Grass-roots network: Community health workers help grow stronger provider-patient ties

As a child growing up in Minnesota, Foua Khang helped her immigrant parents and grandparents cope in a place where few people spoke their native Hmong language.

Now, as a community health worker employed by St. Paul-based HealthEast Care System, she helps those in her Hmong community navigate the complex and confusing U.S. healthcare system, communicate with their providers and meet their daily needs.

Khang helps area refugees and providers bridge the cultural gaps that can lead to miscommunication. For example, Khang's clients may be surprised when she tells them they are welcome to ask their doctors and nurses questions. The system's providers use her as a single point of contact to help coordinate services for their patients.

Khang is one of nearly two dozen lay community health workers hired in the past two years by four-hospital HealthEast to help patients from all demographics and ages with issues that affect their health, including housing problems, food insecurity, lack of transportation and cultural practices. Khang and her colleagues work in HealthEast clinics and hospitals alongside clinical professionals, but do not provide any medical services.

HealthEast is one of a small but growing number of systems hiring community health workers to connect low-income, immigrant, rural and other vulnerable populations with resources to improve their overall health. The University of Pennsylvania Health System also is expanding its community health worker staff, while a New Mexico Medicaid managed-care plan is employing them to improve local health education and patient navigation, according to an Urban Institute report. Community health clinics in several states are using such workers to help released prison inmates manage their chronic health conditions.

Facing greater financial incentives to keep patients healthy and out of the hospital and the emergency department, some health systems and health plans have hired community health workers as one strategy to improve primary and preventive-care delivery and address the multiple social factors that can affect health or create barriers to healthcare.

Community health workers generally are recruited from the communities they serve, armed with a strong network of contacts and a solid knowledge of local helping resources. In Minnesota, where community health workers' roles are defined by scope of practice and certification rules, their job includes health education and patient empowerment, promotion of communication between patients and providers, patient advocacy and support for patients as they navigate local health and human services agencies.

These workers are not healthcare professionals, though as the movement toward team-based care grows, some experts have called for them to take on more clinical roles. Regardless, advocates say community health workers have the local connections that can give providers valuable insights into the daily struggles of their patients.

The U.S. Bureau of Labor Statistics first recognized the occupation in 2010 and projects a 21% employment growth for community health workers and health educators through 2022. About 48,000 community health workers are working in public health and health systems.

Some of these workers have earned certification, while others have received workplace training. Wages vary from $10 to $28 an hour, according to federal data from 2013.

The Patient Protection and Affordable Care Act called for grants to encourage the use of community health workers to improve health among underserved Americans. Under the law, at least two dozen innovation grants have been awarded to states to promote expanded community health-worker services, according to the Urban Institute.

Their services may become more in demand under accountable care and global-budget contracts that financially reward hospitals and medical groups for controlling medical spending. Such contracts enable provider systems to provide care-coordination services that aren't paid for under traditional fee-for-service models. Randall Bovbjerg, a senior fellow with the Urban Institute, said delinking payment from specific services will free providers to develop more innovative and effective ways to help their enrolled populations, including using community health workers.

One argument for using such workers is that they are typically paid far less than registered nurses or social workers. They can perform tasks that free licensed practitioners for more specialized healthcare tasks, which is particularly important given the shortage of primary-care professionals, experts say. Community health workers' 2012 median salary was roughly $34,610, compared with $91,500 for nurse practitioners and $92,500 for physician assistants, according to a November 2013 Health Affairs article.

Hez Obermark, director of clinics and healthcare homes at HealthEast, said her system has been able to hire 21 community health workers over the past two years because their salaries are more affordable than those for RNs and social workers.

But there are multiple challenges to expanding use of these workers, including further defining their role, persuading insurers to pay for their services, and developing solid evidence on whether and how they help patients and affect costs. Some states, including Massachusetts, Minnesota, Oregon and Texas, have sought to define a scope of practice for community health workers.

Dr. Art Kellermann, dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., said he would like to see community health workers receive more training and expand their scope of practice to the primary-care equivalent of an emergency medical technician, working under clinician supervision. “We don't need to have a primary-care shortage in this country,” he said. “What we have is an imagination shortage.”

At HealthEast, nurses and social workers provide clinical guidance to their team of community health workers, who are usually recruited through word of mouth. Many have already been interpreters, such as Khang, or former patients who draw on their own experience, Obermark said. The system subsidizes their education toward certification.

The University of Pennsylvania Health System launched its community health-worker program after researchers interviewed high-risk patients about their perceived barriers to healthcare and good health. Patients cited a lack of connection and trust with healthcare workers as critical, said Dr. Shreya Kangovi, who helped conduct the research. “We trained community health workers to do the things that high-risk patients said would help,” said Kangovi, executive director of the Penn Center for Community Health Workers, which provides tools and training for organizations seeking to employ community health workers. The university currently is expanding its model to total 24 community health workers for 1,500 Penn Medicine patients.

At Kangovi's center, community health workers meet with hospitalized patients to set health goals before discharge, support them for a month with home visits, and accompany them to medical appointments and community events. Kangovi and her team found that patients who were paired with community health workers were more likely to quickly seek primary care after leaving the hospital. They also reported better mental health than patients without that support and were less likely to return to the hospital more than once within 30 days after discharge.

But she acknowledged that evidence is limited so far on how much community health workers can help with chronic-disease management and hospital visit prevention. Last year, her team reported in an article in JAMA Internal Medicine that it found no difference between patient groups that received community health-worker support and groups that did not receive such support, relative to overall medication adherence and the likelihood of a readmission within 30 days of initial discharge.

Reimbursement is a barrier to the expanded use of community health workers. Insurance often does not cover their services under the prevalent fee-for-service model. Medicaid programs in only seven states cover services provided by community health workers, according to a 2012 analysis by the Centers for Disease Control and Prevention.

Another challenge is pressure from other professional disciplines, such as nursing and social work, to define and limit lay community health workers' scope of practice. “It's important to understand the professional boundaries,” said Anne Ganey, director of the community health worker program at South Central College in North Mankato, Minn. “Because it's a new role and it's different, nurses and social workers question how it's different from their role.” Ganey helped develop a scope of practice, curriculum and certification for Minnesota community health workers under a Robert Wood Johnson Foundation-funded initiative.

So far, 700 community health workers in the state have been trained and earned certification.

Community health workers also need to learn how to set personal boundaries on their time with patients and recognize when they need professional support. “That's important to prevent burnout,” Ganey said. “It's also important to know where their authority ends and when they need to refer to someone else.”

Follow Melanie Evans on Twitter: @MHmevans