Community Health Workers in a Reformed Healthcare System

It may be no coincidence that interest in community health workers (CHWs) has been growing alongside momentum for reforming the health delivery system. Research evidence, while limited, indicates that CHWs can facilitate improvement in important areas of healthcare reform like health care access, quality, prevention and self-care. CHWs accomplish these improvements by mobilizing communities for health advocacy and tapping into community knowledge and wisdom about health issues and priorities. CHWs can also be a vehicle for integrating public health and primary care efforts to improve population health by focusing on the social determinants of health. Yet, states seeking to integrate CHWs into healthcare system reforms face a number of challenges, including unreliable funding, fee-for-service reimbursement that separates benefits from costs, and providers unfamiliar with the potential benefits of using CHWs.
Providers are starting to realize CHWs’ potential, but progress on the other fronts is still needed if these community-based workers are to contribute to achieving reform goals, especially because we don’t have many ways to pay for CHWs. Clinicians can benefit from improved productivity if CHWs can help cut the time needed for complex patients, but current fee-for-service payment models do not support the inclusion of new members of care teams. The shift towards global or bundled payments will allow providers to incorporate CHWs into their teams more easily in the future, although it’s not clear just yet where CHWs will best fit into evolving delivery models. To address this, we need promising models for coordinating CHW workforce development, models with a demonstrated return on investment that can be used to make the case for a sustainable funding stream.
The versatility of the CHW workforce can also be a source of confusion. The wide range of roles CHWs play and settings where we find them mean that evaluating their contribution is challenging and costly.  Even defining the CHW has been a subject for disagreement, though the American Public Health Association definition and the Department of Labor occupational classification have been instrumental in recent progress towards a greater consensus on definition.
States that want to expand their CHW workforce as part of their healthcare reform efforts can use their leverage as purchasers, regulators, and conveners to support and promotethe CHW role.  The potential for CHWs to be an effective workforce for tackling health disparities and improving the quality of care can enable states to make progress towards public health goals for population health improvement and healthcare reform goals for delivering healthcare that satisfies the Triple Aim.
There is no one right way for states to expand the use of CHWs, and four case studiesfrom the Urban Institute illustrate different approaches.  Various states and local health departments are:

• putting resources and effort into statewide training infrastructure;
• partnering with training institutes (e.g. LA);
• incorporating CHWs into apprenticeship programs or developing career pathways (e.g. San Francisco);
• looking at changing their payment infrastructure (e.g. NM) and delivery mechanisms (e.g. OH); and
• supporting CHWs through the formation of alliances (e.g. MI, MN), advisory groups (e.g. TX, MA, NY), and through legislation (e.g. MA, NM).

There may also be opportunities for greater federal-state alignment and several federal agencies have introduced measures to support states in developing CHWs. These include:

• CMS has introduced a rule change authorized by the ACA that permits Medicaid reimbursement for preventive services delivered by non-licensed practitioners, such as CHWs on the recommendation of a licensed practitioner;
• CDC has produced training materials for CHWs and posted summary information onstate CHW laws;
• HRSA has issued a toolkit for states evaluating opportunities for developing a CHW program, and, jointly with SAMSHA, is seeking grantees to train and certify behavioral health workers including CHWs.

What is your state doing to promote wider use of CHWs? What opportunities are there for leveraging CHWs to improve the healthcare system? Let us know in a comment below.