milbank presentationfinal cr 11 10-14
TRANSCRIPT
Community Health
Workers:
the State of the Evidence
Ashley Wennerstrom, PhD, MPH, Tulane Schoos of Medicine - New Orleans
Carl H. Rush, MRP, University of Texas School of Public Health - Atlanta
Samantha Sabo, DrPH, MPH, University of Arizona, Mel and Enid Zuckerman College
of Public Health - Scottsdale
9/2/2015 1
Topics Definitions
Why CHWs now?
What CHWs do – and the skills required
State of the Evidence
Activity at the federal and state levels
Key challenges in CHW policy and workforce
sustainability
9/2/2015 2
What’s your definition of CHW?
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Community Health Worker Definition American Public Health Association
The CHW is a frontline public health worker who is a
trusted member of and/or has an unusually close
understanding of the community served.
This trusting relationship enables the CHW to serve as a
liaison/link/intermediary between health/social services and
the community to facilitate access to services and improve
the quality and cultural competence of service delivery.
(cont’d)
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Community Health Worker Definition American Public Health Association
The CHW also builds individual and community capacity by
increasing health knowledge and self-sufficiency through a
range of activities such as:
outreach
community education
informal counseling, social support and
advocacy.
APHA CHW Section, 2006
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CHWs are unlike other
health-related professions
Do not provide clinical care
Generally do not hold another professional
license
Expertise is based on shared life experience
and (usually) culture with the population
served
(cont’d)
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CHWs are unlike other
health-related professions
Rely on relationships and trust more than on
clinical expertise
Relate to community members as peers rather
than purely as client
Can achieve certain results more effectively
than other professionals
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Why CHWs Now?
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Why are we discussing CHWs?
Growing diversity of U.S. population
Growing prevalence of chronic diseases
Growing complexity of health care
Cost pressures on health care system
Shortages of clinical personnel
Commitment to reducing health inequities
Recognition of social/behavioral determinants of health
Growing experience/evidence base with CHWs
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Why are we discussing CHWs?
The “Triple Aim”
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care
Health care reform: changing accountability for outcomes: CHW as members of health care teams
Accountable care organizations (ACOs)
Patient-centered medical homes (PCMHs)
Incentives to reduce costs, improve care
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CHWs can be the integrators!
Health Care Individual Level
Disease Research & Intervention
Public Health
SDOH research & intervention
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
Social determinants
have not been
integrated in clinic
practice or health
care systems
Leads
to lower value, substandard care
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What’s happening in the States -
and at the federal level?
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Peer Support Specialists
While not included in the NTHW rule, peer support specialists will continue to provide addictions and mental health services to Oregon Health Plan clients in coordinated and managed care as defined in the Integrated Services and Supports Rule (ISSR).
Next Steps The Oregon Health Authority will begin a permanent rulemaking process at the close of the 2013 legislative session. Additionally, to support training programs with employment opportunities, OHA is partnering with the Oregon Employment Department to conduct a survey of current and potential NTHW employers. A report of survey results will be available in early March.
Worker Direct Care* Care Coordination/Health Promotion
PopulationBased Prevention/Outreach/
Health Promotion
Payment Options Reporting
CHW PWS NAV
X X X
PCPCH Payment or
CCO‐ICM Capitation
Documentation in Medical Record
CHW PWS NAV
X X X
CCO‐ICM Capitation Or
CCO Sub‐Contracted Entity
CCO Reports Expenditures on
Financial Report **
Doula X Payment to Provider, Hospital or Birthing Center is enhanced
when Doula is utilized
FFS Claim for Delivery is billed with modifier
CCO reimbursement is depend‐ent on the business practice of
the plan
CHW‐Community Health Worker; PWS‐Peer Wellness Specialist; NAV‐Personal Health Navigator *Direct Care services are provided under the supervision of a Licensed Healthcare Professional **(Identify the specific report and line item) ***FFS reimbursable for individuals approved for MH 1915(i) Home and Community Based State Plan Option, Dis‐cussion currently underway to amend the State Medicaid Plan, Rehabilitative Services Option which will authorize FFS OHP for this HCPCS code.
Oregon Health Authority Medical Assistance Programs
NonTraditional Health Workers Financing Options
Source: http://www.oregon.gov/oha/amh/rule/NTHW-BriefwithRules.pdf (p. 2)
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© 2014 Community Resources LLCUpdated 10/1/14
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States are pursuing various models in
CHW policy innovation
Legislative: Texas, Ohio, Massachusetts, New Mexico,
Illinois, Maryland
Medicaid rules: Minnesota, Wisconsin, DC
Policy driven by specific health reform initiatives:
New York, Oregon, South Carolina + SIM states
Broad-based coalition process: Arizona, Florida.
Michigan
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Federal agencies are increasing support
for CHW strategies
CDC priority on support for policy and systems change
CDC and HRSA support for TA at state request
HHS CHW Interagency Work Group
Office of Women’s Health:
Women’s Health Leadership Institute
CMMI Grantee CHW Learning Collaborative
National Health Care Workforce Commission
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What CHWs do –
and the skills required
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CHWs perform a
wide range of Core Roles
Cultural mediation between communities and health
and human services system
Providing culturally appropriate health education
and information
Assuring people get the services they need
Source: National Community Health Advisor Study, Univ. of Arizona, 1998
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CHWs perform a
wide range of Core Roles cont’d
Informal counseling and social support
Advocating for individual and community needs
Providing [some] direct services and meeting
basic needs
Building individual and community capacity
Source: National Community Health Advisor Study, Univ. of Arizona, 1998
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CHWs are employed in many different models
of care
Member of primary care team
Patient navigator
Provider: services, screening, education
Outreach/enroll/inform concerning specific programs or
services
Organizer/advocate
Source: HRSA CHW National Workforce Study, 2007
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CHWs maintain a unique balance of accountability between
community and health care system
Roots of CHWs in social justice and economic opportunity
Many are still grassroots volunteers, especially Promotores
Increasing interest from health care employers
CHWs must preserve integrity of community relationships
As part of personal values
As an essential factor in their effectiveness!
Constant balancing act: relationship vs. task
Compromise: providers/payers can contract with community-based
organizations
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CHWs are increasingly employed in innovative
settings combining clinical care and population
health
Hybrid (Community HUB, Accountable Care
Community, Health Neighborhood)
Outsourcing to CBOs
Social entrepreneurial (Canadian co-op)
South Carolina CHW initiative
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The State of the Evidence
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Evidence base on CHWs is
growing but complicated
Hard to present simple answers,
but impact is evident on health outcomes, health
knowledge/behaviors, and costs
Diversity of CHW activities and health issues means
no unitary measure
Increasing evidence of cost-effectiveness or “return
on investment” from cost savings
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Evidence of CHW impact on
health outcomes is clear in many areas
Birth outcomes: clearest evidence of preventive impact
Diabetes: A1c, BMI, HTN, health behaviors
Asthma: symptom control, missed days
Cancer screening rates > early detection
Immunization rates
Hospital readmissions (care transitions)
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Financial ROI can be dramatic
Recent studies all showing about 3:1 net return or better:
Molina Health Care: Medicaid HMO reducing cost of high utilizers
Arkansas “Community Connectors” keeping elderly and disabled out of long-term care facilities
Community Health Access Program (Ohio) “Pathways” reducing low birth weight and premature deliveries
Texas hospitals: redirecting uninsured from Emergency Depts. to primary care
Langdale Industries: self-insured industrial company working with employees who cost benefits program the most
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Citations for ROI Johnson D, Saavedra, P, Sun E, et al. Community health workers and
Medicaid managed care in New Mexico. J Community Health; 2011; DOI 10.1007/s10900-011-0484-1
Felix HC, Mays GP, Stewart MK, et al. The care span: Medicaid savings resulted when community health workers matched those with needs to home and community care. Health Affairs. 2011;30(7):1366-74.
Redding S, Conrey E, Porter K, Paulson J, Hughes K, Redding M. Pathways Community Care Coordination in Low Birth Weight Prevention. Matern Child Health J; Aug 2014; DOI 10.1007/s10995-014-1554-4
Dols J. Return on investment from CHRISTUS Health CHW program. PowerPoint presentation, Houston TX, 2010.
Miller A. Georgia firm’s blueprint for taming health costs. Georgia Health News; July 27, 2011.
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Key policy areas for consideration in
states that want to advance the CHW
workforce
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4 key policy areas require attention
1. Occupational definition (agreement on scope of
practice and skill requirements)
2. Sustainable financing models
3. Documentation, research and data standards
(records, evidence of effectiveness and “ROI”)
4. Workforce development (training
capacity/resources)
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4 key policy areas require attention
1. Occupational definition
Need agreement on CHW Scope of Practice (SOP)
and skill requirements
Linked to awareness/education effort
Broad consensus needed
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CHW Scope of Practice
gradually gaining traction
SoP formally adopted only in MA, MN
States with certification (TX, OH) currently have broader definitions
States relying on the 1998 National Community Health Advisor Study “Core Roles” as starting point
Derived from national surveys and focus groups of CHWs and employers
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4 key policy areas require attentionCont’d
2. Sustainable financing models
Support CHWs as permanent, integrated workforce,
rather than on short-term
Encourage internal financing by employers as well as
3rd-party payment
High potential in new models of care (PCMH, ACO)
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4 key policy areas require attentionCont’d
3. Documentation, research and data standards
Records, evidence of effectiveness, and ROI
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4 key policy areas require attentionCont’d
4. Workforce development
Training:
Must be competency-based, learner-centered, participatory
Emphasize field work, mentoring, and include on-going practice-based
assessment
Should be offered in various settings: familiar, accessible
Who pays?
How much classroom pre / post-hire?
Employers must consider career development
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Key Strategy Points in Policy Change
Education and awareness effort needed first
Need “Champions” in various stakeholder groups
Interdisciplinary collaboration & self-determination
Recognize history of CHW leadership & advocacy for
profession
Take action with CHWs, not for them
New APHA policy statement under consideration
CHW networks and associations may need support
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Key Strategy Points in Policy Changecont’d
Is legislation needed? At what point?
Learn from other states’ experience with
legislation:
MN, MA, NM, IL, MD & others in progress
Using local and national workforce data
Remember: Not all CHWs work in health care!
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Thank you! Ashley Wennerstrom, PhD, MPH
Carl H. Rush, MRP
Samantha Sabo, DrPH, MPH
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