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

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.