Integrating Community Health Workers on Clinical Care Teams and in the Community
A community health worker (CHW) is defined as a frontline public health worker who is a trusted member of a community or who has a thorough understanding of the community being served.1 This relationship allows CHWs to serve as a link between health and social service programs and the community to promote access to services and improve the quality and cultural competence of service delivery.
CHWs also help build individual and community capacity to improve health outcomes by increasing health knowledge and self-sufficiency through a range of activities, such as outreach, community education, informal counseling, social support, and advocacy. The integration of CHWs on clinical care teams is a strategy that can be considered to straddle Domain 3 (health care system interventions) and Domain 4 (community-clinical links).
The evidence base demonstrating the effectiveness of integrating CHWs on clinical care teams is very strong. Research studies examining this intervention have had strong internal and external validity, the Community Preventive Services Task Force concluded that integrating CHWs on clinical care teams is effective, and trials of interventions that integrated CHWs have been replicated with positive results. Implementation guidance for integrating CHWs on clinical care teams is available from several sources.
Integrating CHWs on clinical care teams or in the community as part of cardiovascular disease (CVD) prevention programs can help program participants lower their blood pressure, cholesterol, and blood sugar levels; reduce their CVD risks; be more physically active; and stop smoking.2 It can also improve patient knowledge and adherence to medication regimens and improve health care services.2
Health Disparity Impact
By design, the CHW model seeks to eliminate health disparities because the populations served usually include people who have more barriers to care.3 A Community Preventive Services Task Force review found that most studies on CHWs focused on underserved populations and concluded that the CHW model can be effective in improving health and reducing health disparities related to CVD.2
A review by the Community Preventive Services Task Force concluded that interventions that integrate CHWs on clinical care teams to prevent CVD are cost-effective.2 The median cost of intervention was $329 (range: $98 to $422) per person per year, with the main cost drivers being CHW time, costs for training and supervision of CHWs, and cost for any additional interventions or staff. The median change in health care costs after a CHW intervention was a reduction of $82 (range: -$415 to $14) per person per year.
One well-designed study found a return on investment of 1.8 to 1 for a large health plan that served an underserved urban population. Overall evidence for an estimated net benefit indicated that health care cost savings did not exceed the cost of intervention (median net benefit: -$311 from seven studies). The median cost per quality-adjusted life year (QALY) saved was $17,670 (range: $8,233 to $24,149), and all estimates were well below the commonly used and conservative threshold of $50,000 per QALY. The review also noted incomplete reporting or inclusion of major cost drivers in some studies. Future studies should assign a cost to CHW services and time, whether those services are voluntary (unpaid) or otherwise.2
CHWs have been integrated in a variety of primary care settings, including Federally Qualified Health Centers (FQHCs), managed care health systems, patient-centered medical homes, and community pharmacies.1–5
Policy and Law-Related Considerations
The need for policies to ensure that CHWs are sustainably reimbursed for their contribution to team-based care is a frequently cited concern.1,3,4 There is also debate about whether states should require credentialing or certification of CHWs. Proponents of credentialing would like policies to support the consistency of training and certification of CHWs across the country. Opponents are concerned that credentialing could reduce the CHW workforce and decrease access to CHWs who may have intrinsic and invaluable qualities that cannot be certified or credentialed. More information is available from CDC in the form of a State Law Fact Sheet Cdc-pdf[PDF-1.1 MB]11 and Policy Evidence Assessment Report Cdc-pdf[PDF-1 MB]12 that address this topic.
CDC has compiled evidence-based research to support the effectiveness of CHWs in the Community Health Worker Toolkit.6 This toolkit also includes information that state health departments can use to train and further build capacity for CHWs in their communities, as well as helpful resources that CHWs can use in their communities.
Many public and private institutions support including CHWs on health care teams. Examples include the following:
CHWs at Mississippi Delta Health Collaborative
The Mississippi Delta Health Collaborative implemented the Clinical-Community Health Worker Initiative (CCHWI) to improve clinical outcomes for CVD through aspirin use, HbA1c control, blood pressure control, cholesterol management, and smoking cessation in the 18-county Mississippi Delta region.13 The CCHWI model emphasizes the importance of CHWs as integral members of clinical care teams. CHWs received 160 hours of core competency training and 40 hours of training specific to CVD prevention. About 1,100 patients from six participating health care systems—including FQHCs, Rural Health Centers, and private providers—were enrolled because they were diagnosed with hypertension, diabetes, or dyslipidemia. After 4 years, seven CHWs were integrated into the participating health care systems and their duties included visiting patients in their homes. CHWs worked to meet patients’ health care needs through chronic disease self-management workshops, trainings on self-measured blood pressure monitoring, and encouragement of medication adherence. From 2012 to 2016, a 1.3% relative decrease in systolic blood pressure and a 1.7% relative decrease in diastolic blood pressure were observed among patients with hypertension who were enrolled in this program.
For more information:
Tameka Walls, Bureau Director, Mississippi State Department of Health
Websites: http://msdh.ms.gov/msdhsite/External and www.cdc.gov/dhdsp/docs/field_notes_clinical_community_health_worker.pdf Cdc-pdf[PDF-246 KB]
- Centers for Disease Control and Prevention. Technical Assistance Guide: States Implementing Community Health Worker Strategies for the Centers for Disease Control and Prevention’s “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health” Program. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2015.
- Community Preventive Services Task Force. The Guide to Community Preventive Services. Cardiovascular Disease: Interventions Engaging Community Health Workers. https://www.thecommunityguide.org/findings/cardiovascular-disease-prevention-and-control-interventions-engaging-community-healthExternal. Accessed October 26, 2016.
- Gutierrez Kapheim M, Campbell J. Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings. Chicago, IL: Sinai Urban Health Institute; 2014.
- Franklin CM, Bernhardt JM, Lopez RP, Long-Middleton ER, Davis S. Interprofessional teamwork and collaboration between community health workers and healthcare teams: an integrative review. Health Serv Res Manag Epidemiol. 2015;2.
- Verhagen I, Steunenberg B, de Wit NJ, Ros WJG. Community health worker interventions to improve access to health care services for older adults from ethnic minorities: a systematic review. BMC Health Serv Res. 2014;14:497.
- Centers for Disease Control and Prevention. Community Health Worker (CHW) Toolkit. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2016.
- Centers for Disease Control and Prevention. The 6|18 Initiative: Accelerating Evidence into Action. https://www.cdc.gov/sixeighteen. Accessed February 1, 2017.
- Million Hearts. https://millionhearts.hhs.gov/index.htmlExternal. Accessed February 16, 2017.
- Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2002.
- Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment. Fed Regist. 2013;78.
- Centers for Disease Control and Prevention. State Law Fact Sheet: A Summary of State Community Health Worker Laws. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2016.
- Centers for Disease Control and Prevention. Policy Evidence Assessment Report: Community Health Worker Policy Components. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2014.
- Centers for Disease Control and Prevention. Field Notes: Clinical Community Health Worker Initiative. https://www.cdc.gov/dhdsp/docs/field_notes_clinical_community_health_worker.pdf Cdc-pdf[PDF-245 KB]. Accessed February 20, 2017.