention effectiveness but additional research using more robust methodological approaches is needed to clarify these relationships.

Studying Executive Directors and Supervisors Views of Organizational and Policy-Level Challenges Faced by Community Health Workers

Within the United States, there is an absence of a national community health worker (CHW) program. There is substantial regional and state-based variability in the population served by CHWs, their disease focus, and availability of training, supervision, and other supports. This article seeks to respond to the call in the literature to work collaboratively with CHW professional associations to identify, reflect, and respond to CHW workforce development and sustainability issues. We partnered with 8 member organizations of the Association of Perinatal Networks of New York and conducted 2 focus groups with 7 executive directors and 6 supervisors. Data were analyzed using thematic analysis. Policy barriers included funding, accessibility of evidence-based practices, and credentialing. Organizational barriers included recruitment and high turnover and interorganizational referral processes and management. This study offers recommendations for supports needed to sustain CHWs, with an emphasis on greater investment in recruitment and training, higher compensation, and interorganizational collaboration.

Clinic-Based Community Health Worker Integration: Community Health Workers', Employers', and Patients' Perceptions of Readiness

Clinic-based community health workers (cCHWs) are a growing workforce who can facilitate medical and social support services, particularly for patients with complex, chronic conditions. We assessed CHWs', employers', and patients' perceptions and readiness for CHW integration into clinical settings. We found varying levels of readiness between the groups, offset by conditional implementation concerns, such as need for clearer training, role delineation, expectations, and trust. Integrating CHWs as members of the complex care team holds promise for optimal patient engagement. Maximizing CHWs' potentials through readiness efforts can further support the triple/quadruple aims and goals for the Health Home Program.

Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes

CONTEXT

The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)-virtual health care networks-to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team.

OBJECTIVE

To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown.

DESIGN, SETTING, AND PARTICIPANTS

Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes.

RESULTS

Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

CONCLUSIONS

CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.

Community Health Workers as Organizational Actors in Community Health Centers in 4 Gulf Coast States

Community health workers (CHWs) are recognized for bridging communities and health care systems; yet, there is limited discussion of CHWs' roles as organizational actors within and outside clinics. Individual semistructured interviews (n = 21) were conducted in 4 Gulf Coast states with CHWs and supervisors to examine the bridging function of CHWs from a community health center's perspective. Results highlight that CHWs can function as gatekeepers and ambassadors who extend the clinics' reach in the community, enhance patient access to resources, and improve organizational efficiency. This study demonstrates the value that CHWs can bring for clients and clinics as organizational actors.

Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA

INTRODUCTION

As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation.

METHODS

The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.

RESULTS

Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.

CONCLUSIONS

Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Community-based outreach associated with increased health utilization among Navajo individuals living with diabetes: a matched cohort study

Background

Navajo community members face high rates of diabetes mellitus and other chronic diseases. The Navajo Community Health Representative Outreach Program collaborated with healthcare providers and academic partners to implement structured and coordinated outreach to patients living with diabetes. The intervention, called Community Outreach and Patient Empowerment or COPE, provides home-based health coaching and community-clinic linkages to promote self-management and engagement in healthcare services among patients living with diabetes. The purpose of this study was to evaluate how outreach by Navajo Community Health Representatives (“COPE Program”) affected utilization of health care services among patients living with diabetes.

Methods

De-identified data from 2010 to 2014 were abstracted from electronic health records at participating health facilities. In this observational cohort study, 173 cases were matched to 2880 controls. Healthcare utilization was measured as the number of times per quarter services were accessed by the patient. Changes in utilization over 4 years were modeled using a difference-in-differences approach, comparing the trajectory of COPE patients’ utilization before versus after enrollment with that of the control group. The model was estimated using generalized linear mixed models for count outcomes, controlling for clustering at the patient level and the service unit level.

Results

COPE enrollees showed a 2.5% per patient per quarter (pppq) greater increase in total utilization (p = 0.001) of healthcare services than non-COPE enrollees; a 3.2% greater increase in primary care visits (p = 0.024); a 6.3% greater increase in utilization of counseling and behavioral health services (p = 0.013); and a 9.0% greater increase in pharmacy visits (p <  0.001). We found no statistically significant differences in utilization trends of inpatient, emergency room, specialty outpatient, dental, laboratory, radiology, or community encounter services among COPE participants versus control.

Conclusions

A structured intervention consisting of Community Health Representative outreach and coordination with clinic-based providers was associated with a modest increase in health care utilization, including primary care and counseling services, among Navajo patients living with diabetes. Community health workers may provide an important linkage to enable patients to access and engage in clinic-based health care.

Trial registration

NCT03326206, registered 10/31/2017, retrospectively registered.

Preparing for Community Health Worker Integration Into Clinical Care Teams Through an Understanding of Patient and Community Health Worker Readiness and Intent

There is a rising demand to expand the successful roles community health workers (CHWs) offer into clinical settings (clinic-based community health worker [cCHW]) to support patient services. Using survey data, we evaluated patient and CHW readiness and intent to adopt cCHW clinical care integration. We found CHW and patient readiness to become or utilize a cCHW significantly predicted CHW and patient intent to become or utilize a cCHW; however, in our study, CHWs experienced greater readiness to serve as cCHWs than did patients to utilize cCHWs.

Who are community health workers and what do they do? Development of an empirically derived reporting taxonomy

Objectives

To develop an empirically-informed reporting taxonomy for Community Health Worker (CHW) services to address concerns about the transparency and consistency of descriptions of these interventions in the existing literature.

Methods

We undertook in-depth interviews (n = 43) with CHWs and service staff working in four case studies selected using maximum variation sampling. Interviewees were encouraged to talk about the service, how they had become involved with the service, the CHW role and relationship with clients.

Results

Thematic analysis identified recurrent cross-case observations which we classed as 'who CHW are' and 'what CHW do'. CHW's personal characteristics comprised the sub-groups knowledge and skills, personal qualities, similarity to client and voluntary/paid status; role characteristics comprised time and continuity, settings, limited responsibility, core task and enacted philosophies.

Conclusions

We have developed a conceptual framework for reporting CHW interventions based on the existing literature and our own empirical work. Compared with existing work in the field, the taxonomy uses nomenclature that minimizes current overlap and confusion, and provides a more complete description of CHW characteristics.

Immigrant health access in Texas: policy, rhetoric, and fear in the Trump era

BACKGROUND

Since the 2016 presidential election, reports have suggested that President Trump's rhetoric and his administration's proposed policies could be exacerbating barriers to accessing health care for undocumented as well as lawfully present immigrants and their families in the United States. However, very little empirical work has analyzed this possibility or detailed how these reports and rhetoric have altered the health seeking behavior of mixed immigration status families.

METHODS

Using a series of focus groups throughout Texas in both English and Spanish, this qualitative study analyzes changes to health access for immigrants. We consulted Community Health Workers to better understand the barriers encountered by their otherwise hard-to-reach undocumented clients and their families as they interface with the health system, revealing key insights about the changing nature of barriers to access under the Trump administration.

RESULTS

We identify four key themes about the changing nature of immigrant health access in the United States: growing fear of interacting with health and social services; that social networks are paradoxically limiting health access in the current political climate; that the administration's rhetoric and proposed policies are impeding health seeking behavior; and that children are encountering new barriers to social program participation.

CONCLUSIONS

The Trump administration, its proposed immigration policies, and his rhetoric are posing new and significant barriers to health access for immigrants and their families.

Community Health Workers in Hawai'i: A Scoping Review and Framework Analysis of Existing Evidence

Introduction: Community health workers (CHWs) play a vital role in health across Hawai'i, but the scope of this work is not comprehensively collated. This scoping review describes the existing evidence of the roles and responsibilities of CHWs in Hawai'i. Methods: Between May and October 2018, researchers gathered documents (eg, reports, journal articles) relevant to Hawai'i CHWs from health organizations, government entities, colleges/universities, and CHWs. Documents were reviewed for overall focus and content, then analyzed using the Centers for Disease Control and Prevention's 10 Essential Public Health Services as well as the Community Health Worker Core Consensus Project roles to identify workplace roles and gaps. Results: Of 92 documents received, 68 were included for review. The oldest document dated to 1995. Document types included curricula outlines, unpublished reports, and peer-reviewed articles. Documents discussed trainings, certification programs, CHWs' roles in interventions, and community-, clinical-, and/or patient-level outcomes. Cultural concordance parity between CHWs and patients, cost savings, and barriers to CHW work were noted. Most roles named by the Community Health Worker Core Consensus Project were mentioned in documents, but few were related to the roles of "community/policy advocacy" and "participation in research and evaluation." Workplace roles, as determined using the 10 Essential Public Health Services, focused more on "assuring workforce competency" and "evaluation," and less on "policy development," and "enforcing laws." Discussion: CHWs are an important part of Hawaii's health system and engage in many public health functions. Although CHW roles in Hawai'i mirrored those identified by the CHW Core Consensus Project and 10 Essential Public Health Services frameworks, there is a noticeable gap in Hawai'i CHW professional participation in research, evaluation, and community advocacy.

Being a Community Health Worker Means Advocating

Community health workers (CHWs) participate in advocacy as a crucial means to empower clients in overcoming health disparities and to improve the health and social well-being of their communities. Building on previous studies, this article proposes a new framework for conceptualising CHW advocacy, depending on the intended impact level of CHW advocacy. CHWs participate in three ‘levels’ of advocacy, the micro, the macro, and the professional. This article also details the challenges they face at each level. As steps are taken to institutionalise these workers throughout the United States and abroad, there is a danger that their participation in advocacy will diminish. As advocacy serves as a primary conduit through which to empower clients, enshrining this role in steps to integrate these workers is essential. Finally, this article provides justification for the impacts of CHWs in addressing the social determinants of health and in helping their communities strive towards health equity.

Opportunities for Community Health Worker Training to Improve Access to Health Care for Medicaid Enrollees

Limited access to care can negatively affect population health, which is particularly concerning for individuals of lower socioeconomic status. Shortages of US health care providers in areas that predominantly serve Medicaid enrollees contribute to a lack of access. The Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative was designed as a workforce development initiative to train and deploy community health workers (CHWs). The authors conducted 55 key informant interviews with preceptors, CHWs, and administrators across 5 sites with the specific aim of improving understanding of common barriers to and benefits of CHW program implementation across different CHW programs in Ohio. CHW programs reportedly act as a bridge between the patient and providers, and program benefits were reported for participants, organizations, and patients. This study found that CHW programs enabled training of health professionals that can empower participants while allowing them to also give back to their communities. Organizations employing CHWs reported being able to extend clinic services, increase utilization of community resources, and improve patient compliance through the efforts of CHWs; program impacts also led to increased patient support, patient education, and overall better care. To better integrate CHWs into health care organizations, organizations should focus on clearly defining the CHW role and ensuring adequate infrastructure to support CHW efforts.

The Patient Protection and Affordable Care Act and Utilization of Preventive Health Care Services Among Asian Americans in Michigan during Pre- and Post-Affordable Care Act Implementation

Since the implementation of the Patient Protection and Affordable Care Act (ACA), significant increases in the percent of insured United States residents has steadily increased. Studies have shown that there is an increase in preventative services usage and a decrease in chronic disease burden with increased access to insurance. However, very little has been studied about how the implementation of ACA has impacted utilization of health services and health status among Asian Americans. In this study, we recruited 427 Asian Americans who attended health fairs and examined (1) changes in health care coverage and utilization of preventive health services before and after ACA, (2) health status on chronic disease risk factors, (3) comparing health services utilization by insurance status and types of insurance, and (4) identifying relationships between health care utilization and demographic factors. Study results indicate that even though the percentage of insured Asian Americans in Michigan increased significantly over study periods, health care utilization and chronic disease burden did not change significantly. The insured tended to utilize preventive health services more than the uninsured, but the types of insurance did not affect health care utilization. Gender and having a primary care physician were significant predictors in determining health care utilization. There is a need in this population for language-appropriate and culturally-sensitive education about the importance and availability of preventive services, which could improve adherence to preventive health services, thereby reducing health disparities.

Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana

OBJECTIVE

Community-based initiatives have enormous potential to facilitate the attainment of universal health coverage (UHC) and health system development. Yet key gaps exist and threaten its sustainability in many low-income and middle-income countries. This study is first of its kind (following the launch of the Sustainable Developments Goal [SDG]) and aimed to holistically explore the challenges to achieving UHC through the community-based health planning and service (CHPS) initiative in Ghana.

DESIGN

A qualitative study design was adopted to explore the phenomenon. Face-to-face indepth interviews were conducted from April 2017 until February 2018 through purposive and snowball sampling techniques. Data were analysed using inductive and deductive thematic analysis approach.

SETTING

Data were gathered at the national level, in addition to the regional, district and subdistrict/local levels of four regions of Ghana. Sampled regions were Central Region, Greater Accra Region, Upper East Region and Volta Region.

PARTICIPANTS

In total, 67 participants were interviewed: national level (5), regional levels (11), district levels (9) and local levels (42). Interviewees were mainly stakeholders-people whose actions or inactions actively or passively influence the decision-making, management and implementation of CHPS, including policy makers, managers of CHPS compound and health centres, politicians, academics, health professionals, technocrats, and community health management committee members.

RESULTS

Based on our findings, inadequate understanding of CHPS concept, major contextual changes with stalled policy change to meet growing health demands, and changes in political landscape and leadership with changed priorities threaten CHPS sustainability.

CONCLUSION

UHC is a political choice which can only be achieved through sustainable and coherent efforts. Along countries' pathways to reach UHC, coordinated involvement of all stakeholders, from community members to international partners, is essential. To achieve UHC within the time frame of SDGs, Ghana has no choice but to improve its national health governance to strengthen the capacity of existing CHPS.

Patient and Community Health Worker Perceptions of Community Health Worker Clinical Integration

Traditional community health workers (CHWs) are expanding their role into clinical settings (cCHW) to support patients with care coordination and advocacy services. We investigated the potential to integrate cCHWs, via evaluation of patients' and CHWs' key demographics, needs, and abilities. This mixed-methods study, including adult patients and CHWs, was conducted in the Inland Valley of Southern California, between 2016 and 2017. Survey data, key informant interviews, and focus group discussions were evaluated to compare patient/CHW core demographics, and contrast patient-identified healthcare needs against CHW-identified cCHW service capabilities. Quantitative data were evaluated descriptively and bi-variably using two-sample independent t tests and Pearson's Chi square tests. Qualitative data were coded for emerging themes using a priori and standard grounded theory methods. Patients and CHWs were significantly similar in age, education, and income, but significantly differed in gender, race, United States generation, and marital status. For all healthcare-related services in which patients and CHWs exhibited significant differences, the odds CHWs perceived themselves capable of performing services were greater than patients' stated need of services. Patients and CHWs overlapped regarding their expectations of cCHWs. Although patients and CHWs differed somewhat, they shared many of the same expectations for cCHW integration. This information is critical to further contextualize cCHW training programs and emphasizes the need to education patients about this exciting new form of healthcare delivery. The active role of cCHWs in the clinical care team and the community may expand patient access to preventive healthcare, improve care quality, and minimize health inequities.

Core Competencies and a Workforce Framework for Community Health Workers: A Model for Advancing the Profession

OBJECTIVES

To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework.

METHODS

We conducted a review of the literature on CHW competency development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States.

RESULTS

The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12-2.27) and a simple majority of participants rated all competencies as "extremely important" or "very important."

CONCLUSIONS

Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development. Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.

New enrollment under the affordable care act: leading the way for community health centers in Southern California

BACKGROUND

The Affordable Care Act (ACA) has improved healthcare access in the community health centers that have played a critical role in enrolling low income and minority patients. This study examined the ACA enrollment for one of the largest federally qualified community health centers in the country.

METHODS

An exploratory sequential mixed method study was used as the main qualitative and quantitative approach for this study. Key stakeholders (n = 6) were interviewed as part of the qualitative component, and information about barriers and best practices were acquired. As part of the quantitative analysis, we examined cross-sectional data among 59,272 AltaMed enrollees in 2013-2015. We analyzed data on age, gender, language, ethnicity, and enrollment periods. The interviews were conducted first and followed by the data analysis.

RESULTS

AltaMed was the top enroller of patients in ACA insurance plans in California (2013-14 and 2014-15) through the state exchange and Medicaid expansion. Using key stakeholder interviews, 5 main barriers were identified and 5 innovative solutions that allowed AltaMed to enroll people into the state exchange and Medicaid expansion. Barriers to enrollment included training, new workflows, and enrollment of Young Invincibles, and these enrollment barriers were overcome with community health workers.

CONCLUSION

Enrollment barriers were overcome through AltaMed's community-based approach and long term community partnerships.

A community health worker intervention to improve blood pressure among Filipino Americans with hypertension: A randomized controlled trial

Behavioral interventions utilizing community health workers (CHWs) have demonstrated effectiveness in improving hypertension disparities in ethnic minority populations in the United States, but few have focused on Asian Americans. We assessed the efficacy of a CHW intervention to improve hypertension management among Filipino Americans with uncontrolled blood pressure (BP) in New York City (NYC) from 2011 to 2013. A total of 240 Filipino American individuals (112 in the treatment group and 128 in the control group) with uncontrolled hypertension (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) were recruited from community-based settings in NYC. Using a community-based participatory research approach, treatment participants received 4 educational workshops and 4 one-on-one visits with CHWs over a 4-month period, while control group participants received 1 educational workshop. Main outcome measures included BP control, changes in SBP and DBP, and changes in appointment keeping at 8-months. At 8-months, BP was controlled among a significantly greater percentage of treatment group participants (83.3%) compared to the control group (42.7%). The adjusted odds of controlled BP for the treatment group was 3.2 times the odds of the control group (P < 0.001). Both groups showed decreases in SBP and DBP, with greater decreases among treatment participants. Significant between-group differences were also demonstrated in adjusted analyses (P < 0.001). Individuals in the treatment group showed significant changes in appointment keeping. In conclusion, a community-based intervention delivered by CHWs can help improve BP and related factors among Filipino Americans with hypertension in NYC.

Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-Based Integration Into Health Care Teams, 2015

The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.

Integrating Community Health Workers Into Medical Homes

PURPOSE

Though evidence supports the value of community health workers (CHWs) in chronic disease self-management support, and authorities have called for expanding their roles within patient-centered medical homes (PCMHs), few PCMHs in Minnesota have incorporated these health workers into their care teams. We undertook a qualitative study to (1) identify facilitators and barriers to utilizing a CHW model among PCMHs in Minnesota, and (2) define roles played by this workforce within the PCMH team.

METHODS

We conducted 51 semistructured, key-informant interviews of clinic leaders, clinicians, care coordinators, CHWs, and staff from 9 clinics (5 with community health workers, 4 without). Qualitative analysis consisted of thematic coding aligned with interview topics.

RESULTS

Four key conceptual themes emerged as facilitators and barriers to utilizing a CHW model: the presence of leaders with knowledge of CHWs who championed the model, a clinic culture that favored piloting innovation vs maintaining established care models, clinic prioritization of patients' nonmedical needs, and leadership perceptions of sustainability. These health care workers performed common and clinic-specific roles that included outreach, health education and coaching, community resource linkage, system navigation, and facilitating communication between clinician and patient.

CONCLUSIONS

We identified facilitators and barriers to adopting CHW roles as part of PCMH care teams in Minnesota and documented their roles being played in these settings. Our findings can be used when considering strategies to enhance utilization and integration of this emerging workforce.

Estimating the costs and cost-effectiveness of promoting mammography screening among US-based Latinas

PURPOSE

We characterize the costs and cost-effectiveness of a community health worker (CHW)-based intervention to promote screening mammography among US-based non-adherent Latinas.

METHODS

The parent study was a randomized controlled trial for 536 Latinas aged 42-74 years old who had sought care within a safety net health center in Western Washington. Participants were block-randomized within clinic to the control arm (usual care) or intervention arm (CHW-led motivational interviewing intervention). We used the perspective of the organization implementing promotional activities to characterize costs and cost-effectiveness. Cost data were categorized as program set-up and maintenance (initial training, booster/annual training) program implementation (administrative activities, intervention delivery); and, overhead/miscellaneous expenses. Cost-effectiveness was calculated as the incremental cost of screening for each additional woman screened between the intervention and control arms.

RESULTS

The respective costs per participant for standard care and the intervention arm were $69.96 and $300.99. There were no study arm differences in 1-year QALYs were small among women who completed a 12-month follow-up survey (intervention= 0.8827, standard care = 0.8841). Most costs pertained to program implementation and administrative activities specifically. The incremental cost per additional woman screened was $2,595.32.

CONCLUSIONS

Our findings are within the ranges of costs and cost-effectiveness for other CHW programs to promote screening mammography among underserved populations. Our strong study design and focus on non-adherent women provides important strengths to this body of work, especially give implementation and dissemination science efforts regarding CHW-based health promotion for health disparity populations.

Protocol for project IMPACT (improving millions hearts for provider and community transformation): a quasi-experimental evaluation of an integrated electronic health record and community health worker intervention study to improve hypertension management among South Asian patients

BACKGROUND

The Million Hearts® initiative aims to prevent heart disease and stroke in the United States by mobilizing public and private sectors around a core set of objectives, with particular attention on improving blood pressure control. South Asians in particular have disproportionately high rates of hypertension and face numerous cultural, linguistic, and social barriers to accessing healthcare. Interventions utilizing Health information technology (HIT) and community health worker (CHW)-led patient coaching have each been demonstrated to be effective at advancing Million Hearts® goals, yet few studies have investigated the potential impact of integrating these strategies into a clinical-community linkage initiative. Building upon this initiative, we present the protocol and preliminary results of a research study, Project IMPACT, designed to fill this gap in knowledge.

METHODS

Project IMPACT is a stepped wedge quasi-experimental study designed to test the feasibility, adoption, and impact of integrating CHW-led health coaching with electronic health record (EHR)-based interventions to improve hypertension control among South Asian patients in New York City primary care practices. EHR intervention components include the training and implementation of hypertension-specific registry reports, alerts, and order sets. Fidelity to the EHR intervention is assessed by collecting the type, frequency, and utilization of intervention components for each practice. CHW intervention components consist of health coaching sessions on hypertension and related risk factors for uncontrolled hypertensive patients. The outcome, hypertension control (<140 mmHg systolic blood pressure (BP) and <90 mmHg diastolic BP), is collected at the aggregate- and individual-level for all 16 clinical practices enrolled.

DISCUSSION

Project IMPACT builds upon the evidence base of the effectiveness of CHW and Million Hearts® initiatives and proposes a unique integration of provider-based EHR and community-based CHW interventions. The project informs the effectiveness of these interventions in team-based care approaches, thereby, helping to develop relevant sustainability strategies for improving hypertension control among targeted racial/ethnic minority populations at small primary care practices.

TRIAL REGISTRATION

This study protocol has been approved and is made available on Clinicaltrials.gov by NCT03159533 as of May 17, 2017.

Public Mistrust of the U.S. Health Care System's Profit Motives: Mixed-Methods Results from a Randomized Controlled Trial

BACKGROUND

Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.

OBJECTIVE

To explore public perceptions of health care costs and how they intersect with medical mistrust.

DESIGN AND PARTICIPANTS

This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.

APPROACH

We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.

KEY RESULTS

Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.

CONCLUSIONS

Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust.

Women's Health Leadership to Enhance Community Health Workers as Change Agents

Objectives A community health worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. While natural leadership may incline individuals to the CHW profession, they do not always have skills to address broad social issues. We describe evaluation of the Women's Health Leadership Institute (WHLI), a 3-year training initiative to increase the capacity of CHWs as change agents. Methods Pre-/postquestionnaires measured the confidence of 254 participants in mastering WHLI leadership competencies. In-depth interviews with CHW participants 6 to 9 months after the training documented application of WHLI competencies in the community. A national CHW survey measured the extent to which WHLI graduates used leadership skills that resulted in concrete changes to benefit community members. Multivariate logistic regressions controlling for covariates compared WHLI graduates' leadership skills to the national sample. Results Participants reported statistically significant pre-/postimprovements in all competencies. Interviewees credited WHLI with increasing their capacity to listen to others, create partnerships, and initiate efforts to address community needs. Compared to a national CHW sample, WHLI participants were more likely to engage community members in attending public meetings and organizing events. These activities led to community members taking action on an issue and a concrete policy change. Conclusions Leadership training can increase the ability of experienced CHWs to address underlying issues related to community health across different types of organizational affiliations and job responsibilities.

Evaluating community health workers' attributes, roles, and pathways of action in immigrant communities

Community health workers (CHWs) are uniquely positioned to improve health outcomes in immigrant communities; however, research on appropriate metrics for evaluating CHW attributes and mechanisms of effectiveness are limited. The objective of this paper is to characterize CHW attributes and pathways of action using adapted measures, develop a scale using these measures, and explore how findings can inform future CHW research and practice. The study analyzed pre- and post-intervention group data from one quasi-experimental and three randomized controlled-design parent trials assessing the impact of CHW-led group and individual health coaching on various health outcomes in four New York City immigrant communities. We conducted descriptive, bi-variate and principal components analysis to develop a 13-item scale assessing CHW attributes, roles, and pathways of action. The sample included 437 individuals completing the intervention arm of a CHW study. We found CHWs were reported to affect change through a number of mechanisms and participants expressed substantial communal concordance with the CHWs in terms of country of birth, language, and culture. Principal components analysis with promax rotation identified 13 items with three factors and high Cronbach's alphas: 1) valued interpersonal attributes of the CHW (alpha=0.784); 2) CHW as a bridge to health and non-health resources (alpha=0.857); and 3) providing accessibility beyond health providers (alpha=0.904). Socio-demographic characteristics and differences in CHW pathways of action were identified by community. Study findings can guide improved selection and training of CHWs. Further, measures identified in the principal components analysis can be used to guide future CHW evaluation efforts.

Community Health Worker Impact on Chronic Disease Outcomes Within Primary Care Examined Using Electronic Health Records

OBJECTIVES

To investigate community health worker (CHW) effects on chronic disease outcomes using electronic health records (EHRs).

METHODS

We examined EHRs of 32 147 patients at risk for chronic disease during 2012 to 2015. Variables included contact with clinic-based CHWs, vitals, and laboratory tests. We estimated a mixed model for all outcomes.

RESULTS

Within-group findings showed statistically significant improvements in chronic disease indicators after exposure to CHWs. In health center 1, HbA1c (glycated hemoglobin) decreased 0.15 millimoles per mole (95% confidence interval [CI] = -0.24, -0.06), body mass index decreased 0.29 kilograms per meter squared (CI = -0.39, -0.20), and total cholesterol decreased 11.9 milligrams per deciliter (CI = -13.5, -10.2). In health center 2, HbA1c decreased 0.43 millimoles per mole (CI = -0.7, -0.17), body mass index decreased by 0.08 kilograms per meter squared (CI = -0.14, -0.02), and triglycerides decreased by 22.50 milligrams per deciliter (CI = -39.0, -6.0). Total cholesterol of 3.62 milligrams per deciliter (CI = -6.6, -0.6) in health center 1 was the only improvement tied to CHW contact.

CONCLUSIONS

Although patients' chronic disease indicators consistently improved, between-group models provided no additional evidence of impact. EHRs' evolution may elucidate CHW contributions moving forward.

The Changing Roles of Community Health Workers

OBJECTIVE

To examine what different types of employers value in hiring community health workers (CHWs) and determine what new competencies CHWs might need to meet workforce demands in the context of an evolving payment landscape and substantial literature suggesting that CHWs are uniquely qualified to address health disparities.

STUDY DESIGN

We used a multimethod approach, including a literature review, development of a database of 76 programs, interviews with 24 key informants, and a qualitative comparison of major CHW competency lists.

PRINCIPAL FINDINGS

We find a shift in CHW employment settings from community-based organizations to hospitals/health systems. Providers that hire CHWs directly, as opposed to partnering with community organizations, report that they value education and training more highly than traditional characteristics, such as peer status. We find substantial similarities across competency lists, but a gap in competencies that relate to CHWs' ability to integrate into health systems while maintaining their unique identity.

CONCLUSIONS

As CHW integration into health care organizations advances, and as states move forward with CHW certification efforts, it is important to develop new competencies that relate to CHW-health system integration. Chief among them is the ability to explain and defend the CHW's unique occupational identity.

Use of Community Health Workers and Patient Navigators to Improve Cancer Outcomes Among Patients Served by Federally Qualified Health Centers: A Systematic Literature Review

Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation.

Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013.

Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members.

Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.

Improving diabetes care and outcomes with community health workers

BACKGROUND

Type II diabetes continues to be a major health problem in USA, particularly in minority populations. The Diabetes Equity Project (DEP), a clinic-based diabetes self-management and education program led by community health workers (CHWs), was designed to reduce observed disparities in diabetes care and outcomes in medically underserved, predominantly Hispanic communities.

OBJECTIVE

The purpose of this study was to evaluate the impact of the DEP on patients' clinical outcomes, diabetes knowledge, self-management skills, and quality of life.

METHODS

The DEP was implemented in five community clinics from 2009 to 2013 and 885 patients completed at least two visits with the CHW. Student's paired t-tests were used to compare baseline clinical indicators with indicators obtained from patients' last recorded visit with the CHW and to assess differences in diabetes knowledge, perceived competence in managing diabetes, and quality of life. A mixed-effects model for repeated measures was used to examine the effect of DEP visits on blood glucose (HbA1c), controlling for patient demographics, clinic and enrolment date.

RESULTS

DEP patients experienced significant (P < 0.0001) improvements in HbA1c control, blood pressure, diabetes knowledge, perceived competence in managing diabetes, and quality of life. Mean HbA1c for all DEP patients decreased from 8.3% to 7.4%.

CONCLUSION

Given the increasing prevalence of diabetes in USA and documented disparities in diabetes care and outcomes for minorities, particularly Hispanic patients, new models of care such as the DEP are needed to expand access to and improve the delivery of diabetes care and help patients achieve improved outcomes.

A qualitative analysis of interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement

Background

Healthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers.

Methods

This is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients’ needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach.

Results

Three focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs.

Conclusion

This work explored interprofessional healthcare team members’ perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1751-5) contains supplementary material, which is available to authorized users.

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND

Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.

OBJECTIVES

We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.

SEARCH METHODS

We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.

SELECTION

We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.

DATA COLLECTION AND ANALYSIS

Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

MAIN RESULTS

All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.

CONCLUSIONS

Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Trauma-Informed Social Policy: A Conceptual Framework for Policy Analysis and Advocacy

Trauma-informed care is a service provision model used across a range of practice settings. Drawing on an extensive body of research on trauma (broadly defined as experiences that produce enduring emotional pain and distress) and health outcomes, we have argued that the principles of trauma-informed care can be extended to social policy. Citing a variety of health-related policy examples, we have described how policy can better reflect 6 core principles of trauma-informed care: safety, trustworthiness and transparency, collaboration, empowerment, choice, and intersectionality. This framework conveys a politicized understanding of trauma, reflecting the reality that trauma and its effects are not equally distributed, and offers a pathway for public health professionals to disrupt trauma-driven health disparities through policy action.

The training and fieldwork experiences of community health workers conducting population-based, noninvasive screening for CVD in LMIC

BACKGROUND

Cardiovascular disease (CVD) is on the rise in low- and middle-income countries and is proving difficult to combat due to the emphasis on improving outcomes in maternal and child health and infectious diseases against a backdrop of severe human resource and infrastructure constraints. Effective task-sharing from physicians or nurses to community health workers (CHW) to conduct population-based screening for persons at risk has the potential to mitigate the impact of CVD on vulnerable populations. CHW in Bangladesh, Guatemala, Mexico, and South Africa were trained to conduct noninvasive population-based screening for persons at high risk for CVD.

OBJECTIVES

This study sought to quantitatively assess the performance of CHW during training and to qualitatively capture their training and fieldwork experiences while conducting noninvasive screening for CVD risk in their communities.

METHODS

Written tests were used to assess CHW's acquisition of content knowledge during training, and focus group discussions were conducted to capture their training and fieldwork experiences.

RESULTS

Training was effective at increasing the CHW's content knowledge of CVD, and this knowledge was largely retained up to 6 months after the completion of fieldwork. Common themes that need to be addressed when designing task-sharing with CHW in chronic diseases are identified, including language, respect, and compensation. The importance of having intimate knowledge of the community receiving services from design to implementation is underscored.

CONCLUSIONS

Effective training for screening for CVD in community settings should have a strong didactic core that is supplemented with culture-specific adaptations in the delivery of instruction. The incorporation of expert and intimate knowledge of the communities themselves is critical, from the design to implementation phases of training. Challenges such as role definition, defining career paths, and providing adequate remuneration must be addressed.

The impact of state certification of community health workers on team climate among registered nurses in the United States

A number of states have adopted certification programs for community health workers (CHWs) to improve recognition of CHWs as members of health care teams, increase oversight, and to provide sustainable funding. There has been little research into the impact of state CHW certification on the diffusion and adoption of CHWs into existing health care systems. This study examined the impact of state CHW certification on the perceptions of team climate among registered nurses (RNs) who work with CHWs in states with and without CHW certification programs. The study recruited RNs using a purposeful sampling method and used an online survey, which included the Team Climate Inventory (TCI), and compared the perceptions of team climate between the two groups. The study found no significant differences in the overall mean TCI score or TCI subscale scores between RNs who work in states with CHW certification programs (n = 81) and those who work in states without CHW certification programs (n = 115). There was a statistically significant difference on one survey question regarding whether RNs believe state certification of CHWs improved the ability of their health care team to deliver quality care. More research is needed to assess impact of state certification of CHWs and other factors that influence the diffusion and adoption of CHWs into the current health care system.

Community Health Workers as a Component of the Health Care Team

In restructuring the delivery of primary care to improve the wellness of a community, every community must review its own circumstances for factors such as resources and capacities, health concerns, social and political perspectives, and competing priorities. Strengthening the health care team with community health workers to create a patient-centered medical home can enhance health care access and outcomes. Community health workers can serve as critical connectors between health systems and communities; they facilitate access to and improve quality and culturally sensitive medical care, emphasizing preventive and primary care.

Strategies to Improve the Integration of Community Health Workers Into Health Care Teams: "A Little Fish in a Big Pond"

Introduction

The Patient Protection and Affordable Care Act acknowledges the value of community health workers (CHWs) as frontline public health workers. Consequently, growing attention has been placed on promoting CHWs as legitimate partners to provide support to health care teams and patients in the prevention, management, and control of chronic disease, particularly among diverse populations and high-need individuals.

Methods

Using a mixed-methods research approach, we investigated the integration of CHWs into health care teams from the CHW perspective. We conducted a survey of 265 CHWs and interviews with 23 CHWs to better understand and describe their experience and their perceived opportunities and challenges regarding their integration within the context of health care reform.

Results

Feelings of organizational support were positively correlated with the number of CHWs in the organization. CHWs reported the following facilitators to integration: having team meetings (73.7%), training inside (70.4%) and outside of the organization (81.6%), access to electronic health records, and ability for CHWs to stay connected to the community.

Conclusion

The perspectives of CHWs on their positive and negative experiences offer useful and innovative insight into ways of maximizing their impact on the health care team, patients, and their role as key emissaries between clinical services and community resources.

Enriching Patient-Centered Medical Homes Through Peer Support

Peer supporters are recognized by various designations-community health workers, promotores de salud, lay health advisers-and are community members who work for pay or as volunteers in association with health care systems or nonprofit community organizations and often share ethnicity, language, and socioeconomic status with the mentees that they serve. Although emerging evidence demonstrates the efficacy of peer support at the community level, the adoption and implementation of this resource into patient-centered medical homes (PCMHs) is still under development. To accelerate that integration, this article addresses three major elements of peer support interventions: the functions and features of peer support, a framework and programmatic strategies for implementation, and fiscal models that would support the sustained viability of peer support programs within PCMHs. Key functions of peer support include assistance in daily management of health-related behaviors, social and emotional support, linkage to clinical care, and longitudinal or ongoing support. An organizational model of innovation implementation provides a useful framework for determining how to implement and evaluate peer support programs in PCMHs. Programmatic strategies that can be useful in developing peer support programs within PCMHs include peer coaching or mentoring, group self-management training, and programs designed around the telephone and information technology. Fiscal models for peer support programs include linkages with hospital or health care systems, service- or community-based nonprofit organizations, and partnerships between health care systems and community groups. Peer support promises to enrich PCMHs by activating patients in their self-care, providing culturally sensitive outreach, and opening the way for partnerships with community-based organizations.