Tuesday, August 17, 2010

Community Health Workers and the Promotion of New Social Norms

Years ago, when a patient showed up in its clinic the morning after a bad ankle injury, the Disease Management Care Blog asked him why he didn't just go to the emergency room. The patient recalled that, about a year before, he had discussed his rising insurance premiums with the DMCB. High ER usage rates were mentioned as one cause. So, one year later, he decided to wait by staying at home with some ice, elevation and aspirin.

Which is why the DMCB agrees with the title of this Health Affairs article titled "Community Health Workers: Part Of The Solution." While authors Lee Rosenthal, Nell Brownstein, Carl Rush, Gail Hirsch, Anne Willaert, Jacqueline Scott, Lisa Holderby and Durrell Fox only hint at the reason why community health workers (CHWs) have much to offer, the DMCB draws on the lessons of behavioral economics to speculate on why.

CHWs can be defined as lay members of a community who provide basic health and medical care to their community. They've been discussed in the medical literature for more than 30 years. Outcomes may be varied but there is impressive evidence from randomized clinical trials (for example, here and here) that CHWs can improve quality and reduce the need for expensive health care services. In the Health Affairs article, Dr. Rosenthal et al argue that both Massachusetts and Minnesota have had a good experience with CHWs, who have helped sign patients up for insurance and increased access to primary care-based education. In fact, Minnesota has established training programs and enabled insurance coverage for CHW services.

However, is that all there is? The DMCB isn't too sure that increasing access to insurance necessarily leads to better and cheaper health care. What's more, the links between patient education, primary care and better and health care savings can be indirect. Ultimately, however, the DMCB buys the notion that CHWs can increase quality and reduce costs, but suspects there's another ingredient at play.

Which brings us back to the ankle patient described above, who adopted a new social norm about avoiding the emergency room, laced with the added convenience of staying home. While the DMCB is no behavioral economist, the ankle patient is a lesson on how people can quickly "tune in" on trying to do the right thing, especially if it's easy. If that sounds like a stretch, then so is the Obama Administration bet that a weakly enforced health insurance mandate will succeed, thanks to it also becoming a social norm.

While the literature shows that CHWs can sign patients up for insurance and behaviorally engage patients in self care, the DMCB also wonders if they also promote new social role models. The DMCB suspects that they are also very effective in developing new attitudes about accessing the health care system in different and ultimately more effective ways. That may also be true for professional and credentialed nurse care managers, but since CHWs have the added advantage of being able to leverage culturally appropriate and trustful relationships, it's possible that they're far more effective in promoting new social norms.

As health reform continues to unfold, CHWs are likely to assume greater roles in the delivery of care services. Hopefully, future research will unravel and help us better understand the interplay between increasing access to insurance, broadening to primary care services, increasing self care and changing attitudes about how and when to access health care services.

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