Community Health Workers — A Local Solution to a Global Problem (New Eng Jour Med)

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Community Health Workers — A Local Solution to a Global Problem

Prabhjot Singh, M.D., Ph.D., and Dave A. Chokshi, M.D.
N Engl J Med - September 5, 2013

In the face of persistently lackluster job creation, the U.S. health sector is paradoxically seen as both a contributor to torpid macroeconomic growth and a source of local employment opportunities. Labor costs account for more than half of U.S. health care spending, but as payment structures shift from volume-based reimbursement to the rewarding of value in improving health, the locus of health care delivery will expand from facilities to communities. Ideally, patient care will take place not just in episodic encounters but also through continuous, community-based partnerships that include new entities and workers. Elsewhere in the world, such care has involved the use of community health workers (CHWs) — lay community members with focused health care training. We believe that scaling up the community health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs.

In many countries, CHWs are becoming paid, full-time members of community health systems. In sub-Saharan Africa, the One Million Community Health Workers Campaign is training, deploying, and integrating CHWs into the health system. In India, 600,000 CHWs are paid through a fee-for-service system to perform a specific set of primary care functions, such as immunization. In Brazil, community health agents are part of family health teams that now care for 110 million people. And growing evidence reveals the effectiveness of interventions by CHWs in multiple health arenas, such as maternal and child health and chronic-disease management.

CHWs have been part of the U.S. health care landscape for decades, serving as community advocates, social activists, health promoters, and patient navigators, among other roles. In California and other border states, promotoras and promotores de salud address reproductive health, diabetes, and cardiovascular health. In Arkansas, CHWs have been shown to reduce Medicaid spending by reaching out to people with long-term care needs; in Alaska, they're part of an effective primary care extension system. Multiple states have created formal accreditation programs for CHWs, and in 2009, the Department of Labor recognized CHWs' jobs as a distinct category of employment. Yet despite these gains — and in part because of the organic way in which CHWs have emerged — there is little standardization across health systems in terms of gaining access to CHWs, integrating them into health care processes, and compensating them.

There are three models for organizing U.S. CHWs: employment of CHWs as extensions of hospital systems, management of CHWs through community-based nonprofit organizations, and management of CHWs by entities that operate at the interface between health systems and the community (see tableModels for Organizing Community Health Workers (CHWs) in the United States.). The first two approaches reflect CHWs' historical roles — as a means for broadening the health care system's reach and as community activists and health educators. The third approach aims to synthesize these roles while borrowing principles from global experiences with scalability and opportunities for financial sustainability. For example, the Prevention and Access to Care and Treatment (PACT) project drew from the nonprofit organization Partners in Health in integrating CHWs into a care-management program for patients in Boston who have HIV–AIDS. The PACT model was subsequently expanded to cover patients with diabetes or other chronic conditions. More generally, organizations dedicated to CHWs could support health systems by recruiting, training, and supervising CHWs. Longitudinally developed expertise in CHW management allows such organizations to provide interventions that are costly when delivered by more extensively trained health care workers and that are difficult to coordinate in community settings.

http://www.nejm.org/doi/full/10.1056/NEJMp1305636?query=TOC