Community Health Workers: New Roles and Policy Challenges

1. Community Health Workers: New Roles and Policy Challenges NASHP 24th Annual State Health Policy Conference Kansas City, October 4, 2011 Carl H. Rush, MRP Project on CHW Policy and Practice University of Texas Institute for Health Policy San Antonio, Texas

2. Community Health Worker definition American Public Health Association (1) The CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW 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.

3. Community Health Worker definition - APHA (2) The CHW also builds 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. • APHA CHW Section (formerly SPIG), 2006

4. What Is Distinctive About CHWs? (1) • Do not provide clinical care • Generally do not hold another professional license • Expertise is based on shared culture and life experience with population served

5. What Is Distinctive About CHWs? (2) • Rely on relationships and trust more than on clinical expertise • Relate to community members aspeers rather than purely as client • Can achieve certain results that other professionals can't (or won't)

6. Pro-active Vs. Reactive Roles • Many stakeholders think of CHWs in limited terms, mainly outreach (proactive) • Many CHWs also are assigned to patients or receive referrals (responsive) • Roles touch entire continuum of care

8. The promise of CHWs • Proven impact in important areas: • Access to care • Prenatal/perinatal • Chronic disease management • Long term care • Utilization / ER diversion • Significant cost saving potential

9. CHW Cost Effectiveness Studies • Baltimore Medicaid Patients with Diabetes, with or without Hypertension: average annual savings of $2,245 per patient. • Denver Health Study: increased use of primary and specialty care, and reduced use of urgent care. ROI 2.28:1. • Hawaii Asthma Management Program: decline in ER visits and increased quality of life. Asthma-related per capita cost decreased 75%. • Arkansas Community Connectors. Avoiding need for nursing home care by connecting to community based services: ROI to Medicaid 2.9:1

10. Unpublished data from CHW employers • Neglected until recently as potential sustainability strategy • Less incentive to publish than researchers • Results can be dramatic

13. CHW roles in PCMH and ACO • Team member with expertise in cultural factors, social determinants • Facilitate patient-provider communication • More time with patient • More complete communication (candor) • Frequency and continuity of communication • Fewer “lost to follow-up” • Example: care transitions/readmissions • Skills applicable to population health as well as patient care roles

14. Policy challenges re: CHWs • Sustainable funding streams • Occupational regulation • Workforce development resources (training) • Research standards and funding • Policy-related environmental factors • Occupational identity (internal, external awareness) • Professional association/network activity

16. Financing/sustainability options • Medicaid waiver/SPA: MN example • Medicare – the door is open • Example: diabetes education • Incentives to third party payers • CHW employment policies in state procurement • Provider/payer internal return on investment

17. CHW credentialing • Only Texas and Ohio have general CHW certification • MN authorizes Medicaid reimbursement for services by CHWs who meet standards • All 3 States base qualification on completing an approved training program, not direct assessment of skills

18. CHW credentialing (2) • IN, AK have certification for CHWs only in specific programs • Opposition to credentialing exists • NIH national strategy workshop Nov. 2010 – recommended: • Only broad common skill standards at national level • Possible national specialty certification

19. CHW credentialing (3) • Mass. has established state CHW credentialing commission • NY, FL initiatives moving in direction of state credentialing

20. Opportunities in State Policy to Promote Employing CHWs • Standards for “patient-centered medical homes” and “community health teams” • Outreach for Health Insurance Exchanges • Rules for health insurance Medical Loss Ratios • Standards for insurance preventive care benefits

21. Oregon House Bill 3650 (2011) • Creates “Integrated and Coordinated Health Care Delivery System” for public programs • “Coordinated Care Organizations” must provide assistance from CHWs in “navigating the health care delivery system and in accessing community and social support services” • Potential national initiative for FQHCs

22. Required reading! Volkmann, K.; Castañares, T. (July 2011) Clinical Community Health Workers: Linchpin of the Medical Home. J Ambulatory Care Manage 34(3) 221–233. (Entire July 2011 issue devoted to CHWs)

23. Potential employers uninformed • Need for major effort in stakeholder education • Provider staff are seen as either clinical or administrative: CHW is neither • Other professions and scope of practice • Stages of employer development: • Clueless • “Why here?” • “Nice, but…” • “True believer”

24. What is needed now? • Employers and other stakeholders join with CHWs for policy change • Coordinated effort in all policy arenas at state level • Learn from/network with other states • What are you willing to do? • What support do you need?

25. Resources • APHA CHW Section • Univ. of Texas Institute for Health Policy:Project on CHW Policy and Practice

26. Useful links/papers handout http://bit.ly/oIUb7O

27. Contact info Carl H. Rush, MRP Project on CHW Policy and Practice PO Box 5533 San Antonio, TX 78201-0533 (210) 775-2709 (210) 241-3983 mobile carl@chrllc.net