Friday, June 26, 2015

The Potential of Community Health Workers (CHWs)

He was among the highest.

Utilizers of healthcare services, that is. 

I had the pleasure of talking to a physician who is leading a group of community health workers (CHWs) assigned to taking care of dozens of patients like this.  Burdened by decades of multiple chronic conditions, patients like him are typically struggling with myriad complications of chronic illness, side effects from numerous medications, mental illness, extreme poverty and homelessness.  The result is an endless cycle of emergency room visits, admissions, discharges and more emergency room visits.

According to the physician I talked to, these highest utilizers don't need more physician care; us docs can only do so much with an office visit. They also don't need health insurance, because they already have it. 

What these patients really need are resources that can help bridge the aspirations of health reform and the reality of the street.

The Population Health Blog agrees. In its professional career, it saw plenty of insured people with access to health care who were still unable to get better.  They didn't need more of the PHB, they needed..... help, in the form of monitoring, education, coaching, encouragement and advice.

Enter this timely article by Dr. Kangovi and colleagues appearing in the June 11 issue of the New England Journal.  It's a good primer on the long history of CHWs and the work that will be necessary to mainsteam them into health reform.  
CHW-based programs in the U.S. have been around since the 1960s. They typically focus on the indigent, are modest in scope, and have been funded "hand-to-mouth" by community organizations.  However, they've also been used to facilitate insurance enrollment, support "Medicaid Health Homes" and provide preventive and screening services on a regional basis. 

The PHB believes, however, that their greatest value proposition may be in supporting interventions for high utilizing patients under Medicaid waiver arrangements or in managed care programs. By coordinating alternatives to the emergency room revolving doors, CHWs can save taxpayers a lot of money.

Dr. Kangovi et al describe five barriers to the widespread adoption of CHWs:

1) Insufficient integration with traditional providers - But the good news is that CHWs can now use the shared data and remote electronic communication of health information technology to extend the reach of the non-physician (e.g. nurses, social workers) members of a medical home.

2) Fragmented health care systems - But the good news is that health care organizations are slowly being forced out into the communities that surround them. CHWs are waiting.

3) Lack of treatment protocols - But the good news is that this is an emerging science. Some on-line resources already exist.

4) High worker turnover - the authors cite one Harlem program that lost a third of their workers over a matter of months.  The good news is that there are ways to identify "keepers" who will find the CHW career to be satisfying.

5) Low quality published evidence - But the good news is that the volume and the quality of published research is going up.  Even better news is that that will help inform accreditation programs.

That high utilizer mentioned above?  The PHB learned that his last encounter with the health care system was in a primary care provider's office, in the company of a CHW.

Image from Wikipedia

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