Community Health Workers: The Time is Now

1. Community Health Workers: The Time is Now Health Workforce Innovations to Support Delivery System Transformation Houston, TX September 12-13, 2016 Geoff Wilkinson Boston University School of Social Work

2. Presentation Objectives • Brief history of CHW workforce development • Define & distinguish CHWs • Roles and skills • Impacts & value in health system transformation • Challenges for implementation

3. Benchmarks of an emerging profession • Long history of CHW work • U.S. community health center movement (1960s) • Europe, Asia, Latin America, Africa • National organizing of and by CHWs (1990s fwd) • APHA Special Interest Group  APHA Section • American Assoc. of CHWs (2006-09)  current organizing • APHA resolution (2001) • IOM disparities report (2002) • National workforce definition • National Community Health Advisors study (1998) • HHS CHW workforce study (2007) • Dept. of Labor Standard Occupational Classification (2010)

4. Benchmarks (cont’d) • Included in ACA (2010) • CMS preventive services ruling (2013) • Proliferation of post-ACA research, grants, & provider models • CDC integrated chronic disease (1305, 1422) • SIM, DISRIP, Home Health SPAs • ACO standards, AHCs • CDC 6/18 Initiative; HHS Million Hearts campaign • CHCs and hospital systems • Telehealth, EMS integration, etc. • State-based credentialing • TX (2001)

5. Community Health Workers (CHWs) Training/Certification Standards Current Status WA ME ND MT MN+ VT OR MA NH WI NY SD ID MI RI CT WY IA PA NJ NE OH DE NV IL IN UT MD WV CA DC VA CO MO KS KY NC TN HI AZ OK SC AR NM AL MS GA TX AK* Legislation introduced LA FL • Pending legislation failed; But Has a Training/Certification Program • Laws/Regulations Establish CHW Certification Program Requirements • Has a Training/Certification Program • Has Training and Certification Program and State Law Licensing CHW businesses • Statute Creates a CHW Advisory Board, Taskforce, or Workgroup to Establish Program Requirements • None *AK does not have a state-run CHW training program, but statutorily provides community health aide grants for third-parties to train community health aides. +MN also allows Medicaid payments for certified CHW services Last updated: 9/12/2016

6. APHA Definition of CHWs “… frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve. This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.  CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

7. CHW Skills CHW Core Consensus (C3) Project • 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 • Professional Skills and Conduct • Evaluation and Research Skills • Knowledge Base

8. CHW RolesCHW Core Consensus (C3) Project • Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems • Providing Culturally Appropriate Health Education and Information • Care Coordination, Case Management, and System Navigation • Providing Coaching and Social Support • Advocating for Individuals and Communities • Building Individual and Community Capacity • Providing Direct Service • Implementing Individual and Community Assessments • Conducting Outreach • Participating in Evaluation and Research

9. Chronic Disease Asthma, Diabetes Cancer Cardio-Vascular Infectious Disease HIV/AIDS Sexually Transmitted Infections Hepatitis C Tuberculosis Violence Domestic Sexual Assault Youth Violence Suicide Nutrition Services Tobacco Control Lead Poisoning Prevention Early Intervention CHWs address diverse issues

10. CHW work in multiple settings • Community Health Centers • Hospitals • Substance abuse service providers • State and municipal heath departments • Community based organizations • Public housing authorities • Public safety

11. Community Health Educator Outreach Educator Outreach Worker Enrollment Worker Health Advocate Peer Advocate Peer Leader Street Worker Youth Outreach Worker Family Advocate Family Planning Counselor Family Support Worker Doula Patient Navigator Promotora de Salud Community Health Representative CHWs work under many job titles

12. CHWs help achieve “Triple Aim”

13. CHWs bridge health care and public health

14. CHWs work across continuum of prevention strategies , education, housing, inequality Poverty, education, housing, inequality Thomas Frieden, AJPH, January, 2010

15. CHW Impacts: Health Equity • Improve health outcomes & reduce disparities for: • Racially and ethnically diverse patients/clients • Patients with high cost, complex conditions • Linguistic minorities • Immigrants, refugees • Low-income communities • Rural communities • Core values based in equality, justice, empathy

16. CHW Impacts: Access • Increase access to health insurance • Increase access to and use of preventive education, screenings, and treatment services • Increase use of primary care • Increase integration of Mental Health/ Behavioral Health services • Link patients to community services addressing “social determinants of health,” e.g., • Housing • Transportation • Food

17. CHW Impacts: Quality • Improve chronic disease management and prevention, e.g., diabetes, asthma, high blood pressure, nutrition • Help improve outcomes of primary care teams • Care coordination • Rx adherence • Care plan utilization • Patient self-management • Improve patient health literacy • Strengthen culturally competent provider practices (organizational effectiveness)

18. CHW Impacts: Cost • Demonstrated Return on Investment: • Asthma • Diabetes • Cardio-vascular disease • Maternal & child health • ER utilization • Hospital readmission • Rx adherence, narcotic use reduction

19. “Distinctive capabilities of CHWs in clinical settings” • Establishing close relationships with patients based on shared life experience and unique community knowledge • Building trust: overcoming power distinctions and mistrust of institutions • Fostering candid and continuous communication Source: Community Resources, LLC

20. “Distinctive capabilities of CHWs in clinical settings” • Managing Social and Behavioral Determinants of Health • Providing context to team members on “whole picture” of patient’s life • Serving as “SDOH expert” on the team • Assisting patient/family in dealing with non-medical issues affecting health status and access • Mobilizing community to deal with macro issues Source: Community Resources, LLC

21. What CHWs deserve

22. Challenges facing CHWs • Low pay, poor benefits • Unstable funding—categorical grants • Poor job security, high turnover • Inconsistent training, supervision • Uneven provider readiness • Emerging professional identity

23. Implementation Challenges • Workforce identity • Provider readiness & respect • Integration strategies • Supervision & training • Career ladders • Financing • Public & private payers • Employer discretion • Cost savings allocation • Credentialing & potential barriers to entry • Training Infrastructure • Over-medicalization of CHW field • Health system investment in primary prevention

24. Guiding Principle • “Nothing about us without us!” --Durrell Fox

25. Contact Information Geoff Wilkinson, MSW Clinical Associate Professor Boston University School of Social Work 264 Bay State Road, Room 128 Boston, MA 02215 gww@bu.edu (617) 353-7721