Why Community Extension and

Transformation of the Medical

Model Matters: Perspectives

from the Community Health

Worker Model

Hector Balcazar, MS., PhD,

Dean

College of Science and Health

CDU

SPECIFIC LEARNING

0BJECTIVES

Describe Integration of the community health worker approach beyond medical model

Describe the key elements of the community health worker model

Describe outcome metrics used to evaluate community health worker programs

WHY CHW/PS? The Key to WHY is

Where are We Going?

Why? THE CHW/PS MODEL?

WHY? We Need Change- Real Change

in Healthcare and the Interdisciplinary

Workforce that Supports Public Health-

Prevention and Control-Management of

Disease Conditions

Real changes are needed

1. How the community systems work?

2. How the infrastructure is used?

3. How to integrate models?

WHY: Invest Differently-

Power of Prevention

Prevention accounts for 25

of 30 years of life gained in the past century

HEALTH CARE IS VERY EXPENSIVE-NOT EFFECTIVE FOR PREVENTION-CURATIVE MODEL IS WHAT WE HAVE!

“The healthcare sector is far and away the most inefficient economic driver in the U.S.”

Peter Orszag, Director, OMB

30% of what we spend adds no clinical value (5% of GDP) – Institute of

Medicine

4.4 million hospital admissions totaling $30.8 Billion in hospital costs could

have been prevented – AHRQ

Barriers = liability, siloed training,

competition, economics

Community Health

Worker

Non-Physician

Provider

Generalist

Specialist

Most

Highly

Specialized

Specialist

Generalist

Non-Physician

Provider

Community Health

Worker

Handshakes = Incentives to collaborate,

partner, interdisciplinary training to build

better teams

Most

Highly

Specialized

Individuals

Clinics/Hospitals

Communities

Nighborhoods

Society-

Systems, Policy

If We Believe There is Real Rationale for Why?

Where to Interject the CHW Model If We Create

Handshakes for Influencing Change?

Family

Diabetes In the U.S., about 7% of

adults reported having been diagnosed with diabetes; in Doña Ana County, almost 10% of adult residents reported having diabetes.

Hispanics in the El Paso area are more likely to have been diagnosed with diabetes than non-Hispanics.

Sharing the Initial Story

50.8

66.8

44.7

67.2

0

10

20

30

40

50

60

70%

of

Yes

Intervention Group Control Group

Family History of Heart Disease Family History of Diabetes

Fifth one percent of the intervention group and 45% of the control group reported having a relative with cardiovascular disease. In both groups, 67% of the participants reported having a relative with Diabetes.

Use of Medication

More than 40% of the participants in both groups used medication to control the blood pressure. Nearly 30% used medication to reduce the blood cholesterol, and 25% of the intervention group and 22% of the control group used medication to control the diabetes.

0

5

10

15

20

25

30

35

40

45

Intervention Group Control Group

25

22.1

42.1 41.9

2927.3

%

Use of Diabetes Medication Use of Hypertensive Medication Use of Cholesterol Medication

Few Examples

Building Models

Clinical- Community-

Ecological

Strengthening the CHW-Approach

Through Accountability- A Start-

• Start The Legacy!!

• Begin The Journey:

Balcazar et al, 2011-

J Ambulatory Care Manage Vol 34(4):362-372

by Paulina Matias, TX

Versatility of PS-CHS Within Their Roles/

Functions?

Connection

to

community

served*

Cultural

Mediation

Health

Education

Assuring

Access to

Care

Informal Counseling

and

Social Support

Individual and

Community

Advocacy

Provision

of Direct

Service

Individual

and

Community

Capacity

Building

Versatility: New Accomplishments

Fresh Out Of The Field

Rosenthal et al, info@C3project.orgCopyright:2016

• The Community Health Worker Core Consensus (C3) Project:

• 2016 Recommendations on CHW Roles, Skills, and Qualities

• Recognition of 10Roles:

• Participation in Evaluation and Research-Implementing Assessments

• Recognition of 8 Skills• Communication Skills,

• Interpersonal and Relationship-Building Skills,

• Service Coordination and Navigation Skills,

• Capacity Building Skills

• Advocacy Skills,

• Education and Facilitation Skills,

•

Individual and Community Assessment Skills

, Outreach Skills

Our Opportunities

Some Reflections

Key Points: Ingredients: Setting: Clinical, Community, Ecological or Hybrids

Ingredients: Capacity Readiness for the CHW Model including –infrastructure-

stages of development of CHW/PS workforce, coalition, groups

Our Opportunities

Some Reflections

Ingredients: CHW/INPUT Sitting at the Table- What would they bring? What training they have- they need? Can a team be integrated from the get go!

Can we infuse CBPR into the mix?

Ingredients: Can I develop the MODEL of

CHWs with what I have thus far?

How would it look like thus far?

Research Opportunities

Some Reflections

Ingredients: Can I Build The Complete Story of the CHW as a Change Agent

What do I mean by change agent?

What are the core elements and active ingredients of community health worker programs? Practice-Based versus Evidence-Based

Can I establish Fidelity/”Validity”

through a research design, CBPR,

Qualitative, Quantitative Evaluation?

Effectiveness- Right on Target!!!

The Community Guide: What Works to Promote Health?

Interventions Engaging

Community Health Workers-

Community Preventive Services

Task Force Recommendation

Promotores de Salud: A Partnership

Model With Medical/Health Sectors

Promotores

Promotores train family members

Family members train

other family members

Promotoras

MD Visit

AssessmentMD Education

(verbal and printed handouts)

Treatment PlanLabs

MedicationCare Plan

Care that Includes PromotorasBalcazar et al 2009. Prev Chronic Dis (6)1

MD Follow up 1 month:Review labs & initial

treatment plan

MD Follow up x 3 months, as needed

Patient educated and more informed

MD visits are more focused, less follow up required

Extensive Education Using glucometer Education on medication use How to check feet How to identify complications Support for lifestyle changes Mental health screening

Group classes and individual support

Appt scheduledReferral to

Promotora program

Sample Results

8.7

7.4

6.5

7

7.5

8

8.5

9

Baseline 3-month

63.3

90.9

0

20

40

60

80

100

Baseline 3-month

•88% Retention Rate in SM Courses;

•49% of clients return to the support groups;

•LDL Cholesterol

Baseline-116 Twelve Months-97

Average-A1c value Knowledgen=29 n=29

Potential Opportunities: Key Successes to Integration

Open and frequent communication

Wide organizational acceptance of promotoras

Regular status meetings to assess progress, identify issues

Extensive training for promotoras

Thorough documentation

Management support

Provider involvement (training, recruitment, support, participation)

Regularly assess patient satisfaction/feedback

THE SPSC-CHW MODELS: Clinical, Community and Ecological Approaches

SPSC-NCLR- Balcazar et al: Prev Chronic Dis 2005, Health Prom Practice 2006

SPSC-UNT- Am J Health Educ 2007, Medina et al

SPSC-NHLBI-HRSA- Balcazar et al, Prev Chronic Dis Jan 2009

SPSC-CDC-UTSPH- Balcazar et al, JHCPU, Nov 2009

SPSC-UTSPH-UTEP NIH HEART1@2- Balcazar et al, PrevChronic Dis March 2010, Education For Health, 2009; PrevChronic Dis Jan 2012, Health Education & Behavior 2012

Phase 1 – HEART INTERVENTION

CBPR RCT

CHAC

192 cases/ 136 controls

2 month CHW-led heart

health education

2 month CHW follow-up

Inputs Evaluation

Clinical Evaluation

BMI, waist circumference

Cholesterol, A1C, blood pressure

HEART Questionnaire

Demographics

Acculturation scale

Stages of change scales

Heart health beliefs

Dietary behaviors

Improved◦ Weight*

◦ LDL Cholesterol

◦ HDL Cholesterol

◦ Systolic and Diastolic Blood Pressure

◦ Framingham Risk Score

◦ Total Cholesterol (p<.05)

Got worse◦ Metabolic Syndrome Risk Factors◦ Balcazar et al, Prev Chronic Disease (2010)

Improved◦ Systolic and diastolic BP

◦ Framingham risk score

Got worse◦ Metabolic Syndrome risk

factors

◦ Hemoglobin HbA1c

◦ Waist circumference

Intervention Group (p <.01) Control Group

Expanding Research Framework Clinical-Community

Interface: HEART Phase 1- Randomized Study-

Change in Clinical Results

The HEART Participant’s Environment

Balcazar et al. 2012 Prev Chronic Dis Vol 9 (11_0100)

www.kentonthemove.org/img/Socio-EcologicalMod..

PolicyAgents: Policy makers

CommunityAgents: Community members, leaders

OrganizationsAgents: YWCA, Parks and Rec Dept., CHALC,

UT—El Paso, UT-SPH, Centro San Vicente, EPCC

InterpersonalAgents: CHWs, family, friends, social networks

IndividualAgents: HEART participant

CBPR Context

Lifestyle/NutritionYour Heart Your Health

Charlas

Cooking Demonstrations

Environmental/Nutrition

Grocery Store Tours

Lifestyle/Fitness

Aerobics

Swimming

Zumba

Environment/Exercise Walking Groups

Soccer and Basketball

CHWPromotores de

Salud

Lifestyle/Environment ProgrammingMy Heart My Community – Mi Corazón Mi Comunidad

0%

20%

40%

60%

Ch

an

ge in

% o

f p

eo

ple

co

nsu

min

g

5 F

&V

/day

Quartiles for number of total sessions attended

Baseline to 4-month change in % consuming 5 Fruits &

Vegetables/day by quartiles

1 2 3 4

**

**

**

Figure: Greater utilization of community resources (attendance) is associated with

greater increases in proportion of participants consuming 5 fruits and vegetables a day at

4-months

Sustainability! Not on Target!!!

Effectiveness,

Versatility,

Workforce Dev.,

Occupation Reg.

Regulation,

Financing, Eval.

and Research

Advocay!

New Directions: Building Sustainabilty

Through Financial Models for CHWs

Structures amenable to greater inclusion of

CHWs: FQHCs payment formulas with HRSA,

Medicaid, Medicare

Structures that promote diversion of ERs-

Hospitals

Structures for long term care and chronic

disease management

Examples of Return on Investment (ROI):

Molina Health Care, New Mexico, Arkansas

Long Term Care, Many More

What is Being Learned From Programmatic Level

Efforts of CHWs- Towards and Advocacy-Policy Model

to Build Sustainability

National Community Health Worker Advocacy

Survey- Sabo et al., 2015

The strongest correlate of advocacy was

membership in CHW association

Community health workers are highly effective

in networking and advocacy efforts to advance

the workforce

Employers stand to benefit from CHW

professional advocacy and play a major role

CHW professional advocacy has resulted in

policy change

What is Being Learned From Programmatic Level

Efforts of CHWs- Towards And Advocacy-Policy Model

to Build Sustainability

“To ensure sustainability of workforce. CHW

networks, employers, state and federal, and

allies should be INTENTIONAL in creating

opportunities for CHWs to promote: 1)

professional identity, 2) increase public image of

CHW roles and skills, 3) develop professional

collaboration, 4) promote workforce-related

legislative and policy initiatives to advance and

sustain the workforce”

” More broadly, CHWs should make up at least

51% of any governing board making decision

regarding the workforce”

Individuals

CHWs Philosophy,

Orientation

CommunitiesSociety

NECESSARY Perspective YES: Synergy and

Cooperation: The Influence of CHWS-

Promotores –Getting Out of the Margins of Work

Family

TRANSFORMATIONAL MODELS with

CHWs in the Context of Variety of Teams-

Approaches-Philosophies towards Building

Equity-Justice

Can we create and validate an agenda of transformational opportunities for CHWs as part of interdisciplinary team packages of key functions, with: health and health care, prevention, wellness, life satisfaction?

Can CHWs help close the gap for meeting a Transformational Agenda?

Can we Move to A HOLISTIC APPROACH TO THIS TRANSFORMATION –IN and OUT OF THE HEALTH SYSTEM?

ARE WE BUILDING ONLY A HEALTH STORY or A HUMAN STORY WITH CHWS- PROMOTORES DE SALUD for A Better World, A better Country?

Moving Toward and Empowerment/Transformational Model: The

Will to Create Change Through Advocacy for Policy Enactment

and Application

Individual Policy Components: Recognition.

Credentialing, Training and Supervision, Scope

of Practice, Career Paths and Workforce

Development

Work-force-level Policies: Financing,

Occupational Regulations, Parameters of

Evaluation

System Level Policy Integration: Strengthen

Community Action, Effective Systems’ Change

for Health Equity

Torres, Balcazar et al, Critical Public Health, 2017

THANKS-

Hector Balcazar and HEART team

And Team: Carl Rush, Lee Rosenthal, Jackie

Scott- from the Institute for Health Policy, The

University of Texas Health Science Center

Houston, School of Public Health, and El Paso

Regional Campus, the HEART TEAM!